good afternoon I'm coming you today to talk about the history of the caprini score and this is dedicated to all of those professionals who have worked so hard on this score around the world and contributed as of today 194 articles in 5 million patients looking at the score and they presented the good parts of it they presented parts that they think need to be maybe updated and also more importantly established the set point between high and very high-risk patients in their individual population and that is the major punchline today which I would like to have everybody understand that we are going to learn from wonderful people all around the world and unfortunately they're not yet part of the guidelines that doesn't in any way lessen their importance and I would like to begin by just showing you a picture of the largest study ever done so far using the caprini score in 20 2,795 th000 patients with a clear relationship between the incidents of Venus thrombosis and the score and as I said before this isn't in the guidelines so let's let's go back and take a look at the guidelines 2012 for the first time the accp guidelines acknowledged the importance of risk assessment and here we see their analysis of the cini score low very low low moderate and high risk and they classify everything as five or above as high risk and this was based on five papers used to develop the guideline and as I told you there's now 100 94 and anyway they envisioned that 6% of the patients that had a score of over five would get a clot if they didn't have prophylaxis we're going to keep that number in mind now nine years have passed and at the end of 2019 the American Society of hology published a very high level high quality update of the original thrombosis prophylaxis guidelines for surgical patients and this time they also included Orthopedics and we were very much looking forward to that because I we had been following all the data from all over the world in the intervening years and couldn't wait to see how the authorities would react to that some of those were observational articles so I wouldn't expect that they would be in a in a highquality document like these guidelines but certainly I would expect that things like the metaanalysis would be there and certainly studies that were as good as the original studies that chest used in 2012 so here's what they said scoring systems that calculate the risk of post-operative VTE for individual patients such as the caprini score have been developed and validated following some surgical procedures a widely used high quality guideline is a 2012 guideline of the American College of Chess Physicians which places a strong emphasis on VTE risk sces in the guideline recommendations for VTE prevention in the non-orthopedic surgical patients patient oriented VTE risk calculators such as the caprini score and the Roger score were adopted now nothing much happened to the to the Roger score but the caprini score as I said before was was widely used based on this very positive recommendation the only guidance was given to the to the people reading the guideline was the original disease of the month publication from 2005 so the original five studies used to calculate the highest risk set point for VTE in the 12 2012 guidelines was five plus currently we have 194 studies demonstrating the direct relationship between the score and VTE incidents now it's very important to understand that the data is especially from the metaanalysis and other studies such as head and neck surgery show that not all of those with a score of five plus are at high risk in some surgical studies the score of five is associated with a low risk and this incidence is not further reduced using anticoagulants that was nicely shown by Christopher Panucci in this very well done metaanalysis in 2017 but what's even more important was these studies also have identified a very high risk score for VTE that also varies according to the surgical population now why is that important you're going to give everybody prophylaxis no no not necessarily those people with very high scores may need ongoing prophylaxis for an extended period of time after hospitalization remember as as we're going to see was done in the Boston studies and also there may be breakthrough thrombosis also shown by the Boston group and that may indicate that you might want to use double the amount of propy in that very highrisk group and in summary it's very important to understand the three pillars like veral Triad of the caprini score number one protecting those low-risk patients from getting anticoagulants that will only increase their bleeding risk number two to provide anticoagulant prophylaxis for those who truly are at risk of VTE and number three to provide those patients with very high risk extended prophylax Andor enhanced prophylaxis let's take a look at some of these studies here's the original study in general surgery and here's the five cut off with a 1.3% incidence of VTE but look what happens when you get over eight 6.5% now let's look at five studies that were done five universities uh plastic surgery patients and the score of five was associated with a little over 1% % incidents of thrombosis look what happened when the score got eight or above 11% that's the high-risk group we're talking about now the corollary of that look at headand neck surgery in this study and there are several studies