How to prevent thrombotic diseases? Sergio Fusco, MD Geriatric - - PowerPoint PPT Presentation

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How to prevent thrombotic diseases? Sergio Fusco, MD Geriatric - - PowerPoint PPT Presentation

Feb 20, 2023 695 likes •1.12k views

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

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How to prevent thrombotic diseases? Sergio Fusco, MD

Geriatric Division - Department of Internal Medicine Ospedale Dell'Angelo - Venice, Italy

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CONFLICT OF IN INTEREST DIS ISCLOSURE

I have no potential conflict of interest to report

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  • EPIDEMIOLOGY
  • AGEING AND THROMBOTIC RISK
  • SIMPLE RISK STRATIFICATION
  • ANTITHROMBOTIC THERAPY
  • VENOUS AND ARTERIAL THROMBOSIS: IS THERE A LINK?

OUTLINE

OUTLINE

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Is it worth offering thrombotic prevention to the elderly?

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Epidemiology of thrombotic diseases

European Heart Journal (2016) 37, 3232–3245

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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

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Eur Heart J. 2015 Dec 7;36(46):3238-49.

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Aging Clin Exp Res (2017) 29:483–490

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ARE GERIATRIC SYNDROMES ASSOCIATED WITH RELUCTANCE TO INITIATE ORAL ANTICOAGULATION THERAPY IN ELDERLY ADULTS ?

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Patients centred care for Older Adults

Prog Cardiovasc Dis. 2014 ; 57(2): 197–203.

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Rapid Screening and Risk assessment tool

  • PADUA SCORE
  • D-DIMER ?
  • ANKLE-BRACHIAL INDEX
  • CHA₂DS₂-VASc - HAS-BLED
  • CLINICAL FRAILTY SCALE
  • Antithrombotic Therapy and Prevention of Thrombosis. Chest. 2016.
  • Diagnosis and Treatment of Peripheral Arterial Diseases 2017

ESC Guidelines

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PADUA SCORE FOR RISK STRATIFICATION IN VTE

Antithrombotic Therapy and Prevention of Thrombosis. Chest. 2016.

VKA/NOAC

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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

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Arch Intern Med. 2013; 163:1939-1942

Ankle-Brachial Index

mean age 80 – 4 year follow up

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HAS-BLED

CHA₂DS₂-VASc

≥2 High risk ≥ 3 High risk

Circulation 2013;125:2298–2307.

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Journal of Pharmacy Practice and Research (2015)

Proposed algorithm for the management of elderly patients requiring anticoagulation

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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

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Asked the secret of his long life :

"Cuban cigars, Armenian brandy and no sport!" Winston Churchill died at 91 years

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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

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European Heart Journal (2016) 36, 3238–3249 Mean age 66 ± 6

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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

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  • European Heart Journal (2016) 36, 3238–3249
  • 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)

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OACs in elderly

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Impact of proteinuria and glomerular filtration rate on risk of thromboembolism in atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study.

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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

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Venous and Arterial Thrombosis: Is There a Link?

Adv Exp Med Biol. 2017;906:273-28

Mean age 62 ± 13

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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.

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Statins and primary prevention

  • f venous thromboembolism: a

systematic review and meta- analysis

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No OACs users OACs users Patient Preference and Adherence 2015:9 133–138

Mean age 65 ± 10

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Take home message

Patient-centred approach: INDIVIDUALIZE!

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Thank you for your attention

“The good physician treats the disease, the great physician treats the patient who has the disease” Sir William Osler

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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

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Antithrombotic Therapy for VTE Disease: 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

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BLEEDING VS THROMBOTIC RISK

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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

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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

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Advantages of LMWH over UFH

Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016