Simple guide for venous thromboembolism (VTE) prophylaxis after surgery or hospitalization
Overview
When is venous thromboembolism (VTE) prophylaxis needed after hospitalization? Not very often. Stay alert for appropriate use.
Management steps
Hip or knee replacement patients
Continue to recommend VTE prophylaxis for 14 to 35 days after knee or hip replacement.
- Recommend using a direct oral anticoagulant (DOAC), such as Eliquis (apixaban) or Xarelto (rivaroxaban), or a low-molecular-weight heparin (Clexane [enoxaparin], etc) for most patients at higher VTE risk. This includes patients with prior VTE, CV disease, extremely limited mobility, etc.
- For lower-VTE-risk patients, consider suggesting a DOAC for 5 days then switching to aspirin 81 mg/day to finish the course. But explain there's not good evidence for using aspirin alone from the get-go.
Nonsurgical patients
Recent evidence is raising questions about continuing VTE prophylaxis after discharge in high-risk NONsurgical patients such as an older heart failure patient with reduced mobility.
- Explain that using Xarelto for 45 days after discharge in high-risk patients only prevents one symptomatic VTE for every 417 treated, but one in 175 have clinically important bleeding.
- Evidence for Eliquis seems even less favourable.
- Don't recommend this "extended-duration" VTE prophylaxis.
Also don't routinely recommend VTE prophylaxis for patients with a lower leg injury requiring immobilization, such as a cast, or in patients who are chronically immobilized, such as nursing home residents. But ensure anticoagulants are continued after discharge for appropriate indications (atrial fibrillation, recent VTE, etc). Get our note, "Optimize anticoagulants to reduce stroke risk in atrial fibrillation patients".
References
- Thrombosis Canada - (2013). Clinical Guides[online]. Available at: https://thrombosiscanada.ca/clinicalguides.
- Spyropoulos AC, Ageno W, Albers GW, et al. Rivaroxaban for Thromboprophylaxis after Hospitalization for Medical Illness. N Engl J Med. 2018 Sep 20;379(12):1118-1127.
- Cohen AT, Harrington RA, Goldhaber SZ, Hull RD, et al. Extended Thromboprophylaxis with Betrixaban in Acutely Ill Medical Patients. N Engl J Med. 2016 Aug 11;375(6):534-44.
- Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e195S-e226S.
- Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e278S-e325S.
