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    Padua Prediction Score for Risk of VTE

    Determines anticoagulation need in hospitalized patients by risk of VTE.
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    When to Use
    Pearls/Pitfalls
    Why Use

    The Padua score can be applied to hospitalized patients who have the potential risk of VTE. Patients who are high risk (Padua ≥4) could benefit from thromboprophylaxis.

    • The Padua prediction score identifies admitted patients who may be high risk for venous thromboembolism (VTE) and would benefit from thromboprophylaxis.
    • Though promising, the Padua score has yet to be validated in large prospective studies and therefore its routine use can not be completely supported.
    • A retrospective review of review of patients with sepsis found no relationship between a Padua ≥4 and VTE, though it was a predictor of mortality.
      • The model was based off of a previously published clinical prediction rule and not derived from formal criteria.
      • The majority of patients who developed VTE had active cancer.
      • Follow-up VTE testing was only performed if the patient was symptomatic.
      • Patients with contraindications to prophylaxis were not included in the study.
    • All hospitalized patients are at increased risk for VTE.
    • High risk patients for VTE are often not adequately prophylaxed.
    • VTE is associated with increased morbidity and mortality.

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • Many of the patients who developed VTE had active cancer or were older.
    • However, this paper does demonstrate an overall lack of appropriate thromboprophylaxis in patients where the benefit may outweigh the risk.
    • In the appropriate setting when a physician is already considering thromboprophylaxis for a patient considered high risk for VTE, a Padua score of ≥4 has the potential to support their clinical gestalt.

    Management

    For patients admitted to a medical floor:

    • Padua Score <4: Low risk of VTE.
      • Thromboprophylaxis should be considered on a case-by-case basis.
    • Padua Score ≥4: High risk of VTE.
      • Thromboprophylaxis (i.e. heparin / enoxaparin) is recommended for non-pregnant patients without contraindications (major bleeding, low platelets, creatinine clearance < 30 mL/min) who are >18 years.

    Critical Actions

    • The Padua score is meant to risk stratify patients who have a potential risk for VTE, not to diagnose VTE.
    • If deemed appropriate, anticoagulation should not be withheld from patients who require it as part of the treatment for their diagnosis.
    • Prior to initiating any anticoagulant therapy a patient’s bleeding risk should be evaluated.

    Formula

    Addition of the selected points, as above.

    Facts & Figures

    Score interpretation:

    • Padua Score ≥ 4 points - Pharmacologic prophylaxis is indicated. If high risk of bleeding, use mechanical prophylaxis.
    • Padua Score < 4 points - Pharmacologic prophylaxis is not indicated, consider using mechanical prophylaxis.

    Evidence Appraisal

    • The purpose of this study was to risk stratify patients admitted to an internal medicine service to either high or low risk of VTE, and the to assess whether prophylaxis in high risk patients reduced the number of VTE events.
      • Time: Jan 2007 to Dec 2008 in Padua Italy.
      • Inclusion: All non-pregnant patients 18 yo or older Admitted to the Second Division Internal Medicine and not on anticoagulation, did not require anticoagulation for a diagnosis and had no contraindications.
      • The prediction score was created by integrating an existing model (Kucher Score) with additional conditions for which thromboprophylaxis is recommended.
    • Prospectively, patients were identified by an operator as being high or low risk for VTE based on the Padua score, where ≥4 was considered high, and <4 low. The physician caring for the patient was not involved in the risk stratification.
      • Charts were monitored for when prophylaxis was initiated within 48 hours of admission.
      • Prophylaxis included heparin, enoxaparin, dalteparin, nagroparin or fondaparinux for at least 80% of admission. Those patients that did not meet criteria were considered to have not received prophylaxis.
      • Patients were monitored and followed up for 90 days after admission.
    • Any suspicion of VTE was ruled out by negative d-dimer in the low risk group, and imaging in positive d-dimer or high risk patients. In the case of patient death, an autopsy report was used.
    • Patients were monitored for major bleeding complications which required transfusion of two units of pRBCs, retroperitoneal, spinal or intracranial bleeding or bleeding in association with a critical organ or death. “Relevant” bleeding events were defined as non-major, but required an intervention.
    • The main outcome measure was 3 month complication of VTE in the high-risk group who were anticoagulated vs not, and then compare the high-risk group to the low-risk.
    • 2,208 eligible patients were screened for the study. 1,028 met exclusion criteria resulting in 1,180 patients in the final cohort. 469 (39.7%) were high risk with a Padua score of ≥4. 711 (60.3%) has a score of <4 and were considered low-risk.
    • 186 (39.7%) of the high risk patients received appropriate pharmacologic thromboprophylaxis. 283 (60.7%) did not (includes compression stockings alone or inappropriate doses of anticoagulation). 52 (7.3%) of the low risk patients received pharmacologic prophylaxis.

