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Prevention of Venous Thromboembolism^*

American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

^* From Sunnybrook Health Sciences Centre (Dr. Geerts), University of Toronto, Toronto, ON, Canada; University Hospital (Dr. Bergqvist), Uppsala, Sweden; Foothills Hospital (Dr. Pineo), University of Calgary, Calgary, AB, Canada; Mayo Clinic (Dr. Heit), Rochester, MN; Hôtel-Dieu University Hospital (Dr. Samama), Paris, France; Hoersholm Hospital (Dr. Lassen), Hoersholm, Denmark; and Scripps Clinic (Dr. Colwell), La Jolla, CA.

Correspondence to: William H. Geerts, MD, FCCP, Thromboembolism Program, Sunnybrook Health Sciences Centre, Room D674, 2075 Bayview Ave, Toronto, ON, Canada M4N 3M5

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggestions imply that individual patient values may lead to different choices (for a full discussion of the grading, see the "Grades of Recommendation" chapter by Guyatt et al). Among the key recommendations in this chapter are the following: we recommend that every hospital develop a formal strategy that addresses the prevention of VTE (Grade 1A). We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A), and we recommend that mechanical methods of thromboprophylaxis be used primarily for patients at high bleeding risk (Grade 1A) or possibly as an adjunct to anticoagulant thromboprophylaxis (Grade 2A).

For patients undergoing major general surgery, we recommend thromboprophylaxis with a low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux (each Grade 1A). We recommend routine thromboprophylaxis for all patients undergoing major gynecologic surgery or major, open urologic procedures (Grade 1A for both groups), with LMWH, LDUH, fondaparinux, or intermittent pneumatic compression (IPC).

For patients undergoing elective hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or a vitamin K antagonist (VKA); international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0 (each Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1B), a VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 1B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty or HFS receive thromboprophylaxis for a minimum of 10 days (Grade 1A); for hip arthroplasty and HFS, we recommend continuing thromboprophylaxis > 10 days and up to 35 days (Grade 1A). We recommend that all major trauma and all spinal cord injury (SCI) patients receive thromboprophylaxis (Grade 1A). In patients admitted to hospital with an acute medical illness, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1A). We recommend that, on admission to the ICU, all patients be assessed for their risk of VTE, and that most receive thromboprophylaxis (Grade 1A).

Key Words: aspirin • deep vein thrombosis • fondaparinux • graduated compression stockings • heparin • intermittent pneumatic compression • low-molecular-weight heparin • pulmonary embolism • thromboprophylaxis • venous foot pump • venous thromboembolism • warfarin