Sergio Fusco, MD · 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

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


Diagnosis and Treatment of Peripheral Arterial Diseases 2017

ESC Guidelines

PADUA SCORE FOR RISK STRATIFICATION IN VTE


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


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


Antithrombotic Therapy for VTE Disease:

CHEST Guideline and Expert


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


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


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


CHEST Guideline and Expert


Documents

Sergio Fusco, MD · 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