Why vte prophylaxis

Use of this content is subject to our disclaimer. For any urgent enquiries please contact our customer services team who are ready to help with any problems. Last reviewed: 12 Oct Last updated: 12 Mar Key diagnostic factors previous VTE, thrombophilia, malignancy, postoperative setting, trauma, and indwelling central catheter chronic medical conditions, paresis, increasing age, obesity, estrogen-containing birth control pills and hormone replacement therapy, varicose veins, pregnancy and up to 6 week postpartum, first-degree relative with a history of VTE, extended travel, and admission to intensive care More key diagnostic factors.

Investigations to consider serum antiplatelet factor 4 antibodies More investigations to consider. Guidelines Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update external link opens in a new window Call to action to prevent venous thromboembolism in hospitalized patients: a policy statement from the American Heart Association external link opens in a new window More guidelines.

Patient leaflets external link opens in a new window Deep vein thrombosis external link opens in a new window DVT and long-distance travel More patient leaflets. I have some feedback on: Feedback on: This page The website in general Something else.

Get Permissions. Read the Issue. Sign Up Now. Jun 15, Issue. Guideline source: American College of Physicians Evidence rating system used? No Literature search described?

No Guideline developed by participants without relevant financial ties to industry? Recommendations Patients should be assessed for the risk of thromboembolism and bleeding before the initiation of VTE prophylaxis. Read the full article. Get immediate access, anytime, anywhere.

Choose a single article, issue, or full-access subscription. Earn up to 6 CME credits per issue. Purchase Access: See My Options close. Best Value! To see the full article, log in or purchase access. More in Pubmed Citation Related Articles. Evidence for outpatients with cancer is addressed in a separate ASH guideline. The guideline panel used indirect evidence from acutely ill medical patients that evaluated extended outpatient prophylaxis and determined that there is low certainty in the evidence for net health harm from that evidence in medical outpatients with minor provoking factors for VTE.

Through extrapolation, the other EtD criteria were generally not in favor of using prophylaxis, because the undesirable consequences were greater than the desirable consequences in these patients. Given that this recommendation was based on indirect data and extrapolation, further research is required. The recommendation against thromboprophylaxis in medical outpatients with minor provoking factors for VTE, cost of treatment in this population, probable inequity of a recommendation, and lack of general acceptability were additional undesirable consequences.

Development of risk-assessment methods to determine absolute risk of VTE in outpatients with minor provoking VTE risk factors and. Trials of interventions pharmacological or nonpharmacological in a high-risk population of outpatients with minor provoking VTE risk factors. Remark: People without known risk factors who place a high value on prevention of VTE may choose to use graduated compression stockings also reduces edema. Worldwide, 3. We identified 1 systematic review evaluating the risk of a symptomatic DVT event within 4 weeks of flights longer than 4 hours.

Air travel is associated with a 2. Our update of the review identified 11 additional relevant studies. These associations were no longer evident by 12 weeks after travel. If symptomatic DVT develops, the potential impact is high. A case-control study did not show a higher risk for VTE with air travel or long-duration travel by car, bus, or train among patients with prior VTE compared with those without prior VTE.

Two available studies assessed the risk of VTE in total joint arthroplasty patients, finding no association between preoperative or postoperative air travel and VTE risk. Several VTE risk factors eg, cancer, plaster casts, hormone replacement therapy, oral contraceptives, and pregnancy multiplicatively increase the risk of air travel—related VTE.

To interpret research for these questions, we used a baseline risk for symptomatic VTE of per million trips for symptomatic VTE after travel longer than 4 hours based on 1 in flights. We found 1 systematic review of 9 RCTs that addressed the impact of graduated compression stockings compared with not using stockings in long-distance travelers. In absolute terms and on a population level, graduated compression stockings appeared to have very small and very uncertain effects on VTE, with an RR of 0.

Death did not occur in any of the studies. The panel did not consider any of the possible harms as critical. The tolerability of graduated compression stockings was described as very good, with no reported side effects in 4 RCTs.

None of the 5 trials reported serious adverse effects of wearing the stockings, but in 1 trial, 4 patients developed varicose vein thrombosis, possibly as a result of the stockings. Overall, the certainty in these estimated effects is very low owing to very serious indirectness and serious risk of bias for the estimates see evidence profile and online EtD framework.

The panel assumed that avoidance of PE, DVT, and bleeding was critical or important for decision making to patients. Graduated compression stockings were considered to not be cost-effective, to be acceptable to some but not to other stakeholders, and probably feasible. We found several narrative and systematic reviews that addressed the impact of LMWH or aspirin compared with no prophylaxis in long-distance travelers. In absolute terms and on a population level, aspirin appeared to have an even smaller and very uncertain effect on VTE compared with no treatment RR, 0.

Overall, the certainty in these estimated effects is very low owing to very serious indirectness and serious risk of bias for the estimates see evidence profile in the online EtD framework. The panel assumed that avoidance of PE, DVT, and bleeding events was critical or important to patients for decision making. Although the panel assumed no impact on health equity for aspirin, it felt that equity would be reduced if LMWH were recommended, given challenges with access.

