Chest
Volume 126, Issue 3, Supplement, September 2004, Pages 338S-400S
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Prevention of Venous Thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

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This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S–187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [≤ 3,400 U once daily] (both Grade 1A). For higher risk general surgery patients, we recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).

Section snippets

1.0 Introduction

This article systematically reviews the literature related to the risks of venous thromboembolism (VTE) and its prevention. Other evidence-based reviews are also available.123

2.1 General surgery

In studies published between 1969 and 1984,4077174 the observed rate of DVT among general surgical patients not receiving prophylaxis varied between 15% and 30%, with rates of fatal PE between 0.2% and 0.9%.The current risk of thromboembolic complications in general surgery is unknown because studies without prophylaxis are no longer performed in these patients. More rapid mobilization, greater use of thromboprophylaxis, and other advances in perioperative care may tend toward reducing the

3.0 Orthopedic Surgery

Patients undergoing major orthopedic surgery, which includes hip and knee arthroplasty and hip fracture repair, represent a group that is at particularly high risk for VTE, and routine thromboprophylaxis has been the standard of care for > 15 years.2331 Randomized clinical trials have demonstrated that the rates of venographic DVT and proximal DVT 7 to 14 days following major orthopedic surgery in patients who received no prophylaxis are approximately 40 to 60% and 10 to 30%, respectively (

4.0 Neurosurgery

Patients undergoing major neurosurgery are known to be at moderately increased risk of postoperative VTE and warrant the routine use of thromboprophylaxis.2539540541542 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%, with a rate of proximal DVT of 5%.2 The risk factors for DVT in neurosurgery patients include intracranial surgery (rather than spinal surgery), active malignancy, more

5.1 Trauma

Among hospitalized patients, those recovering from major trauma have the highest risk of developing VTE.262563564565 Without prophylaxis, patients with multisystem or major trauma have a DVT risk exceeding 50%,262566 with PE being the third leading cause of death in those who survive beyond the first day.62567568569570 In a prospective study of 443 major trauma patients not receiving any thromboprophylaxis, who had undergone routine bilateral contrast venography, the rates of DVT and proximal

6.0 Medical Conditions

Although VTE is most often considered to be associated with recent surgery or trauma, 50 to 70% of symptomatic thromboembolic events677678 and 70 to 80% of fatal PEs121721679680681 occur in nonsurgical patients. Hospitalization for an acute medical illness is independently associated with about an eightfold increased relative risk for VTE499 and accounts for almost one quarter of all VTE events within the general population.9 Thus, the appropriate prophylaxis of medical inpatients offers an

7.0 Cancer Patients

Patients with cancer have a sixfold increased risk of VTE compared to those without cancer.499 Active cancer accounts for almost 20% of all new VTE events occurring in the community.9 Furthermore, VTE is one of the most common complications seen in cancer patients.715716 Unfortunately, there are few data that allow one to predict which cancer patients will develop VTE. The risk varies by cancer type, and is especially high among patients with malignant brain tumors and adenocarcinoma of the

8.0 Critical Care

Two systematic reviews of VTE and its prevention in critical care settings632748 have been published in the past few years. Most critically ill patients have multiple risk factors for VTE.748749750 Some of these risk factors predate admission to the ICU, and include recent surgery, trauma, sepsis, malignancy, immobilization, stroke, advanced age, heart or respiratory failure, previous VTE, and pregnancy. Other thrombotic risk factors may be acquired during an ICU stay, and include

9.0 Long Distance Travel

Despite extensive lay press coverage, the evidence for an association between prolonged travel, whether by air or by land, and VTE remains controversial.512765766767768769770771772773774 Retrospective studies512765771775 have suggested that approximately 4 to 20% of patients presenting with VTE had traveled within a few weeks prior to the event. One study776 found an increased risk of VTE that was present only for the first 2 weeks after arrival from a long-haul flight. The incidence of

Summary of Recommendations

1.0 General Recommendations

1.4.3. We recommend that mechanical methods of prophylaxis be used primarily in patients who are at high risk of bleeding (Grade 1C+) or as an adjunct to anticoagulant-based prophylaxis (Grade 2A). We recommend that careful attention be directed toward ensuring the proper use of, and optimal compliance with, the mechanical device (Grade 1C+).

