VTE prophylaxis for nonsurgical patients

The choice of venous thromboembolism (VTE) (ie deep vein thrombosis [DVT] or pulmonary embolism [PE]) prophylaxis for nonsurgical patients in hospital depends on an assessment of the patient’s risk of developing VTE weighed against their risk of bleeding. Multiple factors are involved and need to be considered, such as:

  • the medical condition leading to the patient’s hospital admission (see Examples of VTE prophylaxis for nonsurgical patients in hospital) and the presence of other comorbidities
  • other VTE risk factors
  • bleeding risk factors (eg active peptic ulcer disease, bleeding in the 3 months before admission, acquired bleeding disorders, acute stroke, thrombocytopenia or uncontrolled systolic hypertension)
  • clinical consequences of bleeding, should it occur.

If VTE prophylaxis is used in nonsurgical patients during a hospital admission, see Examples of VTE prophylaxis for nonsurgical patients in hospital for examples of the suitable type and duration. Low molecular weight heparin (LMWH) is recommended over direct-acting oral anticoagulants (DOACs), because DOACs have an increased risk of major bleeding in this settingSchunemann, 2018.

Do not use anticoagulants in patients with active bleeding, or those who are at risk of intracranial, spinal cord or gastrointestinal bleeding. Carefully consider the bleeding risk in patients with a pre-existing bleeding disorder, thrombocytopenia (eg platelet count less than 50 × 109/L) or platelet dysfunction. Mechanical prophylaxis may be preferred for these patients; however, if the patient’s bleeding risk later decreases, an anticoagulant can replace, or be added to, mechanical prophylaxis.

Evidence for the efficacy of mechanical prophylaxis for nonsurgical patients is limited; an intermittent pneumatic compression device may prevent DVT in patients immobilised after an acute stroke.

For information on the optimal VTE prophylaxis for patients with coronavirus disease (COVID-19), see the Australian guidelines for the clinical care of people with COVID-19.

Table 1. Examples of VTE prophylaxis for nonsurgical patients in hospital

Conditions increasing risk of VTE

Prophylaxis and duration [NB1]

ischaemic stroke with immobility

Depending on degree of immobility, consider LMWH or UFH [NB2]; continue until the patient is mobile or discharged (whichever is sooner)

OR

IPC; continue for up to 30 days, or until the patient is mobile or discharged (whichever is sooner)National Institute for Health and Clinical Excellence (NICE), 2018 (updated 2019)

heart failure

acute or acute-on-chronic lung infection [NB3]

myocardial infarction [NB4]

acute inflammatory disease, including bowel

critical illness

LMWH or UFH [NB2]; continue until the patient is mobile or discharged (whichever is sooner)

active cancer

See VTE prophylaxis for patients with active cancer

pregnancy and childbirth

See VTE prophylaxis during pregnancy and the postpartum period and ‘caesarean section’ in VTE prophylaxis for surgical patients in hospital

Note:

IPC = intermittent pneumatic compression; LMWH = low molecular weight heparin; UFH = unfractionated heparin; VTE = venous thromboembolism

NB1: For drug dosages, see Parenteral anticoagulants for VTE prophylaxis.

NB2: LMWH is preferred over UFH because it is safer and more effective; heparin-induced thrombocytopenia (HIT) also occurs less commonly with LMWH than with UFH.

NB3: Younger patients with acute-on-chronic lung disease may not be at high risk of VTE unless they have other risk factors (see Risk factors for VTE in nonsurgical patients in hospital).

NB4: If patients are taking full-dose therapeutic anticoagulation, VTE prophylaxis is not required.