Desafios da profilaxia estendida do tromboembolismo venoso em pacientes clínicos e cirúrgicos
Challenges of extended venous thromboembolism prophylaxis in medical and surgical patients
Maria Chiara Chindamo; Edison Ferreira Paiva; Plinio Resende do Carmo Jr; Ana Thereza Cavalcanti Rocha; Marcos Arêas Marques
Resumo
Palavras-chave
Abstract
Patients hospitalized for acute medical and surgical illnesses are at risk of developing venous thromboembolism (VTE) during hospitalization and after discharge. Extended pharmacological prophylaxis beyond the hospital stay is recommended for patients undergoing surgeries at high risk for VTE and for selected groups of hospitalized medical patients. This practice involves several challenges, from identification of at-risk populations eligible for extended prophylaxis to choice of the most appropriate anticoagulant and definition of the ideal duration of use. This review will present the main VTE risk assessment models for hospitalized medical and surgical patients, the current recommendations for use of extended prophylaxis, and its limitations and benefits.
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References
1 Barkoudah E, Piazza G, Hecht TEH, et al. Extended venous thromboembolism prophylaxis in medically ill patients: an NATF anticoagulation action initiative. Am J Med. 2020;133(Suppl 1):S1-27.
2 Ortel TL. Acquired thrombotic risk factors in the critical care setting. Crit Care Med. 2010;38(2, Suppl):S43-50.
3 Caprini JA. Risk assessment as a guide for the prevention of the many faces of venous thromboembolism. Am J Surg. 2010;199(1, Suppl):S3-10.
4 Spencer FA, Lessard D, Emery C, Reed G, Goldberg RJ. Venous thromboembolism in the outpatient setting. Arch Intern Med. 2007;167(14):1471-5.
5 Hull RD, Merali T, Mills A, Stevenson AL, Liang J. Venous thromboembolism in elderly high-risk medical patients: time course of events and influence of risk factors. Clin Appl Thromb Hemost. 2013;19(4):357-62.
6 Heit JA, Crusan DJ, Ashrani AA, Petterson TM, Bailey KR. Effect of a near universal hospitalization-based prophylaxis regimen on annual number of venous thromboembolism events in the US. Blood. 2017;130(2):109-14.
7 Flanders SA, Greene MT, Grant P, et al. Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study. JAMA Intern Med. 2014;174(10):1577-84.
8 Piazza G, Anderson FA, Ortel TL, et al. Randomized trial of physician alerts for thromboprophylaxis after discharge. Am J Med. 2013;126(5):435-42.
9 Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in medical patients with enoxaparin study group. N Engl J Med. 1999;341(11):793-800.
10 Leizorovicz A, Cohen AT, Turpie AGG, Olsson CG, Vaitkus PT, Goldhaber SZ, et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004;110(7):874-9.
11 Cohen AT, Davidson BL, Gallus AS, et al. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomized placebo-controlled trial. BMJ. 2006;332(7537):325-9.
12 Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):E195S-E226S.
13 NICE: National Institute for Health and Care Excellence. Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism [Internet]. London: NICE; 2019 [citado em 2021 jan 15]. Disponível em:
14 MacDougall K, Spyropoulos AC. Prevention of venous thromboembolism in Acutely Ill medical patients: a New Era. Semin Respir Crit Care Med. 2021;42(2):308-15.
15 Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and non-hospitalized medical patients. Blood Adv. 2018;2(22):3198-225.
16 Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):E278S-E325S.
17 Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):E227S-277S.
18 Key NS, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update. J Clin Oncol. 2020;38(5):496-520.
19 Barbar S, Noventa F, Rossetto V, et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost. 2010;8(11):2450-7.
20 Spyropoulos AC, Anderson FA Jr, Fitzgerald G, et al. Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest. 2011;140(3):706-14.
21 Chopard P, Spirk D, Bounameaux H. Identifying acutely ill medical patients requiring thromboprophylaxis. J Thromb Haemost. 2006;4(4):915-6.
22 Gibson CM, Spyropoulos AC, Cohen AT, et al. The IMPROVEDD VTE risk score: incorporation of D-Dimer into the IMPROVE score to improve venous thromboembolism risk stratification. TH Open. 2017;1(1):e56-65.
23 Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51(2-3):70-8.