    VTE Complications

    • VTE events occurred in 37/1180 (3.1%) patients in the cohort. 35/469 (7.5%) occurred in the high-risk patients, 4/186 (2.2%) in the patients who received prophylaxis and 31/283 (11.8%) who did not. HR for VTE was 0.13.
    • Two (0.3%) VTE events occurred in the low-risk patients. Relative risk (RR) for high-risk without prophylaxis vs. low-risk was 38.9.
    • After adjustment, calculated Hazards Ratio (HR) for high-risk without prophylaxis vs. low-risk was 32. HRs represent risk of an event during a period of time, as opposed to RR which is the cumulative risk of an event over a study period.
    • There were 942 patients who did not receive prophylaxis. 1/659 (0.2) with a score <4 developed VTE. 15/178 (8.4%) with a score of 4 developed VTE. 11/79 (13.9%) with a score of 5 developed VTE. 5/26 (19.2%) with a score >5 developed VTE.

    Bleeding Complications

    • 3/186 (1.6%) major or relevant bleeding events occurred in high-risk patients who received prophylaxis.
    • 1/711 (0.1%) of the low-risk patients developed gastrointestinal bleeding.

    Mortality

    • 113 patients died in total. 24 (12.9%) from the high-risk group who received prophylaxis, 32 (11.3%) from the high-risk group that did not receive prophylaxis with 1 of these being attributed to PE. 57 (8.0%) of the low-risk patients died.

    A 2012 study at Harvard evaluated the Padua Prediction score in the setting of patients admitted to a medical floor with sepsis.

    • VTE risk was retrospectively calculated and events were cataloged from 1-year post admission.
      • 1080 patients were included with a mean age of 74.68 years.
      • The average Padua score was 4.86 with >72% having a score ≥4. Only 17.8% got anticoagulation.
      • Mortality was 21.9% during hospitalization. Seven patients had VTE on admission, 14 during hospitalization and 7 after discharge. Overall VTE rate through 1 year was 1.94%.
    • The authors found no relationship between administration of anticoagulation and reduced rate of VTE or mortality.
    • A Padua ≥4 was not associated with VTE during or after hospitalization, however a Padua ≥4 was associated with increased mortality.

    Literature

    Other References

    Research PaperNendaz M, Spirk D, Kucher N, Aujesky D, Hayoz D, Beer JH, Husmann M, Frauchiger B, Korte W, Wuillemin WA, Jäger K, Righini M, Bounameaux H. Multicentre validation of the Geneva Risk Score for hospitalised medical patients at risk of venous thromboembolism. Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE).Thromb Haemost. 2014 Mar 3;111(3):531-8. doi: 10.1160/TH13-05-0427. Epub 2013 Nov 14.Research PaperKucher N, Koo S, Quiroz R, Cooper JM, Paterno MD, Soukonni- kov B, Goldhaber SZ. Electronic alerts to prevent venous thrombo- embolism among hospitalized patients. N Engl J Med 2005; 352: 969–77.Research PaperDecousus H, Tapson VF, Bergmann JF, et al. Factors at Admission Associated With Bleeding Risk in Medical Patients. Findings From the IMPROVE Investigators. Chest 2011;139(1):69-79Research PaperVardi M, Ghanem-Zoubi NO, Zidan R, Yurin V, Bitterman H. Venous thromboembolism and the utility of the Padua Prediction Score in patients with sepsis admitted to internal medicine departments. J Thromb Haemost. 2013 Mar;11(3):467-73. doi: 10.1111/jth.12108.Research PaperNendaz M, Spirk D, Kucher N, et al. Multicentre validation of the Geneva Risk Score for hospitalised medical patients at risk of venous thromboembolism. Explicit Assessment of Thromboembolic RIsk and prophylaxis for Medical PATients in SwitzErland (ESTIMATE). Thromb Haemost 2014;111(3):531-538
    Dr. Sofia Barbar

    From the Creator

    Why did you develop the Padua Prediction Score? Was there a clinical experience that inspired you to create this tool for clinicians?
    Medical inpatients are at risk for venous thromboembolism (VTE). About 25% of all cases of VTE are related to hospitalization, and up to 75% of them occur in medical patients. High risk inpatients not receiving thromboprophylaxis develop deep-vein thrombosis in 5 to 15% of cases and pulmonary embolism in up to 1.5%.

