Chest
Volume 133, Issue 6, Supplement, June 2008, Pages 381S-453S
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Antithrombotic and Thrombolytic Therapy, 8th ED: ACCP Guidelines
Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

https://doi.org/10.1378/chest.08-0656Get rights and content

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggestions imply that individual patient values may lead to different choices (for a full discussion of the grading, see the “Grades of Recommendation” chapter by Guyatt et al). Among the key recommendations in this chapter are the following: we recommend that every hospital develop a formal strategy that addresses the prevention of VTE (Grade 1A). We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A), and we recommend that mechanical methods of thromboprophylaxis be used primarily for patients at high bleeding risk (Grade 1A) or possibly as an adjunct to anticoagulant thromboprophylaxis (Grade 2A).

For patients undergoing major general surgery, we recommend thromboprophylaxis with a low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux (each Grade 1A). We recommend routine thromboprophylaxis for all patients undergoing major gynecologic surgery or major, open urologic procedures (Grade 1A for both groups), with LMWH, LDUH, fondaparinux, or intermittent pneumatic compression (IPC).

For patients undergoing elective hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or a vitamin K antagonist (VKA); international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0 (each Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1B), a VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 1B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty or HFS receive thromboprophylaxis for a minimum of 10 days (Grade 1A); for hip arthroplasty and HFS, we recommend continuing thromboprophylaxis > 10 days and up to 35 days (Grade 1A). We recommend that all major trauma and all spinal cord injury (SCI) patients receive thromboprophylaxis (Grade 1A). In patients admitted to hospital with an acute medical illness, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1A). We recommend that, on admission to the ICU, all patients be assessed for their risk of VTE, and that most receive thromboprophylaxis (Grade 1A).

Section snippets

Hospital Thromboprophylaxis Policy

1.2.1. For every general hospital, we recommend that a formal, active strategy that addresses the prevention of VTE be developed (Grade 1A).

1.2.2. We recommend that the local thromboprophylaxis strategy be in the form of a written, institution-wide thromboprophylaxis policy (Grade 1C).

1.2.3. We recommend the use of strategies shown to increase thromboprophylaxis adherence, including the use of computer decision support systems (Grade 1A) , preprinted orders (Grade 1B) , and periodic audit and

General Surgery

Studies20, 134, 135 performed > 20 years ago found that the rates of asymptomatic DVT in patients undergoing general surgical procedures without thromboprophylaxis varied between 15% and 30%, while the rates of fatal PE ranged between 0.2% and 0.9%. The risk of VTE in contemporary general surgical patients is uncertain because studies without thromboprophylaxis are no longer performed. Factors that may tend to reduce the risk of VTE in current patients include improvements in general

ORTHOPEDIC SURGERY

Patients undergoing major orthopedic surgery, which includes THR, TKR, and HFS, represent a group that has a particularly high risk for VTE, and routine thromboprophylaxis has been standard of care for > 20 years.1, 284, 285, 286, 287 Randomized clinical trials1, 288 have demonstrated that the rates of venographic DVT and proximal DVT 7 to 14 days following major orthopedic surgery in patients who received no thromboprophylaxis are approximately 40 to 60% and 10 to 30%, respectively (Table 8).

NEUROSURGERY

Patients undergoing major neurosurgery are considered to be at moderately increased risk for postoperative VTE, and warrant the routine use of thromboprophylaxis.1 In several randomized clinical trials, which included a spectrum of neurosurgery patients, the rate of DVT detected by FUT among the control subjects was 22%, and proximal DVT was detected in 5%.480 Intracranial (vs spinal) surgery, malignancy, prolonged procedures, leg weakness, and advanced age have all been shown to increase the

Trauma

Among hospitalized patients, those recovering from major trauma have among the highest risks for VTE.1, 496, 497, 498 Without thromboprophylaxis, patients with multisystem or major trauma have a DVT risk that exceeds 50%, and PE is the third-leading cause of death in those who survive beyond the first day. Factors that are independent predictors of VTE in trauma patients include the following: spinal cord injury (SCI), lower-extremity or pelvic fracture, need for a surgical procedure, insertion

