This document summarizes guidelines for thromboprophylaxis from the 7th ACCP conference. It discusses the rationale for thromboprophylaxis, including the high prevalence and adverse consequences of unprevented VTE. It outlines risk factors for VTE and basic principles of thromboprophylaxis. It provides recommendations for prophylaxis in different patient groups based on risk level, including for different surgical procedures. It discusses strategies to improve implementation of guidelines in clinical practice.

2. ETIOPATHOGENESIS

3. • Abnormalities of flow
• Abnormalities of vessel wall
• Hypercoagulability of blood
ETIOPATHOGENESIS

4. Objectives/Outline
 Rationale for thromboprophylaxis
 Summary of the 7th ACCP
thromboprophylaxis guidelines
 Implementation strategies

5. Rationale for Thromboprophylaxis
I. High prevalence of VTE in certain
patient groups
II. Adverse consequences of
unprevented VTE
III. Efficacy, effectiveness and cost-
effectiveness of thromboprophylaxis

6. Risk Factors for VTE
 Previous venous thromboembolism
 Increased age
 Surgery
 Trauma - major, local leg
 Immobilization - bedrest, stroke, paralysis
 Malignancy and its Rx (CTX, RTX, hormonal)
 Heart or respiratory failure
 Estrogen use, pregnancy, postpartum, SERMs
 Central venous lines
 Thrombophilic abnormalities

7. Risk Factors for VTE
 Previous venous thromboembolism
 Increased age
 Surgery
 Trauma - major, local leg
 Immobilization - ? bedrest, stroke, paralysis
 Malignancy & its Rx (CTX, RTX, hormonal)
 Heart or respiratory failure
 Estrogen use, pregnancy, postpartum, SERMs
 Central venous lines
 Thrombophilic abnormalities

8. Some Basic Principles of
Thromboprophylaxis
• Group prophylaxis rather than individual
• Mechanical prophylaxis only if high risk of
bleeding
• No role for aspirin alone as DVT prophylaxis
• Epidural analgesia and anticoagulant
thromboprophylaxis are compatible
7th ACCP Conference on Antithrombotic Therapy

9. DVT Prophylaxis:
3 Patient Groups
Low risk
Moderate risk
High risk

10. Patient group: Age < 40 years
Medical – fully mobile, brief admission
Surgical – procedure < 30 min, mobile,
no additional risk factors
Recommendations:
 no specific prophylaxis
 mobilization
[Grade 1C]
Low risk
7th ACCP Conference on Antithrombotic Therapy

11. Patient group: Age between 40 – 60 years + minor surgery
or age < 40 with risk factors
Medical – bedrest / sick
Surgical – major general, urologic,
gynecologic procedures
Evidence: LDH ~ LMWH
Options:  LDH [Grade 1A] 5000 bid
 LMWH [Grade 1A] <= 3400 u once daily
 TEDS, IPC (high bleeding risk) [1C+]
Start: as soon as possible
Duration: until discharge (not “ambulation”)
Moderate risk
7th ACCP Conference on Antithrombotic Therapy

12. Patient group: Major orthopedics (THR, TKA, HFS)
Age 40 – 60 years with major surgery (G +U)
Minor surgery, Age > 60, +/- risk factors
Evidence:
1. Venography: fondaparinux > LMWH > OVKA
2. Clinical: LMWH ~ OVKA
Options:  LMWH [Grade 1A] > 3400 sc daily
 fondaparinux [Grade 1A]
 oral vitamin K antagonist (INR 2-3) [1A]
 LDH or LMWH + GCS or IPC
Start: Postop (preop if HFS delayed)
Duration: > 10 days (2-4 weeks)
7th ACCP Conference on Antithrombotic Therapy
High risk

13. HIT with LDH or LMWH for Prophylaxis
Martel – Blood 2005;106:2710
• meta-analysis of 7 prospective studies comparing
prophylactic LDH and LMWH
Prophylactic
anticoagulant HIT
Heparin 41/1,730 (2.37 %)
LMWH 1/1,762 (0.06 %)
* NNT=43

14. Routine Prophylaxis NOT
Recommended:
• vascular surgery
• laparoscopic surgery
• knee arthroscopy
• spine surgery
• isolated lower extremity fractures
• long distance travel
7th ACCP Conference on Antithrombotic Therapy
Any additional risk factors
will mandate consideration of thromboprophylaxis

15. Benefit:risk favors
routine prophylaxis
• Major orthopedic surgery
(THR, TKR, HFS)
• Major trauma
• Spinal cord injury
• Major general, gyne,
urologic surgery
• Major neurosurgery
• Medical patients with
additional risk factors
• Most ICU patients

16. Benefit:risk favors
routine prophylaxis
• Major orthopedic surgery
(THR, TKR, HFS)
• Major trauma
• Spinal cord injury
• Major general, gyne,
urologic surgery
• Major neurosurgery
• Medical patients with
additional risk factors
• Most ICU patients
Benefit:risk favors
no prophylaxis
• Surgical patients:
- brief procedure
- fully mobile
- no additional RFs
• Medical patients:
- fully mobile
- no additional RFs
• Long distance travel

