Elsevier

Cardiology Clinics

Volume 26, Issue 2, May 2008, Pages 221-234
Cardiology Clinics

Prevention of Venous Thromboembolism in the Geriatric Patient

https://doi.org/10.1016/j.ccl.2007.12.008Get rights and content

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Epidemiology

The rate ratio for VTE among elderly patients is about 10 to 20 times that of young adults [9], making advanced age an important risk factor for VTE. The mechanisms for the age-dependency of VTE are multiple. With aging, there is an increasing prevalence of chronic conditions that contribute to VTE risk, including malignancy, atherosclerosis, heart failure, and immobility. Compared with younger patients, geriatric patients are more often hospitalized for acute illness and for urgent or elective

Risk factor assessment and stratification

Three main factors precipitate venous thrombosis: (1) stasis of blood; (2) damage to vascular structures; and (3) disordered hemostasis (transient or chronic hypercoagulability). These factors have been referred to as “Virchow's triad,” named for the nineteenth century pathologist, Rudolf Virchow, who showed that pulmonary thrombi generally originated in the deep veins of the systemic circulation and were carried to the pulmonary circulation by venous blood flow (although he was not who

Prophylaxis in medical patients

The problem of inadequate and omitted prophylaxis for DVT in medical patients has clearly been shown in the DVT Free Registry. This registry was conducted at 183 United States hospitals and included 5451 patients, both inpatients and outpatients, with ultrasound-confirmed DVT. Approximately 2726 (50%) were inpatients (ie, were diagnosed with DVT in the hospital). Of these only 1147 or 42% had received any prophylaxis before diagnosis. The number of medical inpatients overall who received

Prophylaxis in surgical patients

In addition to early postoperative ambulation, the authors and others recommend pharmacologic thromboprophylaxis for all but the most minor surgical procedures (eg, cataract surgery, tooth extractions, and other minor outpatient procedures) in the elderly. The choice of prophylaxis, however, remains a subject of continued controversy [37]. Mechanical prophylactic measures include graded compression stockings, intermittent pneumatic compression devices, venous foot pumps, and even inferior vena

Timing of prophylaxis in surgical patients

The optimal timing of pharmacologic prophylaxis remains controversial. In Europe, the practice pattern is to initiate LMWH prophylaxis about 10–12 hours before joint replacement surgery, whereas in the United States the LMWH is usually initiated about 12 to 24 hours after surgery. A systematic review that compared LMWH with VKA observed large risk reduction when the LMWH was dosed at half of the usual dose 2 hours before the procedure or 6 to 8 hours after the surgery. In the studies in which

Special considerations with neuroaxial anesthesia

Neuroaxial anesthesia when used concomitantly with anticoagulation increases the risk of epidural hematomas and subsequent spinal cord injury. Detailed guidelines for the use of anticoagulation in the presence of neuroaxial blockade have been developed by the American Society of Regional Anesthesia and Pain medicine [70]. Specific recommendations include waiting 24 hours after a full dose of LMWH, 12 hours after a prophylactic dose of LMWH, and at least 2 hours after removal of the epidural

Special considerations in the elderly

Elderly patients are at higher risk than younger patients for bleeding complications during inpatient and outpatient anticoagulant treatment, and may have concomitant conditions that place them at risk for bleeding complications, such as diabetes, renal impairment, and cardiovascular disease [71], [72], [73], [74]. This should in no way preclude the use of aggressive pharmacologic VTE prophylaxis in elderly persons. To the contrary, the authors advocate careful but aggressive pharmacologic VTE

Inferior vena cava filters

The only purpose of inferior vena cava filters is to prevent thrombi in the leg veins from migrating to the pulmonary circulation. They do not prevent the formation of DVT, and may precipitate lower-extremity thrombosis by impairing venous return from the legs [75]. Furthermore, placement of filters is invasive and requires exposure to intravenous contrast, which may be risky in patients with chronic renal impairment. Finally, there is limited evidence to support the notion that using filters

Duration of prophylaxis

The risk of VTE does not end when the patient is discharged from the hospital. Patients remain at substantial risk for VTE for a few weeks following discharge, and small thrombi that developed while the patient was hospitalized (but remained subclinical) may propagate if anticoagulation is terminated at the time of hospital discharge. Despite the intuitive appeal of continuing anticoagulation following hospital discharge, this practice is rarely used except during inpatient rehabilitation, and

Summary

Elderly patients who are immobilized because of an acute medical illness or surgery have a very high risk of developing VTE. Aggressive pharmacologic prophylaxis is necessary and should be initiated either at admission for a medical condition or shortly after surgery. Aggressive prophylaxis may result in fewer patients developing VTE in the hospital and ultimately lead to fewer patients requiring full-dose anticoagulation for VTE. Mechanical prophylaxis can be used as an adjunct to an

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      This ratio is higher than the ratio in 70–79 year old patients (rate ratio 12.7 and 20.6 respectively) but levels off in patients 90–99 years old [1]. This is usually thought to be paralleled with an increased risk for hemorrhagic complications, leading to the under-use of VTE prophylaxis in the elderly, based more on the fear of a higher risk of bleeding that on an unbiased assessment of benefits and risks [4–6]. We previously reported on the results of CERTIFY which was a randomized clinical trial to demonstrate the non-inferiority of the low molecular weight heparin certoparin at a dose of 3,000 U anti-Xa o.d. versus unfractionated heparin at 5,000 IU t.i.d. in acutely ill, non-surgical patients [7–9].

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    A version of this article originally appeared in Clinics in Geriatric Medicine, volume 22, issue 1.

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