greetings everyone it's a great pleasure to come to you again today uh with my esteemed colleagues uh from Moscow and kov Poland and we're here to discuss the landmark paper about the caprini score set points in various populations and with us today we have Kiri listof who's a Prof associate professor of surgery uh at the P POF Russian national Research Medical University and again very important task he has as a scientific director of the U thrombosis School Educational project very interesting the caprini squ as you know for years made many positive contributions and has a heavy interest in VTE awareness thrombosis prophylaxis and [Music] treatment and also with us today uh is Thomas orbanic who is a professor of vascular surgery at the University of cayia in Kata Poland and he also has been very instrumental and very uh focused on VTE prophylaxis and patient awareness and promoted the caprini score probed it both of these individuals have done that and shown where it works and it doesn't work and today is a dramatic example of the value and one of the reasons why the score is so successful is due to the work of these these folks and I think it's important to mention that he's also very interested in chronic Venus disease and compression therapy and we're going to revisit that Tomas later in the year because I think that's another very important project that we're all very interested in and in 2012 the cini score was first suggested to be used by the chess consensus guidelines and the parameters that they established based on their review of the literature was that people with a score of over five had a 6% chance of Venus Ru embolism now as time went along that was 2012 now that's a decade or more has passed and we know that that's really not uh true and it was very ambivalent about what the scores were in various populations some populations had a low score had low incidence of thr is even though those scores were pretty high and others had extremely high incidence of thrombosis so um K Kiri listof and Tomas put together a study where they looked at at over 4,200,000 patients and they reviewed a number of important references and they came up with a landmark paper on the set points for Venus rombo embolism so without further Ado Ado ado I would like to ask Thomas if he would uh please uh go ahead and present the data for us Thomas thank you very much for this introduction and also for uh sharing with us this topic because uh our inspiration to uh to do this work uh with K together and with the other colleagues uh was professor caprini and undoubtly uh uh without your ideas and and thoughts uh uh this would be uh uh not possible uh so let me share some data which will uh give us the chance uh to answer if we really should use the same threshold for all people in um all hospital and out of Hospital settings uh across different specialities because uh as mentioned before uh in the guidelines we have uh uh the precisely set values specifying the highrisk patient but perhaps high-risk patients in some of the specialities are much um uh they can differ between the the specialities uh so there are several problems related to VT prophylaxis of course there is the issue of awareness uh which is quite common among medical staff but also among the patient population uh there is the huge problem with the proper VT risk assessment and caprini score is one of the excellent examples how this can be provided however however we still many many questions and then of course the third issue is uh how to properly implement the um BT prophylaxis and here we speak about phac olical and non-pharmacological uh measures which sometimes especially in medical patients uh can be related to problem with some they sufficient application one of the good and very good for me risk assessment models is caprini score which is very very commonly used right now in the world especially in our part of the of the world in Europe it's one of the most commonly implemented several individual risk factors but I wanted to mention that if there is any factor which is not mention in this score uh you can use also to Mark other risk factors which is one point in the ca score and we should not forget that some of the factors can be not listed in the original caprini score uh but we can use this option to add more risk factors if present uh of course this factors have different clinical importance clinical wi that's why there is stratification from one uh uh Point uh for the factors like age over 40 or or minor surgical procedures through uh the patients with cancer with two points or even more points in the score for more uh severe cases like previous uh VT episodes uh this score was validated in many but we should emphasize not all specialities and in not all clinical scenarios even in surgery we know that we have various patients because some of them underwent laparoscopy some of them oncological surgery some of them hernia surgery there are various groups of the people and patients and we should have this in our mind uh this watch is already known from the previous studies that uh uh there is usually no direct and linear correlation between BT risk and caprini score if we go to the higher caprini score then there is almost geometric grow of the VT risk especially in the highest score patients we have various VT categories and we know what's the risk related to distal proximal uh DVT or fatal p in the patients with with slow moderate and high risk of course we focus our interest mostly on this