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Venous Thromboembolism Prophylaxis for Hospitalized Medical Patients
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WHAT IS THE RISK FOR VENOUS THROMBOEMBOLISM (VTE) IN HOSPITALIZED MEDICAL PATIENTS?
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Venous Thromboembolism (VTE), which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common cause of morbidity and mortality in hospitalized medical patients. The baseline incidence of asymptomatic VTE in hospitalized medical patients without anticoagulant prophylaxis is 7% to 15%. Linked administrative database studies indicate that 1.7% of hospitalized medical patients develop symptomatic VTE within 3 months of hospitalization. This is lower than in surgical patients, who have a risk of 2% to 3%. However, because of the sheer number of hospitalized medical patients when compared to surgical patients, the burden of illness is high. Approximately 50% to 70% of symptomatic VTE and 70% to 80% of fatal PE occur in medical patients, and recent hospitalization for medical illness accounts for 25% of all VTE diagnosed in the community. The quoted risk of 1.7% is also based on the risk in all medical patients, some of whom have less severe illness. In prospective studies assessing medical patients who have at least one major risk factor for VTE such as severe cardiac or respiratory disease and do not receive VTE prophylaxis, the incidence of DVT as detected by venography is approximately 10% to 15%. In the absence of anticoagulant prophylaxis, the incidence of proximal DVT, which is the type of DVT most likely to embolize, is approximately 5% and the incidence of PE is 0.5%. VTE is associated with potentially serious long-term complications, including post-thrombotic syndrome, cardiorespiratory insufficiency, recurrent VTE, and bleeding associated with anticoagulant therapy. VTE is also a common cause of readmission to the hospital, and is associated with increased hospital costs and length of stay.
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PRACTICE POINT Risk of thrombosis
Approximately 50% to 70% of symptomatic VTE and 70% to 80% of fatal PE occur in medical patients.
Recent hospitalization for medical illness accounts for 25% of all VTE diagnosed in the community.
In prospective studies assessing medical patients who have at least one major risk factor for VTE such as severe cardiac or respiratory disease and do not receive VTE prophylaxis, the incidence of DVT as detected by venography is approximately 10% to 15%.
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Hospitalization for an acute medical illness is independently associated with about an eightfold increased risk for VTE. Chart audits have shown that nearly all hospitalized medical patients have at least one VTE risk factor, be it immobility, increased age, cancer (active or occult), or acute medical illness (eg, congestive heart failure, obstructive lung disease). Certain populations of hospitalized medical patients, such as those in the intensive care unit, have additional risk factors including central venous catheterization; these patients are considered to be at high risk for VTE, even after receiving routine prophylaxis (Table 252-1).
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