A patient was recently admitted for a Deep Vein Thrombosis and was started on Coumadin

Deep vein thrombosis (DVT) is the formation or presence of a thrombus in the deep veins. DVT occurs mostly in the lower extremities and to a lesser extent in the upper extremities. Pulmonary embolism (PE) is an obstruction of the pulmonary artery or its branches by a thrombus (sometimes due to fat or air). The most likely source of thrombus in pulmonary arteries is an embolization from deep veins of the legs. This activity reviews the causes of DVT and highlights the role of the interprofessional team in the prophylaxis against DVT.

Objectives:

• Identify the causes of deep vein thrombosis (DVT).

• Describe the methods used for deep vein thrombosis (DVT) prophylaxis.

• Recall the types of medications used for deep vein thrombosis (DVT) prophylaxis.

• Explain the importance of improving care coordination among the interprofessional team to enhance prophylaxis against deep vein thrombosis (DVT) and improve patient outcomes.

Deep vein thrombosis (DVT) is the formation or presence of a thrombus in the deep veins. DVT occurs mostly in the lower extremities and to a lesser extent in the upper extremities. Pulmonary embolism (PE) is an obstruction of the pulmonary artery or its branches by a thrombus (sometimes due to fat or air). The most likely source of thrombus in pulmonary arteries is an embolization from deep veins of the legs. This occurs in one-third of patients with DVT. Prevention of DVT thereby decreases the incidence of PE, a serious and life-threatening condition.

Venous thromboembolism (VTE) includes DVT and PE. DVT is a major preventable cause of mortality and morbidity worldwide. DVT and PE account for 60,000 to 100,000 deaths annually in the United States.[1]

Normally, there is a balance of procoagulant and anticoagulant factors in the blood that prevents thrombus formation intravascularly. One or more factors of the triad of Virchow can lead to the formation of DVT.

Triad of Virchow

1. Venous stasis (for example, immobility and congestive heart failure [CHF]

2. Endothelial injury (for example, surgery and trauma)

3. Hypercoagulability (for example,  OCP, cancer, thrombophilia) 

Venous stasis is the most important factor, but the presence of endothelial injury and/or hypercoagulability increases the risk of DVT. Hospitalized patients are at risk of venous stasis, and with the presence of other factors, they are at increased risk of DVT compared to patients in the community.

DVT prophylaxis methods target either venous stasis (mechanical methods) or hypercoagulability (pharmacological prophylaxis).

Hospitalized patients are at increased risk of developing DVT (approximately 50%), increasing the risk of PE. PE is one of the most common but preventable causes of death in hospitalized patients.

Only 50% of the hospitalized patients receive DVT prophylaxis. Prevention of DVT in hospitalized patients decreases the risk of DVT and PE, decreasing mortality and morbidity.

DVT prophylaxis can be primary or secondary. Primary prophylaxis is the preferred method with the use of medications and mechanical methods to prevent DVT. Secondary prophylaxis is a less commonly used method that includes early detection with screening methods and the treatment of subclinical DVT.

Deep Veins of Lower Extremities

• Common femoral vein

• Deep femoral vein

• Superficial femoral vein

• Popliteal vein

• Anterior tibial vein

• Posterior tibial vein

• Peroneal vein 

Deep Veins of Upper Extremities

• Paired radial vein

• Paired ulnar vein

• Interosseous vein

• Brachial vein

• Axillary vein

• Subclavian vein

DVT Prophylaxis in Medical Patients

Hospitalized patients are at increased risk of VTE when compared to patients in the community. Therefore, it is imperative to consider DVT prophylaxis in every hospitalized patient. Full history and physical examination are warranted to assess the risk of VTE and bleeding.

Patients with Increased Thrombosis Risk [2]

• Elderly (older than 70)

• Immobile patients

• History of DVT/PE

• Critical ill patients admitted to intensive care unit (ICU)

• Stroke with lower extremity paralysis

• Advanced congestive heart failure (CHF)

• Active cancer 

• Acute respiratory failure

• Thrombophilia

• Recent surgery or trauma

• Obesity

• Ongoing hormonal therapy

Based on thrombosis risk, patients are classified into low risk, moderate risk, and high risk for VTE. 

