The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 59:M42-M47 (2004)
© 2004 The Gerontological Society of America
The Prevention of Venous Thromboembolism in Older Adults: Guidelines
Wilbert S. Aronow
Divisions of Cardiology and Geriatrics, Department of Medicine, New York Medical College, Valhalla.
 |
Abstract
|
|---|
The rationale for thromboprophylaxis is based on the high prevalence of venous thromboembolism (VTE), a disorder involving deep vein thrombosis (DVT) and pulmonary embolism (PE), among hospitalized patients, the clinically silent nature of VTE in most patients, and the morbidity, cost, and potential mortality associated with unprevented thromboembolism. Both DVT and PE cause few specific symptoms, and the clinical diagnosis is unreliable. Since the first clinical manifestation of VTE may be fatal PE, it is inappropriate to wait for symptoms before treatment. Unrecognized and untreated DVT may also cause the postphlebitic syndrome and predispose patients to subsequent episodes of recurrent VTE. Routine screening for VTE has also not been shown to reduce the incidence of symptomatic VTE or fatal PE. Use of effective methods of prophylaxis is more cost effective and is safer than selective, intensive screening for VTE. This article reviews current recommendations for the prevention of VTE as they apply to older adults. The recommendations discussed are based on the Sixth American College of Chest Physicians Consensus Conference on Antithrombotic Therapy reported in Chest. 2001;119:132S–175S.
THE rationale for thromboprophylaxis is based on the high prevalence of venous thromboembolism (VTE), a disorder involving deep vein thrombosis (DVT) and pulmonary embolism (PE), among hospitalized patients, the clinically silent nature of VTE in most patients, and the morbidity, cost, and potential mortality associated with unprevented thromboembolism (1). Both DVT and PE cause few specific symptoms, and the clinical diagnosis is unreliable (2,3). Since the first clinical manifestation of VTE may be fatal PE, it is inappropriate to wait for symptoms before treatment. Unrecognized and untreated DVT may also cause the postphlebitic syndrome and predispose patients to subsequent episodes of recurrent VTE (4). Routine screening for VTE has also not been shown to reduce the incidence of symptomatic VTE or fatal PE (1). Use of effective methods of prophylaxis is more cost effective and is safer than selective, intensive screening for VTE (5).
Therapeutic options for the prevention of VTE include unfractionated heparin (UFH), adjusted-dose heparin (ADH), low-molecular-weight heparins (LMWH), warfarin, elastic (graduated compression) stockings (ES), intermittent pneumatic compression (IPC), and insertion of an inferior vena cava filter.
|
RISK FACTOR STRATIFICATION
|
|---|
Clinical risk factors for VTE include increasing age, prolonged immobility, previous VTE, obesity, varicose veins, congestive heart failure, stroke, cancer, chemotherapy, estrogen use, major surgery, trauma (especially fractures ofthe pelvis, hip, or leg), acute myocardial infarction, central venous catheters, acute infection, acute respiratory disease, inflammatory bowel disease, nephrotic syndrome, pregnancy, and hypercoagulable states (6). The thrombophilic abnormalities include activated protein C resistance; prothrombin variant 20210A; antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibody); deficiency or dysfunction of antithrombin, protein C, protein S, or heparin cofactor II; dysfibrinogenemia; reduced levels of plasminogen and plasminogen activators; hyperhomocysteinemia; polycythemia vera; primary thrombocytosis; and heparin-induced thrombocytopenia (7).
|
LIMITATIONS OF DVT SCREENING METHODS
|
|---|
All of the DVT screening methods have limitations. The fibrinogen uptake test lacks sensitivity and specificity (8). Duplex ultrasonography has poor sensitivity as a screening test in asymptomatic patients (9). Venography is associated with a significant rate of nondiagnostic studies, is no longer widely available, and the clinical relevance of many of the thrombi detected is questionable (1).
