Prevention of Venous Thromboembolism

in Nonsurgical Patients
-----

Antithrombotic Therapy and Prevention of

Thrombosis, 9th ed: American College of Chest
Physicians Evidence-Based Clinical Practice
Guidelines

Copyright: American College of Chest Physicians 2012

 Guideline Team
Expertise in: thrombosis, bleeding disorders,
critical care, preventive medicine,
methodology, cost effectiveness and two
frontline physicians
Susan R. Kahn MD, MSc
Wendy Lim MD, MSc
Andrew Dunn, MD
Mary Cushman, MD
Francesco Dentali, MD
Elie A. Akl, MD, MPH, PhD
Deborah J. Cook MD, MSc
Alex A. Balekian, MD, MSHS
Russell C. Klein, MD
Hoang Le, MD, FCCP
Sam Schulman, MD
Mohammad Hassan Murad, MD, MPH
Hospitalized Acutely Ill Medical Patients

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) .

Remarks: In choosing the specific anticoagulant drug to be used

for pharmacoprophylaxis, choices should be based on patient
preference, compliance, and ease of administration (eg, daily vs
bid vs tid dosing), as well as on local factors affecting acquisition
costs (eg, prices of various pharmacologic agents in individual
hospital formularies).
Hospitalized Acutely Ill Medical Patients

For acutely ill hospitalized medical patients at low risk of

thrombosis, we recommend against the use of pharmacologic
prophylaxis or mechanical prophylaxis (Grade 1B).
Hospitalized Acutely Ill Medical Patients

For acutely ill hospitalized medical patients who are bleeding

or at high risk for bleeding, we recommend against
anticoagulant thromboprophylaxis (Grade 1B).
 Hospitalized Acutely Ill Medical Patients

For acutely ill hospitalized medical patients at increased risk of

thrombosis who are bleeding or at high risk for major bleeding,
we suggest the optimal use of mechanical thromboprophylaxis
with graduated compression stockings (GCS) (Grade 2C) or
intermittent pneumatic compression (IPC) (Grade 2C) , rather
than no mechanical thromboprophylaxis. When bleeding risk
decreases, and if VTE risk persists, we suggest that
pharmacologic thromboprophylaxis be substituted for
mechanical thromboprophylaxis (Grade 2B).

Remarks: Patients who are particularly averse to the potential for

skin complications, cost, and need for clinical monitoring of GCS
and IPC use are likely to decline mechanical prophylaxis.
 Hospitalized Acutely Ill Medical Patients

In acutely ill hospitalized medical patients who receive an

initial course of thromboprophylaxis, we suggest against
extending the duration of thromboprophylaxis beyond the
period of patient immobilization or acute hospital stay
(Grade 2B).
 Critically Ill Patients

In critically ill patients, we suggest against routine ultrasound

screening for DVT (Grade 2C).
 Critically Ill Patients

For critically ill patients, we suggest using LMWH or LDUH

thromboprophylaxis over no prophylaxis (Grade 2C).
 Critically Ill Patients

For critically ill patients who are bleeding, or are at high risk
for major bleeding, we suggest mechanical thromboprophylaxis
with GCS (Grade 2C) or IPC (Grade 2C) until the bleeding risk
decreases, rather than no mechanical thromboprophylaxis.
When bleeding risk decreases, we suggest that pharmacologic
thromboprophylaxis be substituted for mechanical
thromboprophylaxis (Grade 2C).
 Patients With Cancer

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).

Remarks: Additional risk factors for venous thrombosis

in cancer outpatients include previous venous thrombosis,
immobilization, hormonal therapy, angiogenesis inhibitors,
thalidomide, and lenalidomide.
 Patients With Cancer

In outpatients with solid tumors who have additional risk factors

for VTE and who are at low risk of bleeding, we suggest
prophylactic dose LMWH or LDUH over no prophylaxis (Grade
2B).

Remarks: Additional risk factors for venous thrombosis in cancer

outpatients include previous venous thrombosis, immobilization,
hormonal therapy, angiogenesis inhibitors, thalidomide, and
lenalidomide.
 Patients With Cancer

In outpatients with cancer and indwelling central venous

catheters, we suggest against routine prophylaxis with LMWH
or LDUH (Grade 2B) and suggest against the prophylactic
use of vitamin K antagonists (Grade 2C).
 Chronically Immobilized Outpatients

In chronically immobilized persons residing at home or at a

nursing home, we suggest against the routine use of
thromboprophylaxis (Grade 2C).
 Long-distance Travel

For long-distance travelers at increased risk of VTE (including

previous VTE, recent surgery or trauma, active malignancy,
pregnancy, estrogen use, advanced age, limited mobility, severe
obesity, or known thrombophilic disorder), we suggest frequent
ambulation, calf muscle exercise, or sitting in an aisle
seat if feasible (Grade 2C).
 Long-distance Travel

For long-distance travelers at increased risk of VTE (including

previous VTE, recent surgery or trauma, active malignancy,
pregnancy, estrogen use, advanced age, limited mobility, severe
obesity, or known thrombophilic disorder), we suggest use of
properly fitted, below-knee GCS providing 15 to 30 mm
Hg of pressure at the ankle during travel (Grade 2C). For all
other long-distance travelers, we suggest against the use of GCS
(Grade 2C).
 Long-Distance Travel

For long-distance travelers, we suggest against the use of aspirin

or anticoagulants to prevent VTE (Grade 2C).
 Persons With Asymptomatic Thrombophilia

In persons with asymptomatic thrombophilia (ie, without a

previous history of VTE), we recommend against the long-term
daily use of mechanical or pharmacologic thromboprophylaxis
to prevent VTE (Grade 1C).
 Other Nonsurgical Settings

Thromboprophylaxis in these settings is

described in the surgical chapter:
Trauma
Spinal cord injuries
Burn victims
Thromboprophylaxis using aspirin: no
statement was made due to sparse data in
medical patients
 Acknowledgement of Support
The ACCP appreciates the support of the following organizations
for some part of the guideline development process:

Bayer Schering Pharma AG

National Heart, Lung, and Blood Institute (Grant No.R13 HL104758)
With educational grants from
Bristol-Myers Squibb and Pfizer, Inc.
Canyon Pharmaceuticals, and
sanofi-aventis U.S.

Although these organizations supported some portion of the development

of the guidelines, they did not participate in any manner with the scope,
panel selection, evidence review, development, manuscript writing,
recommendation drafting or grading, voting, or review. Supporters did not
see the guidelines until they were published.
 Endorsing Organizations

This guideline has received the endorsement of the

following organizations:

American Association for Clinical Chemistry

American College of Clinical Pharmacy
American Society of Health-System Pharmacists
American Society of Hematology
International Society of Thrombosis and Hemostasis