like this there's almost there's no clots until the patients really get up two t0 of a percent finally not even 1% at five to six then it jumps to 2.4 at 7 to8 and then it jumps to 18.3 when the score gets nine and above do you see how important it is to establish the set point for high and highest risk in your individual population in order to give patients again those lowrisk don't give them prophylaxis those at risk give them standard prophylaxis and those at very high risk either extended prophylaxis Andor enhanced prophylaxis the figures in ICU are a little bit more in a linear fashion with increasing numbers of score related to increasing VTE events if we go back and took look at the original ball article in 2010 from the University of Michigan and about half the patients had a score of five or less but if you look at those people that had a score of 10 and above there weren't too many of them in the study but they all got clots again showing you that High highrisk group I'd now like to present what I call the poster child for thrombosis prophylaxis in the from an American site and of course Michigan had done a tremendous amount before this but this is what they did at Boston University they had a very high incidence of Venus thrombosis in their surgical patients so they put together this system and they took APR score and they divided it into low moderate and high-risk patients with a mandate mandated length of prophylaxis and use of prophylaxis depending on the score and of course the doctor could op out of it if he so choosed or she so choosed but otherwise most most of the people were uh had to have this score done before the orders could be signed and this included length of prophylaxis here we see the the the first part of this and you can see the low uh lowest low and moderate risk patients there was 100% compliance and you could do what you wanted during the hospitalization but you'll notice here they do have Hein or low molecular weight Hein in for these low lowrisk patients why is that that doesn't help we know that now but we didn't know it quite then and at the time they did this study they were under the Jo mandated skip protocol surgical Care Improvement project where every patient having surgery had to have a dose of Hein or low molecular rate Hein within 24 hours of surgery unless they were at high risk of bleeding and later a large study in the VA and other studies showed that this didn't work it one shot of Hein or low molecular weight Hein did not change the VTE incidence now we talk about those people who had a score of 5 to eight they were given 7 to 10 days Al low molecular weight Heine regardless of whether or not they were in the hospital or whether they went home and then if they had a score of nine and above they got 30 days of low molecular weight Hein again regardless of their location now wait a minute you might say it's very difficult to give all these patients 30 days seven days or 30 days of prophylaxis it's very expensive pain painful people don't want to do it well how how do you how do you get this done well for one there was good education by the doctors and number two and a very important point was the hospital Administration made a an arrangement with the drug company so that all patients who were candidates for this treatment got all of the medication they needed regardless of their ability to to pay and look at the astonishing results the very high incidence of Venus thrombo embolism at 30 days in these patients was reduced to a nator of of a tenth of a percent with 30-day results now wouldn't it be wonderful if we could replicate the Boston program everywhere in the country including taking care of the payments in case the patients couldn't pay Food For Thought nowhere to be SE in the guidelines but incredibly important to know now often times people who are very strict Advocates of the guidelin say that um opinions without data meaning the guideline data for example are just opinions and everybody has one but there's another side to this story known as The Real World Experience here we're seeing Real World experience and I can tell you that the Boston University has continued this program publish more papers on this subject right up to today Real World experience is important let's have a look at that metaanalysis just very briefly in these studies these were the 13 best studies that were early done regarding the caprini score in general and vascular surgery and included plastic surgery patients as well Christopher Panucci a bright young investigator who's gone on to be a brilliant plastic surgeon shows that in those patients who had a caprini score and didn't get prophylaxis if the score was 3 to four the incidence was 710 perc 5 to six it went up to 1.8 jumped to 4% when the score was 7 to8 without profilaxis and if the patients did not receive prophylaxis and they had a score of over eight 10% of them got a clot now can and you imagine that you better do scores in your patients and if that patient has a high score that patient could be subject to uh Venus thrombo embolism if they don't get prophylaxis highly statistically significant and there are the details but that's not all patients with scores of six or less which was 75% of the population did not have a significant VTE risk reduction with chemoprophylaxis Excuse me so it didn't help so giving it to them only increased their bleeding