Prevention of Venous

Thromboembolism

2012 CHEST GUIDELINES REVIEW

PRESENTED BY:
.............................................
VENOUS THROMBOEMBOLISM
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 Result of clot formation in

venous circulation
 Manifests as deep vein
thrombosis (DVT) or
pulmonary embolism (PE)
 Develops as a result of three
primary components known
as Virchow’s triad
 Venous Stasis
 Vascular Injury
 Hypercoagulability
 DVT PROPHYLAXIS
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 Incidence of DVT in the hospital is 10-40% per month

for medical or general surgical patients and 40-60%
following major orthopedic surgeries

 Consequences of unprevented VTE:

 Symptomatic DVT or PE
 Fatal PE
 Increased spending for investigation symptomatic patients
 Increased risk of recurrence
 Chronic post-thrombotic syndrome

 DVT prophylaxis, has a desirable benefit-to-risk ratio

 RISK FACTORS

Strong Risk Factors Moderate Risk Factors Weak Risk Factors

Odds Ratio > 10 Odds Ratio 2-9 Odds Ration <2

• Hip or Leg Fracture • Athroscopic Knee Surgery • Bed rest>3 days

• Hip or Knee Replacement • Central Venous Lines • Immobility due to sitting
• Major General Surgery • Chemotherapy • Increasing Age
• Major Trauma • CHF or Respiratory Failure • Laparoscopic Surgery
• Spinal Cord Injury • Hormone Replacement • Obesity
Therapy • Pregnancy/ Antepartum
• Malignancy • Varicose Veins
• Oral Contraceptive Therapy
• Paralytic Stroke
• Pregnancy/ Postpartum
• Previous VTE
• Thrombophilia

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 GENERAL THROMBOPROPHYLAXIS
RECOMMENDATIONS
Level of Risk Estimated DVT Risk Suggested Thromboprophylaxis
Low
 Minor surgery in mobile
patients <10% Early and aggressive ambulation
 Medical patients who are fully
mobile
Moderate
 Medical pts, bed rest or sick LMWH, LDUH BID/TID or
 Most general, open gynecologic Fondaparinux
or urologic surgery patients
10%-40%
 Moderate VTE + High bleeding Mechanical
risk Thromboprophylaxis

High Risk
 Hip or knee arthroplasty,
Major Trauma, SCI LMWH
40% - 80%
 High VTE + High Bleeding risk Mechanical Thromboprophylaxis

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 PREVENTION OF VTE IN
NONSURGICAL PATIENTS
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ANTITHROMBOTIC THERAPY AND

P R E V E N T I O N O F T H R O M B O S I S , 9 TH E D ; A C C P
GUIDELINES
 CONSIDERATIONS
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 50 – 70% of symptomatic thromboembolic events and

70 – 80% of fatal PEs occur in non-surgical patients

 Additional risk factors for VTE in medical patients

Stroke with
Advanced age Previous VTE Cancer lower extremity
weakness

Congestive COPD
Sepsis Bed Rest
Heart Failure Exacerbation
 Acutely Ill Hospitalized Medical Patients
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Recommended
 Low-Molecular Weight
Heparins, Low Dose
Unfractionated Heparin or
Fondaparinux for patients
with high risk for thrombosis
 Optimal use of mechanical
thromboprophylaxis with GCS
or IPC for patients with
contraindications to
anticoagulant
thromboprophylaxis
Recommended Against
 The use of thromboprophylaxis
beyond period of
immobilization or acute
hospital stay
 The use of pharmacologic
prophylaxis or mechanical
prophylaxis in patients at low
risk of thrombosis
Other Nonsurgical Patient Recommendations
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Critically-Ill
 Low-Molecular Weight
Heparins or Low dose
Unfractionated Heparin
is suggested
 Mechanical prophylaxis
with GCS or IPC for
those who are at high
risk for major bleeding
until bleeding risk
decreases
Outpatients with Cancer
 Recommend against routine
prophylaxis with LMWH or
LDUH if no additional risk
factors
 Recommended for patients with solid
tumors who have additional risk
factors
 Recommend against use of
vitamin K antagonists
(Warfarin) for prophylaxis
PHARMACOLOGICAL THERAPY
FOR VTE PROPHYLAXIS
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• Aspirin
• Unfractionated
heparin
• Low-molecular weight
heparins
• Vitamin K antagonists
Warfarin,
• Fondaparinux (Factor
Xa inhibitor)
QUESTIONS?
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