How to prevent thrombotic diseases? Sergio Fusco, MD Geriatric Division - Department of Internal Medicine Ospedale Dell'Angelo - Venice, Italy
CONFLICT OF IN INTEREST DIS ISCLOSURE I have no potential conflict of interest to report
OUTLINE OUTLINE EPIDEMIOLOGY AGEING AND THROMBOTIC RISK SIMPLE RISK STRATIFICATION ANTITHROMBOTIC THERAPY VENOUS AND ARTERIAL THROMBOSIS: IS THERE A LINK ?
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 VTE-PE Atherothrombosis Thrombotic events Heart failure. Antithrombotic Therapy and Prevention of Thrombosis. Chest. 2016. Diagnosis and Treatment of Peripheral Arterial Diseases 2017 ESC Guidelines
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 CHA ₂ DS ₂ -VASc - HAS-BLED CLINICAL FRAILTY SCALE Antithrombotic Therapy and Prevention of Thrombosis. Chest. 2016. Diagnosis and Treatment of Peripheral Arterial Diseases 2017 ESC Guidelines
PADUA SCORE FOR RISK STRATIFICATION IN VTE VKA/NOAC Antithrombotic Therapy and Prevention of Thrombosis. Chest. 2016.
D-Dimer in VTE Conventional D-dimer cutoff value for VTE (500 mcg/L) 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) BMJ . 2013;346:f2492.
Ankle-Brachial Index mean age 80 – 4 year follow up Arch Intern Med. 2013; 163:1939-1942
CHA ₂ DS ₂ -VASc ≥2 High risk HAS-BLED ≥ 3 High risk Circulation 2013;125:2298 – 2307.
Proposed algorithm for the management of elderly patients requiring anticoagulation Journal of Pharmacy Practice and Research (2015)
Smoking cessation • Quitting at older age still ↓ Mortality rates ↓ CV events ↓ New or recurrent stroke Mozaffarian, Circulation 131:e29, 2015 ↑ Quality of life Fleg, Circulation 128:2422, 2013 Enga KF, J Thromb Haemost 2012 VTE ? Physical Activity Moderate-intensity aerobic (endurance) physical ↓ Mortality rates activity ↓ CV events minimum of 30 min on five days each week ↓ New or recurrent stroke vigorous-intensity aerobic activity for a ↑ Quality of life minimum of 20 min on three days each week . I ↓ VTE (A) Nelson, Circulation 116:1094, 2007
Winston Churchill died at 91 years Asked the secret of his long life : "Cuban cigars, Armenian brandy and no sport!"
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 European Heart Journal (2016) 36, 3238 – 3249
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
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) European Heart Journal (2016) 36, 3238 – 3249 Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016
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.
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 Antithrombotic Therapy and Prevention of Thrombosis. Chest. 2012. Phlebology 2011;26:107 – 113
Venous and Arterial Thrombosis: Is There a Link? Mean age 62 ± 13 Adv Exp Med Biol. 2017;906:273-28
N Engl J Med. 2017 Aug 27. Mean age 70 ± 8 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 Mean age 65 ± 10 Patient Preference and Adherence 2015:9 133 – 138
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
CHA ₂ DS ₂ -VASc ≥2 High risk Mean age 76 ± 4 HAS-BLED ≥ 3 High risk J Am Coll Cardiol. 2013 Dec 10;62(23):2199-204. CHEST 2013; 143(1):179 – 184
Thromboprophylaxis medical patients with cancer 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) Antithrombotic Therapy for VTE Disease: CHEST Guideline . Chest 2016
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 European Heart Journal (2015) 36, 3238 – 3249
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 Antithrombotic Therapy and Prevention of Thrombosis. Chest. 2012. Phlebology 2011;26:107 – 113
Advantages of LMWH over UFH Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016
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