Venous thrombo embloism prophylaxis

Last week, the American College of Chest Physicians (ACCP) published updated evidence-based guidelines addressing the prevention and management of thrombosis. Developed by an international panel of 90 experts, these guidelines include more than 700 recommendations related to the prevention and management of thrombotic disorders. While I thought it would be fun to go through all 700 recommendations, I decided to choose a few highlights.

For all of our MOs wondering who should get venous thromboembolism (VTE) prophylaxis, the guidelines recommend it for most patients. However, they do not recommend routine use for patient groups with a very low risk of VTE. This includes patients undergoing laparoscopic surgery, knee arthroscopy, or those who take long airplane flights. The guidelines continue to recommend against the use of aspirin alone for VTE prophylaxis in any population. Several specialized populations are addressed in the new guidelines,including those undergoing surgery. A full chapter is dedicated to the perioperative management of patients on long-term antithrombotic therapy who require surgery or other invasive procedures. Most patients must temporarily stop anticoagulation just prior to undergoing surgery in order to minimize bleeding; however, this can increase the risk of a thromboembolic event. To address this challenge, the guidelines recommend that the risk of a thromboembolic event during interruption of therapy be balanced against the risk for bleeding when antithrombotic therapy is discontinued. The guidelines also recommend routine use of VTE prophylaxis for patients undergoing major general, gynecologic, or orthopedic surgeries and have been expanded to include bariatric and coronary artery bypass surgery. Also specifically addressed in the new guidelines are challenging issues facing women who are pregnant or wish to become pregnant while undergoing long-term antithrombotic therapy. Pregnant women taking vitamin K antagonists (VKAs) such as warfarin have an increased risk for birth defects and miscarriage. For most women taking VKAs who become pregnant, the guidelines recommend substituting low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) and suggest frequent pregnancy tests and the substitution of LMWH or UFH once pregnancy is achieved. For women with mechanical valves who become pregnant, the guidelines suggest either adjusted-dosebid LMWH or UFH throughout pregnancy or adjusted-dose bid LMWH or UFH until the thirteenth weekwithVKA substition untilLMWH or UFH are resumedclose to delivery. In pregnant women with high-risk mechanical valves (i.e., older-generation valve in the mitral position or history of thromboembolism), the use of oral anticoagulants over heparin is suggested because of concerns about the effectiveness of alternative anticoagulants in preventing stroke and valve thrombosis. Remember, this is just a teaser. If youre still interested or have a management question about a patient, check out the full set of guidelines. Here is a copy all the abstracts..