The Generalist: VTE Prophylaxis

The Generalist: VT Prophylaxis in Hospitalized Patients

Jake Anderson, DO, and Heidi James, MD

Jake Anderson joins Heidi to discuss venous thromboembolism prophylaxis in hospitalized patients.

• About half of all venous thromboembolism (VTE) cases are linked to a current or recent hospitalization.
• VTE risk persists for up to 90 days post-hospitalization.
• Risk factors for VTE:
• Immobility
• Older age
• Systemic illness
• Surgery
• Recent trauma
• Central venous catheter use
• The evidence for the benefit of VTE prophylaxis is limited and mixed. 
• There are two different forms of VTE prophylaxis: 
• Pharmacologic (or chemical) prophylaxis
• More effective than mechanical prophylaxis
• Options
• Low-molecular-weight heparin
• Fondaparinux
• Unfractionated heparin
• Direct oral anticoagulants (like rivaroxaban or apixaban) 
• Can be used for prophylaxis if the patient is already taking it for another indication
• Should not be started for the sole reason of prophylaxis in the hospital
• Mechanical prophylaxis
• Options
• Compression stockings
• Foot pumps
• Pneumatic compression devices
• Use caution in people with 
• Sensory impairment
• Lower extremity wounds 
• Peripheral arterial disease 
• Determining patient risk 
• Padua Prediction Score
• 11-item, 20-point scale 
• Considers previous VTE, active cancer, decreased mobility, age ≥70 years, recent trauma or surgery, heart or respiratory failure, and obesity
• Gives a 90-day VTE risk prediction
• 4 points is the cutoff between low and high risk; score ≥4 indicates the need for prophylaxis
• Consider bleeding risk when assessing prophylaxis 
• Risk factors for bleeding with pharmacologic prophylaxis:
• Liver or kidney disease
• Peptic ulcer disease
• Active bleeding
• Concomitant use of medications like aspirin, steroids, nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics
• Duration of therapy
• Prophylaxis should not extend beyond hospitalization for patients admitted with medical illness.

PEARL: When initiating pharmacologic VTE prophylaxis in hospitalized patients consider their VTE risk and bleeding risk. 

References: 

Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, Ninth Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Kahn SR, Lim W, Dunn AS, et al. Chest. 2012;141(2 Suppl):e195S-226S.

American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients
Schünemann HJ, Cushman M, Burnett AE, et al. Blood Adv. 2018;2(22):3198-3225.

RELATED SEGMENTS
PCMA Archive 2012 July: Venous Thromboembolism Prophylaxis In Hospitalized Patients: A Clinical Practice Guideline From The American College Of Physicians