17. Benefit:risk favors
routine prophylaxis
• Major orthopedic surgery
(THR, TKR, HFS)
• Major trauma
• Spinal cord injury
• Major general, gyne,
urologic surgery
• Major neurosurgery
• Medical patients with
additional risk factors
• Most ICU patients
Benefit:risk uncertain-
local practice or
individual prophyl.
• Laparoscopic surgery
• Vascular surgery
• Cardiac surgery
• Elective spine surgery
• Arthroscopic surgery
• Burns
• Isolated lower
extremity fracture
Benefit:risk favors
no prophylaxis
• Surgical patients:
- brief duration
- fully mobile
- no additional RFs
• Medical patients:
- fully mobile
- no additional RFs
• Long distance travel

18. Thromboprophylaxis Use in
Practice 1992-2002
Prophylaxis
Patient Group Studies Patients Use (any)
Orthopedic surgery 4 20,216 90 % (57-98)
General surgery 7 2,473 73 % (38-98)
Critical care 14 3,654 69 % (33-100)
Gynecology 1 456 66 %
Medical patients 5 1,010 23 % (14-62)

19. Recommended VTE Prophylaxis Strategies
in Surgical Settings
Indication Prevention Strategy
General Surgery UFH 5,000 units q 8h, 1
st
dose 2h
preoperatively, continued for 7 days or
LMWH once daily
Cancer Surgery Enoxaparin 40 mg daily or equivalent, 1
st
dose 10-14h preoperatively if possible,
for 28 days
UFH = unfractionated heparin
LMWH = low molecular weight heparin

20. Recommended VTE Prophylaxis Strategies
in Surgical Settings (cont.)
Indication Prevention Strategy
Total Hip
Replacement
Enoxaparin 40 mg daily or equivalent,
beginning preoperative evening, continuing
out-of-hospital for 21-28 days
Enoxaparin 30 mg BID or equivalent, 1
st
dose 12-24h postoperatively, until hospital
discharge
Dalteparin 2,500 units ≥ 4h post-op, then
5,000 units daily until hospital discharge or
for 35 days

21. Recommended VTE Prophylaxis Strategies
in Surgical Settings (cont.)
Indication Prevention Strategy
Total Hip
Replacement (cont.)
Fondaparinux 2.5 mg 4-8h post-op, then ≥
12h after 1st dose, then daily for 5-9 days
Warfarin daily, 1
st
dose 7.5 mg 24-48h
preoperatively, adjusted to target INR of 2.0-
3.0
Warfarin daily, 1
st
dose 5 mg preoperative
evening, adjusted to target INR of 2.0-3.0 and
continued 4-6 weeks

22. Recommended VTE Prophylaxis Strategies
in Surgical Settings (cont.)
Indication Prevention Strategy
Total Knee
Replacement
Enoxaparin 30 mg BID or equivalent, beginning 12-
24h postoperatively, continued for an average of 9
days
Fondaparinux 2.5 mg, 1
st
dose 4-8h postoperatively,
2
nd
dose ≥ 12h after 1
st
dose, then daily for 5-9 days
Hip Fracture
Surgery
Fondaparinux 2.5 mg, 1
st
dose 4-8h postoperatively,
2
nd
dose ≥ 12h after 1
st
dose, then daily for 5-9 days. If
surgery is delayed > 24-48h after admission, give 1
st
dose 10-14h preoperatively

23. Recommended VTE Prophylaxis Strategies
in Surgical Settings (cont.)
Indication Prevention Strategy
Neurosurgery Enoxaparin 40 mg daily or equivalent, 1
st
dose ≤ 24h postoperatively, continued until
hospital discharge, plus GCS
Craniotomy for Brain
Tumor
Enoxaparin 40 mg daily or UFH 5,000 units
BID, 1
st
dose on 1
st
postoperative morning,
continued until hospital discharge, plus
GCS/IPC, plus predischarge venous
ultrasonographyGCS = graduated compression stockings
IPC = intermittent pneumatic compression devices

24. Duration of Prophylaxis
Recommendations for extending the duration of
prophylaxis in high-risk scenarios:
Geerts WH, et al. Chest. 2004;126(suppl 3):338S-400S.
Cancer surgery 28 days postoperatively
Total hip
replacement and
hip fracture repair
28-35 days postoperatively
Trauma Throughout inpatient
rehabilitation and after
discharge in patients with
significantly impaired mobility

25. Objectives/Outline
 Rationale for thromboprophylaxis
 Summary of the 7th ACCP
thromboprophylaxis guidelines
 Implementation strategies

26. Strategies to Improve
Thromboprophylaxis Success
• Excellent quality guidelines
• National body endorsement
• Hospital accreditation (JCAHO)
• Pay for performance (CMS)
• Local written policy (care pathway) for
the hospital / program / patient care unit
• Pharmacist responsibility
• Pre-printed orders
• Computerized orders

27. Take-Home Points
• Know the common VTE risk factors
• Assess VTE risk for each hospitalized patient
individually
• Become familiar with the various VTE
prophylaxis regimens for different at-risk patient
groups
• Apply the current ACCP guidelines to prevent
VTE in hospitalized patients

28. Prevention of VTE: Summary
1. Thromboprophylaxis is indicated for most
hospitalized patients
2. But is under-utilized
3. Not ASA; mechanical rarely; warfarin scary
4. Chest 2004;126(suppl):338S-400S
5. Systems approach / hospital policy
6. Keep it simple, routine: Pre-printed orders
Just do it!

29. Thank you
http://webmm.ahrq.gov
Bill Geerts, MD, FRCPC, FCCP
University of Toronto