Recent updates in the management of thromboembolism - MediBytes February 2022 newsletter

A recently published (February 2022) systematic review and meta-analysis by Forgo G et al.1 updated on the use of thromboprophylaxis globally. In total, 27 studies from 20 countries (total patients = 137,288) were included. Overall, 50.5% of patients had an indication for thromboprophylaxis: of these, 54.5% received adequate thromboprophylaxis. The use of adequate thromboprophylaxis was 66.8% in Europe, 44.9% in Africa, 37.6% in Asia, 58.3% in South America, and 68.6% in North America. Thromboprophylaxis prescriptions are still unsatisfactory among hospitalized medically ill patients around the globe, with marked geographical differences.

Kyriakoulis KG et al. recently published (February 2022)2 a systematic review of the literature (Pubmed/EMBASE) based upon the published guidance reports by national and international societies (33 guidance documents were included: 20 published by national and 13 by international societies) regarding thromboprophylaxis strategies in patients with COVID-19 in different settings (outpatients, hospitalized, postdischarge). Moreover, 81% of the documents recommend thromboprophylaxis for all hospitalized patients with a prophylactic dosage of low molecular weight heparin irrespective of VTE risk. Intermediate or therapeutic dose intensity is recommended in high VTE risk patients by 56% and 28% of documents, respectively.

In another recent review article (February 2022), experts like Jean-Louis Vincent, Marcel Levi, and Beverley J Hunt3 mentioned that antithrombotic prophylaxis should be applied in all patients; therapeutic anticoagulation is of benefit in those requiring supplementary oxygen outside the intensive care unit setting and in those with documented thrombotic complications but should not be applied in all critically ill patients.

Gynecologic malignancies too have high rates of postoperative venous thromboembolism. Currently, there is no consensus for perioperative thromboprophylaxis specific to gynecologic oncology. A prospective study was conducted, wherein laparotomies for gynecologic malignancies from December 2017 to October 2018 were compared to the historical cohort from January 2016 to November 2017 using the institutional National Surgical Quality Improvement Program (NSQIP) database.

Preintervention, patients received low molecular weight heparin during admission, and extended 28-day prophylaxis was continued at the surgeon's discretion. Postintervention, all patients received mechanical thromboprophylaxis with sequential compression devices during admission and 28-day prophylaxis with low molecular weight heparin. In total, 371 and 163 laparotomies were done preintervention and postintervention, respectively. After implementation, pulmonary emboli rates decreased from 5.1% to 0% (p = 0.001). There were more cytoreductive procedures preintervention (p ≤ 0.0001). However, surgical complexity scores were similar (p = 0.82). Dual thromboprophylaxis after laparotomy significantly reduced rates of pulmonary embolus in this high-risk patient population.

    1. Forgo G, Micieli E, Ageno W, et al. An update on the global use of risk assessment models and thromboprophylaxis in hospitalized patients with medical illnesses from the World Thrombosis Day steering committee: Systematic review and meta-analysis. J Thromb Haemost. 2022 Feb;20(2):409–421. doi: 10.1111/jth.15607.
    2. Kyriakoulis KG, Kollias A, Kyriakoulis IG, et al. Thromboprophylaxis in patients with COVID-19: Systematic review of national and international clinical guidance reports. Curr Vasc Pharmacol. 2022;20(1):96–110. doi: 10.2174/1570161119666210824160332.
    3. Vincent JL, Levi M, Hunt BJ. Prevention and management of thrombosis in hospitalised patients with COVID-19 pneumonia. Lancet Respir Med. 2022 Feb;10(2):214-220. doi: 10.1016/S2213-2600(21)00455-0.
    4. Nguyen JMV, Gien LT, Covens A, et al. Dual mechanical and pharmacological thromboprophylaxis decreases risk of pulmonary embolus after laparotomy for gynecologic malignancies. Int J Gynecol Cancer. 2022 Jan;32(1):55–61. doi: 10.1136/ijgc-2020-001205.