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Thromb Haemost 2017; 117(09): 1662-1670
DOI: 10.1160/TH17-03-0168
Invited Clinical Focus
Schattauer GmbH

New paradigms in venous thromboprophylaxis of medically ill patients

Alex C. Spyropoulos
1   Hofstra Northwell School of Medicine, Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health System at Lenox Hill Hospital, New York, New York, USA
,
Gary E. Raskob
2   College of Public Health,University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
› Author Affiliations
Further Information

Publication History

Received: 10 March 2017

Accepted after minor revision: 20 May 2017

Publication Date:
08 November 2017 (online)

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Summary

Acutelly-ill hospitalised medical patients are at risk of venous thromboembolism (VTE), both in-hospital and in the immediate post-discharge period, and mortality from VTE is thought to be particularly high in this patient population. However, despite previous mandates from international antithrombotic guidelines such as those of the American College of Chest Physicians (ACCP) for the “universal” use of thromboprophylaxis in hospitalised medical patients, global audits suggest that implementation of thromboprophylaxis continues to be challenging because of the perceived higher risk of bleeding and lower risk of VTE than that reported in clinical trials. Recent population-based studies also reveal that a “universal” hospital-only thromboprophylactic strategy does not reduce the community burden of VTE from this population, which may constitute nearly one quarter of the attributable risk of VTE. Lastly, four large randomised placebo-controlled trials of extended thromboprophylaxis have failed to show a definitive net clinical benefit in hospitalised medical patients. Recent large-scale efforts in deriving and validating scored VTE and bleed risk assessment models (RAMs) have been completed in the medically-ill population. In addition, an elevated D-dimer as a new biomarker to identify at-VTE risk medically ill patients has also undergone prospective evaluation. This paper will review current concepts of VTE and bleed risk in hospitalised medical patients, both in the hospital as well as the post-hospital discharge period, and will discuss new paradigms of thromboprophylaxis in this population using an individualised, patient-centered approach.

Keywords

Medical patient - risk assessment models - d-dimer - venous thromboembolism - bleeding - thromboprophylaxis - Padua Score - NHS Tool - IMPROVE Score - low-molecular-weight heparin - direct oral anticoagulants
 

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