Before starting therapy to prevent venous thromboembolism (VTE), physicians should evaluate the risk for thromboembolism and bleeding among medical, nonsurgical inpatients, according to a new clinical practice guideline issued by the American College of Physicians (ACP) and reported in the November 1 issue of the Annals of Internal Medicine.

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• The evidence does not support routine VTE prophylaxis in patients hospitalized for medical illnesses, including stroke, lead guideline author Amir Qaseem, MD, FACP, PhD, MHA, ACP director of clinical policy, said in a news release.
• If a patient is at risk for VTE, the [ACP] recommends that physicians prescribe heparin or related blood thinners, unless the assessed risk of bleeding outweighs likely benefits
• Both VTEs (pulmonary embolism [PE] and deep venous thrombosis [DVT]) are highly prevalent conditions with significant morbidity and mortality. Many hospitals routinely prescribe antiplatelet agents or anticoagulants to medical inpatients because most hospitalized patients have 1 or more risk factors for VTE, but these medications are associated with increased risk of bleeding.

Specific ACP Recommendations
1.Before starting prophylaxis for VTE, the ACP recommends evaluating the risk for thromboembolism and bleeding in hospitalized nonsurgical patients, including those with stroke or other medical illnesses (grade: strong recommendation, moderate-quality evidence).
2.Unless the anticipated risk for bleeding outweighs the likely benefits, the ACP recommends pharmacologic prophylaxis for VTE in stroke and other medical inpatients, using heparin or a related drug (grade: strong recommendation, moderate-quality evidence).
3.The ACP recommends against the use of mechanical prophylaxis with graduated compression stockings to prevent VTE (grade: strong recommendation, moderate-quality evidence).

• A related policy implication is that the ACP does not support use of performance measures encouraging universal VTE prophylaxis intervention, regardless of estimated VTE risk among hospitalized patients with stroke or other medical illness.
• Because there is no standard, accepted risk-assessment formula to identify which nonsurgical patients are likely to benefit from VTE prophylaxis, this is best left to physician judgment, and performance measures encouraging routine prevention in all patients are inappropriate, Dr Qaseem said.
• Until we can better identify those patients who truly benefit, performance measures that encourage VTE prophylaxis for patients hospitalized for medical illnesses, including stroke, may encourage physicians to use prevention in low risk patients for whom the risks may exceed the benefit.

Methodology

• The guidelines panel reviewed relevant studies published from 1950 through April 2011 and identified appropriate studies from a search for randomized trials and English-language publications, using MEDLINE and the Cochrane Library.
• They also searched bibliographies of pertinent randomized trials and systematic reviews.
• Total mortality up to 120 days after randomization was the main study endpoint for this guideline, and secondary endpoints were symptomatic DVT, all PEs, fatal PE, all bleeding events, major bleeding events, and effects on skin (for mechanical prophylaxis).

Background Evidence

• Treatment benefits for VTE are primarily related to reduction in mortality, symptomatic DVT, and PE events.
• Prophylaxis with heparin is associated with a statistically significant reduction in PE events among inpatients with stroke or other medical illnesses.
• For most patients, the clinical benefit of lowering PE events will outweigh the harm of increased risk for bleeding events.
• Different types of heparin used for VTE prophylaxis did not vary in benefits or harms.
• Graduated compression stockings were ineffective in preventing VTE or reducing mortality among patients at risk for VTE and bleeding from anticoagulants.
• Furthermore, use of the stockings was associated with clinically important damage to lower extremity skin.
• Among patients with undiagnosed and untreated PE, 26% will have a subsequent fatal embolism, and an additional 26% will have a nonfatal recurrent embolism.
• According to available evidence, PE directly accounts for 5% to 10% of all in-hospital deaths. In the United States, PE results in 200,000 to 300,000 hospitalizations per year.
• Heparin prophylaxis had no significant effect on mortality, may have reduced PE in medical patients and all patients combined, and led to more bleeding and major bleeding events, thus resulting in little or no net benefit, write Frank A. Lederle, MD, from the Minnesota Evidence-Based Practice Center in Minneapolis, and colleagues in a second report on the guidelines, also published in the November 1 issue of the Annals of Internal Medicine.
• No differences in benefits or harms were found according to the type of heparin used.
• Mechanical prophylaxis provided no benefit and resulted in clinically important harm to patients with stroke.

For further reading log on to : http://www.medscape.com/viewarticle/752611