Approach

Most patients are asymptomatic (i.e., no prior venous thromboembolism [VTE]) and, therefore, do not require treatment.

Specific recommendations exist for the primary prevention of VTE in several patient populations.[44][76][93][105][142][143][144]​​​[145][146][147][148]​​ Approaches include pharmacological prophylaxis (e.g., a low molecular weight heparin [LMWH], unfractionated heparin [UFH], direct oral anticoagulants, fondaparinux) and mechanical thromboprophylaxis (e.g., graduated compression stockings [anti-embolism stockings], intermittent pneumatic compression). If mechanical thromboprophylaxis is used long-term, compression devices should be removed for only a short time each day while the patient is mobilising or bathing.

Guideline recommendations may differ by region; refer to local guidelines for further context.​ NICE: venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism Opens in new window

Hypercoagulable states should be incorporated into the risk assessment tools for thromboprophylaxis. Department of Health (UK): risk assessment for venous thromboembolism (VTE) Opens in new window

Patients with an acute medical illness

Thromboprophylaxis should be considered for all patients judged to be at risk for VTE when admitted to hospital with an acute or critical medical illness (impairing mobility).[105][112]

Anticoagulant thromboprophylaxis with LMWH (e.g., enoxaparin, dalteparin), low-dose UFH, or fondaparinux is recommended for acutely ill hospitalised medical patients at increased risk of VTE, but without excessive bleeding risk.[105] LMWH has better pharmacokinetic properties than UFH and is associated with a lower incidence of postoperative heparin-induced thrombocytopenia (HIT).[149] LMWH or fondaparinux are generally recommended over UFH.[105]​​[112][143]

If the patient is at high risk for major bleeding, mechanical thromboprophylaxis with graduated compression stockings (anti-embolism stockings) or intermittent pneumatic compression is recommended.[105][112]

Neither pharmacological nor mechanical thromboprophylaxis is recommended for acutely ill hospitalised medical patients at low risk of thrombosis.[105]

Cancer patients (hospitalised and non-hospitalised)

Recommendations for thromboprophylaxis in patients with active malignancy vary according to setting.

Hospitalised cancer patients with an acute medical condition

Most patients with cancer and an acute medical condition or reduced mobility require pharmacological thromboprophylaxis with LMWH, UFH, or fondaparinux during hospitalisation.​​[145][146]​​[147][148][150]

Hospitalised cancer patients undergoing cancer surgery

Hospitalised patients who are undergoing major cancer surgery require pharmacological thromboprophylaxis with LMWH, UFH, or fondaparinux.​​[145]​​[147][148][150]​ 

Guidelines from the American Society of Clinical Oncology (ASCO) recommend starting thromboprophylaxis preoperatively and continuing postoperatively for at least 7 to 10 days.[148]​ However, guidelines from the American Society of Hematology (ASH) recommend starting thromboprophylaxis postoperatively in patients with cancer undergoing a surgical procedure.[145]

Extending thromboprophylaxis with LMWH for up to 4 weeks postoperatively is recommended for patients with cancer undergoing major open or laparoscopic abdominal or pelvic surgery with high-risk features (e.g., obesity, history of VTE, restricted mobility).​​[145][147]​ 

Mechanical thromboprophylaxis (e.g., graduated compression stockings [anti-embolism stockings] or intermittent pneumatic compression) may be added to pharmacological thromboprophylaxis (particularly in patients at high risk of thrombosis), but should not be used alone unless pharmacological thromboprophylaxis is contraindicated in the patient with cancer (e.g., due to active bleeding or a high risk for bleeding).​​[145][147][148]​​​ 

Non-hospitalised (ambulatory) cancer patients

Thromboprophylaxis for non-hospitalised (ambulatory) patients with cancer remains controversial and is not routinely recommended unless the patient has additional risk factors or cancer associated with a high-risk of VTE, such as multiple myeloma or pancreatic cancer.​[147][150]​ Assessment using a validated VTE risk score (e.g., the Khorana score) may be used to help identify high-risk patients.[150]

Patients who are receiving systemic chemotherapy and are at high risk for thrombosis (e.g., Khorana score of ≥2 prior to initiating systemic chemotherapy) may be considered for thromboprophylaxis with a direct oral anticoagulant (apixaban or rivaroxaban) or LMWH.​​[145][147]​​[151][152]​​[153]​ 

Patients with multiple myeloma who are receiving thalidomide (or its derivatives) with chemotherapy and/or dexamethasone are at high risk for VTE and should receive concomitant aspirin (e.g., if ≤1 risk factor) or LMWH (e.g., if ≥2 risk factors), which should be given for the duration of treatment with thalidomide (or its derivatives).[91]​​​[145][147][148]

The UK guidelines recommend considering thromboprophylaxis for patients with pancreatic cancer receiving chemotherapy.​ NICE: venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism Opens in new window

Further studies are needed to determine the optimal use of thromboprophylaxis for specific groups of non-hospitalised cancer patients undergoing systemic treatment and/or radiotherapy.[145]​[153]

Non-orthopaedic surgery patients

American College of Chest Physicians (ACCP) guidelines for thromboprophylaxis in patients undergoing non-orthopaedic surgery (i.e., general, gynaecological, or urological) adopt a risk-stratification approach (i.e., low, moderate, or high risk for VTE based on the Rogers score or Caprini score).[142] Subsequent guidelines published by ASH focus primarily on patients undergoing major surgery; the ASH guidelines do not employ risk stratification, but their recommendations broadly align with those for patients identified as being at moderate or high risk for VTE by the ACCP.[144] 

Non-orthopaedic surgical patients at very low or low risk for VTE

For patients at very low risk for VTE, early mobilisation is recommended and no pharmacological prophylaxis is required.[142]

For low-risk general, gynaecological, or urological surgery patients, mechanical thromboprophylaxis with intermittent pneumatic compression is recommended.[142]

Non-orthopaedic surgical patients at moderate risk for VTE

For general, gynaecological, or urological surgery patients who are at moderate risk for VTE but not at high risk for major bleeding, LMWH, low-dose UFH, or intermittent pneumatic compression are recommended.[142]

Patients at moderate risk for VTE who are at high risk for major bleeding, or for whom the consequences of major bleeding would be severe, should receive mechanical thromboprophylaxis with intermittent pneumatic compression.[142][154] However, if the bleeding risk decreases, pharmacological thromboprophylaxis should be considered.

