Patients with iliac deep vein thrombosis (DVT) have a poor prognosis and high incidence of postthrombotic syndrome (PTS). We evaluated the effect of low-molecular-weight heparin (LMWH; tinzaparin) versus usual care (tinzaparin plus warfarin for ≥12 weeks at home) in the development of PTS according to DVT location (iliac/noniliac) by retrospective analysis of the Home-LITE cohort (480 patients with proximal DVT). Patients with iliac DVT had an overall odds ratio of 0.53 (95% confidence interval [CI] 0.33, 0.83; P = .0079) for PTS (including ulcer data) in favor of tinzaparin. Patients with noniliac DVT had a similar odds ratio (0.79 [95% CI 0.67, 0.93], P = .0046) to that reported in the overall Home-LITE population (0.76 [95% CI 0.66, 0.89], P = .0004; including ulcer data), both in favor of tinzaparin. Long-term LMWH may be a suitable alternative for the prevention of PTS in patients with iliac DVT who are unlikely to undergo invasive thrombolysis.
Venous thromboembolism (VTE) causes significant morbidity and mortality in hospitalized medical populations; however, medical patients do not currently receive thromboprophylaxis beyond their hospital stay. We reviewed the real-life occurrence of VTE-related care for 100 days post-hospitalization in Calgary, Canada. Using medical visit records with a unique patient identifier number applied throughout the city's hospitals, 989 high-risk patients were selected for review. Almost three-quarters of the elderly patients received appropriate prophylaxis while in hospital, and only 2% received prophylaxis on discharge. Over the 100-day follow-up, 21% of the patients presented with clinically suspected VTE, of which 3.8% had confirmed VTE. Patients with multiple risk factors (≥ 3) had the highest frequency of confirmed VTE (≥ 6.1%). This study suggests that the actual rate of VTE-related follow-up care in patients post-hospitalization is high in the first 100 days, particularly among those who have multiple risk factors, warranting consideration of extended thromboprophylaxis in this population.
Results of our Canadian retrospective study clearly demonstrate that SREs occur in cancer patients and each SRE is associated with considerable institutional consumption of health care resources.
4182 Background: Venous thromboembolism (VTE) prophylaxis has been identified in clinical guidelines as an appropriate strategy for high-risk medical inpatients as it results in reduced VTE events and reduced mortality. However, real life data regarding the timing of VTE events and the relationship between risk factors and VTE in this population is lacking. Further knowledge of the time course of recurrence and influence of risk factors in actual practice may help clinicians determine strategies regarding the frequency of clinical surveillance and the appropriate duration of treatment. Objective: To document the time course of symptomatic VTE events in high-risk medical patients in every day clinical practice and to relate the frequency of risk factors to the likelihood of VTE development. Methods: Charts from 1134 consecutive high-risk medical patients who were hospitalized in the Calgary region and discharged between January and February 2008 were abstracted using standardized case record forms. All hospitals in the region use a common unique patient identifier number, thus enabling the tracking of subsequent patient visits to the emergency room, inpatient admissions or outpatient visits occurring anywhere in the region's acute care system. Any identified patient was followed for a subsequent visit related to VTE. High-risk medical patients were defined as age > 60 years and having at least one of the following risk factors: malignancy, respiratory illness, neurological illness, inflammatory bowel disease, previous VTE, acute infection or heart failure. Records were excluded if the patient was admitted for VTE or to rule out VTE, receiving chronic anticoagulation, experiencing acute coronary syndromes, had a hospital stay ≤ 3 days, was a surgical or orthopedic patient, or pregnant. Data was collected on the timing of VTE related events for up to 100 days post discharge. Results: A total of 989 patients met criteria over the review period. Seventy-four percent (732/989) of all patients received mechanical or pharmacological prophylaxis in hospital. Only 2% (95% CI, 1.6% to 3.6%) of all patients received anticoagulation prophylaxis at discharge. Twenty-one percent of patients in the population studied were identified as requiring medical care for symptoms associated with VTE. Confirmation of VTE by diagnostic testing occurred in 4% (95% CI, 2.7% to 5.2%) while the other 17% (95% CI, 15.0% to 19.8%) had diagnostic tests that were negative or inconclusive. The mean length of time to confirmed first VTE event was 33.5 days. Eighty percent of first events occurred by day 57 and 90% of first VTE events occurred by day 69 post hospital admission. Patients with more than 2 risk factors had a rate of confirmed symptomatic VTE events of 6.1%, increasing to 8.7% for those with more than 3 risk factors while only 2.9% of patients with 2 or less risk factors developed a confirmed VTE. (p=0.015) Conclusion: This study demonstrates that in a real life setting, 6% of those hospitalized medical patients with more than 2 risk factors would develop symptomatic VTE event confirmed by diagnostic testing, increasing to 8.7% for those with more than 3 pre-specified risk factors. The mean time to first VTE event of 33.5 days along with 80% of VTE events occurring by day 57 suggest that more consideration needs to be given to prolonged VTE prophylaxis in this high risk population. The frequency and timing of the VTE events coupled with the results of the EXCLAIM study suggest that this high risk population may benefit from prolonged thromboprophylaxis. Disclosures: Hull: LEO Pharma: Consultancy; sanofi-aventis: Consultancy; Pfizer: Consultancy; Portola: Consultancy; Merck: Consultancy; Bayer: Consultancy; Johnson & Johnson: Consultancy. Merali:LEO Pharma: Consultancy; Genzyme: Consultancy; Boehringer Ingelheim: Consultancy; Abbott: Consultancy; BMS: Consultancy; Pfizer: Consultancy; Amgen: Consultancy; sanofi-aventis: Consultancy; Nycomed: Consultancy; Otsuka: Consultancy. Mills:Pfizer: Consultancy; sanofi-aventis: Research Funding. Komari:sanofi-aventis: Employment.