The use of LMWH was considered acceptable to some but not to other stakeholders and probably not feasible for all travelers, but use of aspirin was considered acceptable and feasible. The guideline panel determined that, although the health effects may suggest net benefit for the use of graduated compression stockings, cost would be moderate, and use of stockings would not be cost-effective.

Equity would probably be reduced because graduated compression stockings would likely be an out-of-pocket cost, and acceptability would vary because insurance companies may not be willing to cover the cost. Proper use of graduated compression stockings might require support in the elderly and people with disabilities, but stockings on a population level were considered probably feasible.

Overall, the panel judged that, for all interventions, the undesirable consequences were greater than the desirable consequences and made recommendations against their use, with the exception of patients with VTE risk factors. People without known VTE risk factors who place a high value on prevention of VTE may choose to use graduated compression stockings. Risk-assessment methods to define travelers at sufficiently high VTE risk to warrant VTE prophylaxis intervention; and.

All guidelines advocated assessing the risk of VTE and bleeding in admitted medical patients. The American College of Physicians issued 2 additional recommendations: for the use of heparin or a related drug, unless patients were at high bleeding risk, and against use of graduated compression stockings. For at-risk medical or critically ill patients, LMWH, UFH twice daily or thrice daily, and fondaparinux were all recommended, with selection among these based on patient preference, compliance, and local factors related to formularies.

For patients at risk of bleeding, the ACCP recommended mechanical prophylaxis with graduated compression stockings or intermittent pneumatic compression, with consideration of pharmacologic prophylaxis if the bleeding risk resolved.

This is similar to the ASH guidelines, although the recommendations were not specifically keyed to bleeding risk but to persons at risk who are not receiving pharmacological prophylaxis. Unlike ACCP, the ASH panel addressed combination mechanical and pharmacological prophylaxis over either alone and suggested against the combination.

For long-distance travelers at increased risk for VTE, the ACCP recommended to mm Hg below-knee graduated compression stockings, frequent ambulation, calf muscle exercise, or sitting in an aisle seat.

They recommended against the use of aspirin or anticoagulants. In the IUA updated guidelines, risk assessment of medically ill patients and treatment with LMWH or fondaparinux was recommended, as was consideration of postdischarge treatment of women, patients older than 75 years, or those with severe immobility.

They also recommended, with moderate certainty, the use of graduated compression stockings plus intermittent pneumatic compression in ischemic or hemorrhagic stroke patients in whom risks of anticoagulant prophylaxis were deemed unacceptable. The Asian Venous Thrombosis Forum updated guidelines for medically ill patients concluded that, if prophylaxis was used, pharmacological prophylaxis was preferred in the absence of bleeding risk; otherwise, intermittent pneumatic compression, but not graduated compression stockings, were recommended.

Differences from the ASH guidelines include:. Use intermittent pneumatic compression in acute stroke patients for 30 days or until the patient is mobile or discharged;. Use pharmacological prophylaxis in acutely ill medical patients for 7 days minimally, with LMWH preferentially;. Use prophylaxis with LMWH in those receiving palliative care if desired, but not in the last days of life;. Use mechanical prophylaxis in critically ill patients if pharmacological prophylaxis is contraindicated;.

The ASH panel addressed use of DOACs for inpatient and postdischarge prophylaxis in medical patients using data not available to other guideline groups and recommended against the use of DOACs over other treatments in the hospital. The other guidelines that we describe here did not address extended postdischarge prophylaxis. The limitations of these guidelines are inherent in the low or very low certainty in the evidence we identified for many of the questions.

The necessary inclusion of results from older trials might pose difficulty in interpretation of findings given secular trends in characteristics of acutely or critically ill medical inpatients over the past 2 decades eg, length of stay, illness severity, duration of administered VTE prophylaxis. We did not address whether twice or thrice daily unfractionated heparin should be used when unfractionated heparin is chosen, because we did not develop a guideline question for this, there are little data, and there are no recent data.

After publication of these guidelines, ASH will maintain them through surveillance for new evidence, ongoing review by experts, and regular revisions. Adaptation of these guidelines will be necessary in many circumstances.

These adaptations should be based on the associated EtD frameworks. On the basis of gaps in evidence identified during the guideline-development process, the panel identified 29 areas for further research, which are summarized in Table 4. Resources for implementing these guidelines, including apps, patient decision aids, and teaching slide sets, may be accessed at the ASH Web page hematology. A template of the guidelines for all panels prepared by H.

Contribution: H. All authors approved the content. Conflict-of-interest disclosure: All authors were members of the guideline panel, members of the systematic review team, or both. As such, they completed a disclosure of interest form, which was reviewed by ASH and is available as Supplements 2 and 3. Correspondence: Holger J.

Sign In or Create an Account. Sign In. Skip Nav Destination Content Menu. Close Abstract. Summary of recommendations. What are others saying and what is new in these ASH guidelines?

