Direct Oral Anticoagulants (DOACs): Current Evidence for Extended VTE Prophylaxis in Medically Ill Patients and Reversal

Program Overview

Patients hospitalized for an acute medical illness are at an increased risk for VTE. With increasingly shortened hospital stays, acutely ill hospitalized patients are at an increased risk of developing VTE both in the hospital and after discharge. Outpatient VTE episodes often occur within 30 days of hospital discharge and less than half of those discharged patients receive VTE prophylaxis. Therefore, it is important for clinicians to be able to risk stratify patients and provide extended prophylaxis for medical patients at increased risk for VTE.
This webcast will discuss the risk factors and burden of VTE and review ACCP guideline recommendations for VTE prophylaxis in acutely ill hospitalized medical patients. Faculty will assess the safety and efficacy of direct oral anticoagulants for extended VTE prophylaxis, explain the stratification of VTE and bleeding risk, as well as the process for devising evidence-based antithrombotic regimens. The presentation will also include an outline of current and emerging options for reversal of direct oral anticoagulants. 

Target Audience
 Hospitalists, Internists, nurse practitioners (NPs), physician assistants (PAs) who practice in a hospital setting.  
Learning Objectives
  1. Outline the risk factors and burden of VTE in medically ill patients post-hospitalization
  2. Review ACCP and ASH guideline recommendations for VTE prophylaxis in acutely ill hospitalized medical patients
  3. Assess the safety and efficacy of direct oral anticoagulants (DOACs) for extended VTE prophylaxis in medically ill patients
  4. Devise evidence-based antithrombotic regimens for medically ill patients taking into consideration patient specific factors that impact VTE and bleeding risk
  5. Outline current and emerging options for reversal of DOACs

Activity Launch Date - 4/2/19
Expiration Date - 6/9/19

Supporter Acknowledgment Statement
This activity is supported by an independent educational grant from Portola Pharmaceuticals. 

Disclosure of Unlabeled Use
This educational activity may contain 
discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. 
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners.  Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient's conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer's product information, and comparison with recommendations of other authorities.

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Horizon CME educational activities are developed and conducted in accordance with the ACCME's Essential Areas and Policies.  It is the mission of Horizon CME to develop and present educational activities that are timely, fair balanced, scientifically rigorous, and that serve to improve patient outcomes.  To that end, we welcome comments about how to better serve your needs.

Copyright Information
© 2018 by Horizon CME.  All rights reserved.  No part of this accredited continuing education activity may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from Horizon CME. 


Amir K Jaffer, MD, MBA
Chief Medical Officer Professor of Medicine
New York Presbyterian Queens Hospital
New York, NY 

Faculty Bio
Amir K Jaffer, MD, MBA, is the Chief Medical Officer at New York Presbyterian Queens (NYPQ) hospital in NYC where he leads Quality, Patient Safety, Accreditation, Comprehensive Clinical Program Development and physician satisfaction. He is working closely with the leadership team to lead transformational change to help the hospital become the Regional Hospital of Choice in Queens, providing premier quality and compassionate care in collaboration with Weill Cornell Medicine and the NYP Medical Group. Prior to moving to New York, Dr. Jaffer worked at Rush University Medical Center as Associate Chief Medical officer, Vice Chair, Quality and Safety in the Department of Internal Medicine and the Division Director of Hospital Medicine.  Over a short period in Chicago, Amir worked across various specialties and the entire continuum of care to lead many Institutional clinical redesign initiatives improving new patient access, patient flow and clinical standardization translating into improved length of stay and value. He was part of a team that contributed to Rush’s success--ranking in the top five for a fourth consecutive year amongst 102 academic medical centers across the United States in the annual Quality and Accountability study conducted by Vizient.

