Note from NGC: The following key points summarize the content of the guideline. Refer to the original guideline document for more information.
The elements of the recommendations rating scheme [A-D] are defined at the end of the "Major Recommendations" field.
Constitutional Risk Factors
Age
- Given the low incidence of venous thromboembolic disease (VTD) for the age factor alone, the risk-benefit ratio excludes prophylactic treatment with anticoagulants. (Evidence: C).
- In subjects over 60 years of age for whom the physician considers prevention of deep vein thrombosis (DVT) as necessary, elastic compression stockings can be an efficacious and safe option (Evidence: C).
Pregnancy and Puerperium
- In pregnancies with a high risk of VTD (prior DVT with thrombophilia or prior idiopathic DVT) prophylaxis with low molecular weight heparin (LMWH) (nadroparin, enoxaparin, or dalteparin) is indicated at doses equivalent to 5,000 IU/day subcutaneous (sc) (Evidence: B).
- The panel recommended:
- Prophylaxis with LMWH in pregnancy if the patient is bedridden together with another risk factor, two clinical circumstances are present, or a single clinical circumstance is associated with a high-score risk factor
- LMWH or physical measures if patient is bedridden and obese with no other factors, or pregnant but not obese with a clinical circumstance associated with a low-score risk factor
- In pregnant women with thrombophilia without prior VTD, a specialist consultation to evaluate the risk, given the heterogeneity of the different thrombophilias (Evidence: Consensus)
Gender
- No gender-based prophylaxis of VTD is recommended (Evidence: C).
Obesity
- Given the low incidence of VTD for obesity as a factor on its own, the risk-benefit ratio excludes prophylactic treatment with anticoagulants (Evidence: C).
- In obese patients for whom the physician is considering prevention of DVT, compressive elastic stockings are an adequate option (Evidence: C).
Lifestyle Dependent Risk Factors
Bedridden/Sedentary Lifestyle
- In subjects over 50 years of age bedridden for more than four days due to exacerbation of medical conditions with risk (congestive heart failure [CHF], chronic obstructive pulmonary disease [COPD]) and the presence of risk factors, prophylaxis with 40 mg of enoxaparin or an equivalent for 10 days is indicated (Evidence: A).
Tobacco Smoking
- Given the low incidence of VTD for the smoking factor alone, the risk-benefit ratio excludes prophylactic treatment with anticoagulants (Evidence: C).
Institutionalization
- Prophylaxis in domiciliary hospitalization is not justified (Evidence: B).
- For admissions of more than 4 days of patients over the age of 50 years due to exacerbation of medical conditions with risk (CHF, COPD, infection) and in the presence of risk factors, prophylaxis with 40 mg/day of enoxaparin or equivalent during the admission is indicated (Evidence: A).
Travel
- No prophylaxis of VTD is prescribed for those subjects for whom air travel is the only risk factor, given the low incidence of VTD (Evidence: C).
- When the flight is high risk due to its duration and immobilization, and an additional individual risk factor concurs, physical prophylactic measures are indicated, as well as treatment with LMWH for high-risk individuals (Evidence: B).
- The expert panel recommends:
- Prophylaxis with LMWH when the travel is associated with a major risk factor, considering the favorable risk-benefit ratio of a single prophylactic dose; and,
- Physical measures in the remaining risk situations (Evidence: Consensus).
Iatrogenic Risk Factors
Antiplatelet Treatment
- Since acetylsalicylic acid (ASA) is considerably less effective than an anticoagulation agent, it cannot be recommended to replace the later as prophylaxis for VTD (Evidence: A).
- However, given its preventive effect, the use of ASA can compensate for the low-incidence risk inherent to certain clinical circumstances. (Evidence: A).
Oral Contraceptives
- Given the low incidence of VTD induced by the use of oral contraceptives (OCs), the risk-benefit ratio excludes prophylactic treatment with anticoagulants (Evidence: C).
- In women taking oral contraceptives for whom the physician is considering DVT prophylaxis, elastic compression stockings are an adequate option. (Evidence: C).
Central Venous Catheter (CVC)
- Treatment with heparin is efficacious to prevent the DVT associated with CVC, but given the low incidence rate, systematic prophylaxis is not justified, excluding situations of prolonged maintenance of the CVC. In such conditions, LMWHs and warfarin at doses of 1 mg/d would be the recommended prophylaxis (Evidence: A).
Pacemaker
- Prophylaxis with heparin reduces the risk of asymptomatic VTD in the period of pacemaker implantation (Evidence: C).
- The expert panel concluded that in the period of implantation of a pacemaker, or immediately after, the risk of clinically relevant events or systemic complications is very low, and therefore prophylaxis of VTD does not appear to be justified (Evidence: Consensus).
Tamoxifen
- Given the low incidence of VTD for the use of tamoxifen, the risk-benefit balance excludes prophylactic treatment with anticoagulants (Evidence: C).
- In persons taking tamoxifen for whom the physician is considering DVT prophylaxis, elastic compression stockings are an adequate option. (Evidence: C).
Hormone Replacement Therapy (HRT)
- Given the low incidence of VTD for the use of HRT alone, the risk-benefit ratio excludes prophylactic treatment with anticoagulants (Evidence: C)
- During the first year of treatment with HRT in those women for whom the physician is considering DVT prophylaxis due to the coincidence with other risk factors, elastic compression stockings can be a valid option (Evidence: C).
Risk Factors Related to Medical Disorders
Acute Cerebrovascular Accident (ACVA)
- In subjects with high risk of DVT (presence of other risk factors) after ischaemic ACVA with motor deficit in the lower limbs and low risk of extracranial bleeding, in those patients for whom intracranial bleeding and neoplasm have been excluded and the risk-benefit ratio is positive, the use of LMWH as prophylaxis of VTD in the first two weeks following the ACVA is recommended (Evidence: A).
