VTE Unplugged Episode 1: Navigating High-Risk Situations — Thrombosis, Bleeding, and Making the Informed Choices
Hello dear listeners, welcome to this podcast session with Dr. Shahri Rosnahan, who is an Assistant Professor of Medicine and Associate Program Director for the Pulmonary and Critical Care Fellowship at the New York University School of Medicine. Her research is focused on pulmonary embolism, thrombotic risk and response to therapy. She has been a site principal investigator for NIH studies as well as completing investigator initiated protocols. She has been a faculty at various national and international VTE events and has worked on the CHEST COVID guidelines committee. In this podcast, we shall discuss high risk situations and thrombosis, mainly relating to thrombosis versus bleeding risks, trying to make the right choice. And how to manage DVT and PE in patients with deranged parameters, whether they are liver related, coagulation or renal. So thank you very much Dr. Shahri Rosnahan for accepting our invitation for this podcast. Thank you so much for having me, I'm very excited to be here. So let's start the ball rolling with our first question. How many patients in the ICU would fall under the category of deranged physiology? Yeah, so I think it depends a lot on each hospital's kind of admission parameters for the ICU. This would depend on various places in terms of even in New York state. I know there are differences and it can depend on how busy we are in our ICU. But if our ICU is near capacity, I would say 80% of our patients could have some kind of coagulopathy or abnormality within their liver or kidney parameters that may make them respond differently to various medications. Right, thank you for that. You know, when we deal with healthcare professionals here in our country, and when we say we want to give an anticoagulant. The apprehension about bleeding comes up. And especially in patients who have got deranged parameters, they perceive a higher risk of bleeding. So how do you go about counseling them or addressing these situations? And as a result of this so-called risk of bleeding, how many times we actually end up not anticoagulating the patients appropriately? Yeah, I think that this is a great question because I think as doctors, one of our first thoughts is first do no harm, right? And so we never want to feel like we are responsible actively making a choice that might hurt someone. But what we forget is by not doing something, sometimes we can hurt someone. So choosing not to give an anticoagulant is as risky in some patients as choosing to give the anticoagulant, right? Because you could be increasing someone's thrombotic risk. So I would say that it's actually fairly rare that I don't give prophylactic anticoagulation in my patients that haven't just undergone trauma or surgery or not currently active bleeding. Pretty much the one that I can think of that happens frequently is a thrombocytopenia that's persistently lower than 50 or under 75 with a high fever or with kind of what I would say is deranged bleeding risk where I see them having pectinii or active bleeding other places. So that's pretty much a hard line for me. But really renal failure and liver failure are not hard lines for me to stop giving prophylactic anticoagulation my patients. And then the things I can do to mitigate the risk of bleeding with that and we can go through those through this hour. But in general, it's just thrombocytopenia that I get concerned about. Right. Thank you very much for that. That was pretty clear. Are we looking at any specific GFRs or liver and xymopathies which help us to determine that a drug may not be used? Do you have any cutoffs that we can tell our listeners? Yeah. So I think the first is that there's no hard cutoffs really for any of them except for maybe an INR, but there are a lot of caveats for that. So anticoagulation can be given safely with renal failure and definitely prophylactic anticoagulation can be given safely with renal failure even to the point where someone is on dialysis. That being said, it might change the medication I'm using for prophylaxis. I am very hesitant to give DOACs in someone who's not stable for prophylaxis in the hospital. So while it is approved, if I'm concerned at all that someone might develop renal failure, I don't want to give a changing dose of DOAC which is what happens when someone's getting worsening renal failure. So those are patients that I will shift towards a Heparin-based therapy. And if someone really has, if I'm really concerned about the bleeding risk, I'll shoot for some things with shorter half-life. But in fact, I can even start dosing the Heparin-based therapy for weight or under-dosing it slightly because we forget we remember when we treat people, right, when we treat people for thrombosis with a Heparin-based therapy, we always do this via weight. But when we do prophylaxis, it's kind of one-size-fits-all. So if we're really worried about bleeding in a patient, I might use a slightly lower dose prophylaxis in them, but I will always give prophylaxis in