Stop Routinely Anticoagulating Hospital Patients

Medpage Editorial Link By George Lundberg, MD, Editor-at-Large, MedPage Today, Editor-at-Large, MedPage Today Published: December 27, 2011 Transcript: Hello and welcome. I'm Dr. George Lundberg and this is At Large at MedPage Today. Another medical shibboleth bites the dust. Again and again, physicians confront bad disease. They use treatments that make intuitive sense without hard data because there aren't any. Then, over time, those procedures become "standard of practice" still without supporting evidence. Then the evidence against the treatment begins to accumulate but, like turning an oil tanker around in the Atlantic, it takes time and a lot of effort. The current best example is routine use of anticoagulants to prevent venous thromboembolism in hospitalized non-surgical patients. Lederle and three co-authors from Minnesota published an article entitled "Venous Thromboembolism in Hospitalized Medical Patients and Those with Stroke: A Background Review for an American College of Physicians Clinical Practice Guideline" in the Annals of Internal Medicine in November 2011. In order "to assess the benefits and harms of anticoagulant prophylaxis in hospitalized adult medical patients and those with acute stroke the authors used MEDLINE and the Cochrane Library from 1950 through April 2011, plus reference lists." "English-language randomized trials were selected if they provided clinical outcomes and evaluated therapy with low-dose heparin or related agents or mechanical measures compared with placebo, no treatment, or other active prophylaxis in the target population." "Two independent investigators extracted data on study characteristics and clinical outcomes up to 120 days after randomization. The primary outcome was total mortality." "In medical patients, heparin prophylaxis did not reduce total mortality but did result in fewer pulmonary embolisms (PEs) and an increase in all bleeding events. Heparin prophylaxis had no statistically significant effect on any outcome in patients with acute stroke except for an increase in major bleeding events." "When trials of medical patients and those with stroke were considered together (18 studies, 36,122 patients), heparin prophylaxis reduced the incidence of PE; absolute reduction, three events per 1,000 patients treated but increased the incidence of all bleeding and major bleeding events, with an absolute increase of nine bleeding events per 1,000 patients treated, four of which were major. No statistically significant differences in clinical outcomes were observed in the 14 trials that compared unfractionated heparin with low-molecular-weight heparin." They concluded that "heparin prophylaxis had no significant effect on mortality," may have reduced non-fatal pulmonary embolism in medical patients and all patients combined, but "led to more bleeding and major bleeding events, thus resulting in little or no net benefit." The authors did not report on the economic costs of this widespread practice but they are large indeed, and with no real benefit. Play it again, Sam, 100,000 times, until the doctors hear the data and practice evidence-based medicine. That's my opinion. I'm Dr. George Lundberg, At Large at MedPage Today.