Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Department of Medicine, McGill University, Montreal, QC, Canada.
Chest (Impact Factor: 7.48). 02/2012; 141(2 Suppl):e195S-226S. DOI: 10.1378/chest.11-2296
Source: PubMed

ABSTRACT This guideline addressed VTE prevention in hospitalized medical patients, outpatients with cancer, the chronically immobilized, long-distance travelers, and those with asymptomatic thrombophilia.
This guideline follows methods described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.
For acutely ill hospitalized medical patients at increased risk of thrombosis, we recommend anticoagulant thromboprophylaxis with low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH) bid, LDUH tid, or fondaparinux (Grade 1B) and suggest against extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay (Grade 2B). For acutely ill hospitalized medical patients at low risk of thrombosis, we recommend against the use of pharmacologic prophylaxis or mechanical prophylaxis (Grade 1B). For acutely ill hospitalized medical patients at increased risk of thrombosis who are bleeding or are at high risk for major bleeding, we suggest mechanical thromboprophylaxis with graduated compression stockings (GCS) (Grade 2C) or intermittent pneumatic compression (IPC) (Grade 2C). For critically ill patients, we suggest using LMWH or LDUH thromboprophylaxis (Grade 2C). For critically ill patients who are bleeding or are at high risk for major bleeding, we suggest mechanical thromboprophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 2C). In outpatients with cancer who have no additional risk factors for VTE we suggest against routine prophylaxis with LMWH or LDUH (Grade 2B) and recommend against the prophylactic use of vitamin K antagonists (Grade 1B).
Decisions regarding prophylaxis in nonsurgical patients should be made after consideration of risk factors for both thrombosis and bleeding, clinical context, and patients' values and preferences.

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    • "Low molecular weight heparins (LMWHs) and the synthetic pentasaccharide (fondaparinux) are the main antithrombotic drugs used for the prevention of VTE in cancer patients.12,13 Unfractionated heparin (UFH), LMWHs, fondaparinux, and vitamin K antagonists (VKAs) are recommended for the treatment of the acute phase of VTE.13 The LMWHs enoxaparin, dalteparin, or tinzaparin rather than VKAs are recommended for long-term treatment (3–6 months) in cancer patients with VTE.12,14 "
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    ABSTRACT: Patients with cancer have a 6-7-fold higher risk of venous thromboembolism (VTE) as compared with non-cancer patients. Effective and safe anticoagulation for the prevention and treatment of VTE is the cornerstone of the management of patients with cancer, aiming to decrease morbidity and mortality and to improve quality of life. Unfractionated heparin, low molecular weight heparins, fondaparinux and vitamin K antagonists (VKAs) are used in the prevention and treatment of VTE in cancer patients. Heparins and fondaparinux are administered subcutaneously. VKAs are orally active, but they have a narrow therapeutic window, numerous food and drug interactions, and treatment requires regular laboratory monitoring and dose adjustment. These limitations among others have important negative impact on the quality of life of patients and decrease adherence to the treatment. New orally active anticoagulant (NOAC) agents are specific inhibitors of activated factor Xa (FXa) (rivaroxaban and apixaban) or thrombin (dabigatran). It is expected that NOACs will improve antithrombotic treatment. Cancer patients are a particular group that could benefit from treatment with NOACs. However, NOACs present some significant interactions with drugs frequently used in cancer patients, which might influence their pharmacokinetics, compromising their efficacy and safety. In the present review, we analyzed the available data from the subgroups of patients with active cancer who were included in Phase III clinical trials that assessed the efficacy and safety of NOACs in the prevention and treatment of VTE. The data from the Phase III trials in prophylaxis of VTE by rivaroxaban or apixaban highlight that these two agents, although belonging to the same pharmacological group (direct inhibitors of factor Xa), have substantially different profiles of efficacy and safety, especially in hospitalized acutely ill medical patients with active cancer. A limited number of patients with VTE and active cancer were included in the Phase III trials (EINSTEIN, AMPLIFY, and RE-COVER) which evaluated the efficacy and safety of NOACs in the acute phase and secondary prevention of VTE. Although, from a conceptual point of view, NOACs could be an attractive alternative for the treatment of VTE in cancer patients, the available data do not support this option. In addition, due to the elimination of the NOACs by the liver and renal pathway as well as because of their pharmacological interactions with drugs which are frequently used in cancer patients, an eventual use of these drugs in cancer patients should be extremely cautious and be restricted only to patients presenting with contraindications for low molecular weight heparins, fondaparinux, or VKAs. The analysis of the available data presented in this review reinforces the request for the design of new Phase III clinical trials for the assessment of the efficacy and safety of NOACs in specific populations of patients with cancer.
    Therapeutics and Clinical Risk Management 06/2014; 10(1):423-36. DOI:10.2147/TCRM.S49063 · 1.47 Impact Factor
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    • "Based on current guidelines, there are general recommendations for preventing VTE during flight including perform regular leg exercises (e.g. ankle movements, isometric exercises, and walking), avoid excessive alcohol consumption, and avoid the use of tranquillizers and sleeping pills whilst sitting position (50-53). The Aerospace Medical Association considered the patient with uncontrolled HF as a moderate risk. "
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    ABSTRACT: Context: Prevalence of patients with heart failure (HF) is increasing in worldwide, and also the number of people with HF traveling long distances is increasing. These patients are more prone to experience problems contributed air travel and needs more attention during flight. However, observational studies about problems of HF patients during flight and appropriated considerations for them are limited. Evidence Acquisition: We evaluated the conditions that may be encountered in a HF patient and provide the recommendations to prevent the exacerbation of cardiac failure during air travel. For this review article, a comprehensive search was undertaken for the studies that evaluated the complications and considerations of HF patients during flight. Data bases searched were: MEDLINE, EMBASE, Science Direct, and Google Scholar. Results: HF patients are more prone to experience respiratory distress, anxiety, stress, cardiac decompensation, and venous thromboembolism (VTE) during air travel. Although stable HF patients can tolerate air travel, but those with acute heart failure syndrome should not fly until complete improvement is achieved. Conclusions: Thus, identifying the HF patients before the flight and providing them proper education about the events that may occur during flight is necessary.
    06/2014; 16(6):e17213. DOI:10.5812/ircmj.17213
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    • "Surgical patients were also less likely to receive LMWH than UFH compared with medical patients, which may reflect concern about increased risk of postoperative bleeding. This situation is paradoxical in that the relative benefit of LMWH over UFH is stronger in surgical populations [35] than in medical populations [1]. Patients receiving renal replacement therapy were also significantly less likely to receive LMWH than UFH. "
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    ABSTRACT: Heparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without an increased bleeding risk. We performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH. We enrolled 1,935 patients (62.3 +/- 16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1 +/- 8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95%CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95%CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95%CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95%CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life-support limitation (6.9%). LMWH was less often administered to sicker patients (OR 0.65, 95%CI 0.48, 0.89 per 10-point increase in APACHE II), surgical patients (OR 0.41, 95%CI 0.24, 0.72), those receiving vasoactive drugs (OR 0.47, 95%CI 0.35, 0.64) or renal replacement therapy (OR 0.10, 95%CI 0.05, 0.23). Guideline concordance for thromboprophylaxis was high, but LMWH was less commonly used, especially in patients who were sicker, had surgery, or received vasopressors or renal replacement therapy, representing a potential quality improvement target.
    Critical care (London, England) 04/2014; 18(2):R82. DOI:10.1186/cc13844 · 4.48 Impact Factor
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