|
GENERAL RECOMMENDATIONS
|
|---|
Because most studies have excluded the patients at highest risk for both thromboembolic and adverse outcomes, the results from these studies may not apply to all patients. Table 1
shows the recommendation categories with the strength of category, the clarity of risk/benefit, and the basis for the recommendation (10). Table 2 states general recommendations for prevention of VTE. Aspirin is not recommended for prophylaxis in any group of patients (grade 1A recommendation) (11). Antithrombotic therapy or prophylaxis should be used with caution in patients having spinal puncture or epidural catheters for regional anesthesia or analgesia (grade 1C+ recommendation) (12).
|
THERAPEUTIC REGIMENS TO PREVENT VTE
|
|---|
Table 3
shows the therapeutic regimens to prevent VTE. The use of low-dose UFH, ADH, LMWH, perioperative warfarin, and IPC/ES to prevent VTE is discussed.
|
GENERAL SURGERY
|
|---|
Table 4 shows recommendations for prevention of VTE in patients undergoing general surgery (1). Low-risk patients should be treated with aggressive mobilization (grade 1C recommendation). Moderate-risk patients should be treated with low-dose UFH every 12 hours, LMWH, ES, or IPC (grade 1A recommendation) (1,13,14). High-risk patients should be treated with low-dose UFH every 8 hours, LMWH, or IPC (grade 1A recommendation) (1,13,14). The highest-risk patients should be treated with low-dose UFH or LMWH combined with ES or IPC (grade 1C recommendation) (1,13,14). The risk reduction of DVT after general surgery was 44% after ES (15), 68% after low-dose UFH (16), 76% after LMWH (17), and 88% after IPC (18).
|
GYNECOLOGIC SURGERY
|
|---|
Table 5 shows the recommendations for the prevention of VTE in patients undergoing gynecologic surgery (1). The risk reduction of DVT after gynecologic surgery was 22% in patients treated with oral anticoagulants (19), 44% in patients treated with IPC (20), 56% in patients treated with low-dose UFH (21), and 99% in patients treated with ES (22).
|
UROLOGIC SURGERY
|
|---|
Table 6 shows the recommendations for the prevention of VTE in patients undergoing urologic surgery (1). Factors that have been demonstrated to increase the risk of VTE and of fatal PE in patients undergoing major urologic surgery include open (versus transurethral) procedures, malignancy, increased age, general (versus regional) anesthesia, and duration of the procedure (1,23).
|
MAJOR ORTHOPEDIC SURGERY
|
|---|
Table 7 shows the recommendations for the prevention of VTE in patients undergoing major orthopedic surgery (1). The risk reduction of DVT after elective total hip replacement was 23% for ES (24), 45% for low-dose UFH (25), 59% for warfarin (26), 63% for IPC (27), 70% for recombinant hirudin (28), 70% for LMWH (29), 71% for danaparoid (30), and 74% for ADH (31).
The risk reduction of DVT after elective total knee replacement surgery was 27% after warfarin (32), 33% after low-dose UFH (33), 37% after a venous foot pump (34), 52% after LMWH (33,34), and 56% after IPC (35). The risk reduction of DVT after surgery for hip fracture was 44% after low-dose UFH (36), 44% after LMWH (37), and 48% after warfarin (38).
The optimal duration of postoperative prophylaxis after total hip replacement, total knee replacement, and hip fracture surgery remain uncertain. In a double-blind study, patients with total knee replacement and total hip replacement with no clinical evidence of VTE after 4 to 10 days of postoperative LMWH prophylaxis were randomized to treatment with continued LMWH or placebo for 6 weeks after surgery (39). After a mean of 7.3 days of in-hospital LMWH prophylaxis, 1.5% of 607 patients receiving extended out-of-hospital LMWH and 1.9% of 588 patients receiving placebo developed symptomatic DVT or PE or died during the interval from hospital discharge to 12 weeks after surgery (39).