1.4.4. We recommend against the use of aspirin alone as prophylaxis against VTE for any patient group (Grade 1A).

1.4.5.1. For each of the antithrombotic

2.1 General surgery

2.1.1. In low-risk general surgery patients (Table 5) who are undergoing a minor procedure, are < 40 years of age, and have no additional risk factors, we recommend against the use of specific prophylaxis other than early and persistent mobilization (Grade 1C+).

2.1.2. Moderate-risk general surgery patients are those patients undergoing a nonmajor procedure and are between the ages of 40 and 60 years or have additional risk factors, or those patients who are undergoing major operations and are <

3.1 Elective hip arthroplasty

3.1.1. For patients undergoing elective THR, we recommend the routine use of one of the following three anticoagulants: (1) LMWH (at a usual high-risk dose, started 12 h before surgery or 12 to 24 h after surgery, or 4 to 6 h after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day); (2) fondaparinux, (2.5 mg started 6 to 8 h after surgery) or (3) adjusted-dose VKA started preoperatively or the evening after surgery (INR target, 2.5; INR

4.0 Neurosurgery

4.0.1. We recommend that thromboprophylaxis be routinely used in patients undergoing major neurosurgery (Grade 1A).

4.0.2. We recommend the use of IPC with or without GCS in patients undergoing intracranial neurosurgery (Grade 1A).

4.0.3. Acceptable alternatives to the above options are prophylaxis with LDUH (Grade 2B) or postoperative LMWH (Grade 2A).

4.0.4. We suggest the combination of mechanical prophylaxis (ie, GCS and/or IPC) and pharmacologic prophylaxis (ie, LDUH or LMWH) in high-risk

5.1 Trauma

5.1.1. We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis, if possible (Grade 1A).

5.1.2. In the absence of a major contraindication, we recommend that clinicians use LMWH prophylaxis starting as soon as it is considered safe to do so (Grade 1A).

5.1.3. We recommend that mechanical prophylaxis with IPC, or possibly with GCS alone, be used if LMWH prophylaxis is delayed or if it is currently contraindicated due to active bleeding or a high risk

6.0 Medical conditions

6.0.1. In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, including active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A).

6.0.2. In medical patients with risk factors for VTE, and in whom there is a contraindication to anticoagulant

7.0 Cancer patients

7.0.1. We recommend that cancer patients undergoing surgical procedures receive prophylaxis that is appropriate for their current risk state (Grade 1A). Refer to the recommendations in the relevant surgical subsections.

7.0.2. We recommend that hospitalized cancer patients who are bedridden with an acute medical illness receive prophylaxis that is appropriate for their current risk state (Grade 1A). Refer to the recommendations in the section dealing with medical patients.

7.0.3. We suggest that

8.0 Critical care

8.1. We recommend that, on admission to a critical care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).

8.2. For patients who are at high risk for bleeding, we recommend mechanical prophylaxis with GCS and/or IPC until the bleeding risk decreases (Grade 1C+).

8.3. For ICU patients who are at moderate risk for VTE (eg, medically ill or postoperative patients), we recommend using LDUH or LMWH prophylaxis (Grade 1A).

8.4.

9.0 Long distance travel

9.1. We recommend the following general measures for long-distance travelers (ie, flights of > 6 h duration): avoidance of constrictive clothing around the lower extremities or waist; avoidance of dehydration; and frequent calf muscle stretching (Grade 1C).

9.2. For long-distance travelers with additional risk factors for VTE, we recommend the general strategies listed above. If active prophylaxis is considered, because of the perceived increased risk of venous thrombosis, we suggest the use of

ACKNOWLEDGMENT

We are grateful to the following external experts who reviewed specific subsections of this article (or the entire article = *) and provided written comments: W. Ageno (Varese, Italy); D. Anderson (Halifax, NS, Canada); R. Arya (London, UK); G. Belcaro (San Valentino, Italy); J.-F. Bergmann (Paris, France); F. Brenneman (Toronto, ON, Canada); R. Buckley (Calgary, AB, Canada); D. Cannavo (New York, NY); J. Caprini (Chicago, IL); M. Cipolle (Allentown, PA); D. Clarke-Pearson (Durham, NC); P. Comp

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