VTE, which is a combination of pulmonary embolism (PE) and deep venous thrombosis (DVT), is a serious, common clinical problem. Most hospitalized patients have at least one VTE risk factor, a reason for many hospitals to routinely administer blood thinners to patients although these medications increase the risk of bleeding.

According to a new clinical practice guideline published today in Annals of Internal Medicine, the American College of Physicians (ACP) suggests that before initiating therapy to prevent venous thromboembolism (VTE) in patients hospitalized for medical illnesses including stroke, doctors should assess the risk of thromboembolism and bleeding.

Amir Qaseem, MD, FACP, PhD, MHA, Director of Clinical Policy at ACP comments:

“The evidence does not support routine VTE prophylaxis in patients hospitalized for medical illnesses, including stroke. If a patient is at risk for VTE, the American College of Physicians recommends that physicians prescribe heparin or related blood thinners, unless the assessed risk of bleeding outweighs likely benefits.”

Blood Thinners and Mechanical Devices – Benefits and Risks

Prevention with any type of heparin is linked to statistically significant reductions in PE events in patients hospitalized for medical illnesses, including stroke. The guidelines say that in the majority of cases, the clinical benefit of reducing PE events outweighs the harm of increased risk of bleeding events.

The ACP does not recommend the use of graduated compression stockings for patients’ at risk for VTE and bleeding from blood thinners, because evidence proved they ineffectiveness in preventing VTE or reducing mortality, and also causes clinically important lower extremity skin damage. The ACP’s recommendations are not applicable to patients hospitalized for surgery.

Performance Measures Encourag Routine VTE Prevention – Not Supported

A Policy Implication statement against hospital performance measures promoting universal VTE prevention regardless of a patient’s individual risks for VTE and bleeding is also included in the guidelines.

Dr. Qaseem commented: “Because there is no standard, accepted risk-assessment formula to identify which non-surgical patients are likely to benefit from VTE prophylaxis, this is best left to physician judgment and performance measures encouraging routine prevention in all patients are inappropriate.”

He concluded: “Until we can better identify those patients who truly benefit, performance measures that encourage VTE prophylaxis for patients hospitalized for medical illnesses, including stroke, may encourage physicians to use prevention in low risk patients for whom the risks may exceed the benefit.”

Venous Thromboembolism

VTE is characterized by blood clots forming in the veins of the leg (DVT). When parts of these clots break off, they travel to the lungs where they can cause a pulmonary embolism, which is a blockage of the main lung artery or one of its branches. A large embolism can result in acute heart failure or sudden death.

In the U.S. about 200,000 to 300,000 hospitalizations occur each year due to PE. Studies have shown that 26% of patients with undiagnosed and untreated PE will suffer a subsequent fatal embolism, with another 26% that will have a non-fatal recurrent embolism. According to studies between 5 and 10% of all in-hospital deaths are a direct result of PE.

Written by: Petra Rattue