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Thromb Haemost 2009; 101(05): 893-901
DOI: 10.1160/TH08-11-0748
Blood Coagulation, Fibrinolysis and Cellular Haemostasis
Schattauer GmbH

In-hospital symptomatic venous thromboembolism and antithrombotic prophylaxis in Internal Medicine

Findings from a multicenter, prospective study
Gualberto Gussoni
1   FADOI Study Centre, Milan, Italy
,
Mauro Campanini
2   Internal Medicine, Maggiore Hospital, Novara, Italy
,
Mauro Silingardi
3   Internal Medicine I, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
,
Gianluigi Scannapieco
4   Internal Medicine, Cà Foncello Hospital, Treviso, Italy
,
Antonino Mazzone
5   Internal Medicine, Civile Hospital, Legnano, Italy
,
Giovanna Magni
6   QBGroup SpA, Padova, Italy
,
Antonella Valerio
1   FADOI Study Centre, Milan, Italy
,
Ido Iori
1   FADOI Study Centre, Milan, Italy
3   Internal Medicine I, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
,
Walter Ageno
7   Department of Clinical Medicine, Insubria University, Varese, Italy
,
the GEMINI Study Group › Author AffiliationsFinancial support: The GEMINI study was supported by a research grant by GlaxoSmithKline, Italy, without involvement in any of the study procedures.
Further Information

Publication History

Received: 14 November 2008

Accepted after minor revision: 23 January 2009

Publication Date:
24 November 2017 (online)

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Summary

Hospitalised medical patients are at increased risk of venous thromboembolism (VTE), but the incidence of hospitalisation-related VTE in unselected medical inpatients has not been extensively studied, and uncertainties remain about the optimal use of thromboprophylaxis in this setting. Aims of our prospective, observational study were to assess the prevalence of VTE and the incidence of symptomatic, hospitalisation-related events in a cohort of consecutive patients admitted to 27 Internal Medicine Departments, and to evaluate clinical factors associated with the use of thromboprophylaxis. Between March and September 2006, a total of 4,846 patients were included in the study. Symptomatic VTE with onset of symptoms later than 48 hours after admission (”hospital-acquired” events, primary study end-point) occurred in 26 patients (0.55٪), while the overall prevalence of VTE (including diagnosis prior to or at admission) was 3.65٪. During hospital stay antithrombotic prophylaxis was administered in 41.6٪ of patients, and in 58.7% of those for whom prophylaxis was recommended according to the 2004 Guidelines of the American College of Chest Physicians. The choice of administering thromboprophylaxis or not appeared qualitatively adherent to indications from randomised clinical trials and international guidelines, and bed rest was the strongest determinant of the use of prophylaxis. Data from our real-world study confirm that VTE is a relevant complication in patients admitted to Internal Medicine Departments, and recommended tromboprophylaxis is still under-used, in particular in some patients groups. Further efforts are needed to better define risk profile and to optimise prophylaxis in the heterogeneous setting of medical inpatients.

Keywords

Deep venous thrombosis - pulmonary embolism - prophylaxis - management of disease

* Members of the GEMINI Study Group are listed at the end of paper.


 