the setting of renal failure. In the setting of liver failure, I think it's really hard to say just from an INR whether someone's actually likely to bleed or likely to clot. And so if I'm not sure, I'll use a thromboelastogram or a tag scan in these patients sometimes. I think INRs of three and four and five, I've even seen these patients not have any sort of coagulopathy when I put a tag on. And I'll feel comfortable giving them prophylaxis even with the INR. If the INR is elevated because of nutritional abnormalities or elevated because they're on a warfarin as an outpatient and just were taking things, that's different. But if it's an elevated INR in the setting of true liver failure, that can mean a lot of different things and does not necessarily mean an elevated bleeding risk. Oh, that's wonderful. A lot of take home messages and that. Thank you very much for that. So I think it's time, don't you think that at institution levels or at hospital levels, there should be certain policies put into place. So how does an institute, what kind of steps should we take to see that an institution has some kind of a policy to reduce the thrombosis risk? And at the same time, like you very rightly said, no harm to the patient in these deranged parameters. Yeah, so I think we kind of, there was a call to action for VTE five to 10 years ago where we really looked at this in the Medicare Medicaid database in the United States. And we found that prompting a physician or prompting a provider to think about thrombotic risk was extremely helpful. And so, and really having a structured way of thinking about this is helpful. So I like to use some of the thrombotic risks calculators. And there are a lot of different ones that you can use. There's no one that's better than others actually. And then I use a bleeding risk calculator to determine whether I think the bleeding risk is higher or the thrombotic risk is higher. Remember I think that in general, the bleeding risk tends to be a lot lower than we think in patients who are just receiving prophylaxis. Great, thank you. We'll come to another high risk situation, which may not be necessarily associated with the drainage parameters, but patients with malignancy cancer. So patients with cancer are at an increased risk of bleeding when they're giving anticoagulants compared to those who don't have cancer. However, while the association of thrombosis and cancer is well understood, we are always worried about the bleeding risk in these patients. So how do we balance that thrombosis and bleeding risk in cancer patients? Because they also have certain delayed parameters, especially thrombocytopenia and chemotherapy, altered liver function, renal system, which is affected by medications. So how are we going to balance this? Yeah, so I would say preventing a thrombosis in a patient that has cancer is extremely important, right? Because when we think about how long we treat patients who get thromboses, we have to treat them until the reversible risk factors are gone. And if someone with cancer gets a thrombosis, then they're basically on anticoagulation until the cancer is gone, which may be never in some of the cases of palliative chemotherapy or non-curative options that they have. And so really preventing the thrombosis is super, super important. Again, thrombocytopenia is the thing that I worry about most. But in general, I don't worry that much about most intercranial malignancies. I do worry about GI luminal malignancies. And I think about this a lot because a patient who has a GI luminal malignancy is likely to have slow bleeds that we kind of go unrecognized. So I think this is a hard patient population to think about, but not a patient population that should not get anticoagulation, right? Again, if you don't give people anticoagulation and they get thrombosis, then they're going to have to be on a higher dose of anticoagulation. So you're almost saving them that therapy. I would say that I will start a lot slower in patients. I'm worried about giving prophylaxis too in these patients. So I might start them. So in general, a starting dose of heparin sub-Q for prophylaxis can be 5,000 units three times a day. I might just start one time a day or twice a day, which is a valid treatment regimen if someone's underweight or has a little bit of renal failure. I think those would be my options. The other things you can do if someone has a true contraindication to get any sort of anticoagulation, meaning their hemoglobin is going down even without or you're seeing melanae clinically and the hemoglobin is lower or just even not a kesia, those patients will be people that I do place mechanical SCDs on or at squeezing devices. And I will also encourage those patients to walk and to move around or to at least move their legs while in bed so that these devices and they can have low risk leading risk as possible. Thank you for that. Thank you for tuning in to VTE Unplugged, a podcast series curated by Sunofi. Stay tuned as we bring to you the next part of an ongoing discussion between Dr. Shari Brosnahan and Dr. Abheh Baveh.
