Advertisement

Internal and Emergency Medicine

, Volume 8, Issue 6, pp 509–520 | Cite as

Prophylaxis of venous thromboembolism in elderly patients with multimorbidity

  • Maura Marcucci
  • Alfonso Iorio
  • Alessandro Nobili
  • Mauro Tettamanti
  • Luca Pasina
  • Codjo Djignefa Djade
  • Alessandra Marengoni
  • Francesco Salerno
  • Salvatore Corrao
  • Pier Mannuccio MannucciEmail author
  • REPOSI (REgistro POliterapie Società Italiana di Medicina Interna) Investigators
IM - ORIGINAL

Abstract

Pharmacological thromboprophylaxis (TP) is known to reduce venous thromboembolism (VTE) in medical inpatients, but the criteria for risk-driven prescription, safety and impact on mortality are still debated. We analyze data on elderly patients with multimorbidities admitted in the year 2010 to the Italian internal medicine wards participating in the REPOSI registry to investigate the rate of TP during the hospital stay, and analyze the factors that are related to its prescription. Multivariate logistic regression, area under the ROC curve and CART analysis were performed to look for independent predictors of TP prescription. Association between TP and VTE, bleeding and death in hospital and during the 3-month post-discharge follow-up were explored by logistic regression and propensity score analysis. Among the 1,380 patients enrolled, 171 (15.2 %) were on TP during the hospital stay (162 on low molecular weight heparins, 9 on fondaparinux). The disability Barthel index was the main independent predictor of TP prescription. Rate of fatal and non-fatal VTE and bleeding during and after hospitalization did not differ between TP and non-TP patients. In-hospital and post-discharge mortality was significantly higher in patients on TP, that however was not an independent predictor of mortality. Among elderly medical patients there was a relatively low rate of TP, that was more frequently prescribed to patients with a higher degree of disability and who had an overall higher mortality.

Keywords

Thromboprophylaxis Venous thromboembolism Medical patients 

Notes

Conflict of interest

None.