1. Low-risk patients: Young patients with no risk factors for VTE. No need for prophylaxis

2. Moderate-risk patients: With at least 1 risk factor, pharmacological prophylaxis is preferred with or without mechanical prophylaxis

3. High-risk patients: With multiple risk factors, pharmacological prophylaxis is preferred with mechanical prophylaxis

Commonly used pharmacological agents for prophylaxis in medical patients are:

1.  Low-molecular-weight heparins (LMWH)

2.  Unfractionated heparin (UFH)

3.  Fondaparinux

LMWH is preferred to UFH due to ease of administration (once daily versus 2 to 3 times per day) and decreased incidence of DVT.[3] A number of LMW heparin preparations are available, all of which have almost equal efficacy against VTE. Their dosages are listed in the table below:

* Prophylactic dosages suggested for medical patients with a creatinine clearance greater than 30 mL/minute with no extremes in body weight. Platelet counts should be monitored regularly to detect the development of heparin-induced thrombocytopenia.

UFH is used in patients with low GFR. Prophylactic dosage for UFH is usually 5000 units given subcutaneously twice or thrice a day. This may be increased to 5000 to 7500 units three times a day in an obese patient. It is typically less expensive than low molecular weight heparin. However, it is also contraindicated in patients with HIT, and platelet counts need to be monitored regularly in all patients receiving low-dose UFH.

Direct oral anticoagulants have been shown to reduce mortality (betrixaban compared with subcutaneous enoxaparin). Betrixaban and rivaroxaban are currently approved for use in hospitalized patients.

Mechanical methods are used in patients with moderate to high risk for DVT with a high risk of bleeding. They include intermittent pneumatic compression, graduated compression stockings, and venous foot pump.

DVT Prophylaxis in Cancer Patients

Patients with active cancer but no additional thrombosis risk factors do not need DVT prophylaxis in the outpatient settings. If they have additional risk factors (do not have a chronic indwelling central venous catheter), either LMWH or UFH are used.

DVT Prophylaxis in Long Distance Travellers

Long-distance travelers with risk factors for VTE can use properly fitted below-knee graduated compressive devices at 15 to 30 mm Hg of pressure along with frequent ambulation and calf muscle exercises. Pharmacological prophylaxis is not recommended.

DVT Prophylaxis in Patients Undergoing Orthopedic Surgeries

VTE (DVT and PE) risk is high in patients undergoing major orthopedic surgeries like knee or hip surgeries. In patients undergoing total hip arthroplasty and total knee arthroplasty, LMWH, apixaban, and rivaroxaban are used. Fondaparinux, UFH, and warfarin are used if the above agents cannot be used or are contraindicated. In patients undergoing hip fracture surgery, LMWH, UFH, and fondaparinux are used for DVT prophylaxis.

Duration:

• At least 10 to 14 days, preferably 35 days from the day of surgery (especially pts undergoing total hip arthroplasty) in the absence of risk factors for bleeding

• LMWH typically started 12 hours before and/or 12 hours after surgery. The rest of the medications are typically started 12 hours postoperatively.

• Aspirin alone is not generally recommended for DVT prophylaxis. Aspirin is efficacious compared to placebo in preventing DVT, but there are no comparison studies done with either UFH or LMWH.[4] Aspirin can be used in hybrid therapy, where other agents are used initially while in the hospital and switched to aspirin at discharge.

• Patients with a high risk of bleeding are placed on mechanical prophylaxis unless contraindicated.

• Patients undergoing an arthroscopic procedure without a prior history of DVT/PE rarely need DVT prophylaxis.

• Patients undergoing isolated lower extremity orthopedic surgery requiring immobilization do not require DVT prophylaxis as long as they can ambulate early and adequately.

DVT Prophylaxis in Patients Undergoing Non-Orthopedic Surgeries

VTE risk is based on the type of surgery and underlying patient's risk factors. Major surgeries are categorized as moderate to high risk for VTE and need DVT prophylaxis. When in doubt about the risk of VTE, a modified Caprini risk assessment score can be used. This tool scores risk factors from 1 to 5. Based on this assessment score, a patient undergoing surgery can be categorized as below.