Limitations of these guidelines. Revision or adaptation of the guidelines. Article Navigation. American Society of Hematology guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients Holger J. This Site. Google Scholar. Allison E. Burnett , Allison E. Susan R. Kahn , Susan R. Frederick A.

Spencer , Frederick A. Suely M. Rezende , Suely M. Neil A. Zakai , Neil A. Kenneth A. Bauer , Kenneth A. Francesco Dentali , Francesco Dentali. Jill Lansing , Jill Lansing. Sara Balduzzi , Sara Balduzzi.

Andrea Darzi , Andrea Darzi. Ignacio Neumann , Ignacio Neumann. Robby Nieuwlaat , Robby Nieuwlaat. Juan J. Yuan Zhang , Yuan Zhang. Wojtek Wiercioch Wojtek Wiercioch.

Blood Adv 2 22 : — Article history Submitted:. Cite Icon Cite. Table 1. RAMs used in medical inpatients. View Large. Table 2. Aspirin vs no prophylaxis. Table 3. Interpretation of strong and conditional recommendations. Implications for:. Strong recommendation. Conditional recommendation. Patients Most individuals in this situation would want the recommended course of action, and only a small proportion would not.

The majority of individuals in this situation would want the suggested course of action, but many would not. Clinicians Most individuals should follow the recommended course of action. Different choices will be appropriate for individual patients, and clinicians must help each patient arrive at a management decision consistent with the patient's values and preferences.

Policy makers The recommendation can be adopted as policy in most situations. Policy-making will require substantial debate and involvement of various stakeholders. Performance measures should assess whether decision making is appropriate. Researchers The recommendation is supported by credible research or other convincing judgments that make additional research unlikely to alter the recommendation.

The recommendation is likely to be strengthened for future updates or adaptation by additional research. Recommendation 1, 2, and 3. The panel identified the following additional research questions:. Better information on baseline risk assessment of thrombosis and bleeding in medical inpatients is needed, in particular whether risk varies over the course of admission; and More information on the optimal dosing of parenteral anticoagulation to prevent VTE in medical inpatients is needed.

There were no future research needs prioritized by the panel. Recommendation 4. Recommendation 5. Tools for quantitative risk assessment for VTE and bleeding in critically ill medical patients; and Determination of the acceptable balance between bleeding and thrombosis risk in the context of selecting the optimal thromboprophylaxis in critically ill medical patients.

Recommendation 6. Recommendation 7. Recommendations 8 and 9. Recommendation Net health benefit of mechanical prophylaxis in a lower-risk medical inpatient population; Utility of outpatient use of mechanical prophylaxis in those at risk of VTE; Direct comparisons between graduated compression stockings and pneumatic compression devices in medical inpatients; and Impact of use of pneumatic compression devices in medical inpatients at high bleeding risk or with active bleeding. Recommendation 8.

Provide more direct evidence on combined mechanical and pharmacological prophylaxis compared with mechanical prophylaxis alone via clinical trials on efficacy, harms, and adherence to the intervention, particularly in high-risk medical inpatients in whom the balance of potential benefits vs harms might be more favorable than among lower-risk patients; Obtain patient preferences for mechanical or pharmacological prophylaxis by studying feasibility, equity, and acceptability; Determine current utilization rate of combined mechanical and pharmacological prophylaxis in practice; and Compare combined mechanical and pharmacological prophylaxis with mechanical prophylaxis alone utilizing comparative effectiveness research studies.

Recommendation 9. With regard to research, the panel felt that:. The panel suggested that future research should address:. DOAC use among medical inpatients or for extended prophylaxis after discharge in larger trials assessing symptomatic VTE and bleeding end points, and in more selected patients based on predicted risk of VTE and of bleeding; and Evaluation of lower-dose DOAC regimens in medical inpatients or for extended use after discharge, to determine whether this might mitigate bleeding risk while preventing VTE.

With regard to future research, the panel suggests:. Studies of risk assessment tools for guidance on defining high-risk status for VTE and bleeding at discharge; Trials of pharmacological or nonpharmacological interventions in selected high-risk medical patients for VTE at discharge ; and Studies that evaluate dose adjustments or lower doses of anticoagulants that might maximize benefit while minimizing harm when used for extended treatment to prevent VTE after hospital discharge.

Studies on identification of high-risk subgroups of chronically ill medical patients who could benefit from VTE prophylaxis, with consideration given to those who are immobilized; Studies of low-dose anticoagulant approaches, including use of DOACs or aspirin in chronically ill medical patients; and Research on current clinical practices for VTE prevention and patient preferences for VTE prevention in chronically ill medical inpatients or nursing home residents.

The panel felt that the following research areas would be helpful:. Development of risk-assessment methods to determine absolute risk of VTE in outpatients with minor provoking VTE risk factors and Trials of interventions pharmacological or nonpharmacological in a high-risk population of outpatients with minor provoking VTE risk factors.

With regard to research needs, the panel identified:. Table 4. Research priorities identified by patient population. The full-text version of this article contains a data supplement. Heart disease and stroke statistics update: a report from the American Heart Association [published correction appears in Circulation.

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