Patient selection for thromboprophylaxis in medical inpatients

Abstract

Acutely ill medical patients may be at increased risk of venous thromboembolism, both during hospitalization and after discharge. International guidelines recommend thromboprophylaxis for high-risk medical patients with low bleeding risk for a maximum of 14 days. There are two approaches to identify the high-risk patient: adhering to the inclusion criteria used in randomized clinical trials or using risk assessment models. With both approaches, about 40% of medical inpatients should result at increased risk of venous thrombosis. However, in the real world, medical inpatients are more fragile than patients enrolled in clinical trials, and thus also require a careful assessment of the individual bleeding risk. The complex balance between risks and benefits of thromboprophylaxis has become particularly relevant in studies assessing extended prophylaxis beyond hospitalization in this setting. In the present review, we will summarize the most recent evidence on this topic.

Keywords::

• medical patients
• prevention
• prophylaxis
• risk assessment model
• venous thromboembolism

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Venous thromboembolism (VTE) is a common complication during and after hospitalization both in surgical and medical wards.

• • Almost 70% of hospitalized patients with thromboembolic disease came from medical wards and in absence of thromboprophylaxis fatal pulmonary embolism represents one of the major cause of death in medical patients.

• • The use of pharmacologic prophylaxis was shown to reduce the risk of deep vein thrombosis by between 50 and 60% and the risk of clinical and fatal pulmonary embolism by about 50% compared with placebo or no treatment.

• • Up to now, pharmacological thromboprophylaxis is still underused mostly due to difficulty in patient’s selection and to the fear of bleeding.

• • Two approaches can be suggested in at risk VTE patients: a group-specific thromboembolic risk assessment and risk assessment models.

• • The group-specific risk approach has some limitations such as the inability to account for large heterogeneity among patient groups, the impossibility to assess patient-specific thrombosis risk factors and how these risk factors interact in determining the overall thromboembolic risk and the uncertainty about the generalizability of the randomized clinical trial results to the ‘real practice’.

• • Most of the available risk assessment models have not been validated and are complex to use in clinical practice.

• • Up to now, the best available evidence for VTE risk stratification in medical patient derives from ‘The Padua Prediction score’.

• • The bleeding risk is the other side of the coin to consider when prescribing pharmacological thromboprophylaxis.

• • Bleeding scores need to be implemented.