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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^*

^* From the Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.

Correspondence to: Samuel Z. Goldhaber, MD, FCCP, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115; e-mail: sgoldhaber{at}partners.org

	Abstract

TOP Abstract Introduction Materials and Methods Results Discussion References

 
Context: Guidelines to prevent venous thromboembolism (VTE) have been widely distributed and generally have been assumed to be effective. Therefore, among hospitalized patients, the development of VTE is thought to occur in the context of omitted prophylaxis.

Objectives: To describe hospitalized patients who develop VTE and to determine whether they received antecedent prophylaxis.

Design: Case series.

Setting: Brigham and Women’s Hospital.

Patients: Three hundred eighty-four patients who developed in-hospital deep venous thrombosis or pulmonary embolism or who developed VTE within 30 days of prior hospital discharge.

Main outcome measures: The relationship of developing new-onset VTE to the use or omission of antecedent in-hospital prophylaxis.

Results: Of the 384 identified patients, 272 had deep venous thrombosis alone, 62 had pulmonary embolism alone, and 50 had deep venous thrombosis and pulmonary embolism. Most were medical service patients; fewer than one fourth were general or orthopedic surgery patients. Overall, 52% had received antecedent VTE prophylaxis. Thirteen deaths (3.4%) were ascribed to pulmonary embolism, and prophylaxis was omitted in only 1 of those 13 patients.

Conclusions: Most deaths from pulmonary embolism among patients hospitalized for other conditions occurred in the setting of failed prophylaxis rather than omitted prophylaxis. High-risk patients, especially medical service patients, warrant intensive VTE prophylaxis and close follow-up to ensure successful outcomes.

Key Words: prophylaxis • pulmonary embolism • venous thromboembolism

	Introduction

TOP Abstract Introduction Materials and Methods Results Discussion References

 
During the past 2 decades, prevention of venous thromboembolism (VTE) has become widely accepted as an effective and worthwhile strategy. North American¹ and European² guidelines have provided detailed recommendations for prophylaxis among virtually all groups of hospitalized patients. Nevertheless, despite favorable outcomes with preventive measures, some patients have not received routine prophylaxis.³

"Primary" VTE occurs outside of the hospital and without predisposing cancer, trauma, or surgery. In contrast, "secondary" VTE occurs during or soon after hospitalization and is precipitated by concomitant illness. Hospitalization provides an opportunity to institute universal prophylaxis against VTE, thus minimizing the occurrence of secondary VTE. In this article, we evaluate those patients who developed secondary VTE at Brigham and Women’s Hospital (BWH). We hypothesized that most patients who developed secondary VTE would have received no in-hospital prophylaxis.

	Materials and Methods

TOP Abstract Introduction Materials and Methods Results Discussion References

 
We searched our hospital database for all discharge diagnoses of secondary deep vein thrombosis (DVT) and pulmonary embolism (PE), except for neurosurgical patients,⁴ from January 1995 through December 1996. We also searched the database for a principal diagnosis of DVT or PE among patients previously discharged from BWH within 30 days. We then reviewed each chart to confirm the diagnosis of VTE. PE was diagnosed primarily by high-probability lung scan (38 patients), intermediate lung scan with high clinical suspicion (50 patients) using revised criteria of the Prospective Investigation of Pulmonary Embolism Diagnosis,⁵ or positive pulmonary angiography (33 patients). DVT was diagnosed primarily by venous leg ultrasound (309 patients). The results of 155 ultrasound examinations showed proximal leg DVT, 108 showed isolated calf DVT, and 46 showed both proximal and calf DVT. We previously validated the accuracy of our ultrasound laboratory for detecting calf DVT against contrast venography.⁶ Software programs were used to analyze demographic and clinical data (SPSS Inc; Chicago, IL)⁷ and statistical calculations (StatCalc, Epi Info version 501b; Centers for Disease Control and Prevention; Atlanta, GA).⁸

	Results

TOP Abstract Introduction Materials and Methods Results Discussion References

 
We identified 384 patients with VTE: 180 men (46.9%) and 204 women (53.1%). Overall, 272 patients had DVT alone, 62 had PE alone, and 50 had concomitant PE and DVT. The ages of the patients spanned a wide range (Fig 1 ).