Prior to Rush, he was involved first at the Cleveland Clinic for a decade then at the University of Miami for five years developing innovative clinical programs in Perioperative Medicine, Anticoagulation, Palliative Care and Hospital Medicine.  Dr. Jaffer received his medical degree from Boston University School of Medicine in 1994.  His postgraduate training includes an internship and residency in internal medicine at Yale New Haven Hospital in New Haven, CT.  He is board certified in Internal Medicine and practices both Hospital and Perioperative Medicine.  He also completed a MBA in Health Care Management and Policy at the University Of Miami School Of Business in 2012. 

He has won several awards for Teaching including the Scholarship in Teaching Award in 2006 and again in 2007 by the Case Western Reserve University Medical School in recognition of his efforts as an educator in Perioperative Medicine. In 2010, he was honored with the Society of Hospital Medicine’s highest Award for Excellence in Teaching for his enormous dedication to the education and mentorship of students, residents and fellows in hospital medicine. He is currently the Associate editor of the book Hospital Medicine Secrets and Editor-in-Chief of a Textbook called Perioperative Medicine: Medical Consultation and Co-management.  He has also served as one of the authors of the highly cited 8th and 9th American College of Chest Physicians Evidence-based Guidelines in Antithrombotic Therapy.  He has published extensively and speaks nationally within his areas of interest and expertise and has directed the Perioperative Summit over the last 12 years. 

Faculty Disclosure Statement
Dr. Jaffer discloses no relevant relationships with ACCME-defined commercial interests.

Alex C. Spyropoulos, MD, FACP, FCCP, FRCPC
Professor, The Merinoff Center for Patient-Oriented Research
The Feinstein Institute for Medical Research
Director, Anticoagulation and Clinical Thrombosis Services
Northwell Health
Albuquerque, NM

Faculty Bio
Alex C. Spyropoulos, MD received his medical degree from the University of Pennsylvania School of Medicine in Philadelphia, PA. He completed his internship and residency in internal medicine at the University of New Mexico Health Sciences Center in Albuquerque, NM. He is board certified in Internal Medicine.

Dr. Spyropoulos was Founder and former Medical Director of the Clinical Thrombosis Center in Albuquerque, New Mexico. He is a Professor of Medicine at Hofstra, Northwell School of Medicine and System Director of Anticoagulation and Clinical Thrombosis Services for the multi-hospital Northwell Health System in NY. He is also a Professor of the Merinoff Center for Patient-Oriented Research as part of the Feinstein Institute for Medical Research. He is co-chair of the Council on Leadership of Thrombosis at Northwell Health System. He is a Fellow of the American College of Physicians, American College of Chest Physicians, International Academy of Clinical and Applied Thrombosis/Haemostasis, and the Royal College of Physicians, Canada.

Dr. Spyropoulos has helped to develop protocols using LMWH in outpatient-based treatment of venous thromboembolic disease, patient self-testing of warfarin, perioperative “bridging” for patients on chronic anticoagulation, medical inpatient thromboprophylaxis, protocols with regards to the use of anticoagulants for HIT, and clinical use of the direct oral anticoagulants, including their use in special patient populations and periprocedural situations. Dr. Spyropoulos is active in assessing outcome and pharmacoeconomic analyses of these protocols and has lectured extensively both nationally and internationally on these issues.

He has been involved as Principal Investigator, Scientific Committee member, Steering and Executive Committee member, or member of Data Safety Monitoring Board in multiple international, multicenter randomized trials in thrombosis and anticoagulant therapy, including the NHLBI BRIDGE and NHLBI Kids DOTT studies and the CIHR PAUSE trial. He is the co-Chair of the Executive Committee for MARINER, a global Phase 3 multicenter study of thromboprophylaxis in medical patients with rivaroxaban, He is a founding member of ATLAS, a US-based ARO-CRO in thrombosis-related research. He is a panel member of a US national experts consensus group for clinical excellence in thrombosis management, a member of the Anticoagulation Forum and the Thrombosis/Haemostasis Society of North America, co-Chair of the Scientific Standardization Committees of Predictive Variables and Perioperative Thrombosis and Haemostasis as part of ISTH, and co-author for the 8th, 9th and currently 10th 2017 ACCP Guidelines on Perioperative Antithrombotic Therapy, the 2008 International Consensus Statement Guidelines in Venous Thromboembolism, and senior author for the 2013 International Consensus Statement on venous  thromboembolic disease. He is also reviewer for the 2014 ESC Guidelines on Pulmonary Embolism. He is Section Editor for Thrombosis and Haemostasis, and is on the editorial staff for Thrombosis Research and Hospital Medicine. He is a reviewer for many journals.

