Venous Thromboembolism
Prophylaxis for Medical Inpatients
Dennis Whang
4/2/12
DSR2 Mini Lecture
Objectives
• Recognize the morbidity and mortality with
venous thromboembolism of inpatients
• Determine the risk of VTE for each nonsurgical
inpatient admitted
• Decide the VTE prophylaxis for each
nonsurgical inpatient admitted
Background
• Most medical inpatients are at risk for venous
thromboembolism (VTE):
– Deep venous thrombosis (DVT)
– Pulmonary embolus (PE)
• 25% of all VTE cases occur during hospitalization
– 50-75% of VTE cases occur on medical service
• 5-10% of inpatient deaths are due to PE
• Heparin prophylaxis has NOT shown to decrease risk
for inpatient mortality
• However it has shown to decrease the incidence of PE
Deciding VTE Prophylaxis
• Must weigh TWO factors before deciding ppx
– VTE Risk
– Bleeding risk
VTE Prophylaxis Guideline
Low
Patient
admitted
Early
ambulation
Determine
risk of VTE
Moderate
Or High
Risk of VTE
Low risk if all 3:
• Younger than 40
• Mobile
• No thrombotic risk factors
Moderate risk: All other
patients
High risk: ICU patients
Low
Anticoagulant
prophylaxis
High
Intermittent
pneumatic
compression
Determine
bleeding risk
High Bleeding Risk
• Active gastroduodenal
bleed
• Bleeding within 3 months
prior to admission
• Platelet count of < 50
Thrombotic Risk Factors for VTE
•
•
•
•
•
•
•
•
•
Obesity: BMI > 30
Smoking
Immobility
Malignancy
Previous VTE
Placement of central venous catheter
Inherited or acquired hypercoagulable states
Oral contraceptives/Hormone replacement therapy/tamoxifen
Admission diagnosis of:
–
–
–
–
–
–
Congestive heart failure (NYHA III/VI)
Acute COPD exacerbation
Acute infectious disease or sepsis
Acute myocardial infarction
Stroke with lower limb paralysis
Inflammatory bowel disease
Mechanical VTE Prophylaxis
• Intermittent pneumatic compression
– Contraindicated in leg ischemia from peripheral
vascular disease
• Ineffective in prevention of VTE
– Graduated compression stockings
– Venous foot pumps
Pharmacological VTE Prophylaxis
• Low dose unfractionated heparin (UFH)
– 5,000 units SQ TID
• Low molecular weight heparin (LMWH)
– Enoxaparin (Lovenox) 40 mg SQ daily
– Do NOT use if CrCl < 30 ml/min
What VTE prophylaxis would you use?
• A 62 yo F is admitted for community acquired
pneumonia. No prior history of VTE, bleeding,
hepatic, or renal failure. Her platelet count is
200.
• Moderate risk of VTE
• Low risk of bleeding
• VTE ppx: unfractionated heparin or
enoxaparin
What VTE prophylaxis would you use?
• A 35 yo M is admitted for acute gout. He is
ambulatory. He has no prior VTE, GI bleed,
thrombophilia, or malignancy. BMI 23. His
platelet count is 240.
• Low risk of VTE
• Low risk of bleeding
• VTE ppx: early ambulation
What VTE prophylaxis would you use?
• 21 yo F admitted to ICU for DKA from poor
insulin compliance. She is ambulatory. She has
no prior VTE, GI bleed, thrombophilia, or
malignancy. Platelet count is 300.
• High risk of VTE
• Low bleeding risk
• VTE ppx: unfractionated heparin or
enoxaparin
What VTE prophylaxis would you use?
• A 65 yo F is admitted for treatment of an
active malignancy. CrCl is 20 ml/min. She has a
history of prior VTE but no history of bleeding,
hepatic failure. Her platelet count is 250.
• Moderate risk for VTE
• Low bleeding risk
• VTE ppx: unfractionated heparin
VTE Prophylaxis Guideline
Low
Patient
admitted
Early
ambulation
Determine
risk of VTE
Moderate
Or High
Risk of VTE
Low risk if all 3:
• Younger than 40
• Mobile
• No thrombotic risk factors
Moderate risk: All other
patients
High risk: ICU patients
Low
Anticoagulant
prophylaxis
High
Intermittent
pneumatic
compression
Determine
bleeding risk
High Bleeding Risk
• Active gastroduodenal
bleed
• Bleeding within 3 months
prior to admission
• Platelet count of < 50
Summary
• Be aware of VTE in all hospitalized patients
• Assess risk of VTE with every admission
• Use pharmacologic prophylaxis with heparin
for patients with moderate to high risk of VTE
• If pharmacologic prophylaxis is
contraindicated due to high risk of bleeding,
use intermittent pneumatic compression
• Do not use compression stockings
References
• Guyatt GH, et al. Executive Summary : Antithrombotic
Therapy and Prevention of Thrombosis, 9th ed: American
College of Chest Physicians Evidence-Based Clinical Practice
Guidelines. Chest 2012;141;7S-47S.
• Francis, CW. Prophylaxis for Thromboembolism in
Hospitalized Medical Patients. N Engl J Med 2007;356:143844.
• Pineo GF. Prevention of venous thromboembolic disease in
medical patients. UpToDate, Mar 2012.
• Qaseem A, et al. Venous Thromboembolism Prophylaxis in
Hospitalized Patients: A Clinical Practice Guideline From the
American College of Physicians. Ann Intern Med.
2011;155:625-632.