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CME / ABIM MOC

From Inpatient to Outpatient: Integrating VTE Prevention Strategies Across the Care Continuum

  • Authors: Deepak Bhatt, MD, MPH, Charles Vega, MD
  • CME / ABIM MOC Released: 1/20/2023
  • Valid for credit through: 1/20/2024
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, surgeons, primary care physicians (PCPs), hem/oncs, and other healthcare practitioners (HCPs) who care for patients at risk of VTE.

The goal of this activity is that learners will be better able to understand effective transition of care strategies to improve VTE prevention in hospitalized medically ill patients.

Upon completion of this activity, participants will:

  • Have greater competence related to
    • Use of effective transition of care strategies to prevent VTE in acute medically ill patients


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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.

Disclosures for additional planners can be found here.


Faculty

  • Deepak Bhatt, MD, MPH

    Director of Mount Sinai Heart
    Icahn School of Medicine at Mount Sinai and the Mount Sinai Health System
    Dr Valentin Fuster Professor in Cardiovascular Medicine
    New York, New York

    Disclosures

    Deepak Bhatt, MD, MPH, has the following relevant financial relationships:
    Research funding from: Abbott; Afimmune; Aker Biomarine; Amarin; Amgen; AstraZeneca; Bayer; Beren; Boehringer Ingelheim; Boston Scientific; Bristol-Myers Squibb; Cardax; CellProthera; Cereno Scientific; Chiesi; CSL Behring; Eisai; Ethicon; Faraday Pharmaceuticals; Ferring Pharmaceuticals; Forest Laboratories; Fractyl; Garmin; HLS Therapeutics; Idorsia; Ironwood; Ischemix; Janssen; Javelin; Lexicon; Lilly; Medtronic; Moderna; MyoKardia; NirvaMed; Novartis; Novo Nordisk; Owkin; Pfizer; PhaseBio; PLx Pharma; Recardio; Regeneron; Roche; Sanofi; Stasys; Synaptic; The Medicines Company; 89Bio

  • Charles Vega, MD

    Clinical Professor of Family Medicine
    University of California, Irvine
    Irvine, California

    Disclosures

    Charles Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline, Johnson and Johnson

Editor

  • Cheryl Perkins, MD, RPh

    Medical Education Director, Medscape, LLC

    Disclosures

    Cheryl Perkins, MD, RPh, has no relevant financial relationships.

Compliance Reviewer

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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CME / ABIM MOC

From Inpatient to Outpatient: Integrating VTE Prevention Strategies Across the Care Continuum

Authors: Deepak Bhatt, MD, MPH, Charles Vega, MDFaculty and Disclosures

CME / ABIM MOC Released: 1/20/2023

Valid for credit through: 1/20/2024

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Activity Transcript

Charles P. Vega, MD: Hello and welcome to the CME-TV program on ‘From Inpatient to Outpatient: Integrating VTE Prevention Strategies Across the Care Continuum’. I’m your host, Chuck Vega, Clinical Professor of Family Medicine at the University of California Irvine.

Venous thromboembolism – including deep vein thrombosis and pulmonary embolism – is a serious life-threatening event. It is estimated that, in the United States, 350,000 to 600,000 people experience VTE each year.

Approximately half of all VTE events occur among patients who are hospitalized or were recently hospitalized, and some reports show that its incidence may actually be increasing. Yet, VTE is preventable. In fact, it is actually considered to be one of the most common preventable causes of hospital deaths.

In today’s program, we’re talking to the eminent Dr Deepak Bhatt, Director of Mount Sinai Heart and the Dr Valentin Fuster Professor of Cardiovascular Medicine at the Icahn School of Medicine and the Mount Sinai Health System in New York.  Dr Bhatt is going to share his insights into the importance of preventing VTE throughout the continuum of care for hospitalized patients.

Dr Vega: Hello Dr Bhatt, thank you for joining us today.

Deepak Bhatt, MD, MPH: It’s my pleasure, Chuck.

Dr Vega: It has been reported that the risk of VTE in hospitalized patients is underrecognized and underappreciated. Is that your experience?

Dr Bhatt: In some situations, yes. VTE is a really common problem that can occur in acutely ill hospitalized patients. This is especially true of patients on the surgical services, and I think that's very well-known and understood.

Around 24% of all VTE events today are due to hospital admission for a surgical procedure. So, there's generally a lot of effort, including at the hospital level, to try to reduce those complications. Surgeons and other doctors consulting on those patients recognize the risk of VTE and the need for prophylaxis.

