Venous Thromboembolism Prophylaxis in Post-Acute and Long-Term Care

Given that at least 60% of all venous thromboembolism (VTE) events in medically ill hospitalized patients occur the weeks after hospital discharge, it seems time to support extended VTE prophylaxis high-risk medical with a low bleeding risk who are discharged post-acute care, said Patrick P. Coll, MD, AGSF, CMD, Annual Conference AMDA – The Society for Post-Acute and Long-Term Care Medicine. “If you believe as I do this is something should be addressing your care patients, may want sit down talk patient about risks benefits [with either low-molecular-weight heparin (LMWH) or direct oral anticoagulants (DOACs) rivaroxaban apixaban] somewhere range four weeks,” Dr. professor family medicine director senior health UConn Health. There paucity high-quality evidence guide prevention PALTC setting overall stay illness. But increasingly similar, their clinical condition rather than location determinant whether offered, he said. “Patients quite early, often not changing much between day prior discharge yet historically get then go don’t,” Coll He recommended review published last year Journal Clinical Medicine documents how thromboprophylaxis DOACs particular has potential significantly reduce VTE-related morbidity mortality (J Clin Med 2020;9:1002). American Hematology 2018 guideline management VTE, which since been updated, recommends using LMWH over acutely patients. told Caring meeting does switch from DOAC admission but will discuss advantages switching if continued being facility home. His recommendation strive anticoagulation based on data indicating most post-hospital VTEs within patient’s discharge. also considered long-term acute illnesses remain treatment sent hospital, meeting. International Medical Prevention Registry Venous Thromboembolism (IMPROVE) assessment model useful deciding an individual high need anticoagulation, Factors included scoring system include cancer, immobilization seven days, intensive unit coronary unit, age older 60 years. Other methods elevated D-dimer value (double upper limit normal). factors would contraindicate bronchiectasis/pulmonary cavitation, active gastrointestinal (GI) bleed GI three months, provision dual antiplatelet therapy, Experience greater orthopedic surgery noted minimum 10 14 days those have had total hip knee arthroplasty. evaluated undergone fracture surgery, so “here you’d probably choose use heparin,” Aspirin generally used sole initial agent arthroplasty, noted. In his practice, prescription aspirin warrants call surgeon “to ask another agent,” separate session evaluation, management, deep thrombosis (DVT) pulmonary embolism (PE) nursing home, Angela Sanford, associate Department Medicine, Division Geriatric Saint Louis University School emphasized home residence “one strongest — independent one.” diagnostic study choice suspected depends resident low–moderate having VTE. A test appropriate individuals pretest probability For deemed risk, duplex Doppler best diagnosis DVT. (Computed tomography angiography PE, fatal 5% 10% time.) Wells DVT consideration its criteria, helpful assessing Sanford Its criteria immobility, calf swelling (>3 cm compared other leg), localized tenderness along system, previously documented goal during phase prevent clot extension, embolization, chronic complications [like post-thrombotic syndrome],” “Latest Approaches Difficult Issues” session. imaging can’t obtained less hours suspicion DVT, consider empiric ... until done.” With advent new options, residents good candidates place, she Patients recent cardiopulmonary instability, signs PE (e.g., hypotension, severe dyspnea, tachycardia), thrombocytopenia, poor renal hepatic function among hospitalization. now widely regarded first-line agents systematic meta-analysis year, demonstrated improved efficacy preventing recurrent deaths adults aged 75 vitamin K antagonists, similar outcomes Am Geriatr Soc 2020;68:2021–2026). presentation, pharmacist Jennifer Pruskowski, PharmD, cautioned main challenge capsules cannot broken open crushed dysphasia. swallow,” said, ”I’d suggest back warfarin.” Pruskowski assistant geriatrics pharmacy, research, education Pittsburgh cases months. proximal persistent factor, recurrence lifelong greatest admission, noted, referring (both patients) Olmstead County, MN, 111 3,465 experienced Incidence was inversely associated highest investigators found (Thomb Haemost 2018;118:1316–1328). Asked question-and-answer period there could future recommendations short-term “It interesting see anything comes pipeline.” illness injury admitted settings “you might able make case prophylaxis.” More research needed, stressed. “A large trial looking long overdue.”