References

  1. 1.
    Silverstein MD, Heit JA, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ III (1998) Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med 158:585–593PubMedCrossRefGoogle Scholar
  2. 2.
    Naess IA, Christiansen SC, Romundstad P, Cannegieter SC, Rosendaal FR, Hammerstrom J (2007) Incidence and mortality of venous thrombosis: a population-based study. J Thromb Haemost 5:692–699PubMedCrossRefGoogle Scholar
  3. 3.
    Piazza G, Seddighzadeh A, Goldhaber SZ (2008) Deep-vein thrombosis in the elderly. Clin Appl Thromb Hemost 14:393–398PubMedCrossRefGoogle Scholar
  4. 4.
    Lopez-Jimenez L, Montero M, Gonzalez-Fajardo JA, Arcelus JI, Suarez C, Lobo JL, Monreal M (2006) Venous thromboembolism in very elderly patients: findings from a prospective registry (RIETE). Haematologica 91:1046–1051PubMedGoogle Scholar
  5. 5.
    Vasco B, Villalba JC, Lopez-Jimenez L, Falga C, Montes J, Trujillo-Santos J, Monreal M (2009) Venous thromboembolism in nonagenarians. Findings from the RIETE Registry. Thromb Haemost 101:1112–1118PubMedGoogle Scholar
  6. 6.
    Douma RA, Le GG, Sohne M, Righini M, Kamphuisen PW, Perrier A, Kruip MJ, Bounameaux H, Buller HR, Roy PM (2010) Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts. BMJ 340:c1475PubMedCrossRefGoogle Scholar
  7. 7.
    Kucher N, Koo S, Quiroz R, Cooper JM, Paterno MD, Soukonnikov B, Goldhaber SZ (2005) Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 352:969–977PubMedCrossRefGoogle Scholar
  8. 8.
    Lecumberri R, Marques M, az-Navarlaz MT, Panizo E, Toledo J, Garcia-Mouriz A, Paramo JA (2008) Maintained effectiveness of an electronic alert system to prevent venous thromboembolism among hospitalized patients. Thromb Haemost 100:699–704Google Scholar
  9. 9.
    Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M, De BE, Tormene D, Pagnan A, Prandoni P (2010) A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost 8:2450–2457PubMedCrossRefGoogle Scholar
  10. 10.
    Spyropoulos AC, Anderson FA Jr, Fitzgerald G, Decousus H, Pini M, Chong BH, Zotz RB, Bergmann JF, Tapson V, Froehlich JB, Monreal M, Merli GJ, Pavanello R, Turpie AG, Nakamura M, Piovella F, Kakkar AK, Spencer FA (2011) Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest 140:706–714PubMedCrossRefGoogle Scholar
  11. 11.
    Tapson VF, Decousus H, Pini M, Chong BH, Froehlich JB, Monreal M, Spyropoulos AC, Merli GJ, Zotz RB, Bergmann JF, Pavanello R, Turpie AG, Nakamura M, Piovella F, Kakkar AK, Spencer FA, Fitzgerald G, Anderson FA Jr (2007) Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest 132:936–945PubMedCrossRefGoogle Scholar
  12. 12.
    Cohen AT, Tapson VF, Bergmann JF, Goldhaber SZ, Kakkar AK, Deslandes B, Huang W, Zayaruzny M, Emery L, Anderson FA Jr (2008) Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 371:387–394PubMedCrossRefGoogle Scholar
  13. 13.
    Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG (2004) Prevention of venous thromboembolism: the 7th ACCP Conference on antithrombotic and thrombolytic therapy. Chest 126:338S–400SPubMedCrossRefGoogle Scholar
  14. 14.
    Ruiz-Gimenez N, Suarez C, Gonzalez R, Nieto JA, Todoli JA, Samperiz AL, Monreal M (2008) Predictive variables for major bleeding events in patients presenting with documented acute venous thromboembolism. Findings from the RIETE Registry. Thromb Haemost 100:26–31PubMedGoogle Scholar
  15. 15.
    Decousus H, Tapson VF, Bergmann JF, Chong BH, Froehlich JB, Kakkar AK, Merli GJ, Monreal M, Nakamura M, Pavanello R, Pini M, Piovella F, Spencer FA, Spyropoulos AC, Turpie AG, Zotz RB, Fitzgerald G, Anderson FA (2011) Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest 139:69–79PubMedCrossRefGoogle Scholar
  16. 16.
    Qaseem A, Chou R, Humphrey LL, Starkey M, Shekelle P (2011) Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med 155:625–632PubMedCrossRefGoogle Scholar
  17. 17.
    Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH (2012) Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141:e195S–e226SPubMedCrossRefGoogle Scholar
  18. 18.
    Nobili A, Licata G, Salerno F, Pasina L, Tettamanti M, Franchi C, De VL, Marengoni A, Corrao S, Iorio A, Marcucci M, Mannucci PM (2011) Polypharmacy, length of hospital stay, and in-hospital mortality among elderly patients in internal medicine wards. The REPOSI study. Eur J Clin Pharmacol 67:507–519PubMedCrossRefGoogle Scholar
  19. 19.
    Linn BS, Linn MW, Gurel L (1968) Cumulative illness rating scale. J Am Geriatr Soc 16:622–626PubMedGoogle Scholar
  20. 20.
    Morris JC, Heyman A, Mohs RC, Hughes JP, van BG, Fillenbaum G, Mellits ED, Clark C (1989) The consortium to establish a registry for Alzheimer’s Disease (CERAD). Part I. Clinical and neuropsychological assessment of Alzheimer’s disease. Neurology 39:1159–1165Google Scholar
  21. 21.
    Sheik J, Yesavage J (1986) Geriatric depression scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 5:165–172CrossRefGoogle Scholar
  22. 22.
    Mahoney FI, Barthel DW (1965) Functional evaluation: the Barthel Index. Md State Med J 14:61–65PubMedGoogle Scholar
  23. 23.
    Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A, Janbon C, Leizorovicz A, Olsson CG, Turpie AG (2004) Risk factors for venous thromboembolism in hospitalized patients with acute medical illness: analysis of the MEDENOX Study. Arch Intern Med 164:963–968PubMedCrossRefGoogle Scholar
  24. 24.
    Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW (2008) Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133:381S–453SPubMedCrossRefGoogle Scholar
  25. 25.
    Chopard P, Spirk D, Bounameaux H (2006) Identifying acutely ill medical patients requiring thromboprophylaxis. J Thromb Haemost 4:915–916PubMedCrossRefGoogle Scholar
  26. 26.
    Zhang H, Holford T, Bracken MB (1996) A tree-based method of analysis for prospective studies. Stat Med 15:37–49PubMedCrossRefGoogle Scholar
  27. 27.
    Austin PC (2010) The performance of different propensity-score methods for estimating differences in proportions (risk differences or absolute risk reductions) in observational studies. Stat Med 29:2137–2148PubMedCrossRefGoogle Scholar
  28. 28.
    Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, Meinow B, Fratiglioni L (2011) Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev 10:430–439PubMedCrossRefGoogle Scholar
  29. 29.
    Linjakumpu T, Hartikainen S, Klaukka T, Veijola J, Kivelä SL, Isoaho R (2002) Use of medications and polypharmacy are increasing among the elderly. J Clin Epidemiol 55:809–817PubMedCrossRefGoogle Scholar
  30. 30.
    Hull RD, Schellong SM, Tapson VF, Monreal M, Samama MM, Nicol P, Vicaut E, Turpie AG, Yusen RD (2010) Extended-duration venous thromboembolism prophylaxis in acutely ill medical patients with recently reduced mobility: a randomized trial. Ann Intern Med 153:8–18PubMedCrossRefGoogle Scholar
  31. 31.
    Vardi M, Haran M (2012) Venous thromboembolism prophylaxis of acutely ill hospitalized medical patients. Are we over-treating our patients? Eur J Intern Med 23:231–235PubMedCrossRefGoogle Scholar
  32. 32.
    Hulley SB, Cummings SR, Browner WR, Grady DG, Newman TB (2007) Designing Clinical Research. (3rd edn) Philadelphia, Lippincott Williams & WilkinsGoogle Scholar
  33. 33.
    Tinetti ME, Studenski SA (2011) Comparative effectiveness research and patients with multiple chronic conditions. N Engl J Med 364:2478–2481PubMedCrossRefGoogle Scholar
  34. 34.
    Kakkar AK, Cimminiello C, Goldhaber SZ, Parakh R, Wang C, Bergmann JF; LIFENOX Investigators (2011) Low-molecular-weight heparin and mortality in acutely ill medical patients. N Engl J Med 365:2463–72Google Scholar
  35. 35.
    Imberti D, Prisco D (2005) Venous thromboembolism prophylaxis in medical patients: future perspectives. Thromb Res 116:365–375PubMedCrossRefGoogle Scholar
  36. 36.
    Ho KM, Litton E (2011) Venous thromboembolism prophylaxis in hospitalized elderly patients: time to consider a ‘MUST’ strategy. J Geriatr Cardiol 8:114–120PubMedCrossRefGoogle Scholar

