Chest
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only ArticlesPrevention of VTE in Nonsurgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Section snippets
Summary of Recommendations
Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded.
2.3. For acutely ill hospitalized medical patients at increased risk of thrombosis, we recommend
Methods
The methodology of these guidelines follows the general approach of Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.3 In brief, panel members conducted literature searches to update the existing evidence base, seeking systematic reviews and trials published since the previous iteration
Risk Factors for VTE in Hospitalized Medical Patients
Hospitalization for acute medical illness is associated with an eightfold increased risk of VTE16 and accounts for about one-fourth of all VTE events in the community.17, 18 Among hospitalized patients, 50% to 75% of VTE events, including fatal PE, occur in those hospitalized on the medical service.16, 19 Risk factors for VTE in hospitalized medical patients include intrinsic factors, such as increasing age (especially > 70 years), previous VTE, known thrombophilia, and various comorbid
Risk of VTE
The risk of VTE in patients who are admitted to an ICU varies, depending on their acute illness (eg, sepsis), chronic illnesses (eg, congestive heart failure), prehospital diagnoses (eg, prior VTE), and ICU-specific exposures and events (eg, immobilization, surgery, and other invasive procedures [such as central venous catheterization] mechanical ventilation, and drugs such as vasopressors and paralytic agents) (Table 10, Table S12).67 There are no validated risk assessment models to stratify
Patients With Cancer in the Outpatient Setting
The role of thromboprophylaxis to prevent VTE in patients with cancer undergoing surgery is addressed in the article about prevention of VTE in surgical patients in this supplement.1
Risk of VTE
The recognition that bedbound hospitalized patients are at increased risk for VTE has led many clinicians to consider whether chronically immobilized outpatients are at similar increased risk, and whether they may also benefit from VTE prophylaxis. The chronically immobile population is large and includes patients who are homebound, as well as residents of nursing homes and postacute care facilities. Despite their similarities to medical inpatients, there have been few studies and no
Risk of VTE
Prolonged air travel results in a very small absolute incidence of VTE. A systematic review and meta-analysis of 14 studies (11 case-control, two cohort, and one case-crossover) of risk for VTE in travelers demonstrated a pooled RR of 2.8 (95% CI, 2.2-3.7). A dose-response relationship was identified, with an 18% higher risk of VTE for each 2-h increase in travel duration.122, 123 However, the overall absolute incidence of a symptomatic VTE in the month following a flight > 4 h is 1 in 4,600
Risk of VTE
Thrombophilia refers to inherited or acquired conditions, measurable in the blood, that are associated with an increased risk of developing venous thrombosis. Inherited conditions include factor V Leiden (R506Q) mutation (average population prevalence, 5%; RR of a first venous thrombosis, compared with the general population, 5-7), prothrombin gene (G20210A) mutation (2%; RR, 2-3), antithrombin deficiency (0.04%; RR, 15-20), protein C deficiency (0.3%; RR, 15-20), and protein S deficiency
Risk of VTE
Statins reduce coagulation potential by decreasing tissue factor expression and decreasing thrombin generation,161 leading to consideration of statin use to prevent VTE. Statin use has been related to risk of VTE in three prospective cohort studies, six case-control studies, and one clinical trial (Tables S31, S32). Considering DVT and PE together, the pooled risk estimate with statin use vs nonuse from several case-control studies162, 163, 164, 165, 166 was 0.61 (95% CI, 0.48-0.81). Two
Acknowledgments
Author contributions: As Topic Editor, Dr Murad oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.
Dr Murad: contributed as Topic Editor.
Dr Kahn: contributed as Deputy Editor.
Dr Lim: contributed as a panelist.
Dr Dunn: contributed as a panelist.
Dr Cushman: contributed as a panelist.
Dr Dentali: contributed as a panelist.
Dr Akl: contributed as a panelist.
Dr Cook: contributed as a panelist.
Dr Balekian: contributed
References (173)
- et al.
Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012) - et al.
Antithrombotic and thrombolytic therapy for ischemic stroke: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012) - et al.
Methodology for the development of antithrombotic therapy and prevention of thrombosis guidelines: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012) - et al.
Patient values and preferences in decision making for antithrombotic therapy: a systematic review: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012) - et al.
Predictive and associative models to identify hospitalized medical patients at risk for venous thromboembolism
Chest
(2011) - et al.
A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score
J Thromb Haemost
(2010) - et al.
Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators
Chest
(2011) - et al.
Venous thromboembolic disease: an observational study in medical-surgical intensive care unit patients
J Crit Care
(2000) - et al.
Variability in the use of thromboprophylaxis and outcomes in critically ill medical patients
Am J Med
(2005) - et al.
Venous thromboembolism in critical illness in a community intensive care unit
J Crit Care
(2007)
New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than by withholding treatment
Chest
Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients: a systematic review and meta-analysis
J Thromb Haemost
Randomized comparison of enoxaparin with unfractionated heparin for the prevention of venous thromboembolism in medical patients with heart failure or severe respiratory disease
Am Heart J
A randomized, double-blind study of certoparin versus unfractionated heparin to prevent venous thromboembolic events in acutely ill, non-surgical patients: CERTIFY study
J Thromb Haemost
Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism
Chest
Murad MH. Dosing frequency of unfractionated heparin thromboprophylaxis: A meta-analysis
Chest
Economic evaluation of enoxaparin vs. placebo for the prevention of venous thromboembolism in acutely ill medical patients
Value Health
Cost-effectiveness of enoxaparin as thromboprophylaxis in acutely ill medical patients in Spain
Value Health
No difference in risk for thrombocytopenia during treatment of pulmonary embolism and deep venous thrombosis with either low-molecular-weight heparin or unfractionated heparin: a metaanalysis
Chest
Why does prophylaxis with external pneumatic compression for deep vein thrombosis fail?
Am J Surg
Deep venous thrombosis prophylaxis in trauma: improved compliance with a novel miniaturized pneumatic compression device
J Vasc Surg
Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study
Lancet
Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Chest
A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis
Am J Cardiol
Antithrombotic and thrombolytic therapy: from evidence to application: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Chest
Incidence of venous thrombosis in a large cohort of 66,329 cancer patients: results of a record linkage study
J Thromb Haemost
Chemotherapy-induced thrombosis
Thromb Res
Enoxaparin or aspirin for the prevention of recurrent thromboembolism in newly diagnosed myeloma patients treated with melphalan and prednisone plus thalidomide or lenalidomide
J Thromb Haemost
Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients
Thromb Haemost
Risk assessment of venous thromboembolism in hospitalized medical patients
Curr Opin Pulm Med
Electronic alerts to prevent venous thromboembolism among hospitalized patients
N Engl J Med
Venous thromboembolism in critically ill patients. Observations from a randomized trial in sepsis
Thromb Haemost
Dalteparin versus unfractionated heparin in critically ill patients
N Engl J Med
Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study
Arch Intern Med
Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study
Arch Intern Med
Venous thromboembolism in the outpatient setting
Arch Intern Med
Risk factors for venous thromboembolism in hospitalized patients with acute medical illness: analysis of the MEDENOX Study
Arch Intern Med
Risk factors for venous thromboembolism
Circulation
Risk factors for venous thrombosis - current understanding from an epidemiological point of view
Br J Haematol
Heparin for the prevention of venous thromboembolism in general medical patients (excluding stroke and myocardial infarction)
Cochrane Database Syst Rev
Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients
Ann Intern Med
A multicenter randomized double-blind study of enoxaparin compared with unfractionated heparin in the prevention of venous thromboembolic disease in elderly in-patients bedridden for an acute medical illness
Thromb Haemost
Calcium nadroparin in the prevention of thromboembolic disease in elderly subjects. Study of tolerance [in French]
Presse Med
The venous thrombotic risk in nonsurgical patients: epidemiological data and efficacy/safety profile of a low-molecular-weight heparin (enoxaparin)
Haemostasis
Economic evaluation of the MEDENOX trial: a Canadian perspective. Medical Patients with Enoxaparin
Can Respir J
Economic and practical aspects of thromboprophylaxis with unfractionated and low-molecular-weight heparins in hospitalized medical patients
Clin Appl Thromb Hemost
Cost utility of substituting enoxaparin for unfractionated heparin for prophylaxis of venous thrombosis in the hospitalized medical patient
J Hosp Med
Economic evaluation of the use of enoxaparin for thromboprophylaxis in acutely ill medical patients
J Med Econ
Cost effectiveness of thromboprophylaxis with a low-molecular-weight heparin versus unfractionated heparin in acutely ill medical inpatients
Am J Manag Care
Cited by (0)
Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants were also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.
Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).