Venous Thromboembolism (vte)

Epidemiology (CDC, Beckman, Am J Prev Med, 2010) ●Includes deep venous thrombosis (DVT) and pulmonary embolism (PE) and affects more than 300,000 to 600,000 patients annually with 60,000-100,000 deaths (some estimates as high as 300,000); AHRQ estimates 2 million affected per year and 200,000 deaths; 50% develop during admission or within 30 days after hospitalization ●PE remains most common preventable cause of in-hospital mortality and a leading cause of maternal mortality in the U.S.; fatal PE is the 3rd most common cause of death in trauma patients who survive the first 24 hours ●Incidence of 1-2/1000 of general population; as high as 1/100 in those >80 years of age; likelihood of developing a VTE doubles with each decade of life after 40 ●2/3rd of VTE present as DVT, 1/3rd PE (+/DVT); 50% are idiopathic; 60% are occult; sudden death is the first symptom in 25% of people who have a PE; in fatal PE, 2/3rd die within 1 hour; 10 to 30% of people will die within one month of diagnosis; 1/3rd of people with DVT/PE will have a recurrence within 10 years ◊3 month mortality 17% increased to 31% to 52% if associated with hemodyamic instability; PE contributed to cause of death in 63-91% (MAPPET and ICOPER studies) ●Outcome of PE dependent on size of embolus and patient’s underlying cardiopulmonary status ●Among people who have had a DVT, 1/3 develop post-thrombotic syndrome ●Approximately 5 to 8 percent of the U.S. population has one of several genetic risk factors in which a genetic defect can be identified that increases the risk for thrombosis ●20% of calf DVTs propagate to thigh; 50% of proximal DVTs embolize to the lungs; 90% of PEs come from lower extremity DVTs) ●Autopsy studies in trauma patients – 65% incidence of DVT and 16% PE (Sevitt, BMJ, 1961) ●Autopsy studies in critically ill patients find that PE was cause of death in 45% of patients and was not suspected ●Incidence in the absence of (appropriate) prophylaxis ◊General surgery – 20-30% incidence of DVT, proximal 7%, fatal PE 0.1 to 0.8% (18% if untreated) ◊Trauma – 58% incidence of DVT, proximal DVT 18%, PE in 2-22%, fatal PE 1% (Geerts, NEJM, 1994) ◊Fractured hip – 50% incidence of DVT, proximal DVT 20%, 4 to 7% risk of fatal PE ◊SCI – 90% incidence of DVT ◊Medical ▪DVT FREE Registry Study – 50% of inpatients who developed VTE were nonsurgical ▪ 17-34% MI, 20-40% CHF, 11-75% stroke, 25-42% MICU ●Numerous initiatives to increase prophylaxis ◊Thrombophylaxis not being offered (or not appropriate method) despite numerous guidelines – only 60% of at-risk surgical patients received American College of Chest Physicians (ACCP)-recommended prophylaxis (ENDORSE Study) ◊Agency for Health Care Research and Quality (AHRQ) #1 strategy to improve patient safety in hospitals is prevention of VTE ◊Surgical Care Improvement Project – CMS considering appropriate VTE prophylaxis to be a pay-forperformance quality measure for specific procedures