- The use of physical measures is not useful as prophylaxis of DVT in patients with ACVA (Evidence: B).
- The expert panel recommended prophylaxis with LMWH in all patients with ACVA during the period of hospitalization. (Evidence: Consensus).
Lower Limb Paralysis As A Sequela of ACVA
- Prophylaxis with LMWH is recommended if an association with a high risk factor is present. Both heparin or physical measures are recommended when associated with a single clinical circumstance or more than three minor risk factors (Evidence: Consensus).
Inflammatory Bowel Disease (IBD)
- There is no evidence to confirm or reject the risk of DVT in presence of inflammatory bowel disease.
Chronic Obstructive Pulmonary Disease (COPD)
- Prophylaxis with 40 mg/sc/day of enoxaparin is justified during admission in the lower-bleeding risk group in which the risk-benefit ratio allows it (Evidence: B).
- Prophylaxis with LMWH is recommended in all patients admitted for COPD while bedridden, or in COPD patients with some other clinical circumstance or major risk factor. When COPD is combined with between one to three minor factors, physical means or LMWH can be used (Evidence: Consensus).
Chronic Liver Disease
- No studies evaluating the possible association between chronic liver disease and DVT were identified.
Acute Myocardial Infarction (AMI)
- Treatment with heparin reduces the risk of VTD in AMI (Evidence A).
- In patients undergoing anti-aggregation treatment with ASA, adding anticoagulation is not justified to avoid VTD, since it does not produce any noticeable preventive effect (Evidence A).
- The expert panel recommends prophylaxis with LMWH in all patients hospitalized with AMI (Evidence: Consensus).
Severe Acute Infection
- Prophylactic treatment with low doses of non-fractionated heparin (NFH) in patients admitted with acute infection is not useful in reducing mortality due to fatal pulmonary thromboembolism (PTE) (Evidence: A).
- Prophylaxis with enoxaparin at doses of 40 mg/sc/day during the period of hospitalization should reduce the incidence of VTD in 1 of 10 patients with acute infection, at a cost of a 2% incidence of mild bleeding. Thus, prophylaxis is justified if the risk-benefit ratio concurs. (Evidence: B).
- Prophylaxis with LMWH is recommended in patients hospitalized with acute infection for as long as they are bedridden. In non-bedridden patients, LMWH is recommended for those over 60 years of age with another associated risk factor, and in those under 60 years of age if there is another comorbidity. Physical means or LMWH may be used when the only risk factor associated with the infection is age or obesity. (Evidence: Consensus).
Heart Failure
- Prophylaxis with enoxaparin at doses of 40 mg/sc/day during the period of hospitalization should reduce the incidence of VTD in 1 out of 10 patients with New York Heart Association (NYHA) class III or IV congestive heart failure (CHF), at a cost of a 2% incidence of mild bleeding. Thus, prophylaxis is justified if the risk-benefit ratio concurs. (Evidence: B).
- Prophylaxis with LMWH is recommended in patients hospitalized with CHF for as long as they are bedridden. In non-bedridden patients, LMWH is recommended for those over 60 years of age with another associated risk factor, and in those under 60 years of age if there is another co-morbidity. Physical means or LMWH may be used when the only risk factor associated is age or obesity. (Evidence: Consensus).
Nephrotic Syndrome and Chronic Renal Failure (CRF)
- Prophylaxis with enoxaparin at doses of 40 mg/sc/day is justified if the risk-benefit ratio concurs. (Evidence: D).
- Prophylaxis with LMWH is recommended in patients hospitalized with nephropathy for as long as they are bedridden. In non-bedridden patients, LMWH is recommended for those over 60 years of age with another associated risk factor, and in those under 60 years of age, if there is another comorbidity. Physical means or LMWH may be used when the only risk factor associated with the infection is age or obesity. (Evidence: Consensus).
Neoplasm
- Prophylaxis of VTD is not justified in most cancer patients (Evidence: B).
- In cancer patients with previous VTD, chemotherapy or CVC, prophylaxis with dicoumarinics or LMWH for periods of 3 to 6 months is justified. (Evidence: B).
- The panel recommended prophylaxis with LMWH in cancer patients with chemotherapy and CVC or another risk factor. In patients not on chemotherapy, the panel recommends LMWH if the patient is bedridden or if there is a combination of clinical circumstances or risk factors. In the other cases, if prophylaxis is not carried out with LMWH, physical measures are recommended (Evidence: Consensus).
Major Nonsurgical Trauma
- Prophylaxis with LMWH at doses equivalent to 5,000 IU/sc/day during the period of immobilization of the injured lower limb is justified (Evidence: B).
Prior Deep Vein Thrombosis (DVT)
- Given the low incidence of VTD in patients with prior DVT, the risk-benefit ratio excludes prophylaxis with anticoagulants (Evidence: C).
- Elastic compressive stockings are an adequate option (Evidence: C).
Thrombophilia
- In subjects with thrombophilia, prophylaxis of DVT must be given in all risk situations in the same way as a subject without this trait (Evidence: A).
- When a personal history of VTD is presented, exposure to another concurrent risk factor requires prophylaxis with LMWH while the exposure exists. (Evidence: C).
- Prevention of recurrence must be performed after an event of VTD with oral anticoagulants in periods of between 1 and 3 years in patients with deficit of protein C, protein S, or antithrombin III, and continuously in those with antiphospholipid syndrome (Evidence: C).
Varicose Veins
- Given the low incidence of VTD in patients with varicose veins after a prior DVT, the risk-benefit ratio excludes the indication of prophylactic treatment (Evidence: C).
Definitions:
Recommendation Grade
- High
- Middle
- Low
- Unknown
