Spring Learning Event: Unanswered Speaker Questions

The Spring Learning Event, held on June 8, 2021, was packed full with clinicaly relevant information on PAD and VTE. There were a few questions that we weren’t able to get to during the event, but our speakers have kindly agreed to answer your questions below.

Reducing Health Disparities Through Increased PAD Awareness, Identification and Management

Abbie Schrader, ARNP

What tests are done to diagnose PAD?

The best test is the Ankle-brachial index (ABI). There are also special ultrasound techniques or angiography that can help with diagnosis.

Any studies with PCSK9 being used with PAD?

Two readings to help answer the question:

• PCSK9 Inhibitor improves outcomes for patients with peripheral artery disease
• Lipid-lowering therapy in patients with peripheral artery disease

Do you have any recommendations for or against compression therapy for leg edema, such as caution based on low ABI, etc?

Compression therapy can be very helpful for lymphedema. We also do EECP therapy in my office. I find it helpful to have a baseline ABI. You do need to be careful with compression therapy in those with prior intervention or stent placement in the legs.

Should we advocate more for screening for PAD for those patients, then that might tip the decision re: which med??

I think it is so important to screening for potential PAD patients. Those patients over 65, or with diabetes or other risk factors would really benefit from a good physical exam and also assessment of walking capability. We are often diagnosing to late. Identifying these patients early helps optimize medical therapy.

Prevention and Treatment of Venous Thromboembolism (VTE) from Hospital to Home

Kelly M. Rudd, PharmD, FCCP, BCPS, CACP

Do you have any evidence on pharmacological DVT prophylaxis for patients on long-term IV antibiotics who are in long-term care/rehab units who are not candidates for the same prophylaxis otherwise?

There are no specific guidance documents which address this. Many of these patients overlap with characteristics of hospital inpatients (indwelling catheter is a risk factor for thrombosis, immbolity, infection, plus likely others) where pharmacoprophylaxis for VTE would certainly be acceptable. This may also be a nice role for rivaroxaban, given the extended duration dosing for medical prophylaxis (though this population specifically was not the cohort of the clinical trials).

Do you expect CIC to be added to thrombosis risk assessment tools?

CIC at present is in it’s own category when considering VTE prophylaxis. It will take time to incorporate into risk assessment tools (technically “re-validation” will be required.) Many sites have not hesitated to add CIC as a criteria within their “High Risk” VTE Bucket.

Please go over again your resource center and how to access it.

Of course! PCNA’s website has several resources:

• Provider tools can be found here.
• VTE tools for patients can be found here.

ASA 325mg twice a day as prophylaxis- what is your opinion on its evidence?

This is a great question and one still greatly debated in the anticoagulation community! There are obviously proponents on both sides of this – much of the renewed interest stems from reanalysis of older data (the same data that had been used to discredit ASA as an option for VTE prophylaxis!) With the lack of strong, randomized head-to-head trials, and the strong data supporting other modalities (ie. heparin), this is a lower line option in my personal practice for moderate to high risk patients…and in many of the guidance documents.

If the patient has a DVT on right leg, can we allow compression therapy or compression socks on the same leg?

Thank you for bringing this up. Yes! Compression stockings are well accepted in the setting of acute VTE, and much like early ambulation, had been feared to precipitate embolism. The data shows quite the opposite – a great increase in symptom relief and some potential reduction in the development of post-thrombotic syndrome (previously recommended in CHEST 2012 guidelines, quality of evidence is considered low due to considerable heterogeneity between studies and lack of blinding.) Within those studies, no serious adverse effects were noted. Note: this is graduated compression stockings, not pneumatic compression devices 🙂 Patients may also require them beyond the initial period to help mitigate swelling from PTS in the future.

What is the recommendation in classifying a pregnant patient with a history of cancer? What about this same patient postpartum after delivery?

Within the risk stratification, ACTIVE cancer is the risk. History of cancer, or cancer considered in remission or cured, does not confer the same risk. ASH, AC Forum and others have issued guidance regarding VTE treatment and prophylaxis in pregnancy. I will point you to a resource that my colleague, Dr. Amanda Winans authored bringing the best evidence together (also posted on the AC Forum Resource Center).

PCNA is a great provider & patient information resource center. Dr. Rudd just mentioned something she even had downloaded on her phone and I wrote down the Anticoagulation Center of Excellence Resource center. Did not know if that was specific to where she works or a site pertinent no matter where you are.

This is a fabulous resource from the AC Forum, continually being updated. My “go-to!”

Dietary vitamin K teaching for DOAC’s too? prefer teaching “keep the amount of greens stable”?

Fluctuations or amount of intake of dietary vitamin K has no impact on DOAC therapy. They bind to and directly inhibit the functionality of the clotting factors well past the point of vitamin K’s involvement in the production of the clotting factor…which is where warfarin exerts it’s pharmacologic effect, and why the warfarin-effect can be negated by increases in vitamin K.

What is the best way to encourage patients to wear Sequential Compression Devices (SCDs) while they are hospitalized after surgery? Most patients refuse SCDs.

Agreed, patients struggle with this, until they have the VTE and then the swelling, pressure and pain really helps change the perspective. Many of our conversations about the use of SCDs comes early in our process (not with the front-line nurse trying to place them!) but rather by getting buy-in from the surgical and pre-admissions teams to help provide education early…both including the WHY (prevent DVT which can turn into a fatal PE) and that they are a standard and you will/may/will likely be asked to wear them in the hospital. (This also brings up conversations about and EARLY risk assessment – the “will” – or institutional policy – example – all surgical vs. some surgical patients will have them ordered.)