• “Coagulation disorder in

acute medically ill patients

and where is the role of
LMWH”

• [Insert name – Institution]

• [insert date]

SAID.ENO.20.04.0271 (05/20)
VTE is a leading cause of death worldwide
 VTE in medical inpatients is common

Half of VTE events occur due to Risk factors for VTE in hospital
hospital admission for surgery (24%) include cancer, older age, prior
or medical illness (22%) VTE, central lines, immobility

40% of hospitalized patients have 3 Increase in thrombosis risk in

or more risk factors medical inpatients persists 45 to
for VTE 60 days after discharge

Schunemann HJ, et al.blood advances.2018;2(22))

 EPIDEMIOLOGY VTE
PE-related mortality among hospitalized patients

• Epidemiological studies show that

VTE remains a major cause of
morbidity and mortality in 25%
hospitalized patients. Surgical
patients
• Although VTE is often considered
to be associated with recent 75%
Medical
surgery or trauma, 50–70% of
patients
symptomatic events and 70–80%
of fatal pulmonary embolisms
(PEs) occur in non-surgical
patients. Three times more medical patients
die from PE than surgical patients.
REFERENCES
Anderson FA, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT
Study. Arch Inter Med 1991;151(5):933–8.
Cooper JW Jr, Groce J. DVT/PE prophylaxis in medically ill patients: a new avenue of clinical management in the long-term care
 Complications from VTE
Chronic Thromboembolic Pulmonary Hypertension (CTEPH)
- complicates 0.4% to 6.2% of acute pulmonary embolic events.
- is an important cause of severe pulmonary hypertension.
- is associated with significant morbidity and mortality (leading to right heart failure
and death)

McNeil K, et al.Heart.2007;93:1152-8; Kim NH, et al.Eur Respir J.2018; doi.org/10.1183/13993003.01915-2018

 PE is a leading cause of preventable death in
hospitalized patients1
Autopsy-detected Fatal PE in Surgical and Medical Patients: Historical trends 1966-2000
(King’s College Hospital, London, UK)

Surgical patients1,2 Medical patients1,2

4.0% 18% reduction
in fatal PE

prophylaxis
3.3%
prophylaxis

Fatal PE (%)
71% reduction
Fatal PE (%)

2.1% in fatal PE

0.6%

1966 2000 1966 2000

1. Cohen AT et al. Haemost 1996;26:65-71

2. Alikhan R et al. J Clin Pathol 2004;57:1254-1257
Incidence of DVT in hospitalized patients w/o
prophylaxis

7
Geerts WH, et al. Chest 2004; 126:338S-400S
 VTE is Associated with High Economic Burden
The real-world data confirm the economic burden of in-hospital
treatment of VTE, and the relatively low costs of thromboprophylaxis
Table. Health costs for the two groups of patients, total and for each activity phase in €

In fact, although a large part of the costs of VTE are associated with managing the acute
event, there are significant costs related to long-term complications such as recurrent VTE,
post-thrombotic syndrome, pulmonary hypertension, and death.

Gussoni G, et al.Thrombosis Research.2013;131:17-23.

Lessons from a recent Nationwide, multicenter
study in China (DissolVE-2)
*using PADUA and CAPRINI score
Result summary (n=13,609)
• High VTE risk in surgical and medical
inpatients was 53.4% and 36,6%,
respectively.
• Among medical patients, overall
rate of prophylaxis was 10.3% and
appropriate prophylaxis was 6.0%.

“A large proportion of hospitalized

patients reported VTE risk and low rate of
CHEST-recommended prophylaxis. The
data highlight the insufficient management
of VTE risk”

Zhai Z, et al.CHEST.2019;155(1):114-22.
IDENTIA REGISTRY : DVT incidence in
Indonesia
n : 334
patients from
12 hospitals in
Indonesia,
using Wells
scores,
RESULT : IDENTIA STUDY: patients ≥2
The incidence of DVT was 37.1% score then
from thel total patients and performed by
40.3% or 124 patients were CUS to
positive DVT with CUS confirm DVT
(Compression Ultra Sonography)
did not show a symptom or sign *CUS: compression USG
(asymptomatic DVT)

Kriteria pasien: >40 thn, rawat inap lebih dari 3 hari dengan diagnosa penyakit kanker, infeksi akut, penyakit saluran
nafas berat, stroke, dan gagal jantung

