Risk Factors and Prophylaxis of Deep Vein Thrombosis and Pulmonary Embolism


1 Point

2 Points

3 Points

1. Age 41–60 years

12. Age 60–74 years

20. Age >75 years

2. Major surgery planned

13. Arthroscopic surgery

21. History of venous thrombosis or pulmonary embolism previously

3. Varicose veins of the lower limbs

14. Cancer (past or present)

22. Family history of thrombosis

4. History of inflammatory bowel disease

15. Major surgery (>45 min)

23. V Factor positive Leiden

5. Recurrent edema of the lower limbs

16. Laparoscopic surgery (>45 min)

24. Prothrombin 20210 A

6. Obesity (BMI > 25 kg/m2)

17. Patient confined to bed (>72 h)

25. Positive lupus anticoagulant

7. Acute myocardial infarction

18. Member immobilization (cast)

26. Elevated serum homocysteine

8. Congestive heart failure

19. Central venous access

27. Elevated anticardiolipin antibodies

9. Sepsis (<1 month)

28. Heparin-induced thrombocytopenia

10. Severe pulmonary disease (<1 month), including pneumonia

29. Other congenital or acquired thrombophilia

11. Chronic obstructive pulmonary disease























5 Points

1 Point (for women only)

30. Elective major lower extremity arthroplasty

35. Oral contraceptives or hormone replacement therapy

31. Hip, pelvis, or leg fracture (<1 month)

36. Pregnancy or postpartum (<1 month)

32. Stroke (<1 month)

37. History of unexplained abortion (>3), premature birth with toxemia or growth-restricted infant

33. Multiple trauma (<1 month)

34. Acute spinal cord injury—paralysis (<1 month)


BMI body mass index

Adapted from: “Guyatt GH, Akl EA, Crowther M, Schünemann HJ, Gutterman DD, Zelman Lewis S, et al. Introduction to the ninth edition: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):48S–52S.” and “Arcelus JIC, J.A. Acute Deep Venous Thrombosis: Prevention and Medical Treatment. In: Rutherford RB, editor. Vascular Surgery. Philadelphi a. 2014. p. 776.” and “Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e227S–77S.” and “Kahn SR, Hirsch A, Shrier I. Effect of postthrombotic syndrome on health-related quality of life after deep venous thrombosis. Arch Intern Med. 2002;162(10):1144–8”




Table 11.2
Classification of risk groups for venous thromboembolism






















Risk group

Total score

Low

0–1 point

Moderate

2 points

High

3–4 points

Very high

≥5 points


Calculated from the scores of individual risk factors

Adapted from: “Caprini JA. Risk assessment as a guide to thrombosis prophylaxis. Curr Opin Pulm Med. 2010;16(5):448–52”




Classification of Groups of Risk for Venous Thromboembolism According to the Individual Risk Factors Scoring


After identification and scoring of all individual risk factors, the patient is categorized into one of the four possible Groups of Risk for the development of venous thromboembolism.


Prophylaxis


According to the stratification described in Table 11.2, an individualized proper prophylaxis for venous thromboembolism is identified. Prophylaxis is medical measure adopted to prevent the formation of thrombus in deep veins and subsequent pulmonary embolism and depends on the correct identification of risk factors. These measures may be (1) early mobilization of patients (i.e., to avoid blood stasis), (2) use of an intermittent pneumatic compression device, (3) use of medicinal compression stockings, and (4) use of anticoagulant medications in low doses [1, 3].

The medicinal socks compression and pneumatic devices are mechanical methods. Although mechanical methods of prophylaxis have not been studied as extensively as the pharmacologic agents, they may represent the sole alternative for patients with contraindications to anticoagulants. Most physical methods may and should be combined with the pharmacologic agents in patients at very high risk to develop venous thromboembolism whenever possible, because they act on different pathogenic factors [3].


Hospitalized Nonsurgical Patients


The mechanical or medical thromboprophylaxis is not recommended for all hospitalized medical patients, with low risk for venous thromboembolism. Whether these patients have a medium to high risk of thrombosis it is indicated low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH) , or fondaparinux [1]. The recommended doses are listed in Table 11.3 [3].


Table 11.3
Recommended doses of medications in the prophylaxis of deep venous thrombosis in nonsurgical patients, according to the stratification of risk factors for thrombosis






















Low risk

Moderate risk

High risk

No medications

LMWH—20 mg daily

LMWH—40 mg daily

LDUH—5000 UI twice a day

LDUH—5000 UI three times a day

Fondaparinux—2.5 mg daily

Fondaparinux—2.5 mg daily


LMWH low-molecular-weight heparin , LDUH low-dose unfractionated heparin

Adapted from: “Arcelus JIC, J.A. Acute Deep Venous Thrombosis: Prevention and Medical Treatment. In: Rutherford RB, editor. Vascular Surgery. Philadelphia. 2014. p. 776”

In cases of high risk for bleeding, it is advisable the use of mechanical thromboprophylaxis [1, 3]. In these cases, intermittent pneumatic compression is recommended in deep venous thrombosis prophylaxis for its known efficacy and reduced risk of bleeding [11]. The recommended doses for patients in the very high risk group are the same as recommended for the high risk group.


Hospitalized Surgical Patients



Early Mobilization


Encouraging the patient to walk should be the first prophylactic measure for deep venous thrombosis. In patients confined to bed, physical therapy may be an alternative to early mobilization in order to help the blood return to the heart. Another measure is the elevation of the lower limbs, which reduces swelling and decreases venous pressure [1, 3].


Intermittent Pneumatic Compression


Pneumatic compression is the positioning of pneumatic boots or clothing around the legs of the patient. It is considered the most effective mechanical prophylactic method and is indicated in cases of moderate or high risk for deep venous thrombosis and bleeding [1]. This method prevents venous stasis by intermittent compression of the calves. The device is inflated to a pressure of 35–55 mmHg for 10–35 s and deflated for about 1 min [1, 12].

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Sep 30, 2017 | Posted by in CARDIOLOGY | Comments Off on Risk Factors and Prophylaxis of Deep Vein Thrombosis and Pulmonary Embolism
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