Risk assessment and prevention of venous thromboembolism among hospitalized patients: Results of the regional multicenter study

Introduction. Venous thromboembolism (VTE) is a major public health issue that is frequently underestimated. The primary objective of this multicenter study was to identify patients at risk for VTE, and to define the rate of patients receiving appropriate prophylaxis in the regions of Kazakhstan.

Materials and methods. Standardized case report forms were filled by trained medical doctors on one predefined day in selected hospitals. Data were analyzed by independent biostatistician. Risk of VTE was categorized according to Caprini score which was recommended by 2004 American College of Chest Physicians (ACCP) guidelines.

Results. 432 patients from 4 regions of Kazakhstan; 169 (39.10%) medical patients and 263 (60.9%) surgical patients were eligible for the study. Patients were at low (10%), moderate (19.2%), high (33.6%) and very high risk (37.3%) for VTE. The main risk factors (RF) of VTE among hospitalized patients were heart failure (HF), obesity, prolonged bed rest, and the presence of acute non-infective inflammation. From total number of hospitalized patients with RF with indications to VTE prophylaxis, 58.1% of patients received pharmacological prophylaxis and only 24.6% of them received VTE prophylaxis according ACCP. On the other hand, 23.5% patients with the risk of VTE but who were not eligible for it received pharmacological prophylaxis.

Conclusion. These results indicate the existence of inconsistency between eligibility for VTE prophylaxis on one hand and its application in practice (p < 0.001). Risk factors for VTE and eligibility for VTE prophylaxis are common, but VTE prophylaxis and guidelines application are low.

1. Konstantinides S.V., Meyer G., Becattini C., Bueno H., Geersing G.-J., Harjola V.-P. et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Heart J. 2020;41(441):543– 603. https://doi.org/10.1093/eurheartj/ehz405 https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehz405#supplementary-data.

2. Raskob G.E., Angchaisuksiri P., Blanco A.N., Buller H., Gallus A., Hunt B.J. et al. Thrombosis: a major contributor to global disease burden. Arterioscler Thromb Vasc Biol. 2014;34(11):2363–2371. https://doi.org/10.1161/ATVBAHA.114.304488.

3. Wendelboe A.M., Raskob G.E. Global Burden of Thrombosis: Epidemiologic Aspects. Circ Res. 2016;118(9):1340–1347. https://doi.org/10.1161/CIRCRESAHA.115.306841.

4. de Miguel-Diez J., Jimenez-Garcia R., Jimenez D., Monreal M., Guijarro R., Otero R. et al. Trends in hospital admissions for pulmonary embolism in Spain from 2002 to 2011. Eur Respir J. 2014;44(4):942–950. https://doi.org/10.1183/09031936.00194213.

5. Heit J.A., Mohr D.N., Silverstein M.D., Petterson T.M., O’Fallon W.M., Melton L.J. Predictors of Recurrence After Deep Vein Thrombosis and Pulmonary Embolism: A Population-Based Cohort Study. Arch Intern Med. 2000;160(6):761–768. https://doi.org/10.1001/archinte.160.6.761.

6. Geerts W.H., Pineo G.F., Heit J.A., Bergqvist D., Lassen M.L., Colwell C.W., Ray J.G. Prevention of venous thromboembolism: the Seventh ACCP Conference on Anti-thrombotic and Thrombolytic Therapy. Chest. 2004;126(3):338S-400S. https://doi.org/10.1378/chest.126.3_suppl.338s.

7. Cohen A.T., Agnelli G., Anderson F.A., Arcelus J.I., Bergqvist D., Brecht J.G. et al. VTE Impact Assessment Group in Europe (VITAE) et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007;98(4):756–764. Available at: https://pubmed.ncbi.nlm.nih.gov/17938798.

8. Clagett G.P., Anderson F.A. Jr., Geerts W., Heit J.A., Knudson M., Lieberman J.R. et al. Prevention of venous thromboembolism. Chest. 1998;114(5):531S-560S. https://doi.org/10.1378/chest.114.5_supplement.531s.

9. Anderson F.A. Jr, Wheeler H.B. Venous thromboembolism. Risk factors and prophylaxis. Clin Chest Med. 1995;16(2):235–251. Available at: https://pubmed.ncbi.nlm.nih.gov/7656537.

10. Arcelus J.I., Monreal M., Caprini J.A., Guisado J.G., Soto M.J., Núñez M.J., the RIETE Investigators. Clinical presentation and time-course of postoperative venous thromboembolism: results from the RIETE Registry. Thromb Haemost. 2008;99(3):546–551. https://doi.org/10.1160/th07-10-0611.

11. Spencer F.A., Lessard D., Emery C., Reed G., Goldberg R.J. Venous thromboembolism in the outpatient setting. Arch Intern Med. 2007;167(14):1471– 1475. https://doi.org/10.1001/archinte.167.14.1471.

12. Geerts W.H., Heit J.A., Clagett G.P., Pineo G.F., Colwell C.W., Anderson F.A. Jr, Wheeler HB. Prevention of venous thromboembolism. Chest. 2001;119(1 Suppl):132S-175S. https://doi.org/10.1378/chest.119.1_suppl.132s.

13. Hirsh J., Guyatt G., Albers G.W., Harrington R., Schünemann H.J. American College of Chest Physician Antithrombotic and thrombolytic therapy: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines (8th ed.). Chest. 2008;133(6):110S-112S. https://doi.org/10.1378/chest.08-0652.

