What is the best choice for prophylaxis against VTE in medical inpatients?

Case

A 76-year-old gentleman is admitted for progressively worsening dyspnea, cough, and bilateral leg edema. Upon admission, his blood pressure is 150/90 mm/Hg, pulse 90 beats per minute, and respiration is 24 per minute.

Pertinent physical findings include jugular venous distension, bilateral crackles, S3 gallop, and 2+ bilateral lower extremity edema. The chest radiograph shows cardiomegaly and pulmonary edema. He is admitted to the hospital with a diagnosis of acute decompensated heart failure and starts aggressive medical therapy.

Overview

Approximately 2 million cases of deep-vein thrombosis (DVT) occur annually in the United States. Based on studies utilizing ventilation-perfusion scanning, half these patients likely have a silent pulmonary embolism (PE); of these, approximately 250,000 die.

The spectrum of venous thromboembolism (VTE), which includes DVT and PE, can vary from being asymptomatic to sudden death. Autopsy studies suggest a leading cause of sudden death in hospitalized medical patients is often a PE. There also are sequelae, such as chronic pulmonary hypertension, occurring in approximately 5% of PE cases, and post-thrombotic syndrome, occurring in approximately 40% of patients with DVT at two years.1

Key Points

  1. All hospitalized medical patients should undergo VTE risk assessment upon admission.
  2. Patients at risk for VTE should receive pharmacologic prophylaxis for seven to 14 days in the absence of any contraindications. Extended prophylaxis for five weeks may be indicated in patients older than 75 and/or those with prior history of VTE or cancer..
  3. Mechanical forms of prophylaxis should only be used if anticoagulants are contraindicated.

The Bottom Line

All medical inpatients should be assessed for VTE prophylaxis upon admission, and prescribed pharmacologic prophylaxis with LMWH for seven to 14 days in the absence of contraindications. If risk factors do not mandate prophylaxis, patients should be assessed daily for any change in clinical status and prophylaxis should be employed as warranted.

Additional Reading

  • Francis CW. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med. 2007;356:1438-1444.
  • Hirsh J, Raschke R. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Chest. 2004;126,3(suppl):163S-697S.

A recent study suggests DVT occurs three times more commonly in the outpatient setting. However, more than half of these patients were hospitalized in the three months prior.2 This is likely due to inadequate in-hospital prevention because of absence of prophylaxis, use of an unsuitable modality, insufficient dose of the drug, or ineffective duration of therapy. Inadequate and omitted VTE prophylaxis for medical patients was clearly demonstrated in the DVT Free Registry. This registry was created by 183 U.S. hospitals and included 5,451 patients, inpatients, and outpatients with ultrasound-confirmed DVT.

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