Chest
Volume 141, Issue 2, Supplement, February 2012, Pages e195S-e226S
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Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only Articles
Prevention of VTE in Nonsurgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.11-2296Get rights and content

Background

This guideline addressed VTE prevention in hospitalized medical patients, outpatients with cancer, the chronically immobilized, long-distance travelers, and those with asymptomatic thrombophilia.

Methods

This guideline follows methods described in 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.

Results

For acutely ill hospitalized medical patients at increased risk of thrombosis, we recommend anticoagulant thromboprophylaxis with low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH) bid, LDUH tid, or fondaparinux (Grade 1B) and suggest against extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay (Grade 2B). For acutely ill hospitalized medical patients at low risk of thrombosis, we recommend against the use of pharmacologic prophylaxis or mechanical prophylaxis (Grade 1B). For acutely ill hospitalized medical patients at increased risk of thrombosis who are bleeding or are at high risk for major bleeding, we suggest mechanical thromboprophylaxis with graduated compression stockings (GCS) (Grade 2C) or intermittent pneumatic compression (IPC) (Grade 2C). For critically ill patients, we suggest using LMWH or LDUH thromboprophylaxis (Grade 2C). For critically ill patients who are bleeding or are at high risk for major bleeding, we suggest mechanical thromboprophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 2C). In outpatients with cancer who have no additional risk factors for VTE we suggest against routine prophylaxis with LMWH or LDUH (Grade 2B) and recommend against the prophylactic use of vitamin K antagonists (Grade 1B).

Conclusions

Decisions regarding prophylaxis in nonsurgical patients should be made after consideration of risk factors for both thrombosis and bleeding, clinical context, and patients' values and preferences.

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

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    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).

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