Venous Thromboembolism Prophylaxis

Venous Thromboembolism Prophylaxis is a topic covered in the Washington Manual of Medical Therapeutics.

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General Principles

Epidemiology

Venous thromboembolism (VTE) is a preventable cause of death in hospitalized patients. In the largest observational study to date attempting to risk-stratify medical patients, 1.2% of medical patients developed VTE within 90 days of admission. A total of 10%–31% of patients were deemed to be at high risk for VTE, defined as having two or more points by weighted risk factors below.1

  • three points: previous VTE, thrombophilia
  • one point: cancer, age >60

Prevention

  • Ambulation several times a day should be encouraged.
  • Pharmacologic prophylaxis results in a 50% decrease in VTE risk, although this includes many asymptomatic calf vein thromboses that do not progress. No overall mortality benefit from prophylaxis has been demonstrated.
  • Acutely ill patients at high risk of VTE, without bleeding or high risk of bleeding, should be treated with low-dose unfractionated heparin (UFH), 5000 units SC q12h or q8, or low-molecular-weight heparin (LMWH); enoxaparin, 40 mg SC daily, or dalteparin, 5000 units SC daily; or fondaparinux, 2.5 mg SC daily.
  • Betrixaban is the only direct oral anticoagulant approved for DVT prophylaxis in hospitalized patients. Betrixaban reduced the composite outcome of asymptomatic and symptomatic VTE plus VTE-related deaths when compared with enoxaparin.2
  • Aspirin alone is not sufficient for prophylaxis in hospitalized patients.3
  • At-risk patients with contraindications to anticoagulation prophylaxis may receive mechanical prophylaxis with intermittent pneumatic compression or graded compression stockings, although evidence of benefit is lacking.4

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