HAEMOSTASIS
Blood coagulation in the spotlight
Almost 300 delegates attended the annual scientific meeting of UK NEQAS for Blood Coagulation, held at Sheffield Hallam University Conference Centre. PETER COTTON reports.
The annual scientific meeting run by UK NEQAS (National External Quality Assessment Service) for Blood Coagulation (BC) is a prestigious event that attracts internationally recognised experts to present state-of-the-art reviews on clinical, laboratory and research aspects of haemostasis. In addition to the formal lecture programme of the meeting, a significant commercial exhibition offered delegates the opportunity to view the most up-to-date analytical, diagnostic and therapeutic innovations in the field of haemostasis.
Oral anticoagulation Professor IsobelWalker UK NEQAS BC scheme director, opened the meeting, welcomed delegates and thanked the speakers and exhibitors, before introducing Dr Mike Makris (Sheffield) to chair the opening session, which focused on venous thrombosis and oral anticoagulation. The first presentation entitled Anticoagulant Dosing – Do We All Agree? was given by Dr Ian Jennings (Sheffield). Dose-adjusted therapy with vitamin K antagonists (e.g. warfarin), according to the international normalised ratio (INR), is an effective and well- established practice for the treatment and prevention of venous thromboembolism (VTE). While many quality assessment schemes are available to monitor the accuracy and precision of the INR result, there is no established system to assess the quality of anticoagulation management and its variation between different centres or individuals. UK NEQAS attempted to address this by providing participating centres with relevant clinical details and historical INR and dose data for four hypothetical cases. Using these data, together with a given
28 THE CLINICAL SERVICES JOURNAL
current INR, participants were asked to suggest the appropriate target INR, dose and retest interval for each case. Case one was considered very straightforward with the previous INRs being stable and in range, the previous doses unchanged and the current INR also in range. Not surprisingly, there was good agreement, with 99% of respondents suggesting the same dose and similar recall interval. The other three cases were less straightforward and showed varying degrees of INR fluctuation, dose variation and changing clinical background. In each of these cases, respondents suggested significantly different target INR, dose and recall interval. The exercise illustrated that, given similar clinical situations, there are large and potentially clinically significant differences in the approach to managing oral anticoagulation other than when the dose is stable and the INRs are stable and in range.
Thromboprophylaxis Hospital-associated venous thrombosis was discussed by Dr Menno Huisman (Leiden, The Netherlands) in his presentation entitled Who is at Risk of Venous Thromboembolism. Hospitalisation is associated with an increased risk of venous thromboembolism (VTE) and it is estimated that about 25,000 people die in hospital in the UK each year from preventable VTE. Until relatively recently there has been a general lack of awareness of this risk, which applies to both surgical and medical patients, and consequently an inconsistent approach to VTE thromboprophylaxis by hospitals is widely reported. A UK survey suggested 71% of patients at medium to high risk of deep vein thrombosis did not receive any form of prophylaxis. Recently published National Institute for Health and Clinical Excellence (NICE) guidelines (Guideline 92, January 2010) should help to address the problem by increasing awareness and thus hopefully reducing hospital- associated VTE. The general aim of the guidelines is to ensure that all hospitalised patients are triaged on admission for thrombotic and bleeding risks according to a standardised assessment pathway, and if the risk of VTE outweighs the risk of bleeding then patients should receive appropriate thromboprophylaxis. It is incumbent on all hospitals to have documented procedures and practices in place to ensure all patients are assessed and appropriate thromboprophylaxis offered if indicated.
Venous thromboembolism Duration of Anticoagulation in Venous Thromboembolism was the title of the presentation given by Dr David Keeling (Oxford). Following a first episode of VTE the generally accepted duration of treatment with oral anticoagulants (e.g. warfarin) has been between three and six months. At the end of this period of treatment, if the risk of VTE recurrence exceeds the risk of anticoagulant-related
MARCH 2012
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