View larger version (27K): [in this window] [in a new window] [Download PPT slide]   Figure 1.. The relationship between age and VTE.

The majority of patients whom we identified were receiving general medicine or medical oncology services (Table 1 ). General surgery and orthopedic surgery patients accounted for less than one fourth of the overall hospital population with secondary VTE.

Secondary VTE caused considerable morbidity from anticoagulation and mortality from hemodynamically important PE. Nineteen patients had GI bleeding, and 1 patient sustained a nonfatal intracranial hemorrhage. Overall, 33 patients died; PE was a major contributor to 13 deaths (seven men, six women; Table 6 ). Thus, in our series, the death rate from secondary pulmonary embolism was 3.4%. Of these 13 patients, prophylaxis was omitted in 1 patient and failed in 12 patients; 11 patients were receiving medical services, and 2 were thoracic surgery patients. An additional 11 patients (five men, six women) had PE considered incidental to death. Nine other patients with secondary VTE died of noncardiovascular causes.

	Discussion

TOP Abstract Introduction Materials and Methods Results Discussion References

Previous clinical trials of VTE prophylaxis have yielded successful outcomes in the vast majority of patients.^{1 2} Thus, we had hypothesized that most cases of secondary VTE would have been due to omitted prophylaxis. Certain groups, such as medical ICU patients, appear to be at especially high risk even when standard prophylaxis is administered.⁹ Compared with prior reports, most patients in our current series are medical patients. However, some patients were initially admitted to a nonsurgical service and subsequently underwent surgery. Our evaluation also tracks rehospitalizations within 30 days of discharge. This approach, combined with the population of high-risk patients (most of whom had three or more high risk factors), contributes to the high failure rate of prophylaxis that we observed.

Undoubtedly, many more patients than we identified actually had secondary VTE, due to the silent nature of DVT and PE. It is possible that the ratio of failed to omitted prophylaxis might change if we could identify definitively the entire cohort of patients with secondary VTE. However, this is not feasible because even if we had undertaken routine VTE screening of the entire hospitalized population, noninvasive imaging tests such as venous ultrasonography are often insensitive in asymptomatic patients.^{10 11} Screening blood tests such as the plasma D-dimer enzyme-linked immunosorbent assay lack specificity, especially among hospitalized patients with cancer, myocardial infarction, pneumonia, sepsis, and the postoperative state.¹²

Our findings should not be misconstrued as endorsing a nihilistic policy of abandoning VTE prophylaxis. Indeed, since the patients we describe represented less than 0.5% of BWH admissions, it is quite possible that, overall, VTE prophylaxis was almost always successful. Based on our findings, we hope that quality improvement committees will emphasize the importance of implementing more intensive prophylaxis among high-risk patients as well as meticulous follow-up of these patients to ensure successful outcomes. In the future, this goal may be achieved with more frequent use of low-molecular-weight heparin prophylaxis, especially among medical patients,¹³ or pneumatic compression boots,¹⁴ or both.

	Footnotes

 
Abbreviations: BWH = Brigham and Women’s Hospital; DVT = deep vein thrombosis; PE = pulmonary embolism; VTE = venous thromboembolism

Received for publication December 23, 1999. Accepted for publication July 7, 2000.

	References

TOP Abstract Introduction Materials and Methods Results Discussion References

 

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4. Chan, AT, Atiemo, A, Diran, LL, et al (1999) Venous thromboembolism occurs frequently in patients undergoing brain tumor surgery despite prophylaxis. J Thromb Thrombolysis 8,139-142[CrossRef][ISI][Medline]
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9. Hirsch, DR, Ingenito, EP, Goldhaber, SZ (1995) Prevalence of deep vein thrombosis among patients in medical intensive care. JAMA 274,335-337[Abstract]
10. Jongbloets, LMM, Lensing, AWA, Koopman, MMW, et al (1994) Limitations of compression ultrasound for the detection of symptomless postoperative deep vein thrombosis. Lancet 343,1142-1144[CrossRef][ISI][Medline]
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