Management of Thrombosis at KHSC

TMED Blog

| 23 March 2024

Written by Declan Gainer, MSc 25' (Candidate)

On February 9th, 2024, the Department of Medicine welcomed Drs. Natasha Satkunam, Kerstin de Wit, Reza Nasirzadeh, and Jenny Wright (NP) to Medical Ground Rounds. These four clinicians delivered an extensive presentation on the complexities of managing thrombotic disorders at the Kingston Health Sciences Centre (KHSC), and new initiatives that aim to improve patient outcomes.

Thrombosis describes a family of diseases collectively characterized by the formation of occlusive blood clots, known as thrombi, in arteries and veins. Thrombotic disorders are a significant cause of human mortality and morbidity, especially in older populations [1] and obese individuals with sedentary lifestyles [2, 3]. In 2010, it was estimated that 1 in 4 deaths globally resulted from thrombotic diseases, a substantial increase from 1 in 5 in 1990 [4], reinforcing the need for effective management and patient education strategies.

Only in September 2021 were dedicated outpatient services made available to the community. Dr. Satkunam highlighted how the implementation of this clinic was critical in clearing an extensive waitlist that had accrued as a consequence of the COVID-19 pandemic. The clinic is now capable of providing timely services, typically within 3 weeks, addressing cases before they complicate and progress to ischemic events or pulmonary emboli (PE) [5]. Drawing upon past clinical experience, Dr. Satkunam overviewed three cases to underscore several key principles of thrombosis management, namely patient education and well-conducted short- and long-term follow-ups. Access to therapy is an important aspect of long-term follow-up and is something that has been limiting for many individuals in the community. Jenny described how the clinic now provides access to affordable anticoagulation therapy (heparins, direct oral anticoagulants (DOACs)) and co-payment options, enabling lower-income individuals to start, or continue receiving, anticoagulation therapy.

Following an extensive review of outpatient resources that exist within the KHSC system, Dr. de Wit called attention to the Pulmonary Embolism Response Team (PERT). When diagnosed with venous thromboembolism (VTE), one is at risk of developing a PE. Low- and high-risk patients are readily identifiable, though intermediate-high risk patients are difficult to identify and manage [6]. Generally, these patients present with right ventricular dysfunction and elevated troponin levels [6, 7], and are more likely to become hemodynamically compromised [8]. Although PERT was designed to address intermediate-high risk cases, it has seen involvement in 13 cases thus far; 6 being intermediate-high, 4 being intermediate-low, and 3 high-risk. Only one high-risk patient has been lost, underscoring the effectiveness of the PERT.

Throughout the rounds, a recurring theme was the importance of rapidly, yet thoroughly, evaluating admitted patients. Dr. Nasirzadeh comprehensively overviewed a clinical case from the perspective of an interventionist on the PERT team, involving a 60 year old male presenting with shortness of breath, cough, and chest tightness. He detailed all necessary information that must be collected, including vitals, any ongoing anticoagulation therapies, ventricular ratios, and any electrocardiogram abnormalities, in order to guide management strategies. Though several therapeutic options are available, catheter-assisted pulmonary embolectomies are extensively utilized for their less-invasive and site-specific modalities, both being advantageous in unstable patients [9].

The importance of patient engagement was re-emphasized by Dr. Satkunam and Dr. de Wit in our post-rounds discussion, who commented on potential strategies to improve education in the clinic [10]. Though no research is being conducted on novel education strategies, Dr. de Wit highlighted how recent work has found that Apixaban may be favorable to other DOACs in the management of gastric cancer-associated VTE (CA-VTE) patients [11, 12]. This patient subset is associated with an elevated risk of bleeding, making management of CA-VTE difficult, and any new findings significant. DOACs, such as Rivaroxaban, are an exceptional example of translational research; screening work for inhibition targets in 1998 led to the identification of Rivaroxaban, a compound that was approved for clinical use only a decade later and has since revolutionized anticoagulation therapy. [13].

Beyond care delay and economic burden on the Canadian healthcare system [14], COVID-19 is also associated with pathological hypercoagulability, putting infected individuals at risk of developing arterial or venous thrombosis [15, 16]. In accordance with inconclusive literature [17], KHSC has not established any formal guidelines for COVID-19 outpatient thromboprophylaxis. Drs. Satkunam and de Wit commented on recent literature, suggesting a benefit in moderate-to-severely ill inpatients, and described how these findings raised discussion surrounding management strategies at KHSC.

I would again like to thank Drs. Satkunam, De Wit, Nasirzadeh, and Jenny for taking the time to inspire and educate the next generation of clinicians and scientists on an exceptionally important and ever-relevant topic.

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17. Kyriakoulis KG, Dimakakos E, Kyriakoulis IG, Catalano M, Spyropoulos AC, Schulman S, et al. Practical Recommendations for Optimal Thromboprophylaxis in Patients with COVID-19: A Consensus Statement Based on Available Clinical Trials. J Clin Med. 2022;11(20).

Management of Thrombosis at KHSC

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Management of Thrombosis at KHSC

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