high-risk patients however we should be aware that the complications VT complication can happen also in moderate and lowrisk patients and for many of us this was like a dogma and still is often like a Dogma that uh according to the caprini 2005 uh the high risk patient is 3 to four and highest is 5 and over and accp 2012 used five or more to Define highrisk patient it's really true for every patients coming to to our Center to uh to our Hospital should be exactly follow this like written in the guideline document uh we know that for example in surgery the the risk of it's one of the wonderful studies validating surgery Pat capr cor general surgery patients we know that the patients with highest risk of VT according to the caprini score will present with a significantly higher risk of VT events and also here we see that of course for Five Points to six points uh the risk of VTE episodes so up to 30 days after surgeries 1.33 but but if we adust the three points and we are at the level of nine and over we go to the level 6.5% of VT episodes so as mentioned before nonlinear correlation between caprini score and VT uh risk however very important P question for me as we see various patients in our daily practice would be the same for surgical population and medical populations and ICU obstetrics or any other kind of the patient should we see exactly the same uh uh scores in patients who we defined as high or highest risk patient and should we use the same caprini score thresholds for all patients to Define High very high or ultra high uh risk groups perhaps the answer is not simple but perhaps you find the answer in the paper with which was published in analys of surgery 2023 uh with the first out kast and then the group of excellent experts and of course Joe caprini who who was the spiritous moments of all this work for our group and the talk is dedicated in reality my talk is dedicated to uh answering the question what are this specific threshold associated with a significant increase of VR risk assessed by C score across different Surgical and Medical uh patients uh not going too much deeply into the details of the study we uh overviewed the literature up to 1st of March 2022 uh looking for full text English language English language uh papers which are focused on the for and reported the incident and risk of BTE and the papers related to medical and surgical patients populations as mentioned huge number of patients over 4 millions of the patients included into 68 uh studies which confirm the correlation between caprin score and VT incidents we started with over 4,000 references and uh uh 68 uh Studies have been uh included uh we look for primary outcome a combination of any symtomatic or asymptomatic DBT superficial vein trombosis and pulmonar embolis that was reported within the period of observation patient with estimated individual risk for pte by caprini score various patients population and you see the wide range of the surgical specialities and uh clinical scenarios to randomize control trials 11 case control studies 6C six cohort studies we of course did the quality assessment and here are the results results which can be at least for some of you surprising but I think that this opens new discussion about defining the high-risk patients in individual specialities uh because as you see here for example for uh mix hospital patients Surgical and Medical patients uh it's not five as was stated by U accp 2011 uh but it seems that the highrisk patients are patients with nine and over uh in the background of Hospital prophylaxis for medical patients we speak about the highrisk group of the patients with the threshold eight uh and over uh in the p over8 in the patients being on chemical and medical prophylaxis Co is a special issue but also here uh we see that if you have seven eight points the risk is going up and if you have nine and over it's really dramatic one third of the patients can develop VT cancer patients um also here uh if we speak about General cancer patient population not only surgical uh patients uh the risk of which defines highrisk patients is nine and over for burns similar situation for trauma and Orthopedics which is the speciality related with in the normal settings with the high risk of of of VT here of course we have the significant number of BT episodes even in the patients with the caprini threshold of 5 to six uh by but in the patients with saw 11 points and over uh the rate of VT can reach even 47% which is really a traumatic uh value Urology and Gynecology in most of the studies there was the minimal invasive surger or trans I mean endoscopic andur Urological surgery that's why here the BT rates are a little bit uh lower few studies which renal cancer and blood cancer which are related to the highest risk of trom bolic complications vascular surgery which is always the problem how to implement the proper prophylaxis especially in the cases when we have anti ples treatment together or if we use the heparine inoperativity here also we can Define the patient with high risk and thresholds of 7 to n with 5.6 presence of V episodes and over 10 points 10 and over means 14% head and next surgery is something which happens quite often in many of our Hospital uh significant significantly higher rate of vtf is in patients we saw score 9 and over surgical patients also here as there were very unhomogeneous populations many patients operated with minor surgeries but also the cases of the major uh surgery and here the scoring seems