Tambunan KL, et al.Indonesian Society on Thrombosis Hemostasis 1st ed.2018

Most hospitalized adults have multiple risk factors
for VTE

• Advancing age
• Immobilisation • Surgery
• Cord injury • Prior DVT

En
e
• Venous access

tat
• Heart or lung failure

do
• Trauma

s
• Hyperviscosity

th
le
• Sepsis

eli
• Obesity
lab
• Vasculitis

a
• Stroke

l in
u
ag

j ur
Virchow’s
rco

y
pe

triad
Hy

Circulatory stasis
• Cancer
• Oestrogen use • Protein C, S or ATIII deficiency
• Family history • Activated protein C resistance
• Sepsis • Hyperhomocysteinaemia
• Heparin-induced thrombocytopenia • Antiphospholipid antibody

1. Adapted from Kyrie PA. Lancet 2005;365:1163-74.

Majority of hospitalized patients are at risk of
VTE

VTE risk varied according to medical

diagnosis, from 31.2% of patients with

gastrointestinal/hepatobiliary diseases to

100% of patients with acute heart failure,

active noninfectious respiratory disease, or
pulmonary infection.

Global rate, 41.5%

Bergmann JF,et al. Thrombosis and Haemostasis 103.4/2010

The challenge of assessing VTE risk

Symptomatic VTE
In rest Is that a risk?

Patient may not

Silent DVT/PE
perceive the risk
VTE Scoring Chart

Tambunan KL, et al.Indonesian Society on Thrombosis Hemostasis 1st ed.2018

 VT E ris k o f you r
s ing
First step is asses
patients

Risk Assessment Tools

• The Padua Prediction Score
• Modified Padua Prediction Score
• IMPROVE Bleeding score

• Two level DVT Wells Score

The Padua Prediction Score
Baseline features Score
Active cancer* 3
Previous VTE 3
Reduced mobility ≥ 3 days 3
Thrombophilic condition 3
Recent (≤ 1 month) trauma / surgery 2
Elderly (≥ 70 years) 1
Heart and/or respiratory failure 1
Acute myocardial infarction / ischemic stroke 1
Acute infection and/or rheumatologic disorder 1
Obesity (BMI ≥ 30) 1
Ongoing hormonal treatment 1
*Patients with local or distant metastases and/or in whom chemotherapy or radiotherapy had been performed in the previous 6 months

High risk of VTE : score 4 or more

(VTE developed in 11.0% patients without prophylaxis and 2.2% with prophylaxis)

Tambunan KL, et al.Indonesian Society on Thrombosis Hemostasis 1st ed.2018

A Risk Assessment Model
The Modified Padua Prediction Score

Point Risk Recommendation

<4 Low VTE Risk VTE prophylaxis not needed
High VTE risk and Low bleed risk Pharmacologic prophylaxis
≥4
High VTE risk and High bleed risk Mechanical prophylaxis

Tambunan KL, et al.Indonesian Society on Thrombosis Hemostasis 1st ed.2018

Tambunan KL, et al.Indonesian Society on Thrombosis Hemostasis 1st ed.2018
IMPROVE Bleeding Risk Score

Score ≥ 7 is associated with increased bleeding risk

Tambunan KL, et al.Indonesian Society on Thrombosis Hemostasis 1st ed.2018

Hospitalized medical patients:
a gap between high risk VTE and prophylaxis

 Several studies from US, 29 Canadian hospitals and

32 countries: 42-90% acute medical hospitalized
patients at risk for VTE (according ACCP criteria)
 ACCP evidence-based clinical practice guidelines:
included thromboprophylaxis recommendations
 Unfortunately, these guidelines are not routinely
followed.

Reference : Kahn SR, et al.CHEST.2012;141(2)(Suppl):e195S-e226S

Underutilization of Anticoagulant for Venous Thrombo-
embolism Prophylaxis
(in Three Hospitals in Jakarta)

a multicenter, prospective, disease registry recruiting patients with medically ill at risk of VTE

RESULT :
 of 401 patients, 46.9% received anticoagulants (53.1%
patients did not);
 Most patients received UFH (64.4%)
 The most frequent reason of not giving anticoagulant was no
anticoagulant indication (46.2%)  This is contradictory to the
eligibility criteria of this study (patients at risk of VTE)
 During hospitalization, VTE were found in 3.2% patients;
 The rate of major bleeding : 2.1%; no patients died due to
bleeding complication

Conclusion: the study showed underutilization of prophylaxis anticoagulants. VTE

thromboprophylaxis strategy in medically ill patients needs to be improved in clinical setting.