Copyright information

© SIMI 2013

Authors and Affiliations

  • Maura Marcucci
    • 1
    • 2
  • Alfonso Iorio
    • 1
    • 2
  • Alessandro Nobili
    • 3
  • Mauro Tettamanti
    • 3
  • Luca Pasina
    • 3
  • Codjo Djignefa Djade
    • 3
  • Alessandra Marengoni
    • 4
  • Francesco Salerno
    • 5
  • Salvatore Corrao
    • 6
  • Pier Mannuccio Mannucci
    • 7
    Email author
  • REPOSI (REgistro POliterapie Società Italiana di Medicina Interna) Investigators
  1. 1.Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonCanada
  2. 2.Department of MedicineMcMaster University HamiltonONCanada
  3. 3.Mario Negri Institute for Pharmacological ResearchMilanItaly
  4. 4.Geriatric Unit, Ospedali Civili, Department of Medical and Surgery SciencesUniversity of BresciaBresciaItaly
  5. 5.Internal Medicine, IRCCS Policlinico San Donato, Department of Medical and SurgeryUniversity of MilanMilanItaly
  6. 6.Biomedical Department of Internal MedicineUniversity of PalermoPalermoItaly
  7. 7.Scientific Direction, IRCCS Ca’ Granda Maggiore Hospital FoundationMilanItaly

Personalised recommendations