Dr. Spyropoulos’ research studies, articles, letters, and editorials have been published in over 170 peer-reviewed journals including The New England Journal of Medicine, Blood, Circulation, Annals of Internal Medicine, American Journal of Hematology, American Journal of Medicine, Chest, Thrombosis Haemostasis, American Journal of Cardiology, Journal of Thrombosis and Haemostasis , Journal of the American College of Cardiology, Clinical Applied Thrombosis and Haemostasis, and Thrombosis Research.

Faculty Disclosure Statement
Dr. Spyropoulos has performed contracted research for Boehringer Ingelheim and Janssen. He has served on Advisory Boards for Bayer, Boehringer Ingelheim, Daichi Sankyo, Janssen and Portola.

Alan Jacobson, MD, FACC
Associate Chief of Staff/ Research 
Loma Linda University School of Medicine
Director, Anticoagulation Services
Jerry L. Pettis VA Medical Center
Loma Linda, California 

Faculty Bio
Alan K. Jacobson, MD, FACC, is a staff cardiologist and the Associate Chief of Staff for Research at the Loma Linda VA Medical Center in Southern California. A native of Canada, Dr. Jacobson has been at Loma Linda since heading south in 1977 for medical school. In addition to practicing general cardiology, Dr. Jacobson has a special interest in antithrombotic therapy. He has been the medical director of the Cardiology Anticoagulation Clinic since 1990 and has overseen the initiation of both Point-of-Care testing and Patient self-testing for the monitoring of the prothrombin time.
Dr. Jacobson has also been active in research relating to standardization of laboratory methods for PT determinations, clinical use of antithrombotic therapy in atrial fibrillation, evaluation of novel antithrombotic therapies and development of anticoagulant monitoring methodologies.
Dr. Jacobson received his bachelor's degree in chemistry from Walla Walla University and his medical degree from Loma Linda University. 

Faculty Disclosure Statement
Dr. Jacobson has served on an Advisory Board, on a Speakers Bureau and provided non-CME promotional services for Boehringer Ingelheim, Bristol-Myers Squibb, Daichi Sankyo, Janssen and Portola.

External Reviewer
Ty J. Gluckman, MD, FACC, FAHA 
Medical Director of Clinical Transformation 
Providence Heart and Vascular Institute 
Portland, OR 

Dr. Gluckman has served on an Advisory Board for Boehringer Ingelheim. His Advisory Board role was not related to the content presented in this educational activity.

Planning Committee & Non-faculty Contributors 
Additional non-faculty contributors and others involved in the planning, development, and editing/review of the content have no relevant financial relationships to disclose in the last 12 months. 

Learner Assurance Statement
Horizon CME requires instructors, planners, managers and other individuals who are in a position to influence the content of this activity to disclose any real or apparent conflict of interest (COI) which may arise as a result of prospective faculty members' relevant relationships with drug or device manufacturer(s). Horizon CME is committed to resolving all conflicts of interest and retaining only those speakers with financial interest conflicts that can be reconciled with the goals and educational integrity of the CME activity.


Accreditation Statement
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the providership of Horizon CME. Horizon CME is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation
Horizon CME designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 

ABIM MOC Statement
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How To Claim Credit
To receive credit, participants must:
1.  Complete the entire activity 
2.  Correctly complete 75% of the post-activity questions (3/4) in a maximum of 10 attempts
3.  Complete the program evaluation 
4.  The certificate may be downloaded upon completion of the evaluation