14. Nicolaides A., Fareed J., Kakkar A.K., Comerota A.J., Goldhaber S.Z., Hull R. et al. Prevention and Treatment of Venous Thromboembolism: International Consensus Statement (Guidelines according to scientific evidence). Clinical and Applied Thrombosis/ Hemostasis. 2013;19(2):116–118. https://doi.org/10.1177/1076029612474840.

15. Rogers F., Cipolle M., Velmahos G., Rozycki G., Luchette F.A. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group. J Trauma. 2002;53(1):142–164. https://doi.org/10.1097/00005373-200207000-00032.

16. Skeik N., Westergard E. Recommendations for VTE Prophylaxis in Medically Ill Patients. Ann Vasc Dis. 2020;13(1):38–44. https://doi.org/10.3400%2Favd.ra.19-00115.

17. Tooher R., Middleton P., Pham C., Fitridge R., Rowe S., Babidge W., Maddern G. A systematic review of strategies to improve prophylaxis for venous thromboembo-lism in hospitals. Ann Surg. 2005;241(3):397–405. https://doi.org/10.1097/01.sla.0000154120.96169.99.

18. Cohen A., Tapson V., Bergmann J.F., Goldhaber S.Z., Kakkar A.K., Bruno Deslandes B. et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational crosssectional study. Lancet. 2008;371(9610):387–394. https://doi.org/10.1016/s0140-6736(08)60202-0.

19. Taher A., Aoun J., Salameh P. The AVAIL ME study: a multinational survey of VTE risk and prophylaxis J Thromb Thrombolysis. 2011;31(1):47–56. https://doi.org/10.1007/s11239-010-0492-2.

20. Geerts W.H., Selby R. Prevention of venous thromboembolism in the ICU. Chest. 2003;124(6):357S-363S. https://doi.org/10.1378/chest.124.6_suppl.357s.

21. Сaprini J.A. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51(2-3):70–78. https://doi.org/10.1016/j.disamonth.2005.02.003.

22. Amin A., Stemkowski S., Lin J., Yang G.J. Thromboprophylaxis rates in US medical centers: success or failure? Thromb Haemost. 2007;5(8):1610–1616. https://doi.org/10.1111/j.1538-7836.2007.02650.x.

23. Awidi A., Obeidat N., Magablah A., Bsoul N. Risk stratification for venous thromboembolism in hospitalized patients in a developing country: a prospect ive study. J Thromb Thrombolysis. 2009;28(3):309–313. https://doi.org/10.1007/s11239-008-0291-1.

24. Goldhaber S.Z., Tapson V.F. A prospective registry of 5451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004;93(2):259–262. https://doi.org/10.1016/j.amjcard.2003.09.057.

25. Henke P.K., Kahn S.R., Pannucci C.J., Secemksy E.A., Evans N.S., Khorana A.A. et al. Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association. Circulation. 2020;141(24):e914-e931. https://doi.org/10.1161/cir.0000000000000769.

26. Bergmann J.F., Kher A. Venous thromboembolism in the medically ill patient: a call to action. A Int J Clin Pract. 2005;59(5):555–561. https://doi.org/10.1111/j.1368-5031.2005.00529.x.

27. Sandler D.A., Martin J.F. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med. 1989;82(4):203–205. https://doi.org/10.1177/014107688908200407.

28. Chuang L.H., Gumbs P., Hout B., Agnelli G., Kroep S., Monreal M. et al. Health-related quality of life and mortality in patients with pulmonary embolism: a prospective cohort study in seven European countries. Qual Life Res. 2019;28(8):2111–2124. https://doi.org/10.1007/s11136-019-02175-z.

29. Carvalho Bricola S.A., Paiva E.F., Lichtenstein A., Gianini R.J., Duarte J.G., Shinjo S.K. et al. Fatal pulmonary embolism in hospitalized patients: a large autopsy-based matched case-control study. Clinics (Sao Paulo). 2013;68(5):679–685. https://doi.org/10.6061/clinics/2013(05)16.

30. Tapson V.F., Decousus H., Pini M., Chong B.H., Froehlich J.B., Monreal M. et al. Venous throm-boembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest. 2007;132(3):936–945. https://doi.org/10.1378/chest.06-2993.

31. Deheinzelin D., Braga A.L., Martins L.C., Martins M.A., Hernandez A., Yoshida W.B. et al., the Trombo Risc Investigators. Incorrect use of thromboprophylaxis for venous thromboembolism in medical and surgical patients: results of a multicentric, observational and cross-sectional study in Brazil. J Thromb Haemost. 2006;4(6):1266–1270. https://doi.org/10.1111/j.1538-7836.2006.01981.x.

32. Benberin V.V., Tanbaeva G.Z., Sugraliev A.B., Aktayeva S.S., Rainhold N.A. Thrombosis risk assessment as a guide to quality patient care. Vestnik meditsinskogo tsentra upravleniya delami Prezidenta Respubliki Kazakhstan = Medical Bulletin Center for Administration of the President of the Republic Kazakhstan. 2017;(1):90–99. (In Russ.) Available at: http://www.mcudprk.kz/upload/heraldmed/vestnik-1-2017.pdf.

33. Baroletti S., Munz K., Sonis J., Fanikos J., Fiumara K., Paterno M., Goldhaber S.Z. Electronic alerts for hospitalized high-VTE risk patients not receiving prophylaxis: a cohort study. J Thromb Thrombolysis. 2008;25(2):146–150. https://doi.org/10.1007/s11239-007-0081-1.

34. Nicholson M., Chan N., Bhagirath V., Ginsberg J. Prevention of Venous Thromboembolism in 2020 and Beyond. J Clin Med. 2020;9(8):2467. https://doi.org/10.3390/jcm9082467.