  • References

  • 1 Geerts WH, Bergqvist D, Pineo GF. et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Ed.). Chest 2008; 133: 381S-453S.
    CrossrefPubMedGoogle Scholar
  • 2 Zakai NA, Wright J, Cushman M. Risk factors for venous thrombosis in medical inpatients: validation of a thrombosis risk score. J Thromb Haemost 2004; 02: 2156-2161.
    CrossrefPubMedGoogle Scholar
  • 3 Dunn AS, Brenner A, Halm EA. The magnitude of an iatrogenic disorder: a systematic review of the incidence of venous thromboembolism for general medical inpatients. Thromb Haemost 2006; 95: 758-762.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Cohen AT, Davidson BL, Gallus AS. et al. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. Br Med J 2006; 332: 325-329.
    CrossrefPubMedGoogle Scholar
  • 5 Lawall H, Hoffmanns W, Hoffmanns P. et al. Prevalence of deep vein thrombosis (DVT) in non surgical patients at hospital admission. Thromb Haemost 2007; 98: 765-770.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Samama MM, Cohen AT, Darmon J-Y. et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. N Engl J Med 1999; 341: 793-800.
    CrossrefPubMedGoogle Scholar
  • 7 Oger E, Bressolette L, Nonent M. et al. High prevalence of asymptomatic deep vein thrombosis on admission in a medical unit among elderly patients. The TA-DEUS Project. Thromb Haemost 2002; 88: 592-597.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Goldhaber SZ, Tapson VF. DVT FREE Steering Committee.. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol 2004; 93: 259-562.
    CrossrefPubMedGoogle Scholar
  • 9 Gallus AS, Hirsh J, Tutle RJ. et al. Small subcutaneous doses of heparin in prevention of venous thrombosis. N Engl J Med 1973; 288: 545-551.
    CrossrefPubMedGoogle Scholar
  • 10 Belch JJ, Lowe GD, Ward AG. et al. Prevention of deep vein thrombosis in medical patients by low-dose heparin. Scott Med J 1981; 26: 115-117.
    CrossrefPubMedGoogle Scholar
  • 11 Garlund B. The Heparin Prophylaxis Study Group. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. Lancet 1996; 347: 1357-1361.
    CrossrefPubMedGoogle Scholar
  • 12 Harenberg J, Roebruck P, Heene DL. Subcutaneous low-molecular-weight-heparin versus standard heparin and the prevention of thromboembolism in medical in-patients: the Heparin Study in Internal Medicine Group. Haemostasis 1996; 26: 127-139.
    PubMedGoogle Scholar
  • 13 The International Stroke Trial (IST).. A randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. Lancet 1997; 349: 1569-1581.
    CrossrefPubMedGoogle Scholar
  • 14 Fraisse F, Holzapfel L, Couland JM. et al. Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD. Am J Respir Crit Care Med 2000; 161: 1109-1114.
    CrossrefPubMedGoogle Scholar
  • 15 Leizorovicz A, Cohen AT, Turpie AG. et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation 2004; 110: 874-879.
    CrossrefPubMedGoogle Scholar
  • 16 Diener HC, Ringelstein EB, von Kummer R. et al. Prophylaxis of thrombotic and embolic events in acute ischemic stroke with the low-molecular-weight-heparin certoparin: results of the PROTECT trial. Stroke 2006; 37: 139-144.
    CrossrefPubMedGoogle Scholar
  • 17 Lowe GDO, Sandercock PAG, Rosendaal FR. Prevention of venous thromboembolism after orthopaedic surgery: is fondaparinux an advance?. Lancet 2003; 362: 504-505.
    CrossrefPubMedGoogle Scholar
  • 18 Dentali F, Douketis JD, Gianni M. et al. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med 2007; 146: 278-288.
    CrossrefPubMedGoogle Scholar
  • 19 Själander A, Jansson J-H, Bergqvist D. et al. Efficacy and safety of anticoagulant prophylaxis to prevent venous thromboembolism in acutely ill medical inpatients: a meta analysis. J Intern Med 2008; 263: 52-60.
    PubMedGoogle Scholar
  • 20 Francis CW. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med 2007; 356: 1438-1444.
    CrossrefPubMedGoogle Scholar
  • 21 Ageno W, Squizzato A, Ambrosini F. et al. Thrombosis prophylaxis in medical patients: a retrospective review of clinical practice patterns. Haematologica 2002; 87: 746-750.
    PubMedGoogle Scholar
  • 22 Caiafa JS, de Bastos M, Moura LK. et al. Managing venous thromboembolism in Latin American patients: emerging results from the Brazilian Registry. Semin Thromb Haemost 2002; 28: 47-50.
    PubMedGoogle Scholar
  • 23 Bergmann JF, Mouly S. Thromboprophylaxis in medical patients: focus on France. Semin Thromb Haemost 2002; 28: 51-55.
    PubMedGoogle Scholar
  • 24 Rahim SA, Panju A, Pai M. et al. Venous thromboembolism prophylaxis in medical inpatients: a retrospective chart review. Thromb Res 2003; 111: 215-219.
    CrossrefPubMedGoogle Scholar
  • 25 Vallano A, Arnau JM, Miralda GP. et al. Use of venous thromboprophylaxis and adherence to guideline recommendations: a cross-sectional study. Thromb J 2004; 02: 3.
    CrossrefPubMedGoogle Scholar