MEDICAL CONDITIONS

Although VTE is most often considered to be associated with recent surgery or trauma, 50 to 70% of symptomatic thromboembolic events and 70 to 80% of fatal PEs occur in nonsurgical patients.1, 573 From the perspective of the general population, hospitalization for an acute medical illness is independently associated with about an eightfold- increased risk for VTE574 and accounts for almost one fourth of all VTE events.6 The risks of VTE and its prevention in stroke patients are discussed in

CANCER PATIENTS

Patients with cancer have at least a sixfold- increased risk of VTE compared to those without cancer,574, 607 and active cancer accounts for almost 20% of all new VTE events occurring in the community.6 Furthermore, VTE is one of the most common and costly complications seen in cancer patients.607, 608, 609, 610 Once VTE develops in a cancer patient, the VTE recurrence rate is high both after and during traditional anticoagulation.609, 610, 611, 612 The development of VTE in cancer patients is

CRITICAL CARE

While the risks of VTE in critically ill patients vary considerably depending primarily on their reason for intensive care, most ICU patients have multiple risk factors for VTE.1, 679, 680 Some of these risk factors predate admission to the ICU, and include recent surgery, trauma, sepsis, malignancy, stroke, advanced age, heart or respiratory failure, previous VTE, and pregnancy. Other thrombotic risk factors may be acquired during the ICU stay, and include immobilization, pharmacologic

LONG-DISTANCE TRAVEL

Prolonged air travel appears to be a risk factor for VTE, although this risk is mild.1, 582, 691, 692, 693, 694, 695, 696, 697, 698 Depending on differences in study design and populations, the magnitude of the reported risk of VTE associated with prolonged travel varies widely, ranging from no increased risk to a fourfold-increased risk.582, 691, 692, 693, 699, 700, 701, 702 The incidence of travel-related VTE is influenced by the type and duration of travel, and by individual risk factors.703

CONLICT OF INTEREST DISCLOSURES

Dr. Geertsdiscloses that he has received grant monies from the Canadian Institutes for Health Research, Sanofi-Aventis, and Pfizer. He has received consultant fees from Bayer, Eisai, GlaxoSmithKline, Lilly, Merck, Pfizer, Roche, and Sanofi-Aventis, along with speakers honoraria from Bayer, Calea, Oryx, Pfizer, and Sanofi-Aventis.

Dr. Bergqvistdiscloses that he has received grant monies from the Swedish Research Council and the Heart and Lung Foundation. He has also served on advisory committees

Acknowledgments

We are grateful to the following for providing very helpful reviews of the manuscript: Dr. Clive Kearon, Dr. Jack Hirsh, Dr. Gordon Guyatt, and Dr. Michael Gould. We thank Dr. David Matchar for providing an economic review of the duration of thromboprophylaxis after orthopedic surgery. Special thanks to Artemis Diamantouros and Tina Papastavros for invaluable assistance with the references.

REFERENCES (728)

  • S Timmons et al.

    Audit-guided action can improve the compliance with thromboembolic prophylaxis prescribing to hospitalized, acutely ill older adults

    J Thromb Haemost

    (2005)
  • D Mosen et al.

    The effect of a computerized reminder system on the prevention of postoperative venous thromboembolism

    Chest

    (2004)
  • P Chopard et al.

    Identifying acutely ill medical patients requiring thromboprophylaxis

    J Thromb Haemost

    (2006)
  • SM Schellong et al.

    Ultrasound screening for asymptomatic deep vein thrombosis after major orthopaedic surgery: the VENUS study

    J Thromb Haemost

    (2007)
  • AY Lee et al.

    Bilateral vs. ipsilateral venography as the primary efficacy outcome measure in thromboprophylaxis clinical trials: a systematic review

    J Thromb Haemost

    (2004)
  • S Schulman et al.

    Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients

    J Thromb Haemost

    (2005)
  • AE Segers et al.

    Is contrast venography a valid surrogate outcome measure in venous thromboembolism prevention studies?

    J Thromb Haemost

    (2005)
  • M O'Donnell et al.

    Thromboembolism prevention in ischaemic stroke

    Lancet

    (2007)
  • DJ Quinlan et al.

    Association between asymptomatic deep vein thrombosis detected by venography and symptomatic venous thromboembolism in patients undergoing elective hip or knee surgery

    J Thromb Haemost

    (2007)
  • SL Schulz et al.