What I think is not appreciated quite as well is that medically ill patients who are hospitalized, say with pneumonia or heart failure – or these days with COVID – are also at risk for VTE. More than 1 in 5 VTE events today are due to hospital admission for medical illness, so these patients also require prophylaxis. In those situations, however, VTE risk isn't always foremost in the physician's minds. Yet if they have decompensated heart failure, for example, and experience a pulmonary embolism, that might not be a survivable event.

Dr Vega: VTE can be a very serious complication – why do you think that it isn’t more of a focus in medically ill patients?

Dr Bhatt: I think that, in part, there’s been a perception for many years (or even decades) that if a patient is able to walk around somewhat in the hospital, they're not at significant risk for DVT.

But that's really not accurate. Just because the patient can walk to the bathroom, it doesn’t really mean they’re fully ambulatory. Their mobility is often still very restricted, and that raises their risk for VTE. Beyond that, we also need to bear in mind that there’s a reason why they're in the hospital, such as the examples that I gave a moment ago – pneumonia, heart failure exacerbation, or COVID.

In many cases, the underlying illnesses that caused these patients to be hospitalized in the first place are also associated with being hypercoagulable. In fact, a lot of sick patients are dehydrated, and that alone can help make them more hypercoagulable. So, infections of any sort tend to make patients more hypercoagulable; having a low ejection fraction can make them more hypercoagulable. There are a variety of different diseases that medical inpatients have been admitted with. And they may have comorbidities that didn’t bring them into the hospital per se, but can certainly raise their risk for VTE.

Dr Vega: And, of course, many patients can have other factors that increase their thrombotic risk...

Dr Bhatt: Yes, absolutely. The majority of these acutely ill hospitalized patients are older, and age is a VTE risk factor. And patients who are hospitalized with a COPD exacerbation typically have a history of smoking, which further increases their risk for DVT or PE. 40% of hospitalized patients actually have 3 or more risk factors for VTE.

Dr Vega: When symptomatic DVT or PE occurs in hospitalized patients, it commonly results in extended stays and generally requires therapeutic anticoagulation for a minimum of 3 months. The fatality rate among these patients is high – around 10-15%. And those who survive the initial VTE event are at risk for other complications, such as post-thrombotic syndrome following DVT or chronic thromboembolic pulmonary hypertension after a PE. And approximately 1 in 5 patients who experience VTE will have a repeat event at some point. These serious consequences indicate that effective prophylaxis is essential for some acutely ill hospitalized patients.

Dr Vega: Dr Bhatt, what are the established approaches to VTE prophylaxis today?

Dr Bhatt: In acutely ill and critically ill medical patients, as well as postsurgical patients, the current American Society of Hematology guideline recommends the administration of a parenteral anticoagulant, which can reduce VTE by 30% to 65%. Low-molecular-weight heparin, unfractionated heparin, fondaparinux, and direct oral anticoagulants (or ‘DOACs’) are all established options. In situations where there's an absolute contraindication to any anticoagulant – even at prophylactic doses – alternative approaches might be considered, such as mechanical prophylaxis with compression stockings. An example may be a patient that had an intracranial hemorrhage and just underwent a neurosurgical procedure. But other than those exceptions, the majority of acutely ill medical patients should receive an anticoagulant for VTE prophylaxis. The evidence for any benefit from compression stockings, et cetera, is rather weak.

Dr Vega: Low-molecular-weight heparins have been available for almost 30 years now. What are the main pros and cons of these agents?

Dr Bhatt: Low-molecular-weight heparins, such as dalteparin and enoxaparin, have been available for a long time, so their effectiveness is well established. But all anticoagulants, including low-molecular-weight heparins, are associated with some increased risk for bleeding. When that happens, the recommended course of action is discontinuation of the heparin and administering of protamine sulfate, which effectively inactivates the circulating heparin. Another important consideration is the route of administration.

Low-molecular-weight heparins are given via subcutaneous injection and many patients dislike these injections, particularly if they have to administer those injections themselves after discharge. They often complain of pain and bleeding at the injection site. And, unfortunately, many patients will not use injectable anticoagulants because of fear, discomfort, or anxiety, or because they’re inconvenient.