  • 26 Chopard P, Dorffler-Melly J, Hess U. et al. Venous thromboembolism prophylaxis in acutely ill medical patients: definite need for improvement. J Intern Med 2005; 257: 352-357.
    CrossrefPubMedGoogle Scholar
  • 27 Kahn SR, Panju A, Geerts W. et al. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients. Thromb Res 2007; 119: 145-155.
    CrossrefPubMedGoogle Scholar
  • 28 Tapson VF, Decousus H, Pini M. et al. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest 2007; 132: 936-945.
    CrossrefPubMedGoogle Scholar
  • 29 Wein L, Wein S, Haas SJ. et al. Pharmacological venous thromboembolism prophylaxis in hospitalized medical patients. A meta-analysis of randomized controlled trials. Arch Intern Med 2007; 167: 1476-1486.
    CrossrefPubMedGoogle Scholar
  • 30 Hirsh J, Bauer KA, Donati MB. et al. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Ed.). Chest 2008; 133: 141S-159S.
    CrossrefPubMedGoogle Scholar
  • 31 Geerts WH, Pineo GF, Heit JA. et al. Prevention of venous thromboembolism. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 338S-400S.
    CrossrefPubMedGoogle Scholar
  • 32 Agnelli G, Bolis G, Capussotti L. et al. A clinical-outcome based prospective study on venous thromboembolism after cancer surgery – The @RISTOS project. Ann Surg 2006; 243: 89-95.
    CrossrefPubMedGoogle Scholar
  • 33 Schuurman B, den Heijer M, Nijs AM. Thrombosis prophylaxis in hospitalised medical patients: does prophylaxis in all patients make sense?. Neth J Med 2000; 56: 171-176.
    CrossrefPubMedGoogle Scholar
  • 34 Cohen AT, Tapson VF, Bergmann J-F. et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational, cross-sectional study. Lancet 2008; 371: 387-394.
    CrossrefPubMedGoogle Scholar
  • 35 Cohen AT, Agnelli G, Anderson FA. et al. Venous thromboembolism VTE in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007; 98: 756-764.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Alikhan R, Cohen AT, Combe S. et al. Risk factors for venous thromboembolism in hospitalized patients with acute medical illness. Analysis of the MEDENOX Study. Arch Int Med 2004; 164: 963-968.
    CrossrefPubMedGoogle Scholar
  • 37 Kleber FX, Witt C, Vogel G. et al. Randomized comparison of enoxaparin with unfractionated heparin for the prevention of venous thromboembolism in medical patients with heart failure or severe respiratory disease. Am Heart J 2003; 145: 614-621.
    CrossrefPubMedGoogle Scholar
  • 38 Spyropoulos AC. Emerging strategies in the prevention of venous thromboembolism in hospitalized medical patients. Chest 2005; 128: 958-969.
    CrossrefPubMedGoogle Scholar
  • 39 Arcelus JJ, Candocia S, Traverso CI. et al. Venous thromboembolism prophylaxis and risk assessment in medical patients. Semin Thromb Hemost 1991; 17 (Suppl. 03) 313-318.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Thromboembolic Risk Factor THRIFT Consensus Group.. Risk of and prophylaxis for venous thromboembolism in hospital patients. Br Med J 1992; 305: 567-574.
    CrossrefPubMedGoogle Scholar
  • 41 Lutz L. Venous thromboembolism in internal medicine: risk assessment and pharmaceutical prophylaxis. Med Welt 2002; 53: 231-234.
    PubMedGoogle Scholar
  • 42 Haas SK. Venous thromboembolic risk and its prevention in hospitalized medical patients. Semin Thromb Haemost 2002; 28: 577-584.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Cohen AT, Alikhan R, Arcelus JJ. et al. Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients. Thromb Haemost 2005; 94: 750-759.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 Jubelirer SJ, Reyes B, Boce M. et al. Pharmacologic thromboembolic prophylaxis for medical patients in a tertiary care, teaching community hospital: room for improvement. W V Med J 2008; 104: 10-14.
    PubMedGoogle Scholar
  • 45 Goldhaber SZ, Dunn K, MacDougall RC. New onset of venous thromboembolism among hospitalized patients at Brigham and Women’s Hospital is caused more often by prophylaxis failure than by withholding treatment. Chest 2000; 118: 1680-1684.
    CrossrefPubMedGoogle Scholar
  • 46 Hirsh J, Raschke R. Heparin and Low-Molecular-Weight Heparin. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 188S-203S.
    CrossrefPubMedGoogle Scholar
  • 47 Mahè I, Aghassarian M, Drouet L. et al. Tinzaparin and enoxaparin given at prophylactic doses for eight days in medical elderly patients with impaired renal function. A comparative pharmacokinetic study. Thromb Haemost 2007; 97: 581-586.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 48 Spencer FA, Lessard D, Emery C. et al. Venous thromboembolism in the outpatient setting. Arch Int Med 2007; 167: 1471-1475.
    CrossrefPubMedGoogle Scholar
  • 49 Goldhaber SZ. Outpatient venous thromboembolism. A common but often preventable public health threat. Arch Int Med 2007; 167: 1451-1452.
    CrossrefPubMedGoogle Scholar