What DVT prophylaxis and dose should be started for a patient with history of heart failure (HF), diabetes mellitus (DM), hypertension (HTN), atrial fibrillation (AFib), severe aortic insufficiency (AI) and aortic stenosis (AS), bioprosthetic aortic valve replacement (AVR), coronary artery bypass grafting (CABG), impaired renal function (GFR 26), non-ST elevation myocardial infarction (NSTEMI), and recent mechanical fall?

From the Guidelines

For this patient with multiple comorbidities including heart failure, diabetes, hypertension, atrial fibrillation, valve disease with bioprosthetic AVR, CABG, impaired renal function (GFR 26), NSTEMI, and recent mechanical fall, I recommend enoxaparin 30 mg subcutaneously every 12 hours for DVT prophylaxis, as the standard dose of 40 mg daily may need to be adjusted due to renal impairment 1. Given the patient's renal impairment, with a GFR of 26, it's crucial to consider the dosing of anticoagulants carefully to avoid increased risk of bleeding.

• Enoxaparin at a reduced dose is a reasonable choice because it has been shown to reduce demonstrable venous thrombosis in patients with adequate renal function, although effects on mortality or clinically significant pulmonary embolism rates are unclear 1.
• Alternatively, unfractionated heparin 5000 units subcutaneously every 8 hours could be considered, as it does not require dose adjustment for renal impairment, providing a predictable anticoagulant effect without the need for monitoring in this context.
• Mechanical prophylaxis with sequential compression devices should be added to pharmacological prophylaxis, especially if the latter needs to be temporarily held due to bleeding concerns. The patient's recent mechanical fall increases the bleeding risk but does not absolutely contraindicate pharmacological prophylaxis; thus, the decision should balance thrombotic risk against bleeding risk, considering the patient's high thrombotic risk due to multiple comorbidities, recent NSTEMI, and likely immobility.
• Early ambulation should be encouraged as the patient's condition allows, to further reduce the risk of venous thromboembolism. The choice of DVT prophylaxis should be guided by the most recent and highest quality evidence, which in this case supports the use of enoxaparin or unfractionated heparin for hospitalized patients at risk of VTE, with careful consideration of renal function and bleeding risk 1.

From the FDA Drug Label

A number of well-controlled clinical trials have demonstrated that low-dose heparin prophylaxis, given just prior to and after surgery, will reduce the incidence of postoperative deep vein thrombosis in the legs (as measured by the I-125 fibrinogen technique and venography) and of clinical pulmonary embolism The most widely used dosage has been 5,000 units 2 hours before surgery and 5,000 units every 8 to 12 hours thereafter for seven days or until the patient is fully ambulatory, whichever is longer.

The patient should be started on low-dose heparin prophylaxis with a dose of 5,000 units every 8 to 12 hours to prevent deep vein thrombosis (DVT) 2.

• Key considerations:
  • The patient has a history of severe medical conditions, including heart failure, diabetes mellitus, hypertension, atrial fibrillation, and severe aortic insufficiency and aortic stenosis.
  • The patient has undergone bioprosthetic aortic valve replacement, coronary artery bypass grafting, and has impaired renal function.
  • The patient has recently experienced a non-ST elevation myocardial infarction and a mechanical fall.
  • Heparin dose adjustment may be necessary based on the patient's renal function and other clinical factors.
  • Monitoring of the patient's coagulation parameters and clinical status is essential to minimize the risk of bleeding complications.

From the Research

DVT Prophylaxis for Patient with Renal Impairment

• The patient has a history of heart failure (HF), diabetes mellitus (DM), hypertension (HTN), atrial fibrillation (AFib), severe aortic insufficiency (AI) and aortic stenosis (AS), bioprosthetic aortic valve replacement (AVR), coronary artery bypass grafting (CABG), impaired renal function (GFR 26), non-ST elevation myocardial infarction (NSTEMI), and recent mechanical fall.
• For patients with severe renal insufficiency, the use of low-molecular-weight heparin (LMWH) such as dalteparin or enoxaparin for DVT prophylaxis is a consideration, but the risk of bleeding must be carefully weighed against the benefits of thromboprophylaxis 3, 4.
• A study comparing enoxaparin and unfractionated heparin (UFH) for VTE prophylaxis in medically ill patients receiving hemodialysis found that enoxaparin may be as safe and effective as UFH 5.
• However, another study found that enoxaparin was associated with an increased risk of major bleeding compared to UFH in critically ill patients with renal impairment 6.
• The use of dalteparin for DVT prophylaxis in critically ill patients with severe renal insufficiency was found to be safe and effective, with no evidence of bioaccumulation or excessive anticoagulant effect 3.

Recommended DVT Prophylaxis

• Based on the available evidence, dalteparin 5000 IU once daily may be a suitable option for DVT prophylaxis in this patient, given the patient's severe renal insufficiency and high risk of bleeding 3, 4.
• However, the decision to use dalteparin or another anticoagulant should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.
• Close monitoring of the patient's renal function and anticoagulation status is recommended, regardless of the chosen DVT prophylaxis regimen 4, 6.