to be really very important uh if we have over 11 and and over caprini score points is 8.6 and 12 to 15 means over half of the patients getting VT so 65% thoracic surgery in most of the studies happens without pharmacological prophylaxis and here even if we have five points it means that this this is really very very uh high-risk patients with 10 to 12% of V episodes and if we go to nine or or over [Music] [Music] [Music] [Music] [Music] uh the part of the group which is with the score 78 and then in majority of the specialities uh uh in the patients having nine and over nine uh uh caprini score points the risk is uh really really significant with the significant percentage of the VT episodes uh of course this is not only the type of the speciality but type of VT prophylaxis type of surgery there is no time to go more into details because this studies differs between the study populations and specialities and of course the time of observation in some studies during the hospitalization in some studies up 30 days uh this also differs and that's why we are not able to perform meta analysis we have to go um uh into direction of systemic review and finally the paper was published as a systemic review due to unhomogeneous data available so in conclusion caprini score is a highly validated traum as we heard more than four millions of patients in many specialities and clinical conditions in majority but not all cases the individual VT risk increases significantly with threshold scores of 7 to 11 so not always five but in many specialities this will be more points in the caprini score and of course we need toh conduct the further trials to validate the caprini score in other specialities and individual clinical scenarios uh to establish individual thresholds uh thank you very much and I would encourage you to read this paper because I think it gives us uh new data and better understanding of uh the thresholds in the caprini score and for the first time uh we can try to find the dedicated thresold to the dedicated specialities thank you very much thank you very much Thomas it was a brilliant presentation that you and Kiri have put together uh and it certainly moves the uh moves the needle forward uh I'd like to uh ask Ki to uh share your observations on this paper and uh any uh questions you might have thank you very much uh uh ladies and gentlemen it's a big pleasure to be here and to discuss this very important problem and uh uh actually uh when we started to use caprin score in our country in our Clinic uh we were wondered why this group of five and most SC combine a lot of very different patients who uh have absolutely different risk of the development of postoperative ET so patient with five score he usually benefits from the standard prophylax with compression and low molecular Heins but if this score elevates to 10 or 11 this profilaxis is absolutely insufficient insufficient and we see a development of postoperative ET despite all the standard doses of low molecular hpin and standard compression so uh we uh started to uh think about it and we started to uh uh develop some program to improve this uh uh situation and how to prevent these life threating complications in R very sever patients who have a lot of risk factors and who have a lot of caprini score and the advantage of caprini score is that the standard well known and well accepted version of 2005 as we saw in our systematic review it's works well absolutely in most specialities where it was um validated uh but however there is some uh limitations and some problems in validation in different specialities and what we found out why in some studies there there is no good correlation good correlation is not shown it's that again because of the use of not standard thresholds so in some studies people try to combine patients with absolute different scores in the one group and of course they see big group which has low incidence of VT and this make an illusion that in these big groups the incidence of VT is low but however if you will separate this big group to smaller groups you will find that there is a specific subgroup of the patients with a higher risk who uh actually uh needs some more attention and some more intensive maybe aggressive perlex to prevent postoperativ vity uh so I believe that uh this systematic review will give uh to Physicians to administrators to other researchers some uh uh new chance to review their uh approach for BT profilaxis and maybe to make new studies to validate caprini Cor in those specialities when it was not done yet thank you very much uh I I uh I would like to point out something that Tomas said that is absolutely brilliant and is a mark of a real clinician and people forget about this all the time and that is the other category now um I I know doctors and even famous doctors and people who are have worked a lot on the caprini score will look at a patient and the patient will have a score of X and they will say that that patient doesn't need prophylaxis but what they miss is that that patient might have other risk factors sickle cell disease uh diabetes requiring insulin HIV blood transfusions smoking there there's all sorts of new risk factors that have been associated with thrombosis and if you have a risk factor that has EV evidence in the literature that ties it to thrombosis then you can know that it's at least worth one point and you can put it into the to the to the other category and and protect your patient and I think that that was a very important