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A 72-year-old man is hospitalized with pneumonia and treated with intravenous antibiotics. His medical history is significant for a right hip replacement 1 year ago, complicated by heparin-induced thrombocytopenia and subsequent deep venous thrombosis in his left popliteal vein. He takes no regular medications.
Which of the following is the most appropriate next step in reducing this patient's risk for venous thromboembolism?
A Enoxaparin, 40 mg subcutaneously daily
B Aspirin, 325 mg daily
C Warfarin adjusted to an INR of 3.5
D Intermittent pneumatic compression
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(Correct Answer = D)
Key Point
Intermittent pneumatic compression is effective prophylaxis in patients at moderate to high risk for venous thrombosis in whom heparin and low-molecular-weight heparin are contraindicated.
Although the clinical evidence for reducing risk for venous thromboembolism with intermittent pneumatic compression is not as strong as that for heparin and low-molecular-weight heparin, it carries a very low risk of adverse effects and has been associated with substantial reductions in the incidence of embolism in populations at risk. Intermittent pneumatic compression is recommended for patients at moderate to high risk in whom heparin and low-molecular-weight heparin are contraindicated. This patient's history of heparin-induced thrombocytopenia with thrombosis (HITT) is a contraindication for the use of heparin and all low-molecular-weight heparins, because the antibodies that cause HITT cross-react with both medication classes. Warfarin has not been as well studied for prophylaxis in medical patients, but there is no evidence to support the use of high-dose warfarin in therapy for venous thrombosis, let alone for prophylaxis. Aspirin alone is not recommended for prophylaxis against venous thrombosis. The left popliteal vein would have about a 50% chance of showing some residual noncompressibility on ultrasound, even a year after treatment. The ultrasound findings described would not necessarily indicate the presence of a new venous thrombosis, especially in the absence of symptoms.
