Table 3.19-9. Prevention of VTE in medical patients

Clinical condition

Recommended prevention

Ischemic stroke with impaired mobilitya

Options:

– Adequate prophylactic dose of LMWHb (preferred)

– SC UFH 5000 IU every 12 h

– IPC and/or graduated compression elastic stockings in patients with contraindications to anticoagulant treatment

Note: You can safely use a prophylactic dose of heparin in combination with ASA. Do not use heparin in the first 24 h after thrombolytic treatment of stroke.

Hemorrhagic strokea

– Use IPC in early treatment

– In clinically stable patients at very high risk of VTE you may use LMWH at an adequate prophylactic doseb (preferred dose) or SC UFH 5000 IU every 12 h starting on day 2-4 after the bleeding if considered safe (documented cessation of bleeding)

Note: The time for starting heparin administration depends on the evaluation of the risk of thrombosis and the risk of recurrent bleeding in the patient.

Hospitalized acutely ill medical patients at high risk of VTE (Padua Score ≥4)c

Options:

– Adequate prophylactic dose of LMWHb

– SC UFH 5000 IU every 12 h

– SC fondaparinux 2.5 mgd SC every 24 h

– In the case of bleeding or high risk of bleedinge use IPC and/or graduated compression elastic stockings at least in early treatment until the risk of bleeding is reduced

Use pharmacologic prophylaxis during the patient’s immobilization or hospitalization.

Long-term immobilized patients remaining at home or in an institution

Do not use VTE prevention routinely.

a Recommendations for the management of patients with stroke apply to VTE prophylaxis only, and not to the anticoagulant and thrombolytic treatment of stroke.

b Agents: see Deep Vein Thrombosis. Dosage: see Table 3.19-10.

c See Table 3.19-8.

d 1.5 mg in patients with a creatinine clearance <50 mL/min.

e The risk of bleeding is highest in patients with active gastric or duodenal ulcers, a history of severe bleeding within the prior 3 months, platelet counts of <50 × 109/L, or liver failure (INR >1.5). Other risk factors of bleeding: ≥85 years of age (vs <40 years), severe renal failure (GFR <30 mL/min/1.73 m2), admission to an intensive care unit or coronary care unit, insertion of a central venous catheter, chronic arthritis, cancer, male sex. The coexistence of several of these factors indicates a significant increase in the risk of bleeding. Moreover, these factors often increase the risk of VTE. Hence the decision to start anticoagulant treatment should be based on a joint evaluation of all these risks.

ASA, acetylsalicylic acid; GFR, glomerular filtration rate; INR, international normalized ratio; IPC, intermittent pneumatic compression; LMWH, low-molecular-weight heparin; SC, subcutaneous; UFH, unfractionated heparin; VTE, venous thromboembolism.