Double Trouble for 2,609 Hospitalized Medical Patients Who Developed Deep Vein Thrombosis

Prevalence of use of anticoagulants in 502 elderly hospitalized patients at increased risk for systemic embolism or venous thromboembolism without contraindications to anticoagulants in a university hospital

We investigated, in a university hospital, the prevalence of use of anticoagulants in 502 elderly hospitalized patients at increased risk for systemic embolism or venous thromboembolism without contraindications to anticoagulants. The 502 patients included 291 men and 211 women with a mean age of 77 +/- 7 years (range, 65-98 years). Anticoagulants were used to treat 479 of 502 hospitalized patients (95%) at increased risk for systemic embolism or venous thromboembolism. Of the 479 patients treated with anticoagulants, 317 (66%) were treated with unfractionated heparin, 203 (42%) with warfarin, 81 (17%) with low-molecular-weight heparin, two (<1%) with fondaparinux, and two (<1%) with argatroban.

Physician alerts to prevent symptomatic venous thromboembolism in hospitalized patients

BACKGROUND

Venous thromboembolism (VTE) prophylaxis remains underused among hospitalized patients. We designed and carried out a large, multicenter, randomized controlled trial to test the hypothesis that an alert from a hospital staff member to the attending physician will reduce the rate of symptomatic VTE among high-risk patients not receiving prophylaxis.

METHODS AND RESULTS

We enrolled patients using a validated point score system to detect hospitalized patients at high risk for symptomatic VTE who were not receiving prophylaxis. We randomized 2493 patients (82% on Medical Services) from 25 study sites to the intervention group (n=1238), in which the responsible physician was alerted by another hospital staff member, or the control group (n=1255), in which no alert was issued. The primary end point was symptomatic, objectively confirmed VTE within 90 days. Patients whose physicians were alerted were more than twice as likely to receive VTE prophylaxis as control subjects (46.0% versus 20.6%; P<0.0001). The symptomatic VTE rate was lower in the intervention group (2.7% versus 3.4%; hazard ratio, 0.79; 95% CI, 0.50 to 1.25), but the difference did not achieve statistical significance. The rate of major bleeding at 30 days in the alert group was similar to that in the control group (2.1% versus 2.3%; P=0.68).

CONCLUSIONS

A strategy of direct notification of the physician by a staff member increases prophylaxis use and leads to a reduction in the rate of symptomatic VTE in hospitalized patients. However, VTE prophylaxis continues to be underused even after physician notification, especially among Medical Service patients.

Epidemiology of venous thromboembolism in cardiorespiratory and infectious disease

Venous thromboembolic complications -- deep vein thrombosis and pulmonary embolism -- occur in a significant proportion of hospitalized medical patients. The incidence in acutely ill medical patients is 10%-40%, equivalent to that seen in general surgical patients. Prophylaxis is effective and well tolerated, yet remains under-prescribed in medical wards. Current recommendations for prophylaxis are generalized and do not specifically address many patient groups. Data on the prevalence in patients with chronic obstructive pulmonary disease, heart failure, and infectious diseases are limited. However, studies on large numbers of hospitalized patients with these admission diagnoses have provided important information on incidence, and the efficacy of thromboprophylaxis. This review summarizes current knowledge of the epidemiology of venous thromboembolism in patients with chronic obstructive pulmonary disease, heart failure, and infectious diseases, and highlights the benefits of, and needs for, appropriate prophylaxis in these groups. Increased awareness of the prevalence of thrombosis in the major subgroups of medical inpatients should improve the prescribing of prophylaxis and prevent potentially avoidable and costly complications.

Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients

BACKGROUND

It has been suggested that combined modalities (methods of treatment) are more effective than single modalities in preventing venous thromboembolism (defined as deep vein thrombosis and pulmonary embolism, or both) in high-risk patients.

OBJECTIVES

To assess the efficacy of intermittent pneumatic leg compression combined with pharmacological prophylaxis versus single modalities in preventing venous thromboembolism in high-risk patients.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases (PVD) Group searched their Specialized Register (last searched 17 July 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched The Cochrane Library 2008, Issue 3). We searched the reference lists of relevant articles to identify additional trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) or controlled clinical trials (CCTs) of combined intermittent pneumatic leg compression and pharmacological interventions used to prevent venous thromboembolism in high-risk patients.

DATA COLLECTION AND ANALYSIS

Data extraction was undertaken independently by two review authors using data extraction sheets.

MAIN RESULTS

Eleven studies, six of them randomized controlled trials, were identified. The trials included 7431 patients, in total. Compared with compression alone, the use of combined modalities reduced significantly the incidence of both symptomatic pulmonary embolism (PE) (from about 3% to 1%; odds ratio (OR) 0.39, 95% confidence interval (CI) 0.25 to 0.63) and deep vein thrombosis (DVT) (from about 4% to 1%; OR 0.43, 95% CI 0.24 to 0.76). Compared with pharmacological prophylaxis alone, the use of combined modalities significantly reduced the incidence of DVT (from 4.21% to 0.65%; OR 0.16, 95% CI 0.07 to 0.34) but the included studies were underpowered with regard to PE. The comparison of compression plus pharmacological prophylaxis versus compression plus aspirin showed a non-significant reduction in PE and DVT in favor of the former group. Repeat analysis restricted to the RCTs confirmed the above findings.

AUTHORS' CONCLUSIONS

Compared with compression alone, combined prophylactic modalities decrease significantly the incidence of venous thromboembolism. Compared with pharmacological prophylaxis alone, combined modalities reduce significantly the incidence of DVT but the effect on PE is unknown. The results of the current review support, especially in high-risk patients, the use of combined modalities. More studies on their role in PE prevention, compared with pharmacological prophylaxis alone, are urgently needed.