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Should all hospitalized medical and stroke patients receive venous thromboembolism prophylaxis?
Although prophylaxis with heparin reduces pulmonary embolism (PE), it increases the risk for bleeding and has no effect on mortality in hospitalized medical and stroke patients. Citing this evidence, the American College of Physicians recommends against the use of universal venous thromboembolism (VTE) prophylaxis in this population. The decision to initiate prophylaxis should be left to physician judgment and should be based on an individual's risk for VTE and risk for bleeding. Pharmacologic prophylaxis with heparin or a related product is preferred unless the risk of bleeding outweighs the benefits. In addition, compression stockings should not be used for mechanical prophylaxis given the lack of benefit and risk for skin damage. For patients at high risk for bleeding or in whom heparin products are contraindicated, intermittent pneumatic compression is an option, though evidence for this is scarce in the medical population. (LOE = 1a)
Qaseem A, Chou R, Humphrey LL, Starkey M, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Venous thromboembolism prophylaxis in hospitalized patients: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2011;155(9):625-632. Lederle FA, Zylla D, MacDonald R, Wilt TJ. Venous thromboembolism prophylaxis in hospitalized medical patients and those with stroke: a background review for an American College of Physician Clinical Practice Guideline. Ann Intern Med 2011;155:602-615. [PMID:22041951]
Inpatient (any location) with outpatient follow-up
The American College of Physicians developed this guideline based on a systematic review of the literature that evaluated the risks and benefits of VTE prophylaxis in hospitalized medical and acute stroke patients. The authors searched MEDLINE, the Cochrane Library, and reference lists of pertinent studies to identify randomized trials that compared different modalities of VTE prophylaxis in this patient population. Two investigators extracted data and assessed study quality, and data were combined for meta-analysis. The primary outcome was mortality up to 120 days after randomization. In trials comparing heparin products with no heparin for VTE prophylaxis in medical patients, there was a decrease in PEs in the heparin group (odds ratio [OR] = 0.69; 95% CI, 0.25-0.90), but no significant difference in mortality. In addition, there was an increase in bleeding events with the use of heparin (relative risk [RR] = 1.34; 1.08-1.66). For every 1000 medical patients treated with heparin prophylaxis, you would prevent 4 PEs but cause 9 bleeding events. Similarly, in stroke patients, heparin prophylaxis did not reduce mortality or PE but did increase major bleeding events (RR = 1.66; 1.20-2.28). In studies of stroke patients that compared mechanical devices for prophylaxis versus no mechanical devices, there was no significant difference in mortality or PE. In fact, data from one large trial showed that the use of graduated compression stockings led to increased skin damage (RR = 4.02; 2.34-6.91). Finally, although intermittent pneumatic compression has shown benefit in the surgical population, it has not been sufficiently evaluated in medical patients. Based on this evidence, the American College of Physicians does not support a policy of universal VTE prophylaxis for all medical and stroke patients, regardless of risk. The guideline committee makes the following recommendations for this patient population: (1) assess an individual's risk of VTE and risk of bleeding prior to initiating VTE; (2) if VTE prophylaxis is started, heparin or related products should be used unless the risk of bleeding outweighs the benefits; and (3) compression stockings should not be used for mechanical prophylaxis.