Arman Qamar, MDVascular Medicine SectionCardiovascular DivisionBrigham and Women’s HospitalHarvard Medical School

www.brighamandwomens.org/heart

Extended Thromboprophylaxisin Medically Ill Patients: TheoryOr Real Concern?

Disclosures•None

Agenda

• Discuss real-world presentations of VTEin medically ill patients

Case 1

• 73 yoM with history of OSA, COPD, & strokepresented with acute onset dyspnea

• He is s/p hospitalization for COPD 2 wks ago

• HR 130 BP 90/60 RR 30 O2 sat 90% on RA

CT Angiogram showed Saddle PE

RV

• sPESI ≥ 1

• RV/LV ratio 1.5

• Troponin T 0.52 µg/L

• NT-proBNP 1800 pg/mL

• Echo- +RV strain

Risk Stratification: High

Rx: Surgical Embolectomy

Q. Was this Preventable?

A.YesB.No

Case 2

• 65 yoF with history of hypertension, T2DM & HFpEF p/w acute onset pleuritic chest pain

• She is s/p hospitalization for CHF 3 wks ago

• HR 90 bpm BP 120/70 O2 sat 93% on RA

CT Angiogram: Bilateral PE

Risk Stratification: Intermediate Low

• sPESI ≥ 1• RV/LV ratio 1.3

• Troponin T <0.01 µg/L• NT-proBNP <300 pg/mL• Echo- no RV strain

• Enoxaparin (1mg/kg BID) till resolution of chest discomfort

• Discharged on a NOAC

• Normal hypercoagulable work up

Clinical Management

Q. Was this Preventable?

A.YesB.No

Case 3• 60 yoF with history of SLE and chronic back pain p/w severe right lower extremity pain & swelling

• She is s/p hospitalization for pneumonia2 weeks ago

• HR 70 BP 130/70 RR 12 O2 sat 98 on RA

Duplex US: Common Femoral Vein DVT

Reflux

Clinical Management

• Initial treatment with unfractionated heparin

• Underwent catheter directed thrombolysis (CDT)for severe symptoms

• Discharged on a NOAC after 4 days of hospital stay

Q. Was this Preventable?

A.YesB.No

Summary

• Despite in-hospital thromboprophylaxis, 75% of VTE’s occur after discharge

• ~ 50% VTE’s occur in first 6 weeks of discharge

• Currently, no anticoagulant is approved for extended VTE prophylaxis in medically ill patients

Summary

• Betrixaban offers safe and effective extendedthromboprophylaxis in medically ill patients

(NEJM 2016; 375: 534-544)