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Several national organizations advise treating hospitalized medical patients routinely with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) to prevent venous thromboembolism (VTE). In a new guideline, the American College of Physicians suggests that evidence does not support routine prophylaxis and makes three recommendations for VTE prevention in hospitalized medical and stroke patients:
Prophylaxis with UFH or LMWH should be based on risk and benefit and is unnecessary in patients with low VTE risk.
UFH versus LMWH: Data do not favor the use of one agent over the other.
Use of graduated compression stockings is not advised because they are not effective in preventing VTE or in preventing mortality, and they are associated with lower-extremity skin breakdown.
Qaseem A et al. Venous thromboembolism prophylaxis in hospitalized patients: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2011 Nov 1; 155:625. (http://www.annals.org/content/155/9/625.long)
Comment
Given that low-risk patients do not benefit from VTE prophylaxis, this new guideline does not support universal use of VTE prophylaxis in hospitalized medical patients. A measured approach would be to avoid prophylaxis in patients without obvious risk factors for VTE and to initiate UFH or LMWH in patients with at least one risk factor and without elevated risk for bleeding. Although many risk assessment tools are available, evidence is insufficient to endorse any single tool. Notably, the guideline concludes with this provocative statement: “Because no standard, accepted formula for risk assessment exists to identify which medical patients are likely to benefit from VTE prophylaxis, the decision is best left to physician judgment, and performance measures targeting all patients are inappropriate.”