Venous thromboembolism (VTE), which includes deep venous thrombosis (DVT) and pulmonary embolism (PE), affects about 1 in 1000 persons annually. The incidence and case-fatality of venous and arterial thromboembolic events increase with age. The increased risk of VTE in elderly patients reflects the increased prevalence of risk factors (temporary and permanent), prothrombotic changes in coagulation with advanced age, and an independent contribution of advancing age.
The diagnosis of VTE is more challenging in the elderly patient, as clinical presentations are more often atypical than in younger patients and the diagnostic properties of some tests appear to be influenced by advancing age. However, the general approach to diagnosis of VTE in the elderly is much the same as in younger patients.
While anticoagulant therapies have comparable relative risk reductions for prevention of VTE in older compared to younger patients, elderly patients are at increased risk of major bleeding and particularly intracranial bleeding. Therefore, decisions regarding optimal duration of anticoagulant therapy for VTE are influenced by the patient's age.
In this chapter, we review the epidemiology, pathophysiology, natural history, diagnosis, and treatment of VTE in the elderly patient.
The incidence of VTE increases exponentially with advancing age (i.e., approximately twofold increase with each decade) rising from an annual incidence of 0.03% at age 40 years, to 0.09% at 60 years, and 0.26% at age 80 years.
Most patients with VTE have one or more clinical risk factors for venous thrombosis. The most common risk factors in hospitalized elderly patients are recent surgery, previous VTE, trauma, and immobility, as well as serious illness, including malignancy, chronic heart failure, stroke, chronic lung disease, acute infections, and inflammatory bowel disease. A particularly important major risk factor for VTE in elderly patients is major orthopedic surgery, both elective and after hip fracture, where fatal PE is a leading cause of in-hospital death. Common risk factors in outpatients include hospital admission within the past 3 months, malignancy, previous VTE, cancer chemotherapy, estrogen therapy, presence of an antiphospholipid antibody, and familial thrombophilia. Less common risk factors are paroxysmal nocturnal hemoglobinuria, nephrotic syndrome, and polycythemia vera. A recent study of elderly patients has reported frailty to be a risk factor for VTE.
Age is thought to have at least an additive influence on the risk of VTE when combined with other risk factors for VTE and the prevalence of many risk factors is greater in the elderly. Consequently, the risk of VTE in high-risk situations, such as following surgery, is greater in older than younger persons.
The risk of thrombosis is about 50-fold higher in persons with a previous VTE than in the general population, and recurrent thrombosis accounts for about one quarter of all acute episodes of VTE. When anticoagulant therapy is stopped after 3 or more months of ...