Atmakusuma TD, Tambunan KL, Sukrisman L, et al.Acta Medic Indonesiana.2015;47(2):136-45

 Mechanism of Action : Anticoagulants
Intrinsic pathway Extrinsic pathway
(surface contact) (tissue damage)
XII XIIa Tissue factor

XI XIa
Heparins and
LMWH2
IX IXa VIIa VII
Vitamin K antagonists3

Direct thrombin inhibitors4

VIII VIIIa

Factor Xa inhibitors5 X Xa
LMWH
and
V Va Heparins

II IIa
IIa (Thrombin)
1
Adapted with permission from Petitou M, et al. Nature. 1991;350(suppl):30-33.
2
Hirsh J, et al. Chest. 2001;119(suppl):64S-94S.
3
Hirsh J, Fuster V. Circulation. 1994;89:1449-1468. Fibrinogen Fibrin
4
Weitz JI, Hirsh J. Chest. 2001;119(suppl):95S-107S.
5
Herbert JM, et al. Cardiovasc Drug Rev. 1997;15:1.
Pharmacologic Thromboprophylaxis :
Focus on Enoxaparin
Enoxaparin studies in VTE
VTE prophylaxis
Medically ill :
- MEDENOX (n=1,102)*
- THE PRIME (n=959)
- PRINCE (n=665)
- Hilbom et al (n=212)
- Dahan et al (n=270)
- Bergman & Neuhart (n=442)
Surgical :
- ITALIAN Study Group (n=1,122)
- SURGEX Study Group (n=1,444)
- Haas & Flosbach (n=9,902)
- ENOXACAN (n=1,116)*
- ENOXACAN II (n=505)
- ENOXART (n=201)
- Gramse et al (n=2,453)
- Scholten et al (n=481)
- Agenili et al (307)
- Spiro et al (n=572)*
Injuries & trauma :
- Harris et al (n=105)
- Deep et al (n=276)
- Geerts et al (n=265)
- Norwood et al (n=118)
Enoxaparin
Orthopedic surgery :
- Enoxaparin Clinical Trial Group
(n=607)
- Turpie et al (n=100)*
- Levine et al (n=665)
- Leclerc et al (n=131 & 670)
- Colwell et al (n=453)*
- Fitzgerald et al (n=349)
- Planès et al (n=237 & 173*)
- Barsotti et al (n=97)
- Fauno et al (n=224)
- Bergqvist et al (n=233)*
- Comp et al (n=435)
VTE treatment
Inpatient :
- Simonneau et al (n=134)
- PREPIC (n=400)
- Enoxaparin Clinical Trial Group
(n=900)*
Outpatient :
- Levine et al (n=500)*
- ANTENOX (n=223)
- Enoxaparin Study Group (n=298)
Long term :
- Pini et al (n=187)
- Veiga et al (n=100)
- Gonzalez – Fajardo et al (n=165)
- CANTHANOX (n=146)
*Registration studies
 Thromboprophylaxis of Medically ill Patients : Clear
Benefits Over Placebo
Study RRRRRR NNT Prophylaxis Patients with VTE, %

MEDENOX1 63%
63% 10 Placebo 14.9* (n=288)

P<0.001 Enoxaparin 40 mg 5.5 (n=291)

PREVENT2 49%
45% 45 Placebo 5.0 (n=1,473)†
P=0.0015 Dalteparin 2.8 (n=1,518)

ARTEMIS3 47%
47% 20 Placebo
10.5‡ (n=323)

P=0.029 Fondaparinux 5.6 (n=321)

*VTE at day 14; †VTE at day 21; ‡VTE at day 15. NNT = number needed to treat;
RRR = relative risk reduction.

Adapted from: 1Samama et al. N Engl J Med 1999;341:793-800.

2
Leizorovicz et al. Circulation 2004;110:874-9.
3
Cohen et al. Br Med J 2006.
 The MEDENOX Study
Prevention of
Venous Thromboembolism
in Medical Patients

The Medenox Study Group

Reference :
Samama MM, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. N
Engl J Med 1999;341(11):793–800.
MEDENOX STUDY
Objectives
• To evaluate the incidence
of DVT and PE in patients Treatment phase Follow-up phase
with acute medical min 6 days, max 14 days
conditions and the Enoxaparin
optimal dose regimen for 4000 IU/0.4mL
thromboprophylaxis with Days 0–3
enoxaparin. Selection of
Enoxaparin
Follow-up
2000 IU/0.2mL
Study Design patients

• Randomized, double Placebo

blind, Day 1 Days 6–14 Days 83–110
placebo controlled, Inclusion/randomization Bilateral End of follow-up
venography
international multicenter
trial.