|
NEUROSURGERY
|
|---|
Table 8 shows the recommendations for the prevention of VTE after neurosurgery (1). The risk reduction of DVT after neurosurgery using fibrinogen leg scanning was 60% for ES (40), 73% after low-dose UFH (41), and 66% after IPC (42). The risk reduction of DVT after neurosurgery using routine venography was 38% for ES plus LMWH (43).
|
TRAUMA SURGERY
|
|---|
Table 9 shows the recommendations for the prevention of VTE in patients undergoing trauma surgery (1). Without prophylaxis, patients with multisystem or major trauma have a risk for DVT that exceeds 50% (44) and for fatal PE of 0.4% to 2.0% (45). Unfortunately, few studies of VTE in patients with trauma meet the minimum methodology criteria (1).
|
ACUTE SPINAL CORD INJURY
|
|---|
Patients with acute spinal cord injury have the highest risk of developing DVT among all hospital admissions (46). Table 10 shows the recommendations for the prevention of VTE in patients after acute spinal cord injury (1). Although no large, well-controlled studies of prophylaxis for VTE following acute spinal cord injury have been reported, the very high risk of DVT and of PE combined with the data from available studies support the aggressive use of early prophylaxis in all patients with acute spinal cord injury (46,47).
|
ACUTE MYOCARDIAL INFARCTION
|
|---|
Table 11 shows the recommendations for the prevention of VTE in patients with acute myocardial infarction. The incidence of DVT in patients with acute myocardial infarction is 24% for patients not treated with antithrombotic therapy (48). The risk reduction of DVT in patients with acute myocardial infarction was 71% for patients treated with low-dose UFH (48) and was 86% for patients treated with high-dose UFH (49). On the basis of the available data, most patients with acute myocardial infarction should be treated with intravenous heparin or subcutaneous low-dose UFH (grade 1A recommendation) (1).
|
ISCHEMIC STROKE
|
|---|
The incidence of DVT is 55% for patients with ischemic stroke not treated with antithrombotic therapy (50). Table 11 shows the recommendations for the prevention of VTE in patients with ischemic stroke (1). The risk reduction for DVT in patients with ischemic stroke was 56% for patients treated with low-dose UFH (51), 58% in patients treated with LMWH (51), and 82% in patients treated with the heparinoid danaparoid (52).
|
MEDICAL PATIENTS WITH RISK FACTORS FOR VTE
|
|---|
The incidence of DVT in hospitalized patients with medical conditions other than acute myocardial infarction or ischemic stroke with risk factors for VTE not treated with antithrombotic therapy is 16% (53). These patients include patients with heart failure, chronic obstructive pulmonary disease, infection, cancer, and at bed rest. Table 11 states the recommendations for prevention of VTE in these patients (1). The risk reduction of DVT in these medical patients was 61% in patients treated with low-dose UFH (54) and 76% in patients treated with LMWH (54).
View this table:
[in this window]
[in a new window]
|
Table 7. Recommendations for Prevention of Venous Thromboembolism in Patients Undergoing Major Orthopedic Surgery.
|
|
|
Acknowledgments
|
|---|
This review article was abstracted from the American College of Chest Physicians, Sixth Consensus Conference on Antithrombotic Therapy, Chest. 2001;119:132S–175S. The guidelines were abstracted by Wilbert S. Aronow, MD, FGSA.
Address correspondence to Wilbert S. Aronow, MD, FGSA, Cardiology Division, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595, E-mail: wsaronow{at}aol.com
Received June 5, 2003
Accepted June 6, 2003
|
References
|
|---|
- Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest.. 2001;119:132S-175S.[Medline]
- Hull RD, Pineo GF. Clinical features of deep venous thrombosis. In: Hull RD, Raskob GE, Pineo GF, eds. VTE: An Evidence-Based Atlas. Armonk, NY: Futura Publishing; 1996:87–91.
- Stein PD. The clinical diagnosis of acute pulmonary embolism. In: Hull RD, Raskob GE, Pineo GF, eds. VTE: An Evidence-Based Atlas. Armonk, NY: Futura Publishing; 1996:161–167.
