9th Edition Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Summary

Prevention of VTE; CHEST 2012

MEDICAL PATIENTS
RISK GROUP RECOMMEND PROPHYLAXIS
Low VTE Risk Recommend against the use of pharmacologic or mechanical prophylaxis (Grade 1B)
Padua Score < 4
Low VTE Risk with High Bleed Risk Recommend against anticoagulant thromboprophylaxis (Grade 1B)
High VTE Risk Thromboprophylaxis with LMWH (Grade 1B), LDUH BID or TID (Grade 1B), or
Padua Score ≥ 4 fondaparinux (Grade 1B).
High VTE Risk with High Bleed Risk Mechanical thromboprophylaxis with graduated compression stockings (GCS) (Grade
2C) or intermittent pneumatic compression (IPC) (Grade 2C).
When bleeding risk decreases suggest pharmacologic thromboprophylaxis is substituted
for mechanical thromboprophylaxis (Grade 2B).
Extended duration thromboprophylaxis Recommend against extending the duration of thromboprophylaxis beyond the period of
patient immobilization or acute hospital stay.
CRITICAL CARE PATIENTS
PATIENT CHARACTERISTICS RECOMMENDED PROPHYLAXIS
Admitted to a critical care unit Thromboprophylaxis with LMWH or LDUH thromboprophylaxis over no prophylaxis
(Grade 2C).
Bleeding or at a High Bleed Risk Mechanical thromboprophylaxis with GCS (Grade 2C) or IPC (Grade 2C).
When bleeding risk decreases suggest pharmacologic thromboprophylaxis is substituted
for mechanical thromboprophylaxis (Grade 2C).
CANCER IN OUTPATIENT SETTING
PATIENT CHARACTERISTICS RECOMMENDED PROPHYLAXIS
No additional risk factors for VTEa Recommend against routine prophylaxis with LMWH and LDUH (Grade 2B) and
recommend against the prophylactic use of vitamin K antagonists (Grade 1B).
Solid tumors with additional risk factors for Thromboprophylaxis with LMWH or LDUH thromboprophylaxis over no prophylaxis
VTEa and low bleed risk (Grade 2B).
Indwelling central venous catheters Recommend against routine prophylaxis with LMWH and LDUH (Grade 2B) and
recommend against the prophylactic use of vitamin K antagonists (Grade 2C).
a. Additional risk factors for VTE in cancer outpatients: previous VTE, immobilization, hormonal therapy, angiogenesis inhibitors, thalidomide,
and lenalidomide.
LONG-DISTANCE TRAVEL
PATIENT CHARACTERISTICS RECOMMENDED PROPHYLAXIS
Any long distance traveler Recommend against the use of aspirin or anticoagulants to prevent VTE (Grade 2C).
Recommend against the use of GCS (Grade 2C)
With additional risk factors for VTEb Recommend frequent ambulation, calf muscle exercises, or sitting in an aisle seat if
feasible (Grade 2C)
Recommend properly fitted, below knee graduated compression stockings, providing 15-
30 mmHg pressure at the ankle during travel (Grade 2C)
b. Additional risk factors for long distance travelers: previous VTE, recent surgery or trauma, active malignancy, pregnancy, estrogen use,
advance age, limited mobility, severe obesity, or known thrombophilic disorder

IMMOBILIZATION AND ASYMPTOMATIC PATIENTS

PATIENT CHARACTERISTICS RECOMMENDED PROPHYLAXIS
Chronically immobilized patients residing at Recommend against the routine use of thromboprophylaxis (Grade 2C).
home or a nursing home
Asymptomatic thrombophilia patients without a Recommend against the long-term daily use of mechanical or pharmacologic
previous history of VTE thromboprophylaxis (Grade 1C).
 GENERAL AND ABDOMINAL-PELVIC SURGERY
Applies to: General, Bariatric, GI, Gynecologic, Vascular, Urologic, Plastic and Reconstructive Surgery
RISK GROUP RECOMMENDED PROPHYLAXIS
Very Low VTE risk Recommend that no specific pharmacologic (Grade 1B) or mechanical (Grade 2C)
Rogers Score: < 7 prophylaxis be used other than early ambulation
Caprini Score: 0
Low VTE Risk Recommend mechanical prophylaxis, preferably intermittent pneumatic compression
Rogers Score: 7-10 (IPC), over no prophylaxis (Grade 2C)
Caprini Score: 1-2
Moderate VTE Risk with Low Bleed Risk Recommend thromboprophylaxis with LMWH or LDUH (each Grade 1B) or
Rogers Score: > 10 mechanical prophylaxis, preferably IPC (Grade 2C), over no prophylaxis
Caprini Score: 3-4
High VTE Risk with Low Bleed Risk Recommend thromboprophylaxis with LMWH or LDUH (each Grade 1B)
Caprini Score: ≥ 5 Recommend adding mechanical prophylaxis with compression stockings (CS) or IPC to
pharmacologic prophylaxis (Grade 2C)

If both LMWH or LDUH is contraindicated suggest low dose aspirin, fondaparinux, or

mechanical prophylaxis with IPC alone (Grade 2C)
Any VTE Risk with High Bleed Risk Recommend mechanical prophylaxis, preferably IPC (Grade 2C), over no prophylaxis
When the bleeding risk decreases, recommend that pharmacologic thromboprophylaxis
be substituted for or added to the mechanical prophylaxis (Grade 2C)