observation and I'm glad you pointed that out Thomas I haven't heard that uh before from others although I've tried to promote it and the other thing that is not often talked about and you both have talked about this is the dynamic nature of how you have to update the score so uh Thomas any final remarks U I think that having this data we we need really new approach to validation of this CA score because as K mentioned we still use the initially proposed threshold values uh right now it's probably the time to use uh this findings to to the validation study based on on the uh on the thresholds which really uh specify this highest group of patient but here again coming to one of our previous talks the quality of the studies is important and if we have here someone in the audience who is uh thinking about this study on caprini score uh that's why this should be really well projected study with the proper long-term follow up at least 30 days prophylaxis if used this should be not one day we should go for 5 10 seven days and sometimes will be even longer uh so this what we realize analyzing this studies that they are not only unhomogeneous due to different kind of patients different specialities and clinical scenario but there was the huge un homogeneity Also regarding the uh applied prophylaxis uh so the way of prophylaxis the uh the the days of the application and this is something which really creates a huge problem also in the daily daily medicine recently we we met professor caprini in Kaku and some of the colleagues discussed if one day uh if one shot of heparine can prevent VT in varicus vein surgery because many people do not apply the longer prophylaxis than just just one day which is according to the data that we have uh I think the completely wrong approach so even in the medical field Among The Physician there is still a lot of things to do regarding education but also uh showing the things which uh you you try to to to educate us for many years and and thank you once again for for This brilliant works because uh me personally and I think the uh and I think also for CUA you are our teacher and thank you once again because we learned a lot of things and uh we are part of the big group of people who thinks about uh the best as possible uh VT prophylaxis implementation and so it's really the great pleasure to be the part of this research well thank you very much and and you know this is emblematic the reason why this is so exciting is because people like both of you have worked so hard to probe this and you you you put your finger into another very important sore of mine that really that I really am a uh passionate about because I lived through all of this I was at the 1975 trial of kar in London when he presented the TR the results of the multi- center trial and showed a highly statistically significant lowering of fatal pulmonary ambili from uh giving little doses of Heparin uh in surgical patients uh there were 16 PE deaths in the control group and two in the treated group and and people made didn't believe him but then R Collins came along in 1988 and presented the results of 70 additional studies in 13,000 patients which had the same trial design as Kar and guess what it showed the same results there was a 66% relative risk reduction in the incidence of fatal pulmonary embolism in the 13,000 patients from 9/10 of a percent to 3/10 of perc in the use of of Hein and there were the bleeding there was no difference in leading death six in one group and seven in the other now the the the third thing that comes along is that Kar and now Lord Kar who's the son of VJ and and Sylvia hos from Munich a brilliant uh investigator published a study of 23,000 surgical patients who got either Hein or low molecular weight Hein a drug company sponsored that because they wanted to show whether or not their drug could prevent more deaths then unfractionated heprin and the end point was was autopsy adjudicated fatal PE the ultimate endpoint and there was a in the 23,000 patients 79% were Surgical and 21% Orthopedic the incidence of fatal PE was a tenth of a percent and of course right away the Skeptics jumped in and they said well there was some patients that died that didn't get autopsies so the investigator said fine we we'll include all of those people that died and didn't get an autopsy as dying of a fatal PE and that raised the incidents to a half a percent so they showed that 99.5% of all fatal pulmonary Amite could be prevented with Hein or low molecular weight Hein but here's the punch line that has been not forgotten and and and I'm ashamed to say that people today say that we can't use the old studies because they're out of date well I got news for you the old studies had hard end points autopsy adjudicated vetal PE venography the ultimate test of DVT and you can't repeat those studies today and we so we have 10 uh 160 trials and 46 uh 43,000 patients over 30 years that guess what the E Period of efficacy was 7 to 10 days it wasn't one day it wasn't two days it wasn't while people were in the hospital hospital it wasn't until they got up and so that's the standard and I'm I'm so happy that you reminded me to point that out to the audience go back and look at the history and now th for those of you that are interested in this subject please take a look at your own populations and continue to to explore and probe this score and try to make it better so thank you again uh gentlemen it's been a real pleasure and uh we'll see you again again real [Music] soon