- Prandoni P, Lensing AWA, Cogo A, et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med.. 1996;125:1-7.[Abstract/Free Full Text]
- Salzman EW, Davies GC. Prophylaxis of VTE: analysis of cost-effectiveness. Ann Surg.. 1980;191:207-218.[Medline]
- Rosendaal FR. Risk factors for venous thrombotic disease. Thromb Haemost.. 1999;82:610-619.[Medline]
- Bick RL, Kaplan H. Syndromes of thrombosis and hypercoagulability: congenital and acquired thrombophilias. Clin Appl Thromb/Hemostasis.. 1998;4:25-50.
- Flordal PA, Bergqvist D, Ljungstrom K-G, et al. Clinical relevance of the fibrinogen uptake test in patients undergoing general abdominal surgery—relation to major thromboembolism and mortality. Thromb Res.. 1995;80:491-497.[Medline]
- Davidson DL, Elliott CG, Lensing AWA, et al. Low accuracy of color Doppler ultrasound in the detection of proximal leg vein thrombosis in asymptomatic high-risk patients. Ann Intern Med.. 1992;117:735-738.[Medline]
- Guyatt G, Schunemann H, Cook D, et al. Grades of recommendation for antithrombotic agents. Chest.. 2001;119:3S-7S.[Medline]
- Clagett GP, Anderson FA, Geerts W, et al. Prevention of VTE. Chest.. 1998;114:(Suppl): 531S-560S.[Medline]
- Consensus Conference of the American Society of Regional Anesthesia. Recommendations for neuraxial anesthesia and anticoagulation. American Society of Regional Anesthesia; 1998:1–12.
- Gallus AS, Salzman EW, Hirsh J. Prevention of VTE. In: Colman RW, Hirsh J, Marder VJ, et al, eds. Hemostasis and Thrombosis: Basic Principles and Clinical Practice. 3rd Ed. Philadelphia, PA: JB Lippincott; 1994:1331–1345.
- Nicolaides AN, Bergqvist D, Hull R, et al. Prevention of VTE: international consensus statement (guidelines according to scientific evidence). Int Angiol.. 1997;16:3-38.[Medline]
- Allan A, Williams JT, Bolton JP, et al. The use of graduated compression stockings in the prevention of postoperative deep vein thrombosis. Br J Surg.. 1983;70:172-174.[Medline]
- Gallus AS, Hirsh J, O'Brien SE, et al. Prevention of venous thrombosis with small, subcutaneous doses of heparin. JAMA.. 1976;235:1980-1982.[Abstract/Free Full Text]
- Bergqvist D, Burmark US, Flordal PA, et al. Low molecular weight heparin started before surgery as prophylaxis against deep vein thrombosis: 2500 versus 5000 Xal units in 2070 patients. Br J Surg.. 1995;82:496-501.[Medline]
- Butson ARC. Intermittent pneumatic calf compression for prevention of deep venous thrombosis in general abdominal surgery. Am J Surg.. 1981;142:525-527.[Medline]
- MacCallum PK, Thomson JM, Poller L. Effects of fixed minidose warfarin on coagulation and fibrinolysis following major gynaecological surgery. Thromb Haemost.. 1990;64:511-515.[Medline]
- Clarke-Pearson DL, Synan IS, Dodge R, et al. A randomized trial of low-dose heparin and intermittent pneumatic calf compression for the prevention of deep venous thrombosis after gynecologic oncology surgery. Am J Obstet Gynecol.. 1993;168:1146-1154.[Medline]
- Fricker J-P, Vergnes Y, Schach R, et al. Low dose heparin versus low molecular weight heparin (Kabi 2165, Fragmin) in the prophylaxis of thromboembolic complications of abdominal oncological surgery. Eur J Clin Invest.. 1988;18:561-567.[Medline]
- Turner GM, Cole SE, Brooks JH. The efficacy of graduated compression stockings in the prevention of deep vein thrombosis after major gynaecological surgery. Br J Obstet Gynaecol.. 1984;91:588-591.[Medline]
- Dillioglugil O, Leibman BD, Leibman NS, et al. Risk factors for complications and morbidity after radical retropubic prostatectomy. J Urol.. 1997;157:1760-1767.[Medline]
- Samama CM, Clergue F, Barre J, et al. Low molecular weight heparin associated with spinal anesthesia and gradual compression stockings in total hip replacement surgery. Arar Study Group. Br J Anaesth.. 1997;78:660-665.[Abstract/Free Full Text]
- Colwell CW, Spiro TE, Trowbridge AA, et al. Use of enoxaparin, a low-molecular weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement: a trial comparing efficacy and safety. J Bone Joint Surg.. 1994;76A:3-14.
