New VTE Guidelines Focus on Prevention in Medical, Surgical Patients

Internal Medicine World ReportJanuary 2007
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From the VEITH Symposium

Int Angiol

NEW YORK CITY—A much-needed set of updated recommendations for the appropriate treatment of venous thromboembolism (VTE) and medical strategies for the prevention of VTE in patients at increased risk were presented at this year’s VEITH symposium, sponsored by the Cleveland Clinic. The consensus statement is also available in print (. 2006; 25:101-161) and on a CD.

In updating the earlier guidelines, “The key question that was asked was, ‘What is the evidence?,’ because the answer determines the grade of recommendation,” said Andrew N. Nicolaides, MS, FRCS, lead author of the international consensus statement.

VTE refers to both deep vein thrombosis (DVT) and pulmonary embolism (PE). According to the American Heart Association, 2 million Americans are hospitalized each year because of DVT. About 30% of these patients subsequently also have PE, which is responsible for 60,000 deaths annually.

One major change from the previous recommendations is, “We now have fondaparinux [Arixtra], which is a new option for the treatment of DVT and PE,” said Dr Nicolaides, emeritus professor of vascular surgery at the Department of Biomedical Sciences University of Cyprus.

Initial treatment of DVT with fondaparinux has been assigned a grade A recommendation—based on consistent level 1 evidence from randomized controlled trials that is directly applicable to the target population.

Discussing the highlights of the consensus statement, Dr Nicolaides emphasized, “Here is another highlight: the recommendation to treat patients with established DVT with low-molecular-weight heparin or fondaparinux, followed by warfarin for 3 months—or longer if the DVT is idiopathic—and immediate mobilization with elastic compression stockings worn for at least 2 years to reduce the postthrombotic syndrome.”

Other key points highlighted include:

1. Routine assessment of all acutely ill patients for risk of VTE and consideration of appropriate thromboprophylaxis is strongly recommended (Table).

2. Choosing appropriate prophylaxis is emphasized, both in terms of the specific drug selected as well as the duration of its use, considering that some patients need prophylaxis for up to 4 to 6 weeks.

3. Use of mechanical methods, such as intermittent pneumatic compression and graduated compression stockings to prevent DVT when drugs are contraindicated.

Dr Nicolaides emphasized the need to educate patients about VTE prevention, noting that “although the guidelines have been published and are distributed to the medical profession throughout the world in the form of a booklet and a CD-ROM, the faculty feel that in order to ensure full compliance, it is important to educate the patients and the public.”

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