This problem can be exacerbated in overweight patients, who need higher doses and, in some cases, 2 doses each day for a period of time. We know that patients would rather take an oral medication; so, for some of them – especially those who may need a longer period of anticoagulation – a DOAC can be a more attractive option. And, in fact, a recent analysis showed that the use of a DOAC for post-discharge VTE prevention has been increasing, while the use of heparins has been decreasing.

Dr Vega: The optimal duration of anticoagulant therapy across the continuum of care has been the subject of considerable discussion lately. One reason for that is the persistence of VTE risk far beyond the period when patients are actually in the hospital – more than half of all VTE events occur after discharge. The risk of symptomatic VTE is at its highest throughout the first 19 days after hospital admission. The thrombotic risk then begins to gradually decline, but it has been shown to persist for 45 to 60 days after discharge.

Dr Vega: Dr Bhatt, is there a standard duration of anticoagulant use for VTE prophylaxis?

Dr Bhatt: Well, for acutely ill patients who require hospitalization, thromboprophylaxis with parenteral heparin or fondaparinux should be given for 6 to 14 days. So, there’s a window, but the ASH guidelines recommend a minimum of 7 days. Today, however, the average length of a hospital stay following admission for an acute medical event is only 3 to 5 days. So, even if they receive anticoagulation while they’re in the hospital, the majority of patients are discharged before completing the course.

Dr Vega: So, could DOACs be a good way to ensure that patients are receiving effective prophylaxis throughout the duration of risk?

Dr Bhatt: We know that some DOACs can be very effective for preventing thrombosis across a range of clinical situations. And a number of years ago, the ADOPT trial enrolled acutely ill hospitalized patients with at least 1 additional risk factor. It compared the standard 6- to 10-day enoxaparin regimen against the factor Xa inhibitor apixaban, taken twice daily for 30 days. Apixaban provided a similar degree of risk reduction as the recommended course of enoxaparin, but the rate of bleeding was higher.

In 2017, another oral anticoagulant – betrixaban – was approved for VTE prophylaxis in adult patients hospitalized for an acute medical illness and at risk for thromboembolic complications. That approval was based on data from the APEX trial, in which patients receiving betrixaban for 35 to 42 days experienced fewer events than patients receiving the recommended course of enoxaparin. The most common adverse reactions with betrixaban were related to bleeding, but the number of serious adverse reactions was similar for both treatments.

Dr Vega: Now, betrixaban is no longer available, is that right?

Dr Bhatt: That’s correct – it was manufactured by a relatively small pharmaceutical company that decided to discontinue producing the medication for business reasons. But in 2019, rivaroxaban was also approved for the prevention of VTE in hospitalized acutely ill medical patients. This decision was supported by 2 separate studies – MAGELLAN and MARINER.

In MAGELLAN, patients hospitalized for acute medical illness and treated with rivaroxaban for 31 to 39 days were slightly less likely to experience asymptomatic proximal or symptomatic VTE compared with those given subcutaneous enoxaparin injections for 6 to 14 days.

Dr Vega: How did the 2 approaches compare with respect to the risk of bleeding?

Dr Bhatt: That’s a really important question. Major or clinically relevant nonmajor bleeding was more common in the rivaroxaban group. Between day 1 and day 35, 1.1% of rivaroxaban-treated patients had major bleeding, compared to 0.4% of the enoxaparin-group. Similarly, in the rivaroxaban group, 3% of patients experienced non-major bleeding events, compared with 1.3% of the enoxaparin group.

However, when they looked back at the data, they saw that about 20% of the participants in the study had at least one of 5 risk factors for major bleeding – active cancer, dual antiplatelet therapy at baseline, bronchiectasis or pulmonary cavitation, gastroduodenal ulcer, or bleeding less than 3 months prior to the study. When they analyzed what would happen if they used those 5 criteria to identify and exclude patients who were at high risk for bleeding, the rate of bleeding was lower. Yet the reduction in VTE events was similar for both rivaroxaban and enoxaparin, and better with rivaroxaban over 35 days.

Dr Vega: Were the results of the second trial similar to the findings from MAGELLAN?

Dr Bhatt: MARINER was again looking at these medically ill patients who were hospitalized for 3 to 10 days and, in this case, at increased risk for VTE. They received low-molecular-weight heparin or unfractionated heparin during their hospital stay, followed by either extended prophylaxis with once-daily rivaroxaban or placebo for 45 days after hospital discharge. The rates of symptomatic VTE or death due to VTE were similar for both groups and the incidence of major bleeding was very low, regardless of treatment.