- Paiement G, Wessinger SJ, Waltman AC, et al. Low-dose warfarin versus external pneumatic compression for prophylaxis against VTE following total hip replacement. J Arthroplasty.. 1987;2:23-26.[Medline]
- Francis CW, Pellegrini VD, Marder VJ, et al. Comparison of warfarin and external pneumatic compression in prevention of venous thrombosis after total hip replacement. JAMA.. 1992;267:2911-2915.[Abstract/Free Full Text]
- Eriksson BI, Wille-Jorgensen P, Kalebo P, et al. A comparison of recombinant hirudin with low-molecular-weight heparin to prevent thromboembolic complications after total hip replacement. N Engl J Med.. 1997;337:1329-1335.[Abstract/Free Full Text]
- Norgren L, Austrell CH, Brummer R, et al. Low incidence of deep vein thrombosis after total hip replacement: an interim analysis of patients on low molecular weight heparin vs sequential gradient compression prophylaxis. Int Angiol.. 1996;15:(Suppl 1): 11-14.[Medline]
- Comp PC, Trowbridge A, Voegeli T, et al. A comparison of danaparoid and warfarin for prophylaxis against deep vein thrombosis after total hip replacement. Orthopedics.. 1998;21:1123-1128.[Medline]
- Leyvraz PF, Bachmann F, Hoek J, et al. Prevention of deep vein thrombosis after hip replacement: randomised comparison between unfractionated heparin and low molecular weight heparin. Br Med J.. 1991;303:543-548.[Abstract/Free Full Text]
- Francis CW, Pellegrini VD, Jr. Leibert KM et al. Comparison of two warfarin regimens in the prevention of venous thrombosis following total knee replacement. Thromb Haemost.. 1996;75:706-711.[Medline]
- Colwell CW, Spiro TE, Trowbridge AA, et al. Efficacy and safety of enoxaparin versus unfractionated heparin for prevention of deep venous thrombosis after elective knee arthroplasty. Clin Orthop.. 1995;321:19-27.[Medline]
- Blanchard J, Meuwly J-Y, Leyvraz P-F, et al. Prevention of deep-vein thrombosis after total knee replacement: randomised comparison between a low-molecular weight heparin (nadroparin) and mechanical prophylaxis with a foot-pump system. J Bone Joint Surg Br.. 1999;81:654-659.[Medline]
- Haas SB, Insall JN, Scuderi GR, et al. Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep vein thrombosis after total knee arthroplasty. J Bone Joint Surg Am.. 1990;72:27-31.[Abstract/Free Full Text]
- Monreal M, Lafoz E, Navarro A, et al. A prospective double-blind trial of a low molecular weight heparin once daily compared with conventional low-dose heparin three times daily to prevent pulmonary embolism and venous thrombosis in patients with hip fracture. J Trauma.. 1989;29:873-875.[Medline]
- Barsotti J, Gruel Y, Rosset P, et al. Comparative double-blind study of two dosage regimens of low-molecular weight heparin in elderly patients with a fracture of the neck of the femur. J Orthop Trauma.. 1990;4:371-375.[Medline]
- Powers PJ, Gent M, Jay RM, et al. A randomized trial of less intense postoperative warfarin or aspirin therapy in the prevention of VTE after surgery for fractured hip. Arch Intern Med.. 1989;149:771-774.[Abstract/Free Full Text]
