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9 Edition Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Summary Prevention of VTE CHEST 2012
9 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
Inferior vena cava filters should not be used for primary VTE prevention (Grade 2C)
Extended Duration Thromboprophylaxis Recommend extending pharmacologic prophylaxis for 4 weeks with LMWH (Grade
Abdominal or Pelvic Surgery for Cancer 1B)
THORACIC SURGERY
RISK GROUP RECOMMENDED PROPHYLAXIS
Moderate VTE Risk with Low Bleed Risk Recommend thromboprophylaxis with LDUH, LMWH (each Grade 2B) or mechanical
*Most patients prophylaxis with IPC (Grade 2C)
High VTE Risk with Low Bleed Risk Recommend thromboprophylaxis with LDUH, LMWH (each Grade 1B). Suggest
Extended pulmonary resection, mechanical prophylaxis with CS or IPC be added to pharmacologic prophylaxis (Grade
pneumonectomy, extrapleural pneumonectomy 2C)
or esophagectomy
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)
CARDIAC SURGERY
PATIENT CHARACTERISTICS RECOMMENDED PROPHYLAXIS
Uncomplicated post-operative course Recommend mechanical prophylaxis preferably IPC over either no prophylaxis or
pharmacologic prophylaxis (Grade 2C)
Prolonged hospitalization due to non- Recommend addition of pharmacologic prophylaxis with LDUH or LMWH to
hemorrhagic surgical complications mechanical prophylaxis (Grade 2C)
Inferior vena cava filters should not be used for primary VTE prevention (Grade 2C)
ORTHOPEDIC SURGERY
PROCEDURE RECOMMENDED PROPHYLAXIS
Total Hip Arthroplasty (THA) Recommend anticoagulation with one of the following: LMWH, fondaparinux, apixaban,
Total Knee Arthroplasty (TKA) 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
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)
Hip Fracture Surgery (HFS) 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)