Which one is more expensive? Is it Thrombo-prophylaxis or Treatment for VTE?

Sometimes a question is raised about the cost benefit of thromboprophylaxis over the treatment of confirmed VTE in our hospitalized patients. In one study Gualberto Gussoni et al (2013) from Italy showed that the VTE management costs 4 times more than the prophylaxis.

They have examined in-hospital paths of 160 patients with VTE (VTE group) and 160 patients receiving prophylaxis and without VTE (NO-VTE group) retrospectively within 26 internal medicine units in Italy. The total median costs for VTE management were around four-times higher than those for prophylaxis (€ 1,348.68 vs € 373.03). Human resources were the most important cost-driver (55.5% and 65.7% in the VTE and NO-VTE groups), followed by instrumental (24.6% in VTE and 15.5% in NO-VTE) and haematologic tests (12.6% in VTE patients and 13.3% in controls). In the NO-VTE group the direct costs for prophylaxis accounted for 4.5% of total.  The real-world data of this study confirm the economic burden of in-hospital treatment of VTE, and the relatively low costs of thromboprophylaxis. A greater adherence to evidence-based protocols for VTE prevention could probably reduce the current financial burden of VTE on healthcare systems

The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults

PTS is a frequent complication of UEDVT, yet little is known regarding risk factors and optimal management. A standardized means of diagnosis would help to establish better management protocols. The impact of upper extremity PTS on quality of life should be further quantified.
Seven studies were reviewed. The frequency of PTS after UEDVT ranges from 7- 46% (weighted mean 15%). Residual thrombosis and Axillo-Subclavian vein thrombosis appear to be associated with an increased risk of PTS, whereas catheter-associated UEDVT may be associated with a decreased risk. There is currently no validated, standardized scale to assess upper extremity PTS, and little consensus regarding the optimal management of this condition. Quality of life is impaired in patients with upper extremity PTS, especially after DVT of the dominant arm.

In our clinical practice, we generally recommend heparin therapy for the  upper limb DVT,  which is less expensive and easy to administer. We do not have  cost benefit evaluation studies comparing the thrombolytic and heparin therapies for upper limb DVT. It is possible to expect the results of thrombolysis in the Upper limb DVT, similar to lower limb DVT. It is also common to see the upper limb DVT in the patients who are on IJV or subclavian catheter for the hemodialysis. In our hospital this aspect of the DVT in the upper limb can be studied further to understand the significance of the PTS in the upper limb DVT associated with central venous catheters.


References:

Elman E E, Kahn SR.The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: a systematic review. Thromb Res.2006;117(6):609-14. Epub 2005 Jul 6.

Impact of the Initial High Dose of Rivaroxaban on Thrombus Resolution in VTE patients

Initial heparin therapy followed by oral anticoagulation for 3 to 6 month has been standard therapy for DVT in many clinics. The recently introduced Rivaroxaban, Apixaban are given without initial heparin therapy. So, few doctors are still comfortable giving initial heparin therapy and later oral anticoagulation. The question is about the effectiveness of the high dose of Rivaroxaban or Apixaban given initially? Can resolution of the thrombus in those who received Rivaroxaban and Apixaban  can be comparable to that in patients who received the Inj. Heparin? 

Bauersachs R et al (Feb 2017) presented Data accumulating on the use of non-VKA oral anticoagulants, such as Rivaroxaban. He is of the opinion that these may provide greater thrombus resolution compared with VKAs. Data from the phase III Rivaroxaban studies discussed showed that a 21-day intensive dosing regimen of Rivaroxaban 15 mg twice daily is effective during the acute treatment phase for VTE, with similar recurrence rates and thrombus resolution to standard anticoagulation.

Probably one may need some more time, studies and availability of the antidote to reverse these drug effects, before he or she can consider recommending the high dose initial therapies of NOACs with more confidence.

References:

1). Bauersachs R¹, Koitabashi N. Overview of Current Evidence on the Impact of the Initial High Dose of the Direct Factor Xa Inhibitor Rivaroxaban on Thrombus Resolution in the Treatment of Venous Thromboembolism. Int Heart J. 2017 Feb 7;58(1):6-15.

https://www.ncbi.nlm.nih.gov/pubmed/28123163

Cardiovascular Disease and mortality- Is it changing in Type 1 and Type 2 Diabetes, Now ?

It is our hope that the morbidity and mortality should be much less with introduction of many antidiabetic, antihypertensive and anti lipidemic therapies in the past few decades. In one recent study published in the NEJM.org the absolute changes in the incidence rates of sentinel outcomes per 10,000 person-years were observed in the type 1 and type 2 diabetes patients 198-2012.

Patients with type 1 diabetes had roughly 40% greater reduction in cardiovascular outcomes (CVOs) than controls, and patients with type 2 diabetes had roughly 20% greater reduction than controls. Reductions in fatal outcomes were similar in patients with type 1 diabetes and controls, "whereas patients with type 2 diabetes had smaller reductions in fatal outcomes than controls".

This finding of Swedish doctors from 1998 through 2014, mortality and the incidence of cardiovascular outcomes declined substantially among persons with diabetes, although fatal outcomes declined less among those with type 2 diabetes than among controls, makes us think what could be reason for failure to reduce the fatal outcomes more significantly ? we have introduced so many new ways to treat these patients medically with drugs and interventions! Why these are adding up to reduce the fatal outcomes! in type 2 diabetes.  May be we have not understood the pathophysiology adequately and so the corrective measures are not effective too!