    Even though the usefulness of thromboprophylaxis is well known, the choice to prescribe it in clinical practice, especially in complex medical patients, is challenging. Age, immobility, active cancer, infections and acute inflammatory states are known major risk factors for hospitalization-related VTE; however, the contribution of each risk factor to the “magnitude” of VTE risk and the interaction between them is not easy to determine in clinical practice.

    The Padua Prediction Score (PPS) has been created to guide clinicians in identifying patients at "sufficient" risk to warrant prophylaxis.

    What pearls, pitfalls and/or tips do you have for users of the Padua Prediction Score? Are there cases in which it has been applied, interpreted, or used inappropriately?
    The PPS has been created to stratify VTE risk in general medical inpatients, but it has not been validated for specific populations as Intensive Care Unit patients or others. This is the most common mistake made. Moreover, PPS is a guide, but its value is not "universal" and it can never overwhelm clinical judgment.

    What recommendations do you have for health care providers once they have applied the Padua Prediction Score? Are there any adjustments or updates you would make to the score given recent changes in medicine?
    PPS can be applied in all patients admitted in general medicine wards.  It is a guide to thromboprophylaxis, but it doesn't take into account hemorrhagic risk that could easily be evaluated, at the moment, with the use of IMPROVE bleeding score (Decousus 2011).

    Do you have any thoughts on the sepsis trial by Vardi and colleagues which demonstrated no relationship between a positive Padua score and VTE?
    Vardi et al tested PPS in a sub-selected medical population of medical inpatients with sepsis. The PPS has been recently tested (and compared with another risk assessment model, namely Geneva score) in a cohort of around 1500 general medical inpatients (Nendaz 2014). Both scores demonstrated a good discrimination between low- and high-risk patients (cumulative rate of VTE and VTE-related death at 90 days post-discharge 3.5 vs. 1.1% [p=0.002] in high- vs. low-risk patients according to PPS).

    Many of the patients that developed VTE during your study had active cancer. How could this have affected your prediction rule?
    Cancer is a very well known and strong risk factor for VTE. Thrombotic risk is particularly increased when associated with other conditions such as bed-rest or acute infections. Accordingly, the weight of this risk factor has been calculated with a score of 3 in PPS.

    Are there any further prospective trials in the works to validate the Padua score?
    Further studies are ongoing to adapt/validate PPS in other setting of patients, with special regard to nursing home resident and outpatients with comorbidities when experiencing acute conditions. In fact, both of these populations are at increased risk of VTE and data on management of these patients are scanty in literature.

    About the Creator

    Sofia Barbar, MD, is a physician at Civic Hospital of Cittadella (Padua) in Italy. She graduated with honors from Medical School at Padua University, where she also completed Internal Medicine training, subsequently majoring in Emergency Medicine. She is an active researcher studying prevalence and treatment of venous thromboembolism. Her scientific interests particularly focus on clinical research in the field of venous thromboembolism (VTE), with special regards to prevention of VTE in medical ill patients and diagnosis and treatment of VTE even in unusual sites.

    To view Dr. Sofia Barbar's publications, visit PubMed

    Dr. Paolo Prandoni

    About the Creator

    Paolo Prandoni, PhD, is professor of the Department of Medical and Surgical Sciences, Thromboembolism Unit, at the University of Padua. He trained at the University of Padua from 1971 to 1979 before moving to Holland, where he studied for his PhD at the University of Amsterdam in 1992. Professor Prandoni’s research and professional experiences encompass the epidemiology, diagnosis, and management of thromboembolism. Of particular interest to him are studies addressing cancer-associated venous thromboembolism (VTE).

    To view Dr. Paolo Prandoni's publications, visit PubMed

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