Dr Vega: So that what do you take away from those results?

Dr Bhatt: Well, the overall trial doesn't appear to support extended use of a DOAC in addition to heparin for all hospitalized patients. But, for selected patients – such as those at particularly high thromboembolic risk, yet very low bleeding risk – continuing VTE prophylaxis with rivaroxaban following discharge may prevent them from having a serious event. And then there are patients who are not in the hospital long enough to get at least 6 days of low-molecular-weight heparin – they are under-protected and extended use of a DOAC could be especially beneficial in those individuals. I think we need more studies to really nail down all of these details.

Dr Vega [to camera]: When individuals are hospitalized with an acute medical illness, they typically go through a series of transitions of care – points when they are admitted to, transferred between, or discharged from either the healthcare facility or hospital wards. As Dr Bhatt mentioned, the average period between hospital admission and discharge, today, is shorter than the minimum recommended duration of VTE prophylaxis. So it’s vital that anticoagulant therapy is not only considered for all patients, but also, when appropriate, continued seamlessly across those transitions of care.

Dr Vega: Do you see transitions of care as an area where there’s a lot of room for improvement in VTE prophylaxis?

Dr Bhatt: Absolutely – I think that transitions from say the intensive care unit to the floor, or from inpatient care to the outpatient setting, provide opportunities for things to fall through the cracks. And VTE prophylaxis is one of those things that sometimes does get overlooked. Patients in the intensive care unit need to be on VTE prophylaxis for sure – I think that’s widely accepted and many ICUs have algorithms of care which, among other things, make sure that patients are getting the proper prophylaxis for VTE. So, ICUs are typically pretty good about that sort of thing. But things often fall apart when a patient is transferred to the floor.

Dr Vega: What do you think the main reasons for that are?

Dr Bhatt: The transition typically occurs when patients are considered to be getting better. And so, as I mentioned earlier, there can be this belief that because they’re out of the ICU, they're no longer bedbound and therefore they don't need VTE prophylaxis. But that’s not the case. Although they are getting better, that doesn't make them fully ambulatory and it doesn’t mean they are out of VTE risk. So, it’s very important for the receiving physician on the floor to make sure VTE prophylaxis is continued for the full duration. And, there’s always a possibility that it wasn't started in the intensive care setting for some reason – maybe there was some concern about extreme bleeding risk. But if they're now more stable, it isn’t too late to initiate anticoagulant therapy at that point.

Dr Vega: So, throughout transitions in care, it sounds like physicians need to be vigilant of any changes that may impact the patient’s risk for VTE, and re-evaluate the best approach to prophylaxis.

Dr Bhatt: That’s exactly right – optimal prevention of VTE requires ongoing patient assessments and, in many cases, adjustments to therapeutic strategies as the patient progresses through each hospital and outpatient setting. And it isn’t just something for physicians to think about. Interdisciplinary pathways have been shown to decrease VTE-related utilization of hospital resources and healthcare costs.

Dr Vega: What about when the patient is being discharged?

Dr Bhatt: The most important thing here is to be aware that their risk of VTE persists well beyond the hospital phase of therapy. And I think that really hasn't been appreciated until relatively recently. Remember that when they get home, they may not really be fully mobile – oftentimes they are still just sitting around or lying around in bed until they feel better. So, when we’re preparing patients for that transition, we need to identify those who might be candidates for extended prophylaxis.

As I said earlier, the data are open to some interpretation, but there are certainly signals that some patients are more likely to benefit from a DOAC. So, at all stages of the continuum of care, we should be assessing their VTE risk. There are quantitative tools that we can use to help us in that regard, such as the IMPROVE-VTE or PADUA models. We’re then going to look at whether they have an increased risk for bleeding.

There is no point in curing the acute illness that brought them to the hospital if we then allow them to experience a serious thrombotic event while they’re in our facility, or if they need to be readmitted with VTE a few weeks later. So, at each critical point in their care, we want to be sure that we’ve taken the appropriate steps to prevent those things from happening.

Dr Vega: On that note, Dr Bhatt, I’d like to thank you for joining us today – it was very good speaking to you.

Dr Bhatt: You too, Chuck.

Dr Vega: As always, we hope that you found this program informative and that you are able to apply the insights in your own clinical practice. Please continue on, to answer the questions that follow and complete the evaluation. Thank you for watching today’s discussion – goodbye for now.

This is transcript has not been copyedited.

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