Are All Patients Really Suitable for Thromboprophylaxis Treated This Way?

Recommendations vs. Practice

Venous thromboembolism (VTE) is a preventable cause of increased morbidity and mortality, especially in acutely ill patients requiring hospitalization. Many studies have highlighted pharmacological prophylaxis as a safe and effective approach in patients at high risk of developing VTE. Despite recommendations, it appears that pharmacological prophylaxis is actually administered to these patients far less frequently than it should be.

Assessment Methodology

Records of consecutive hospitalized patients were evaluated: 3000 patients in 2013 and 1000 in 2018. This was a retrospective evaluation of records, documenting demographic data, clinical complaints, possible thromboprophylaxis with LMWH (enoxaparin as per hospital recommendations), and how the patients fared during hospitalization and for 90 days after discharge. The Padua score was used to assess VTE risk, and the VTE diagnosis was made based on clinical suspicion.

Results

The average age of patients, 52.6% of whom were women, was 67 ± 21.56 years. Of these patients, 21% were suitable for prophylaxis. The proportion of patients whose VTE risk score was assessed increased after the score was implemented as a quality care parameter (from 13% to nearly 100%). Patients who received thromboprophylaxis were generally sicker than those who, although indicated for prophylaxis based on VTE risk, were not treated accordingly. The proportion of symptomatic patients with VTE was low: 0.24%, of which 0.12% were at low VTE risk vs. 0.55% at high risk.

In 2018, nearly all patients had a VTE risk score assessed, but only 46% of them actually received thromboprophylaxis. Non-significant bleeding was observed in 11% of patients on thromboprophylaxis.

Discussion and Recommendations

The authors derive several insights for practice from these findings:

• VTE risk assessment should be a standard of care for patients admitted to hospital.
• About 25% of patients in internal wards are suitable candidates for VTE prophylaxis.
• The initiation of thromboprophylaxis may be related to fear of bleeding or physicians focusing more on the current illness rather than preventing possible future complications.
• The most common contraindications for thromboprophylaxis are thrombocytopenia and recent bleeding, while bleeding disorders or a history of heparin-induced thrombocytopenia are less common.
• Since Doppler ultrasound was not a standard part of the examination, the incidence of VTE is probably underdiagnosed considering only symptomatic cases of VTE were included.

Conclusion

Despite certain limitations of this retrospective study, it is true that the evaluated participants represented typical patients in common internal wards. There is a need to increase the proportion of people treated in these wards who receive pharmacological thromboprophylaxis. It should concern all patients at high risk of VTE, not just those who are very ill.

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Source: Mahlab-Guri K., Otman M. S., Replikanski N. et al. Venous thromboembolism prophylaxis in patients hospitalized in medical wards. A real life experience. Medicine (Baltimore) 2020 Feb; 99 (7): e19127, doi: 10.1097/MD.0000000000019127.