Reference: 

1). Aidin Rawshani,., Araz Rawshani, Stefan Franzén, Björn Eliasson,, Ann-Marie Svensson, Mervete Miftaraj, Darren K. McGuire, Naveed Sattar, Annika Rosengren, and Soffia Gudbjörnsdottir. Mortality and Cardiovascular Disease in Type 1 and Type 2 Diabetes. N Engl J Med 2017; 376:1407-1418

Is there Risk of Bleeding After Carotid Endarterectomy with dual antiplatelet therapy?

May of us are concerned about the unexpected bleeding after carotid endarterectomy. Some times suture needle puncture bleeds for a long time after endarterectomy. Some of  us assume that this could be more if the patient is on two or more anti platelet drugs preoperatively. Most of these patients might have already undergone coronary stenting procedures earlier. The cardiologist would like to  continue the antiplatelet drugs in perioperative period as there is risk of stent thrombosis in the absence of these drugs. Giulio Illuminati et al recently published their data related to the safety of using dual antiplatelet therapy in the carotid endarterectomy patients. 188 patients received dual anti platelet drugs (Aspirin 100mg, Clopidogrel 75mg) and Inj. LMWH- 2000 units B.D (till discharge) in the post operative period, started 6 hours after surgery without any complications. There were no postoperative cervical hematomas requiring surgical evacuation. There was one hypoglossal nerve palsy, which regressed within 2 weeks. There was no postoperative mortality and neurologic and cardiac morbidity.
This study is too good to believe and I am sure some surgeons will be still apprehensive to use this regimen after carotid endarterectomy in their practice.

Reference:
1) Giulio Illuminati, Fabrice Schneider, Giulia Pizzardi, Federica Masci, Francesco G. Calio', Jean-Baptiste Ricco. Dual Antiplatelet Therapy Does Not Increase the Risk of Bleeding After Carotid Endarterectomy: Results of a Prospective Study. Annals of Vascular Surgery. 2017; 40:39 - 43

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Giulio Illuminati

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Affiliations

• The Department of Surgical Sciences, University of Rome “La Sapienza”, Rome, Italy

Correspondence

• Correspondence to: Giulio Illuminati, MD, The Department of Surgical Sciences, University of Rome “La Sapienza”, Via Vincenzo Bellini 14, Rome 00198, Italy

Real-world economic burden of VTE and VTE prophylaxis in clinical practice

It is a general opinion that the treatment of VTE will be more expensive than the prevention of VTE with prophylactic measures. So, there is need to consider the thromboprophylaxis in our patients who are at high risk of VTE to reduce the overall economic burden in the world. In their study, Gussoni G et al (1) noticed that costs for VTE management (the total median) were around four-times higher than those for VTE prophylaxis (€ 1,348.68 vs € 373.03). This means if we follow the evidence-based protocols for VTE prevention, it could limit the current financial burden of VTE on our health budgets. Many clinicians may not feel this net clinical benefit in their small group of patients to get convinced about the larger role of thromboprophylaxis in the health care systems. 

Reference

1). Gussoni G, Foglia E, Frasson S, Casartelli L, Campanini M, Bonfanti M, Colombo F, Porazzi E, Ageno W, Vescovo G, Mazzone A; FADOI Permanent Study Group on Clinical Governance. A real-world economic burden of venous thromboembolism and antithrombotic prophylaxis in medical inpatients. Thromb Res. 2013 Jan;131(1):17-23

Can Arterio-Venous Fistula (AVF) precipitate or worsen congestive heart failure in ESRD patients going for initiation of hemodialysis?

The chronic kidney disease patients are referred to vascular surgeons for creating an arterio-venous fistula for hemodialysis with different types of hidden cardio-vascular problems. We have noted that those patients with sub clinical congestive heart failure are at greater risk of worsening of the cardiac condition after creation of the arterio-venous fistula for hemodialysis. In general, it was observed that patients with CHF and ESRD have poor prognosis. Optimizing the hemodynamics is crucial in both these conditions. Adding the AVF as a third factor in these patients can also make the optimization of hemodynamics more difficult. When an AVF is created, it reduces peripheral resistance, increases the preload and the stroke volume and cardiac output are increased. In 7 to 10 days the cardiac output is increased by 15% to 20%, left ventricular end diastolic pressure is increased by 5% to 10%. The Atrial naturietic and brain naturietic factors (ANP, BNP) are elevated.  The higher flows throughs the AVF was not seem to be linked to the incidence of high output failure. The fistula flows will be twice higher in the upper limb than those at the wrist. The upper arm AVF flows (Q_a) will be between 1.13 to 1.72 Lit/min. The fistula flow can be higher than 2 lit/min (Q_a) in 15% of the patients. Generally, the ratio between cardiac output and fistula flow (Q_a) is 22% in the upper limbs. The risk of high output heart failure is high when CO/Q_a is more than 40%. It was observed that 17% of the patients developed de novo congestive heart failure in the HEMO study. Median time to develop high output heart failure will be 51 days and it is noted in 40% of the upper limb Brachio-cephalic and 8% of the Radio-cephalic arteriovenous fistula.

Dr. Pinjala R K

14 April 2017