Reference :
Samama MM, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. N
Engl J Med 1999;341(11):793–800.
Reference :
Samama MM, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. N
Engl J Med 1999;341(11):793–800.
 MEDENOX STUDY SUBGROUP
Results at day 14
Heart failure (NYHA class III and class IV), Acute respiratory disease, reduction of VTE
reduction of VTE by 72% by 75%

NYHA : New York Heart Association.

REFERENCE
Alikhan R, et al. Prevention of venous thromboembolism in medical patients with enoxaparin:
a subgroup analysis of the MEDENOX study. Blood Coagul Fibrinolysis 2003;14(4):341–6
MEDENOX STUDY SUBGROUP
Results at day 14
Acute infectious disease, reduction of Efficacy in cancer patients
VTE by 59%

Conclusion
Enoxaparin 4000 IU is effective in preventing VTE in different types of acute medical
illness and predefined risk factors

REFERENCE
Alikhan R, et al. Prevention of venous thromboembolism in medical patients with enoxaparin
: a subgroup analysis of the MEDENOX study. Blood Coagul Fibrinolysis 2003;14(4):341–6.
 Hemorrhage at Day 14
14 NS
Major
12 hemorrhage
n=4 n=5
Minor
Patients (%)

10 hemorrhage
n=36 n=34
Hematomas
8
n=27 at injection
site
6

2
n=4 n=6
0

Placebo Enox. 20 mg Enox. 40 mg

NS: Non Significant

REFERENCE
Samama MM, et al. A comparison of enoxaparin with placebo for the prevention of
venous thromboembolism in acutely ill medical patients. N Engl J Med 1999;341(11):793–800.
 Thrombocytopenia at Day 14

4
Severe
3.5
n=8 Moderate
3
Mild
Patients (%)

2.5
n=6
2
n=6
1.5
n=3
1
n=4
0.5
n=3 n=2
0
Placebo Enox. 20 mg Enox. 40 mg

Reference :
Samama MM, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. N
Engl J Med 1999;341(11):793–800.
Prevention of VTE in Medical Patients:
MEDENOX Conclusion

• MEDENOX is the first placebo-controlled study of thromboprophylaxis in

medical patients using bilateral venography .
• In hospitalized acutely ill medical patients, immobilization should be regarded
as necessary to initiate VTE prophylaxis.

• In hospitalized medically ill patients, early ambulation should not be regarded

as a reason to discontinue VTE prophylaxis.

• Patient’s age, past medical history, risk factors, and medical condition are the
main determinants of the risk of VTE, whatever the patient’s level of
immobilization.

• Immobilization may be a risk factor, but is most likely a risk marker for VTE

Reference :
Samama MM, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. N
Engl J Med 1999;341(11):793–800.
Guideline for Prophylaxis VTE
Guideline Statements
In acutely ill medical patients, LMWH or fondaparinux is preferred compared to UFH.
LMWH showed reductions in PE, symptomatic DVT, major bleeding, and HIT, also was
2018 American cost-effective compared with UFH.
Society of
Hematology In critically ill medical patients, LMWH of UFH is recommended; while fondaparinux was
Guideline not mentioned
(Schunemann HJ, et
al.bloodadvances.2018;2(2
2)) LMWH is preferred in hospitalized patients over DOACs

2012 Asian VTE
Guideline
(Liew NC, et al.Int
Angiol.2012;31:501-16)
In critically ill medical patients, LMWH of UFH is recommended; while fondaparinux was
not mentioned. “Pharmacological agents of choice are LMWHs, except in patients with
renal failure who require UFH with close monitoring”

In critically ill medical patients, LMWH of UFH is recommended; while fondaparinux was
2012 CHEST Guideline not mentioned
(Kahn SR, et
al.CHEST.2012;141(2)(Suppl))
ASH Recommendation 2018
2019 PERDICI CONSENSUS