- Heit JA, Elliott CG, Trowbridge AA, et al. Ardeparin sodium for extended out-of-hospital prophylaxis against VTE after total hip or knee replacement: a randomized, double-blind, placebo-controlled trial. Ann Intern Med.. 2000;132:853-861.[Abstract/Free Full Text]
- Turpie AG, Hirsh J, Gent M, et al. Prevention of deep vein thrombosis in potential neurosurgical patients: a randomized trial comparing graduated compression stockings alone or graduated compression stockings plus intermittent pneumatic compression with control. Arch Intern Med.. 1989;149:679-681.[Abstract/Free Full Text]
- Cerrato D, Ariano C, Fiacchino F. Deep vein thrombosis and low dose heparin prophylaxis in neurosurgical patients. J Neurosurg.. 1978;49:378-381.[Medline]
- Salzman EW, McManama GP, Shapiro AH, et al. Effect of optimization of hemodynamics on fibrinolytic activity and antithrombotic efficacy of external pneumatic calf compression. Ann Surg.. 1987;206:636-631.[Medline]
- Agnelli G, Piovella F, Buoncristiani P, et al. Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of VTE after elective neurosurgery. N Engl J Med.. 1998;339:80-85.[Abstract/Free Full Text]
- Geerts WH, Code KI, Jay RM, et al. A prospective study of VTE after major trauma. N Engl J Med.. 1994;331:1601-1606.[Abstract/Free Full Text]
- O'Malley KF, Ross SE. Pulmonary embolism in major trauma patients. J Trauma.. 1990;30:748-750.[Medline]
- Consortium for Spinal Cord Medicine. Prevention of thromboembolism in spinal cord injury. J Spinal Cord Med.. 1997;20:259-283.[Medline]
- Hull RD. VTE in spinal cord injury patients. Chest.. 1992;102:(Suppl): 649S-651S.[Medline]
- Warlow C, Beattie AG, Terry G, et al. A double-blind trial of low doses of subcutaneous heparin in the prevention of deep-vein thrombosis after myocardial infarction. Lancet.. 1973;2:934-936.[Medline]
- Wray R, Maurer B, Shillingford J. Prophylactic anticoagulant therapy in the prevention of calf-vein thrombosis after myocardial infarction. N Engl J Med.. 1973;288:815-817.[Medline]
- Prasad BK, Banerjee AK, Howard H. Incidence of deep vein thrombosis and the effect of pneumatic compression of the calf in elderly hemiplegics. Age Ageing.. 1982;11:42-43.[Abstract/Free Full Text]
- McCarthy ST, Turner J. Low dose subcutaneous heparin in the prevention of deep-vein thrombosis and pulmonary emboli following acute stroke. Age Ageing.. 1986;15:84-88.[Abstract/Free Full Text]
- Turpie AGG, Gent M, Cote R, et al. A low-molecular-weight heparinoid compared with unfractionated heparin in the prevention of deep vein thrombosis in patients with acute ischemic stroke: a randomized, double-blind study. Ann Intern Med.. 1992;117:353-357.[Medline]
- Samama MM, Cohen AT, Darmon J-Y, et al. A comparison of enoxaparin with placebo for the prevention of VTE in acutely ill medical patients. N Engl J Med.. 1999;341:793-800.[Abstract/Free Full Text]
- Bergmann J-F, Neuhart E. A multicenter randomized double-blind study of enoxaparin compared with unfractionated heparin in the prevention of venous thromboembolic disease in elderly in-patients bedridden for an acute medical illness. Thromb Haemost.. 1996;76:529-534.[Medline]
Top
Abstract
Risk Factor Stratification