complications on the other hand patients with scores of 7 to eight and over eight had significant VTE risk reduction post-operatively when they received chemoprophylaxis now we don't have length of prophylaxis here and this is one of the few places that we can find that in hospital prophylaxis even though it wasn't long as as long as we might like was important to prevent Venus Thro embolism very important data and this data needs to be understood by everyone because it's very very important for a clinical practice now let's talk about about the Vietnamese study in four Hanoi hospitals over two years they collected 2,795 th000 surgical patients and scored them and what they showed was that the incidents of VTE went up as you can see here but when it got to five or six only 1.9% but then at 7 to eight it jumped and over eight it jumped again don't these curves look familiar people have said well how can you trust data from all over the world and so forth this data is corresponding this is exactly the same kind of data we see from the metaanalysis the same kind of data we see from the University of Michigan and we're going to see more cases like this very good data very important data now let's go to China talk about lung surgery patients and this was a group of of patients that had lung surgery and there were over 200 patients and what happened here was those that had a low score none of them got a clot those that had a moderate score of 5 to8 even with prophylaxis got a clot 12% but those that had a 40 those that had a score of nine or above 40% of them got a clot very powerful information again that same curve that we're seeing in the other studies now let's go to Russia same same deal Professor listof very important investigator from Russia he and his associates have put together some beautiful programs and studied about venuso embolism and here's one of them these are very high-risk patients and you can see in this population they all had scans only one person with a with a 5 to8 score I got a clot but when it went up to 9 to 11 26% and when the score was 12 or 15 look at that 65% incidence of Venus Thro embolism again that set point that very high set point now back to China and let's talk about the use of the caprini score in burn patients same story caprini score of 5 to six less than 1% incidents of DBT you get over eight it's 8.82% very very powerful data and again these data regardless of what country you go to they all when the people collect the data properly and report it properly the results are almost superimposable but they're different depending on the group so the the they're superimposable for equivalent groups but they do vary according to the population as you can see and then let's take a look at oenology and this is another study in head neck surgery and as you can see those people that had a score of of of six or less nobody got a clot but when the score went up to eight and above and certainly above 10 there was a very high risk of thrombosis and here you can see that 133% of people with a score of over eight got a clot I'm sorry for repeating the same thing over and over again but this is to illustrate to everyone around the world all the beautiful work that was done by all these brilliant investigators from the four corners of the world and they're all showing the same type of data and that's why people continue to use this score because it works in their patients to take a look at at um uh a number of patients here it's about 10,000 patients alog together 5,000 from the ICU population score of over eight incidence 6.3% 11% 18% 8% extended prophylaxis Andor double prophylaxis may be appropriate in these patients I know that has to be studied but if you start to get patients with these high scores and you send them home in prophylaxis and they continue to recur then you better think about doubling their prophylaxis well now let's talk about medical patients there's 20 articles with the caprini score and medical patients it works for medical patients you know this isn't rocket science the caprini score is the most comprehensive history in physical available today that's been tested on a wide scale you do a comprehensive history in physical you're going to pick up more events I don't care if it's surgery patients medical patients what kind of patients they are and here in this study with a the caprini score and these are in medical patients a very large population of medical patients a score of 5 to six was a three-fold increase over a low score 9.4 fold increase for 7 to eight scores but again what happens when you get to the over nine group 24% 25% relative risk relative risking fold increase in the instance of VTE and then comparing the Pota and the caprini scores while they both worked the uh this was a series of 402 controls and 222 cases and as you can see here the caprini scores showed uh was able to identify 82% of those patients whereas only 30% were identified by the POA score now let's go to Thailand and this was a prospective study in 92 hip fracture patients screened preoperatively with duplex scans the caprini score well scoring a d dier the since the pre-operative DVT was 16.3% shocking study DVT group had a significantly higher Wells and caprini score compared to the non-dvt group The sensitivity of the wells score greater than equal to two or the caprini score of greater equal to over 12 were 47 and 81 and 93 