Venous Thromboembolism Prophylaxis: Need for Continuous Assessment Due to Changes in Risk During the Same Hospitalization

Caprini versus Padua venous thromboembolism risk assessment scores: A comparative study in hospitalized patients at a tertiary center

OBJECTIVES

To assess and compare the Caprini and Padua risk assessment models (RAMs) for predicting venous thromboembolism (VTE) in hospitalized patients.

METHODS

We retrospectively reviewed 28 VTE and 450 non-VTE patients hospitalized at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, in 2019. Their baseline medical, demographic, and radiological reports were recorded. We compared Caprini scores (defined at admission) and Padua scores (calculated retrospectively) for their ability to predict VTE. A cumulative risk score was created by adding the individual scores for each risk factor. We also analyzed the sensitivity, specificity, and diagnostic accuracy of the RAM scores.

RESULTS

Major differences in risk factors were shown between patients with and without VTE. Previous VTE was significantly associated with a higher risk of VTE (28.6%), as was reduced mobility (57.1%), acute infection (25%), high Caprini score (50%), and high Padua score (64.3%, p<0.05). The sensitivity of the Caprini score (96%) was higher than that of the Padua score (64.3%), as was the specificity (92.1% vs. 46.9%), positive predictive value (93% vs. 7%), and accuracy (94.1% vs. 47.9%). The specificity of the Caprini score was higher than that of the Padua score in Critical Care, Gynecology/Obstetrics, and Surgical departments. The Caprini RAM showed the lowest level of specificity in the medical department.

CONCLUSION

The Caprini RAM demonstrated higher sensitivity, specificity, and predictive accuracy than did the Padua RAM and thus distinguished low and high VTE risk in hospitalized patients.

Dissecting the rationale for thromboprophylaxis in challenging surgical cases

Pulmonary embolism (PE) is a leading preventable cause of death in surgical patients, and rates of fatal PE are increasing. Individual assessment, to balance the risks of thrombosis and bleeding, is the key to providing appropriate prophylaxis. The risk assessment process includes use of evidence-based guidelines, literature published since the latest guidelines, large registries, and risk scoring systems together with clinical experience and judgment. Risk assessment is a dynamic process and needs to be updated both during the hospital stay and just prior to discharge since clinical events may change the level of risk. The final assessment may identify patients who require ongoing anticoagulant prophylaxis after discharge. The Caprini risk score is widely used in surgical patients and is a composite of the number of risk factors and their relative weights. The Caprini risk score set point for risk levels requiring anticoagulant prophylaxis varies depending on the type of surgical procedure, surgical population, and number of risk factors. Mandatory implementation of evidence-based care pathways is helpful in lowering PE-related mortality. This review presents several challenging cases, emphasizing the importance of employing all available assessment tools, including dynamic assessment of risk during hospitalization. Finally, the limitations of evidence-based guidelines in complex scenarios and the need to employ all available tools to properly protect very high-risk patients are emphasized.

Derivation and External Validation of a Risk Assessment Model of Venous Thromboembolism in Hospitalized Chinese Patients

AIM

To develop and validate a risk assessment model (RAM) of venous thromboembolism (VTE) in hospitalized Chinese patients.

METHODS

We reviewed data from 300 patients with VTE and 300 non-VTE patients at Beijing Shijitan Hospital. The risk factors related to VTE were analyzed, and the VTE RAM (Shijitan (SJT) version) was developed according to the weight of each risk factor. A total of 407 patients with VTE and 533 non-VTE patients were enrolled for external validation. The sensitivity, specificity, Youden index, receiver operating curve (ROC), and area under the ROC curve (AUC) were used to evaluate the performance of VTE RAM (SJT version) compared with Caprini RAM and Padua RAM.

RESULTS

The VTE RAM (SJT version) contained six risk factors (age >60 years, lower limb edema, chronic obstructive pulmonary disease (COPD), central venous catheterization (CVC), VTE history, and D dimer). In the external validation group, for medical patients, the AUC value of SJT RAM (0.82 ± 0.03) is significantly higher than Caprini RAM (0.76 ± 0.04; P < 0.05), SJT RAM has a higher sensitivity, specificity, and Youden index than Caprini RAM (P < 0.05), which means that the SJT RAM has a much better predictive value than Caprini RAM. While SJT RAM and Padua RAM have the similar predictive value for medical patients (P > 0.05). For surgical patients, the AUC value of SJT RAM (0.72 ± 0.04) is significantly higher than the value of Padua RAM (0.66 ± 0.04; P < 0.05), SJT RAM has a higher sensitivity, specificity, and Youden index than Padua RAM (P < 0.05), which shows that the VTE RAM has better predictive value than Padua RAM. While SJT RAM and Caprini RAM have the similar predictive value for surgical patients (P > 0.05).

CONCLUSION

The SJT RAM derived from general hospitalized Chinese patients will be time-saving for physicians and has a better predictive ability for patients at risk of VTE.