Nicola et al reported an algorithm for reducing thromboembolism in a woman receiving tamoxifen in the perioperative period. This algorithm can reduce risk of thrombosis while optimizing tamoxifen coverage. The authors are from Guy's and St. Thomas' Hospitals in London.
Patient selection: woman receiving tamoxifen in the perioperative period
Very High-Risk Factors
High Risk Factors
Other
Risk Group
>= 1
NA
NA
very high risk
0
>= 2
NA
high risk
0
0 or 1
history of chemotherapy
moderate risk
0
0 or 1
surgical time >= 90 minutes
moderate risk
0
0 or 1
neither of above
low risk
Very high-risk findings:
(1) personal history of deep vein thrombosis or pulmonary embolism
(2) non-mobilizing patient
(3) prosthetic valve
(4) on therapeutic anticoagulation
(5) (free-flap OR procedure requires that patient be bed bount for >= 2 weeks) AND (2 or more high risk factors)
High risk - 2 or more of the following:
(1) age >= 60 years
(2) family history of deep vein thrombosis or pulmonary embolism
(3) BMI over 30 kg per square meter
(4) significant comorbid condition
(5) known thrombophilia
(6) active cancer
(7) varicose veins with thrombophlebitis
Risk Group
Management to Reduce Thrombosis Risk
low
continue tamoxifen; anti-embolic stockings
moderate
stop tamoxifen 2 weeks before surgery and restart day after surgery; anti-embolic stockings; LMW heparin for 5 days
high risk
stop tamoxifen 2 weeks before surgery and restart 2 weeks after surgery; intermittent pneumatic compression until mobile; LMW heparin according to surgical thromboprophylaxis guidelines
very high risk
stop tamoxifen 2 weeks before surgery and restart 2 weeks after surgery; intermittent pneumatic compression until mobile; LMW heparin according to surgical thromboprophylaxis guidelines; refer to hematology for follow-up; if prosthetic valve use heparin or LMW heparin per guideline
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