24 Rogers SO Jr, Kilaru RK, Hosokawa P, Henderson WG, Zinner MJ, Khuri SF. Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1211-21.
25 Rocha AT, Paiva EF, Lichtenstein A, Milani R Jr, Cavalheiro CF, Maffei FH. Risk-assessment algorithm and recommendations for venous thromboembolism prophylaxis in medical patients. Vasc Health Risk Manag. 2007;3(4):533-53. PMid:17969384.
26 Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3, Suppl):338S-400S.
27 Decousus H, Tapson VF, Bergmann JF, et al. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest. 2011;139(1):69-79.
28 Spyropoulos AC, Raskob GE. New paradigms in venous thromboprophylaxis of medically ill patients. Thromb Haemost. 2017;117(9):1662-70.
29 Nicolaides AN, Fareed J, Kakkar AK, et al. Prevention and treatment of venous thromboembolism – International Consensus Statement. Int Angiol. 2013;32(2):111-260. PMid:24402349.
30 Hull RD, Schellong SM, Tapson VF, et al. EXCLAIM (Extended Prophylaxis for Venous Thromboembolism in Acutely Ill Medical Patients with Prolonged Immobilization) study. Extended-duration venous thromboembolism prophylaxis in acutely ill medical patients with recently reduced mobility: a randomized trial. Ann Intern Med. 2010;153(1):8-18.
31 Goldhaber SZ, Leizorovicz A, Kakkar AK, et al. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med. 2011;365(23):2167-77.
32 Cohen AT, Spiro TE, Büller HR, et al. Extended-duration rivaroxaban thromboprophylaxis in acutely ill medical patients: MAGELLAN study protocol. J Thromb Thrombolysis. 2011;31(4):407-16.
33 Cohen AT, Harrington RA, Goldhaber SZ, et al. Extended thromboprophylaxis with betrixaban in acutely Ill medical patients. N Engl J Med. 2016;375(6):534-44.
34 Raskob GE, Spyropoulos AC, Zrubek J, et al. The MARINER trial of rivaroxaban after hospital discharge for medical patients at high risk of VTE. Thromb Haemost. 2016;115(6):1240-8.
35 Goldhaber SZ. Thromboembolism prophylaxis for patients discharged from the hospital: easier said than done. J Am Coll Cardiol. 2020;75(25):3148-50.
36 Spyropoulos AC, Ageno W, Albers GW, et al. Rivaroxaban for thromboprophylaxis after hospitalization for medical illness. N Engl J Med. 2018;379(12):1118-27.
37 Spyropoulos AC, Lipardi C, Xu J, et al. Improved benefit risk profile of rivaroxaban in a subpopulation of the MAGELLAN study. Clin Appl Thromb Hemost. 2019;25:1076029619886022.
38 Bajaj NS, Vaduganathan M, Qamar A, et al. Extended prophylaxis for venous thromboembolism after hospitalization for medical illness: a trial sequential and cumulative meta-analysis. PLoS Med. 2019;16(4):e1002797.
39 Cassidy MR, Rosenkranz P, McAneny D. Reducing postoperative venous thromboembolism complications with a standardized risk-stratified prophylaxis protocol and mobilization program. J Am Coll Surg. 2014;218(6):1095-104.
40 Hanh BM, Cuong LQ, Son NT, et al. Determination of risk factors for venous thromboembolism by an adapted Caprini scoring system in surgical patients. J Pers Med. 2019;9(3):36.
41 Flevas DA, Megaloikonomos PD, Dimopoulos L, Mitsiokapa E, Koulouvaris P, Mavrogenis AF. Thromboembolism prophylaxis in orthopedics: an update. EFORT Open Rev. 2018;3(4):136-48.
42 Heijkoop B, Parker N, Kiroff G, Spernat D. Effectiveness and safety of inpatient versus extended venous thromboembolism (VTE) prophylaxis with heparin following major pelvic surgery for malignancy: protocol for a systematic review. Syst Rev. 2019;8(1):249.
43 Laureano M, Ebraheem M, Crowther M. Extended venous thromboembolism prophylaxis after abdominopelvic cancer surgery: a retrospective review. Curr Oncol. 2019;26(1):e106-10.
Submitted date:
10/31/2021
Accepted date:
04/06/2022