Extended Duration Thromboprophylaxis
Abdominal or Pelvic Surgery for Cancer
RISK GROUP
Moderate VTE Risk with Low Bleed Risk
*Most patients
High VTE Risk with Low Bleed Risk
Extended pulmonary resection,
pneumonectomy, extrapleural pneumonectomy
or esophagectomy
Any VTE Risk with High Bleed Risk
PATIENT CHARACTERISTICS
Uncomplicated post-operative course
Prolonged hospitalization due to non-
hemorrhagic surgical complications
Inferior vena cava filters should not be used for primary VTE prevention (Grade 2C)
Recommend extending pharmacologic prophylaxis for 4 weeks with LMWH (Grade
1B)
THORACIC SURGERY
RECOMMENDED PROPHYLAXIS
Recommend thromboprophylaxis with LDUH, LMWH (each Grade 2B) or mechanical
prophylaxis with IPC (Grade 2C)
Recommend thromboprophylaxis with LDUH, LMWH (each Grade 1B). Suggest
mechanical prophylaxis with CS or IPC be added to pharmacologic prophylaxis (Grade
2C)
Recommend mechanical prophylaxis, preferably IPC (Grade 2C), over no prophylaxis
When the bleeding risk decreases, recommend that pharmacologic thromboprophylaxis
be substituted for or added to the mechanical prophylaxis (Grade 2C)
CARDIAC SURGERY
RECOMMENDED PROPHYLAXIS
Recommend mechanical prophylaxis preferably IPC over either no prophylaxis or
pharmacologic prophylaxis (Grade 2C)
Recommend addition of pharmacologic prophylaxis with LDUH or LMWH to
mechanical prophylaxis (Grade 2C)

ELECTIVE SPINAL SURGERY

RISK GROUP RECOMMENDED PROPHYLAXIS
Moderate VTE Risk Recommend mechanical prophylaxis, preferably IPC, over either no prophylaxis or
pharmacologic prophylaxis (Grade 2C)
High Risk for VTE Recommend adding pharmacologic prophylaxis to mechanical prophylaxis once
*Malignant disease or surgery with a combined adequate hemostasis is established and the risk of bleeding decreases (Grade 2C)
anterior-posterior approach
 CRANIOTOMY
RISK GROUP RECOMMENDED PROPHYLAXIS
Moderate VTE Risk Recommend mechanical prophylaxis preferably IPC over either no prophylaxis or
pharmacologic prophylaxis (Grade 2C)
Very High Risk for VTE Recommend adding pharmacologic prophylaxis to mechanical prophylaxis once
*Malignant disease adequate hemostasis is established and the risk of bleeding decreases (Grade 2C)
TRAUMA
Applies to: Major Trauma, Traumatic Brain Injury, Acute Spinal Cord Injury and Traumatic Spine Injury
RISK GROUP RECOMMENDED PROPHYLAXIS
Moderate VTE Risk Recommend thromboprophylaxis with LDUH, LMWH, or mechanical prophylaxis,
preferably IPC, over either no prophylaxis (Grade 2C)
High VTE Risk Recommend adding mechanical prophylaxis to pharmacologic prophylaxis (Grade 2C)
*Acute spinal cord injury, traumatic brain when no contraindication by lower extremity injury
injury, and spinal surgery for trauma
Any VTE Risk with High Bleed Risk Recommend mechanical prophylaxis, preferably IPC (Grade 2C), over no prophylaxis
When the bleeding risk decreases, recommend that pharmacologic thromboprophylaxis
be substituted for or added to the mechanical prophylaxis (Grade 2C)

Inferior vena cava filters should not be used for primary VTE prevention (Grade 2C)

PROCEDURE
Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
ORTHOPEDIC SURGERY
RECOMMENDED PROPHYLAXIS
Recommend anticoagulation with one of the following: LMWH, fondaparinux, apixaban,
dabigatran, rivaroxaban, LDUH, adjusted dose VKA, aspirin (Grade 1B) or an
intermittent pneumatic compression device (IPCD)a (Grade 1C) for a minimum of 10 to
14 days rather than no prophylaxis

Hip Fracture Surgery (HFS)
Prefer LMWH to other alternative agents b (Grade 2B/C) to be started either 12 hours or
more pre-operatively or 12 hours or more post-operatively (Grade 1B)
Recommend anticoagulation with one of the following: LMWH, fondaparinux, LDUH,
adjusted dose VKA, aspirin (Grade 1B) or an IPCD a (Grade 1C) for a minimum of 10
to 14 days rather than no prophylaxis

Prefer LMWH to other alternative agents b (Grade 2B/C) to be started either 12 hours or
more pre-operatively or 12 hours or more post-operatively (Grade 1B)
Any Major Orthopedic Surgery with Low Recommend dual prophylaxis with antithrombotic agent and IPCD a during the hospital
Bleed Risk stay (Grade 2C)

If patient declines or uncooperative with injections or IPCD recommend apixaban,

dabigatran rivaroxaban, or VKA (Grade 1B)
Any Major Orthopedic Surgery with High Recommend use of IPCD a or no prophylaxis over a pharmacologic treatment (Grade
Bleed Risk 2C)
Inferior vena cava filters should not be used for primary VTE prevention (Grade 2C)
Extended Duration Thromboprophylaxis Recommend extended thromboprophylaxis for outpatients for up to 35 days from the day
of surgery (Grade 2B)
Isolated Lower-Leg Injuries Requiring Suggest no prophylaxis (Grade 2C)
Immobilization
Knee Arthroscopy Without Previous VTE Suggest no prophylaxis (Grade 2B)
Screening for DVT in asymptomatic patients Recommend against the routine use of DUS screening (Grade 1B)
a. IPCD – efforts should be made to achieve 18 hours of daily compliance
b. Limitations to alternative agents to LMWH:
Potential for increase bleed risk: fondaparinux, rivaroxaban, VKA
Potential for decreased efficacy: LDUH, VKA, aspirin, and IPCD alone