KONSENSUS PENATALAKSANAAN TROMBOEMBOLI VENA (TEV) PADA PENYAKIT

KRITIS 2019
 Rekomendasi Panduan Nasional PTHI

PANDUAN NASIONAL TROMBOEMBOLI VENA PERHIMPUNAN TROMBOSIS DAN HEMOSTASIS INDONESIA (PTHI) 2018
 Rekomendasi Panduan Nasional PTHI
(Dosage)

PANDUAN NASIONAL TROMBOEMBOLI VENA PERHIMPUNAN TROMBOSIS DAN HEMOSTASIS INDONESIA (PTHI) 2018
VTE Treatment : focus on Enoxaparin
Two-level DVT Wells Score
Clinical feature Points Patient score
Active cancer (treatment ongoing, within 6 months, or palliative) 1  
Paralysis, paresis or recent plaster immobilisation of the lower
1  
extremities
Recently bedridden for 3 days or more or major surgery within
1  
12 weeks requiring general or regional anaesthesia
Localised tenderness along the distribution of the deep
1  
venous system
Entire leg swollen 1  
Calf swelling at least 3 cm larger than asymptomatic side 1  
Pitting oedema confined to the symptomatic leg 1  
Collateral superficial veins (non-varicose) 1  
Previously documented DVT 1  
An alternative diagnosis is at least as likely as DVT −2  
Clinical probability simplified score
DVT likely 2 points or more  
DVT unlikely 1 point or less  

Tambunan KL, et al.Indonesian Society on Thrombosis Hemostasis 1st ed.2018

Subcutaneous Enoxaparin Once or Twice Daily Compared with
Intravenous Unfractionated Heparin for Treatment of VTE

Patients : (n=900). Setting : 74 hospitals in 16 countries

Design : Randomized, controlled, partially blinded equivalence trial.
Symptomatic lower-extremity confirmed DVT, symptomatic confirmed PE (32%), or positive pulmonary angiography
with confirmation of DVT

VTE : Venous Thromboembolic Disease

Reference : Merli G, Spiro TE, Olsson CG, et al.Ann Intern Med.2001;134:191-202.

Subcutaneous Enoxaparin Once or Twice Daily Compared with
Intravenous Unfractionated Heparin for Treatment of Venous
Thromboembolic Disease.
Safety :
Treatment groups did not differ significantly in safety profile : No significant or clinically
relevant differences among groups in the incidence of all and major hemorrhagic
complications or transfusion requirements.
Parameter UFH Enox OD Enox BID
(n=290) (n=298) (n=312)

Any hemorrhagic episode during treatment period (%) 39 (13.4) 46 (15.4) 54 (17.3)

Major hemorrhage (%) 6 (2.1) 5 (1.7) 4 (1.3)

Thrombocytopenia during treatment period (%) 4 (1.4) 5 (1.5) 7 (2.2)

Thrombocytopenia was defined as platelet count < 100 x 109 cells/L.

CONCLUSION : Subcutaneous enoxaparin OD or BID is as effective and safe as

dose-adjusted, continuously infused unfractionated heparin in the prevention of
recurrent symptomatic venous thromboembolic disease

Reference : Merli G, Spiro TE, Olsson CG, et al.Ann Intern Med.2001;134:191-202.

Diagnosing Pulmonary Embolism

2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism.Eur Heart J.doi:10.1093/eurheartj/ehu283
Diagnosing Pulmonary Embolism

2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism.Eur Heart J.doi:10.1093/eurheartj/ehu283
Guidance for the Treatment of DVT and PE : Treatment
options in different phase of VTE

IV : intravenous; SQ : subcutaneous; LMWH : low molecular weight heparin; ASA : acetyl salicylic acid
DOAC : direct oral anticoagulant Streiff MB, et al.J Thromb Thrombolysis.2016;41:32-67
Guideline for Treatment VTE
Guideline Statements
In obese patients : initial LMWH dose selection according to actual body weight rather than dose
2018 American Society of selection based on a fixed maximum daily dose and anti-Xa monitoring is not recommended.
Hematology Guideline
(Witt DM, et
al.Bloodadvances.2018;2(22))

LMWH is preferred over oral anticoagulants in VTE and cancer.