and 35% respectively so what we see from all of this is the sensitivity and specificity of the capr score is high and if it's over 13 the results are 60 and 73% based on all of these data the do the Physicians recommended pre-operative screening of hip fracture patients with high scores preoperatively and this is the first instance when this type of scanning was recommended but this isn't routine there's no routine here this is for people only with very high risk scores very very powerful data now let's swing back to New York City and to the northwell health system where Professor Krauss was head of the Department of orthopedic surgery there in this Hospital uh they studied a thousand patients over 15mon period and these orthopedists used a protocol it was agreed upon by seven of the orthopedists they would follow this protocol they would consider everybody low risk unless they had a VTE within a prior year morbid obes BMI of over 40 with additional comorbidities active malignancy bilateral stage joint replacement and inherited or acquired thrombophilia those were the high-risk group So based on that they treated low-risk patients with aspirin and those in the high-risk group received a conventional anticoagulation with a conventional dose of a direct oral anticoagulant now after the study was all over the authors went back and did a caprini score in all of these patients and what did they find well let's talk about the department Score first here in the first part of this you see the department score there were eight clots that were found and of those eight clots the department considered classified only one of them as high- risk and seven were classified as low risk as you can see here now if we take a look when they went back and did caprini scores on all these patients seven of the eight patients could be correctly identif ified using the caprini score with a cut off of 10 or above so now we know that that's probably the set point for orthopedist so remember and and I may have not said this before but orthopedist would come up to me and said you know Joe this is a nice score but this doesn't work for Orthopedics because the chess guidelines have shown that people have a score of five and above or at high risk well all of our patients have a score of five that's what you give them for a joint replacement so it doesn't help us yes it does help you because it's a high risis score isn't not five for that population it's 10 and above and we know that based on what Northfield did North viiew did and now North View has done this is they're doing prospective caprini scores and everybody with a score of nine and Below gets aspirin everybody with a score of 10 and above gets low molecular weight Hein I don't have the final results yet but they told me they're very very good so in conclusion ladies and gentlemen the competing score increases in direct proportion to the incidence of Cl clinically relevant BTE events identifying those at high risk according to the population tested and the original concept that everyone with a score over five is high risk is no longer true some patients with a score of five or six may be spared anticoagulants remember the oenology population remember the metaanalysis those low-risk patients were not benefited with anticoagulants it only increased their bleeding rate the set point for high-risk patients needing prophylaxis is varied according to the population and I've given you maybe even too many examples of that but I've tried to acknowledge important investigators from around the world who have done very important work and I also apologize for anybody that I left out finally Studies have ident now identified due to all of these wonderful people from everywhere a very highrisk group that may benefit from extended anticoagulant prophylaxis and perhaps even from enhanced prophylaxis and then I'd like to talk about making sure all of you do something and that is take your caprini score take it to your doctors put it in your medical record so when you get sick or injured the doctor will know what the score is you can't come running into the hospital with a serious covid-19 infection they're trying to save your life nobody's going to ask you 40 questions including your past obstetrical history and whether Aunt Tilly had a clot you got to have that in your record and remember the importance of that is performing a thorough history and physical gives you knowledge about your patient as if they were your good friend and of course you would never kill a friend and of course you would never treat a stranger tra a stranger I'm indebted to my dear friend in Maine who's an academic dentist who has given me this thought and then Sergio gazini has made this popular around the world and I'm indebted to those individuals and all of again all of you around the world who have contributed to the success of this scoring system it's not about me it's about all of you and congratulations I'd like you all to visit my website Venus disease.com and be on the lookout we have a new website plan that we're going to roll out very soon and also finally visit YouTube Venus Resource Center I've got over 30 videos on there that you can take a look at and you can get more information so again thank you very much for your attention it's been a great pleasure to present these data and please stay safe have a good day and we hope everybody has a great 2021