From the Editor

Preventing clots: Don’t let the complex overshadow the simple

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Although we often approach anticoagulation therapy with a confidence born of familiarity, it is not for the faint of heart. We start chronic anticoagulation in several clinical settings, such as to prevent a recurrence after a thromboembolic event. But this decision requires weighing the increased risk of bleeding from the anticoagulant therapy against the risk of another thromboembolic event.

Along with massive pulmonary embolism, the most feared thromboembolic event is the clot that migrates to the brain, resulting in life-altering stroke. We assess this risk in a semiquantitative manner in patients with atrial fibrillation using the CHADS2 score, hoping to maximize the benefits of anticoagulation while reducing the risks. We recognize that patients at the greatest risk of stroke in this setting are those with a history of a prior stroke. Also, patients bedridden with a recent cerebrovascular accident (CVA) seem to be hypercoagulable, potentially adding risk to recent injury. Thus, we try to start anticoagulation as soon as feasible after the diagnosis of a possible thrombotic event.

But the decision to start or resume anticoagulation is especially agonizing in a patient who has suffered an intracerebral hemorrhage. In this issue of the Journal, Drs. Joshua Goldstein and Steven Greenberg and Dr. Franklin Michota provide a thoughtful discussion of the issues we need to consider in these patients.

While not contributing to the prevention of additional CVAs or other arterial thrombotic events, a modality often underused in the prevention of thrombotic disease is the application (not just the ordering) of compressive leg stockings to bedridden hospitalized patients who cannot, for any reason, be provided pharmacologic anticoagulation therapy. I just completed a stint of hospital consultation, and I was pleased to see the widespread integration of prophylactic anticoagulation therapy, but somewhat dismayed by the number of compressive stockings I watched pumping with vigor, but to no one’s benefit, as they were draped over a bed rail.

As we struggle with complex clinical decisions, we need to also be attentive to the simple and the seemingly mundane: using the foam dispenser at the door, offering the verbal greeting and patient touch at the bedside, and rewrapping the pneumatic stockings that have somehow migrated between mattress and footboard.

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