    Graduated compression stockings for the prevention of venous thromboembolism in surgical patients in the age of low molecular weight heparins

    J Thromb Haemost

    (2005)
  • AJ Comerota et al.

    Why does prophylaxis with external pneumatic compression for deep vein thrombosis fail?

    Am J Surg

    (1992)
  • FS Haddad et al.

    Unanticipated variations between expected and delivered pneumatic compression therapy after elective hip surgery: a possible source of variation in reported patient outcomes

    J Arthroplasty

    (2001)
  • R Ramos et al.

    The efficacy of pneumatic compression stockings in the prevention of pulmonary embolism after cardiac surgery

    Chest

    (1996)
  • AG Turpie et al.

    Fondaparinux combined with intermittent pneumatic compression versus intermittent pneumatic compression alone for prevention of venous thromboembolism after abdominal surgery: a randomized, double-blind comparison

    J Thromb Haemost

    (2007)
  • C Patrono et al.

    Platelet-active drugs: the relationships among dose, effectiveness, and side effects. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

    Chest

    (2004)
  • MM Hovens et al.

    Aspirin in the prevention and treatment of venous thromboembolism

    J Thromb Haemost

    (2006)
  • National Institute for Health and Clinical Excellence

    Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. NICE clinical guideline No. 46:1–160

  • FA Anderson et al.

    The prevalence of risk factors for venous thromboembolism among hospital patients

    Arch Intern Med

    (1992)
  • FR Rosendaal

    Risk factors for venous thrombotic disease

    Thromb Haemost

    (1999)
  • JA Heit et al.

    Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study

    Arch Intern Med

    (2002)
  • FA Anderson et al.

    Risk factors for venous thromboembolism

    Circulation

    (2003)
  • MM Samama et al.

    Quantification of risk factors for venous thromboembolism: a preliminary study for the development of a risk assessment tool

    Haematologica

    (2003)
  • MJ Edmonds et al.

    Evidence-based risk factors for postoperative deep vein thrombosis

    ANZ J Surg

    (2004)
  • N Kucher et al.

    for the DVT FREE Steering Committee. Risk factors associated with symptomatic pulmonary embolism in a large cohort of deep vein thrombosis patients

    Thromb Haemost

    (2005)
  • C Gangireddy et al.

    Risk factors and clinical impact of postoperative symptomatic venous thromboembolism

    J Vasc Surg

    (2007)
  • C Zhan et al.

    Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

    JAMA

    (2003)
  • C Kearon

    Natural history of venous thromboembolism

    Circulation

    (2003)
  • RH White et al.

    Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures

    Thromb Haemost

    (2003)
  • Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices;...
  • SD Sullivan et al.

    Measuring the outcomes and pharmacoeconomic consequences of venous thromboembolism prophylaxis in major orthopaedic surgery

    Pharmacoeconomics

    (2003)
  • J Avorn et al.

    Comparing the costs, risks, and benefits of competing strategies for the primary prevention of venous thromboembolism

    Circulation

    (2004)
  • R Collins et al.

    Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic, and urologic surgery

    N Engl J Med

    (1988)
  • GP Clagett et al.

    Prevention of venous thromboembolism in general surgical patients: results of meta-analysis

    Ann Surg

    (1988)
  • LN Jorgensen et al.

    Prophylaxis of postoperative thromboembolism with low molecular weight heparins

    Br J Surg

    (1993)
  • DP Thomas

    Does low molecular weight heparin cause less bleeding?

    Thromb Haemost

    (1997)
  • S Haas et al.

    Prevention of fatal pulmonary embolism and mortality in surgical patients: a randomized double-blind comparison of LMWH with unfractionated heparin

    Thromb Haemost

    (2005)
  • AN Nicolaides et al.

    Prevention and treatment of venous thromboembolism: international consensus statement (guidelines according to scientific evidence)

    Int Angiol

    (2006)
  • HA Ahmad et al.

    Deep venous thrombosis prophylaxis: are guidelines being followed?

    ANZ J Surg

    (2002)
  • AK Kakkar et al.

    Venous thrombosis in cancer patients: insights from the FRONTLINE survey

    Oncologist

    (2003)
  • MH Ellis et al.

    Perioperative venous thromboembolism prophylaxis in Israel: a survey of academic surgical departments

    Eur J Haematol

    (2004)
  • Cited by (3832)

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