• Very low-risk patients: No DVT prophylaxis needed

• Low risk: Mechanical methods preferred

• Moderate to high-risk patients: Pharmacological agents used with or without mechanical methods

LMWH is preferred, but UFH is used in patients with renal insufficiency. Fondaparinux is used in patients with heparin-induced thrombocytopenia. Other agents are typically not used for DVT prophylaxis. Duration of DVT prophylaxis is typically for a few days or until patients can ambulate or discharge from the hospital. Prolonged duration of prophylaxis even after discharge from the hospital is not typically recommended. In patients undergoing abdominal or pelvic surgery for cancer and with a low risk of bleeding, pharmacological prophylaxis is extended to a total of 4 weeks.

Pharmacological Agents

• Low-molecular-weight heparin: Enoxaparin, 40 mg subcutaneously once daily or dalteparin, 5000 units subcutaneously once daily

• Unfractionated heparin: 5000 units subcutaneously every 8 to 12 hours

• Fondaparinux: 2.5 mg subcutaneously daily

• Direct oral anticoagulants: betrixaban or rivaroxaban

• Warfarin

Mechanical Agents

• Intermittent pneumatic compressions (IPC)

• Graduated compression stockings (GCS)

• Venous foot pump

DVT Prophylaxis in Pregnancy

Incidence of venous thromboembolism is increased during or trimester of pregnancy and is highest during the postpartum period. Most pregnant patients do not require therapy other than observation. Pharmacological prophylaxis is considered in individual cases, particularly in those with the following risk factors:

• A prior history of VTE

• Hospitalization for an acute illness or cesarean delivery

• The presence of an inherited thrombophilia (e.g., factor V Leiden mutation, prothrombin gene mutation, or antithrombin III, protein C, or protein S deficiencies).

Antepartum pharmacological prophylaxis is continued throughout the pregnancy. The optimal duration of outpatient postpartum prophylaxis is unknown. However, the American College of chest physicians suggests at least six weeks postpartum, with a longer duration of up to three months for those at greater risk. Inpatient from prophylaxis is continued until the patient is ambulatory, provided there is no need for outpatient prophylaxis.

Contraindications for Pharmacological DVT Prophylaxis

• Active bleeding or recent bleeding or high risk for bleeding (active PUD)

• Patients with coagulopathy (INR greater than 1.5)

• A planned surgical procedure in the next 6 to 12 hours

• Thrombocytopenia (Less than 50,000, sometimes less than 100,000)

• Bleeding disorders

 Contraindications for Mechanical Prophylaxis

• Limb ischemia due to peripheral vascular disease

• Skin breakdown

The complications from pharmacological prophylaxis include:

• Disturbed renal function

• Bleeding

• Heparin induced thrombocytopenia (HIT)

DVT increases the risk of pulmonary embolism by 50% and also leads to post-thrombotic syndrome. Using DVT prophylaxis in hospitalized patients decreases the risk of DVT anywhere from 10 to 80%. DVT prophylaxis decreases the risk of DVT/PE in both hospitalized medical and surgical patients. However, mortality benefits have been reported in surgical patients but not in medical patients.[5]

Interprofessional teamwork is essential in preventing DVT in hospitalized patients. Good interprofessional communication between attending physicians, surgeons (in surgical patients), and nursing staff is vital in using the appropriate prophylaxis methods. All hospitals should have a formal strategy that increases compliance with the use of DVT prophylaxis.

Review Questions

1.

Stone J, Hangge P, Albadawi H, Wallace A, Shamoun F, Knuttien MG, Naidu S, Oklu R. Deep vein thrombosis: pathogenesis, diagnosis, and medical management. Cardiovasc Diagn Ther. 2017 Dec;7(Suppl 3):S276-S284. [PMC free article: PMC5778510] [PubMed: 29399531]

Spyropoulos AC, McGinn T, Khorana AA. The use of weighted and scored risk assessment models for venous thromboembolism. Thromb Haemost. 2012 Dec;108(6):1072-6. [PubMed: 23138506]

Alikhan R, Bedenis R, Cohen AT. Heparin for the prevention of venous thromboembolism in acutely ill medical patients (excluding stroke and myocardial infarction). Cochrane Database Syst Rev. 2014 May 07;(5):CD003747. [PMC free article: PMC6491079] [PubMed: 24804622]

Karthikeyan G, Eikelboom JW, Turpie AG, Hirsh J. Does acetyl salicylic acid (ASA) have a role in the prevention of venous thromboembolism? Br J Haematol. 2009 Jul;146(2):142-9. [PubMed: 19438502]

Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988 May 05;318(18):1162-73. [PubMed: 3283548]