sergio fusco, md · extreme deformity to the leg, or unusual leg shape or size preventing correct...
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How to prevent thrombotic diseases?
Sergio Fusco, MD
Geriatric Division - Department of Internal Medicine
Ospedale Dell'Angelo - Venice, Italy
CONFLICT OF INTEREST DISCLOSURE
I have no potential conflict of interest to report
EPIDEMIOLOGY
AGEING AND THROMBOTIC RISK
SIMPLE RISK STRATIFICATION
ANTITHROMBOTIC THERAPY
VENOUS AND ARTERIAL THROMBOSIS: IS THERE A LINK?
OUTLINE OUTLINE
Is it worth offering thrombotic prevention
to the elderly?
Epidemiology of thrombotic diseases
European Heart Journal (2016) 37, 3232–3245
Risk factors for thrombotic diseases
Atherothrombosis
VTE-PE
Heart failure.
Antithrombotic Therapy and Prevention of Thrombosis. Chest. 2016.
Diagnosis and Treatment of Peripheral Arterial Diseases 2017
ESC Guidelines
Thrombotic
events
Eur Heart J. 2015 Dec 7;36(46):3238-49.
Aging Clin Exp Res (2017) 29:483–490
ARE GERIATRIC SYNDROMES ASSOCIATED WITH RELUCTANCE TO INITIATE ORAL ANTICOAGULATION THERAPY IN ELDERLY ADULTS ?
Patients centred care for Older Adults
Prog Cardiovasc Dis. 2014 ; 57(2): 197–203.
Rapid Screening and Risk assessment tool
PADUA SCORE
D-DIMER ?
ANKLE-BRACHIAL INDEX
CHA₂DS₂-VASc - HAS-BLED
CLINICAL FRAILTY SCALE
Antithrombotic Therapy and Prevention of Thrombosis. Chest. 2016.
Diagnosis and Treatment of Peripheral Arterial Diseases 2017
ESC Guidelines
PADUA SCORE FOR RISK STRATIFICATION IN VTE
Antithrombotic Therapy and Prevention of Thrombosis. Chest. 2016.
VKA/NOAC
Use an age-adjusted D-dimer cutoff (patient’s age in years × 10 mcg/L)
for patients over age 50 years when evaluating for venous
thromboembolism (VTE)
Conventional D-dimer cutoff value for VTE (500 mcg/L)
BMJ. 2013;346:f2492.
D-Dimer in VTE
Arch Intern Med. 2013; 163:1939-1942
Ankle-Brachial Index
mean age 80 – 4 year follow up
HAS-BLED
CHA₂DS₂-VASc
≥2 High risk
≥ 3 High risk
Circulation 2013;125:2298–2307.
Journal of Pharmacy Practice and Research (2015)
Proposed algorithm for the management of elderly patients
requiring anticoagulation
Smoking cessation
•Quitting at older age still
↓ Mortality rates
↓ CV events
↓ New or recurrent stroke ↑ Quality of life
Mozaffarian, Circulation 131:e29, 2015
Fleg, Circulation 128:2422, 2013
Enga KF, J Thromb Haemost 2012
VTE ?
Physical Activity
Moderate-intensity aerobic (endurance) physical activity
minimum of 30 min on five days each week vigorous-intensity aerobic activity for a minimum of 20 min on three days each week. I (A)
Nelson, Circulation 116:1094, 2007
↓ Mortality rates ↓ CV events ↓ New or recurrent stroke
↑ Quality of life
↓ VTE
Asked the secret of his long life :
"Cuban cigars, Armenian brandy and no sport!"
Winston Churchill died at 91 years
Systematic review of clinical practice
guidelines recommendations about
primary cardiovascular disease prevention
for older adults
BMC Family Practice (2016) 16:104
Therapy for Peripheral Artery Disease
European Heart Journal (2016) 36, 3238–3249
Mean age 66 ± 6
ANTIPLATELET IN VTE/PE
In patients with an unprovoked proximal DVT or PE who are stopping anticoagulant therapy and do not have
a contraindication to aspirin, we suggest aspirin over no aspirin to prevent recurrent VTE
(Grade 2B).
Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert
Panel Report. Chest 2016
European Heart Journal (2016) 36, 3238–3249
Antithrombotic Therapy for VTE Disease:
CHEST Guideline and Expert
Panel Report. Chest 2016
4.2.2. In patients with solid tumors who have additional risk factors for VTE and who are at low risk of bleeding, we suggest prophylactic dose LMWH or LDUH over no prophylaxis (Grade 2B)
OACs in elderly
Impact of proteinuria and glomerular filtration rate on risk of thromboembolism in atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study.
Antithrombotic Therapy and Prevention of
Thrombosis. Chest. 2012.
Phlebology 2011;26:107–113
contraindications for mechanical prophylaxis
Suspected or proven peripheral arterial disease
Peripheral neuropathy or other causes of sensory impairment
Fragile skin, dermatitis, gangrene, or recent skin graft
Cardiac failure or severe edema
Allergy to material or inability to fit stocking
Extreme deformity to the leg, or unusual leg shape or size preventing correct fit
Venous and Arterial Thrombosis: Is There a Link?
Adv Exp Med Biol. 2017;906:273-28
Mean age 62 ± 13
Mean age 70 ± 8
N Engl J Med. 2017 Aug 27.
Rivaroxaban plus aspirin had better cardiovascular outcomes and
more major bleeding events than those assigned to aspirin alone.
Rivaroxaban alone did not result in better cardiovascular outcomes
than aspirin alone and resulted in more major bleeding events.
Statins and primary prevention
of venous thromboembolism: a
systematic review and meta-
analysis
No OACs users
OACs users
Patient Preference and Adherence 2015:9 133–138
Mean age 65 ± 10
Take home message
Patient-centred approach:
INDIVIDUALIZE!
Thank you for your attention
“The good physician treats the disease, the great physician treats
the patient who has the disease” Sir William Osler
HAS-BLED
CHA₂DS₂-VASc
≥2 High risk
≥ 3 High risk
CHEST 2013; 143(1):179–184
J Am Coll Cardiol. 2013 Dec 10;62(23):2199-204.
Mean age 76 ± 4
Antithrombotic Therapy for VTE Disease:
CHEST Guideline . Chest 2016
4.2.1 In patients with cancer who have no additional risk factors for VTE, we suggest against routine prophylaxis with LMWH or LDUH (Grade 2B) and recommend against the prophylactic use of VKAs (Grade 1B)
4.2.2. In patients with solid tumors who have additional risk factors for VTE and who are at low risk of bleeding, we suggest prophylactic dose LMWH or LDUH over no prophylaxis (Grade 2B)
Thromboprophylaxis medical patients with cancer
BLEEDING VS THROMBOTIC RISK
Risk factors for thrombotic diseases
Clotting disorders (Thrombophilia)
Personal or family history of DVT
Obesity/metabolic syndrome
Cigarette smoking
Heart failure. Atrial Fibrillation
Cancer. Being restricted to bed rest.
Surgery
European Heart Journal (2015) 36, 3238–3249
Antithrombotic Therapy and Prevention of
Thrombosis. Chest. 2012.
Phlebology 2011;26:107–113
contraindications for mechanical
prophylaxis Suspected or proven peripheral arterial disease
Peripheral neuropathy or other causes of sensory impairment
Fragile skin, dermatitis, gangrene, or recent skin graft
Cardiac failure or severe edema
Allergy to material or inability to fit stocking
Extreme deformity to the leg, or unusual leg shape or size preventing correct fit
Advantages of LMWH over UFH
Antithrombotic Therapy for VTE Disease:
CHEST Guideline and Expert
Panel Report. Chest 2016