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VTE Prevention in Medical Patients

Primary preventive measures can reduce morbidity and mortality

Venous thromboembolism (VTE) is a well-recognised cause of preventable morbidity and mortality in hospitalised patients. About one in four cases of VTE is associated with hospitalisation, and VTE may occur in patients hospitalised to treat medical illness as well in those undergoing surgery.3, 64
Deep vein thrombosis (DVT) is often asymptomatic. The first sign of thrombosis may be pulmonary embolism (PE) — a potentially fatal cardiovascular event, responsible for between 5% and 10% of deaths in the hospital.64 Therefore, waiting for the signs and symptoms of VTE to appear before instituting anticoagulant treatment increases the risk of morbidity and mortality. The most effective approach to decreasing the burden of VTE is primary prophylaxis (by improving venous return or decreasing coagulability) in patients at high risk.64

VTE prevention with pharmacologic treatment

Anticoagulant therapy with unfractionated heparin, low-molecular-weight heparin (LMWH), and fondaparinux in high-risk medical patients has been shown to reduce the incidence of VTE (both symptomatic and asymptomatic DVT detected by venography or ultrasound).67, 68, 69, 119 While this means of prophylaxis has been more extensively studied in surgical than in medical patients, the balance of evidence from trials involving medical patients provides strong support for this approach. There is less conclusive data about the impact on fatal and nonfatal PE, although a recent meta-analysis indicated a treatment benefit.69

VTE prevention with nonpharmacologic approaches

Both early ambulation and foot extension exercises help minimise venous stasis and should be encouraged. While a number of clinical trials have shown a benefit for graduated compression stockings and pneumatic leg compression devices postoperatively, these methods have not been well studied in hospitalised medical patients. In addition, meaningful research in this area is hampered by the lack of blinding.64 These methods of prophylaxis should be employed for patients with an elevated risk of bleeding complications from anticoagulant therapy.
Treatment of Established DVT and PE >
  • 3 - Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 suppl):338S-400S.
  • 64 - Francis CW. Clinical practice. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med. 2007;356(14):1438-1444.
  • 67 - Cohen AT, Davidson BL, Gallus AS, et al; ARTEMIS Investigators. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. BMJ. 2006;332(7537):325-329.
  • 68 - Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999;341(11):793-800.
  • 69 - Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med. 2007;146(4):278-288.
  • 119 - Leizorovicz A, Cohen AT, Turpie AG, Olsson CG, Vaitkus PT, Goldhaber SZ; PREVENT Medical Thromboprophylaxis Study Group. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004;110(7):874-879.
Venous thromboembolism
A condition in which a blood clot (thrombus) forms in a vein, which in some cases then breaks free and enters the circulation as an embolus, finally lodging in and completely obstructing a blood vessel, e.g., in lungs causing a PE. The term encompasses both DVT and PE.
Prophylaxis
The prevention of a disease or pathological condition.
Fondaparinux
An indirect Factor Xa inhibitor comprising a synthetic pentasaccharide sequence matching the part of the heparin molecule that binds to antithrombin. It is administered by subcutaneous injection.
Heparin
An anticoagulant that exerts its activity by binding to antithrombin and greatly increasing its activity. The principal coagulation factors inhibited by heparin are Factors IIa and Xa. It is administered by intravenous or subcutaneous injection.
Venography
An X-ray of the veins performed by first injecting a radiopaque contrast (shows up on X-ray) into the vein in question and then taking a conventional X-ray. Used to demonstrate blockage of a vein. Commonly used in the lower extremities to diagnose DVT.
Venous stasis
The presence of an abnormally low rate of blood flow in the veins. This can be caused by, for example, the use of a tourniquet or prolonged immobility.

More about Current Approaches to Antithrombotic Therapy

From the Image Library

Patient figure: major veins and deep vein thrombosis (DVT) Vein image 1: venous thrombus formation in cusps of veins Micrograph: deep vein thrombosis See all Venous Thrombosis

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In your experience, after a patient is diagnosed with deep vein thrombosis (DVT) or pulmonary embolism (PE), which of the following long-term complications of venous thromboembolism (VTE) are you most concerned about?

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Did You Know?

Hospitalised patients and residents of nursing homes account for about 60% of all cases of VTE.11

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