2016 CHEST Guideline LMWH is preferred over DOACs in patients with liver disease and coagulopathy.
(Kearon C, et
al.CHEST.2016;149(2):315-52)

In-hospital : UFH or LMWH is preferred due to shorter T½ that facilitate peri-procedural

2016 Guidance for DVT &
PE Treatment
(Streiff MB, et al.J Thromb
Thrombolysis.2016;41)
management.
While DOACs are optimized for outpatient rather than inpatient use.
Given disadvantages associated with UFH (inter-individual dose response, need laboratory
monitoring, difficult to achieve optimal management with UFH in routine practice, 8-10 fold
higher risk of HIT), LMWH is often preferred.
 Rekomendasi Panduan Nasional PTHI

PANDUAN NASIONAL TROMBOEMBOLI VENA PERHIMPUNAN TROMBOSIS DAN HEMOSTASIS INDONESIA (PTHI) 2018
2019 PERDICI CONSENSUS

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KRITIS 2019
Take Home Messages
• If neglected, DVT is associated with increased mortality, morbidity
and substantial costs for its management.
• There are risk assessment tools available to simply categorize
patients according to their risk of developing DVT
• Routine VTE prophylaxis should be considered and discussed after
careful assessment of each individual patients due to it’s
established risk-benefit profile.
• International guidelines are available as references for both
prophylaxis and treatment of VTE
VTE in Critically Ill Patients
 Key Facts : VTE in Critically Ill Patients

• Autopsy studies detected PE in 7 to 27 % of critically ill patients; 1/3 were clinically

suspected. In general, they are moderate – high risk group for VTE.
• ICU patients share similar general risk factors for VTE with other patients + specific risk
factors (i.e mechanical ventilation, central venous catheter, coma) but also at higher
bleeding risk due to comorbid (massive blood loss, sepsis, multi organ failure, DIC).
• Up to 80 % of patients under thromboprophylaxis have at least one episode of bleeding, more often minor.

• ICU patients are in the The American College of Chest Physicians (ACCP) & Asian VTE
guideline recommend thromboprophylaxis for prevention of VTE in critical care
patients (grade Ia: strong recommendation).
• Duration of prophylaxis varies (depends on VTE risk), often continue until patient return
to general ward and able to ambulate.

Minet C, et al.Critical Care.2015;19:287; LiewNC< et al.Int Angiol.2012;31:501-16.

VTE Incidence in Patients with Severe Sepsis and Septic
Shock – A 3 Hospitals Registry
N= 113 (ICU patients; All patients received VTE thromboprophylaxis)

Main Finding : high incidence of VTE in patients with severe sepsis and septic shock,
despite the use of universal, guideline-recommended thromboprophylaxis (53.8% UFH;
41.8% LMWH)

Kaplan D, et al.CHEST.2015;148(5):1224-30.
ASH Recommendation 2018
In critically ill medical patients, the panel suggests using LMWH over UFH
(conditional recommendation, moderate certainty)

LMWH compared with UFH in critically ill patients:

Anticipated absolute effects (95% CI)
Relative
Outcomes effect: Risk with
RR (95% CI) Risk difference with LMWH
UFH

Mortality 0.90 243 per 24 fewer deaths per 1,000

(0.75 to 1.08) 1,000 (61 fewer to 19 more)
Critically ill patients
PE 0.80 11 per 1,000 2 fewer PE per 1,000 may require other
(0.44 to 1.46) (6 fewer to 5 more)
prophylaxis options
Symptomatic 0.87 25 per 1,000 3 fewer DVT per 1,000 due to hepatic or
proximal DVT (0.60 to 1.25) (10 fewer to 6 more)

0.98 1 fewer bleeds per 1,000

renal dysfunction.
Major bleeding 53 per 1,000 (13 fewer to 14 more)
(0.76 to 1.27)
Heparin-
4 fewer episodes per
induced 0.42 6 per 1,000 1,000
thrombocytop (0.15 to 1.18) (5 fewer to 1 more)
enia
Schunemann, HJ. American Society of
Hematology 2018 guidelines for
management of venous thromboembolism:
Quality of Evidence (GRADE): Low Moderate Strong prophylaxis for hospitalized and non-
hospitalized medical patients. Blood
Advances 2018; 22(2): 1-28
 Rekomendasi Panduan Nasional PTHI

PANDUAN NASIONAL TROMBOEMBOLI VENA PERHIMPUNAN TROMBOSIS DAN HEMOSTASIS INDONESIA (PTHI) 2018
2019 PERDICI CONSENSUS

KONSENSUS PENATALAKSANAAN TROMBOEMBOLI VENA (TEV) PADA PENYAKIT

KRITIS 2019