82 Background: Current guidelines recommend that venous thromboembolism (VTE) prophylaxis should be given to high-risk medical inpatients based on evidence of reduced VTE events and reduced mortality. However, current guidelines do not specify the appropriate length of VTE prophylaxis in this population, especially after discharge. The EXCLAIM study showed a 90 day VTE incidence of 4.2% in those patients who received enoxaparin for 10 days in the hospital, with 1.1% being symptomatic VTE. However, real world data is needed to understand the risk of VTE for this patient population after they are discharged from acute care and the prevalence of symptomatic VTE. Objective: To determine the incidence of late VTE events in high-risk medical patients in every day clinical practice and in the absence of systematic screening for VTE. Methods: Charts from 1134 consecutive high-risk medical patients who were hospitalized in the Calgary region and discharged between January and February 2008 were abstracted using standardized case record forms. All hospitals in the region use a common unique patient identifier number, thus enabling the tracking of subsequent patient visits to the emergency room, inpatient admissions or outpatient visits occurring anywhere in the region's acute care system. High-risk medical patients were defined as age > 60 years and having at least one of the following risk factors: malignancy, respiratory illness, neurological illness, inflammatory bowel disease, previous VTE, acute infection or heart failure. Records excluded were those of patients who were admitted for VTE or to rule out VTE, those receiving chronic anticoagulation, those with acute coronary syndromes, patients whose hospital stay was ≤ 3 days, surgical patients, orthopedic patients, and pregnant patients. Data was collected on patient risk factors, thromboprophylaxis received in hospital and at discharge, VTE related events for up to 100 days post discharge. Results: 989 patients met criteria over the review period. 74% (733/989) of all patients received mechanical or pharmacological prophylaxis in hospital: 28% (281) received unfractionated heparin, 28% (281) received LMWH and 4% (40) received mechanical prophylaxis and 13% (131) received a combination of modalities. The prevailing medical risk factors were malignancy (46%), respiratory illness (44%), neurological illness (15%), inflammatory bowel disease (6%), previous VTE (4%), acute infection (17%), heart failure (9%). Only 2% (95% CI, 1.6% to 3.6%) of all patients received anticoagulation prophylaxis at discharge. Twenty one percent of patients in the population studied received medical care for symptoms associated with VTE. Of these, 4% (95% CI, 2.7% to 5.2%) had confirmation of VTE by diagnostic testing while the other 17% (95% CI, 15.0% to 19.8%) had diagnostic tests that were negative or inconclusive. The mean length of time to confirmed VTE was 34.1 days post hospital admission. Conclusion: This study demonstrates that in a real life setting 21% of high-risk patients would develop symptoms of VTE requiring a health professional's attention with 4% having VTE confirmed by diagnostic testing. These events occurred despite prophylaxis in hospital and suggest that the risk of symptomatic VTE could be higher in real life compared to that reported in randomized clinical trials where patients are screened for asymptomatic VTE. These findings show that the prevalence of VTE warrants consideration of extended thromboprophylaxis in selected high-risk medical patients, as the benefits of extended prophylactic therapy may outweigh the risks in this population. Disclosures: Hull: sanofi-aventis Canada Inc: Consultancy, Research Funding. Brocklebank:sanofi-aventis Canada Inc: Honoraria; Bayer, Inc.: Honoraria; Leo Pharma: Honoraria. Komari:sanofi-aventis Canada Inc: Employment. Merali:sanofi-aventis Canada Inc: Consultancy, Research Funding.
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