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The Fallacy of Individual Risk Stratification and Chemoprophylaxis

  • Eric Swanson
Chapter

Abstract

In an effort to identify patients at greater risk of venous thromboembolism (VTE), individual risk assessment using Caprini scores has been promoted. The Venous Thromboembolism Prevention Study, published in 2011, claims that patients with higher Caprini scores are at greater risk for VTE and the risk may be reduced by administering enoxaparin, despite an equal VTE incidence, 1.2%, in both control and anticoagulated patients overall, and no significant difference comparing anticoagulated and control patients with higher Caprini scores. Many VTEs occur in patients with low Caprini scores. Unfortunately, some plastic surgeons have testified that risk stratification and chemoprophylaxis represent the standard of care.

Caprini scores were not developed scientifically and do not correlate with relative risk values. Affected patients cannot be reliably predicted (97% false-positive rate). Caprini has numerous financial conflicts with anticoagulant manufacturers. Subsequent studies and meta-analyses fail to support risk stratification and chemoprophylaxis as an effective means to reduce VTE risk.

The same meta-analyses show that chemoprophylaxis increases the risk of bleeding. Oral anticoagulants are not FDA approved for VTE prophylaxis in plastic surgery patients and also increase the risk of hematomas.

Sequential compression devices are widely used and perceived to reduce risk, but there is little evidence of their efficacy. Alternative methods to reduce risk for all patients include recognition of the need to preserve the calf muscle pump during surgery by avoiding general endotracheal anesthesia with paralysis. Surgeons using intravenous sedation report lower VTE rates. Clinical findings are notoriously unreliable. Doppler ultrasound surveillance can be used to detect deep venous thromboses, replacing ineffective risk models.

Keywords

Venous thromboembolism VTE Fallacy Risk Stratification Chemoprophylaxis Caprini Bleeding 

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Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Eric Swanson
    • 1
  1. 1.Swanson CenterLeawoodUSA

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