Thromboprophylaxis for patients with HF

“Based on the absolute risk reduction estimated in this meta-analysis, if prophylaxis is used, approximately 185,255 VTE [venous thromboembolism] events would be prevented in the world annually,” says Yu Hu, lead author of a systematic review published in the Lancet Haematology.

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VTE, which manifests as deep-vein thrombosis or pulmonary embolism, is a multifactorial disease. An association with heart failure (HF) in elderly patients has been observed in previous studies, and thromboprophylaxis is recommended in acutely ill, hospitalized patients with HF. However, no evidence supports routine use of thromboprophylaxis in these patients. A number of studies have been conducted to explore the risks of VTE and benefits of prophylaxis, but reported rates vary considerably. Therefore, Hu and colleagues performed a systematic review and meta-analysis to quantify the rates of VTE and relative risks in hospitalized patients with HF.

Analysis of 71 studies showed that, after adjusting for confounders, HF was an independent risk factor for VTE with a relative risk of 1.51. The researchers also noted that rates of VTE varied widely with patients' characteristics and were highest in patients with cancer (6.7%) — an important finding given that clinicians are often reluctant to prescribe thromboprophylaxis in this population because of concerns about bleeding complications. Moreover, meta-analysis showed that the use of thromboprophylaxis reduces the absolute risk of thromboembolism in hospitalized patients from 3.73% to 1.47%. Finally, the researchers report a racial difference in the absolute risk of VTE. Without prophylaxis, the median rate of VTE was much lower in Asian cohorts (0.77%, IQR 0.51–3.80%) than in non-Asian cohorts (6.44%, IQR 2.91–7.68%).

“Personalized management of venous thromboembolism should be developed to account for patient characteristics”

Despite the limitation of considerable heterogeneity between the studies included in the analysis, this study raises an important clinical question, which is posed by Torben Bjerregaard Larsen in an accompanying Comment article: “Can we identify patients with heart failure at risk of venous thromboembolism, and should we offer routine thromboprophylaxis to patients with heart failure?” On the basis of their findings, Hu and colleagues propose that personalized management of VTE should be developed to account for patient characteristics.

A further limitation of the study is that analysis of subgroups by severity of HF using the NYHA classification was not possible, because these data were not available in most of the included studies. Therefore, the group will now focus further research efforts on investigating the effects of severity of HF on the risk of VTE.

“Adequate and rigorous VTE prophylaxis for HF as done in clinical trials is needed in clinical practice, and greater efforts are urgently required to increase physician awareness of HF-associated VTE,” concludes Hu.

Related links

Related links in Nature Research

Larsen,T.B.etal.Riskofvenousthromboembolisminpatientswithheartfailure.LancetHaemtol.http://dx.doi.org/10.1016/S2352-3026(15)00249-5