Non-orthopaedic surgical patients at high risk for VTE

Patients at high risk for VTE who are not at high risk for major bleeding should receive LMWH or low-dose UFH, and mechanical thromboprophylaxis (graduated compression stockings [anti-embolism stockings] or intermittent pneumatic compression).[142]

Low-dose aspirin, fondaparinux, or mechanical thromboprophylaxis are preferred to no prophylaxis when LMWH and UFH are contraindicated.[142] Intermittent pneumatic compression is recommended for patients who are at high risk for VTE and at high risk for major bleeding, or those for whom the consequences of bleeding are thought to be severe.[142] However, if the bleeding risk decreases, pharmacological thromboprophylaxis should be considered.

Orthopaedic surgery patients

Patients undergoing major orthopaedic surgery (e.g., total hip or knee arthroplasty, or hip fracture surgery) are at high risk for VTE.[155][156] An extended course of thromboprophylaxis (e.g., up to 5-6 weeks) is recommended for these patients.[93][144]

Patients undergoing total hip or knee arthroplasty

Pharmacological thromboprophylaxis with a direct oral anticoagulant (apixaban, dabigatran, rivaroxaban), LMWH, or aspirin can be used in patients undergoing total hip or knee arthroplasty.[93][144] ACCP guidelines recommend LMWH as the preferred agent.[93] However, subsequent guidance published by ASH recommends direct oral anticoagulants.[144] Mechanical thromboprophylaxis with an intermittent pneumatic compression device can be added to pharmacological thromboprophylaxis, or used alone if risk of bleeding is a concern or there are contraindications to pharmacological agents.[93]

Early mobilisation lowers risk of VTE following total hip arthroplasty.[157]

Patients undergoing hip fracture surgery

Pharmacological thromboprophylaxis with LMWH, UFH, fondaparinux, or aspirin can be used in patients undergoing hip fracture surgery.[93][144]

Mechanical thromboprophylaxis with an intermittent pneumatic compression device can be added to pharmacological thromboprophylaxis, or used alone if risk of bleeding is a concern or there are contraindications to pharmacological agents.[93]

Major trauma patients

Thromboprophylaxis with LMWH, low-dose UFH, or intermittent pneumatic compression is recommended for major trauma patients.[142][144]

Pharmacological thromboprophylaxis is recommended for patients at high risk for VTE (e.g., those with acute spinal cord injury, traumatic brain injury, and spinal surgery for trauma) if/when risk of bleeding allows; intermittent pneumatic compression can be added when not contraindicated by lower extremity injury.[142][144][154]

Intermittent pneumatic compression alone is recommended (if not contraindicated) for major trauma patients in whom LMWH and low-dose UFH are contraindicated (e.g., due to bleeding risk).[142] LMWH or low-dose UFH may be added to intermittent pneumatic compression when the risk of bleeding reduces or the contraindication to heparin resolves.[142] 

Pregnancy and post-caesarean section

The optimal management of asymptomatic pregnant women with hereditary thrombophilia remains controversial. The ACCP, the UK Royal College of Obstetricians and Gynaecologists, and the Italian Society for Haemostasis and Thrombosis recommend:[44][118][158] 

  • Asymptomatic pregnant women with antithrombin deficiency should receive pharmacological thromboprophylaxis (with LMWH or UFH) throughout pregnancy and for 4-6 weeks postnatal

  • Individual risk assessment for asymptomatic women with other heritable thrombophilia, with antenatal clinical surveillance or pharmacological thromboprophylaxis (with LMWH or UFH) and postnatal thromboprophylaxis.

ASH guidelines make the following recommendations, some of which are conditional:[159]

  • Antenatal and postnatal thromboprophylaxis for women with a family history of VTE who have antithrombin deficiency

  • Antenatal and postnatal thromboprophylaxis for women who are homozygous for the factor V Leiden mutation or who have combined thrombophilias, regardless of family history of VTE

  • Postnatal thromboprophylaxis for women with a family history of VTE who have protein C or protein S deficiency

  • Postnatal thromboprophylaxis for women who are homozygous for the prothrombin gene mutation, regardless of family history of VTE.

For women with antiphospholipid syndrome with a history of recurrent miscarriage or late pregnancy loss but no prior VTE or arterial thrombosis, prophylactic UFH or LMWH in addition to aspirin is recommended throughout pregnancy.[44]

For women at low risk of VTE after caesarean section, early and frequent mobilisation is recommended, without thromboprophylaxis.[44] For women at moderate risk of VTE after caesarean section because of the presence of at least one risk factor in addition to pregnancy and caesarean section, pharmacological thromboprophylaxis (LMWH or UFH) or mechanical thromboprophylaxis (in those with contraindications to anticoagulants) is recommended while in hospital following delivery.[44] 

Pharmacological thromboprophylaxis combined with graduated compression stockings (anti-embolism stockings) and/or intermittent pneumatic compression is recommended for women undergoing caesarean section who are at high risk of VTE with multiple additional risk factors for thromboembolism.[44]

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