Venous thromboembolism prophylaxis in medical patients

PURPOSE OF REVIEW: Venous thromboembolism, including deep vein thrombosis and pulmonary embolism, represents a significant source of morbidity and mortality in the United States and worldwide. Most acutely ill medical patients are at risk for venous thromboembolism, and prophylaxis is recommended. However, acutely ill medical patients are heterogeneous, and the degrees of risk, the length of prophylaxis, as well as the most safe and efficacious strategies to prevent venous thromboembolism in specific medical patients continue to evolve.

RECENT FINDINGS: Most medically ill patients in the hospital do not receive any form of venous thromboembolism prophylaxis despite evidence that their venous thromboembolism risk is similar to surgical patients. Low-molecular weight heparins demonstrate at least equal efficacy and improved safety over standard unfractionated heparin for the prevention of venous thromboembolism in medical patients. Patients with renal impairment, obesity, or those who are critically ill are special populations for prophylaxis that require individual approaches. Many patients recently discharged from the hospital remain at high risk for thrombosis.

SUMMARY: All hospitalized patients should be assessed for venous thromboembolism risk. Most acutely ill medical patients will be in the high- to very high-risk category for thrombosis. Patients who have an estimated thrombosis risk greater than bleeding risk should receive pharmacologic prophylaxis. Low-molecular weight heparin is the preferred drug-based approach over standard unfractionated heparin for the prevention of venous thromboembolism in the acutely ill medical patient. Patients with higher risks for bleeding than thrombosis should receive mechanical methods of prophylaxis. Patients who have not returned to baseline health should be considered for extended venous thromboembolism prophylaxis out of the hospital.