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==Classification==
==Classification==
Venous thromboembolism (VTE) may be classified into:<ref name="pmid22084692">{{cite journal |vauthors=Moheimani F, Jackson DE |title=Venous thromboembolism: classification, risk factors, diagnosis, and management |journal=ISRN Hematol |volume=2011 |issue= |pages=124610 |year=2011 |pmid=22084692 |pmc=3196154 |doi=10.5402/2011/124610 |url=}}</ref>
Venous thromboembolism (VTE) may be classified into:<ref name="pmid22084692">{{cite journal |vauthors=Moheimani F, Jackson DE |title=Venous thromboembolism: classification, risk factors, diagnosis, and management |journal=ISRN Hematol |volume=2011 |issue= |pages=124610 |year=2011 |pmid=22084692 |pmc=3196154 |doi=10.5402/2011/124610 |url=}}</ref>
* Deep vein thrombosis (DVT)
* [[Deep vein thrombosis]] ([[DVT]])
* Pulmonary embolism (PE)
* [[Pulmonary embolism]] (PE)
The following table further classifies DVT and PE:<ref name="pmid9546569">{{cite journal |author=Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS |title=Does this patient have deep vein thrombosis? |journal=JAMA |volume=279 |issue=14 |pages=1094–9 |year=1998 |month=April |pmid=9546569 |doi= |url=}}</ref><ref name="pmid7752753">{{cite journal |author=Wells PS, Hirsh J, Anderson DR, ''et al.'' |title=Accuracy of clinical assessment of deep-vein thrombosis |journal=Lancet |volume=345 |issue=8961 |pages=1326–30 |year=1995 |month=May |pmid=7752753 |doi= |url=}}</ref><ref name="pmid8257253">{{cite journal |author=Cogo A, Lensing AW, Prandoni P, Hirsh J |title=Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound |journal=Arch. Intern. Med. |volume=153 |issue=24 |pages=2777–80 |year=1993 |month=December |pmid=8257253 |doi= |url=}}</ref><ref name="pmid19718469">{{cite journal |author=Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I |title=Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study |journal=Thromb. Haemost. |volume=102 |issue=3 |pages=493–500 |year=2009 |month=September|pmid=19718469|doi=10.1160/TH09-01-0053 |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th09-01-0053&no_cache=1|accessdate=2011-12-14}}</ref><ref name="pmid8257253">{{cite journal| author=Cogo A, Lensing AW, Prandoni P, Hirsh J| title=Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound. | journal=Arch Intern Med | year= 1993 | volume= 153 | issue= 24 | pages= 2777-80 | pmid=8257253 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8257253  }} </ref><ref name="pmid15353493">{{cite journal |author=Joffe HV, Kucher N, Tapson VF, Goldhaber SZ |title=Upper-extremity deep vein thrombosis: a prospective registry of 592 patients |journal=[[Circulation]] |volume=110 |issue=12 |pages=1605–11 |year=2004 |month=September |pmid=15353493 |doi=10.1161/01.CIR.0000142289.94369.D7 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15353493 |accessdate=2012-10-07}}</ref><ref name="pmid20406709">{{cite journal| author=Isma N, Svensson PJ, Gottsäter A, Lindblad B| title=Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality. | journal=Thromb Res | year= 2010 | volume= 125 | issue= 6 | pages= e335-8 | pmid=20406709 | doi=10.1016/j.thromres.2010.03.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20406709  }} </ref><ref name="pmid17925416">{{cite journal| author=Muñoz FJ, Mismetti P, Poggio R, Valle R, Barrón M, Guil M et al.| title=Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. | journal=Chest | year= 2008 | volume= 133 | issue= 1 | pages= 143-8 | pmid=17925416 | doi=10.1378/chest.07-1432 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17925416  }} </ref>
The following table further classifies DVT and PE:<ref name="pmid9546569">{{cite journal |author=Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS |title=Does this patient have deep vein thrombosis? |journal=JAMA |volume=279 |issue=14 |pages=1094–9 |year=1998 |month=April |pmid=9546569 |doi= |url=}}</ref><ref name="pmid7752753">{{cite journal |author=Wells PS, Hirsh J, Anderson DR, ''et al.'' |title=Accuracy of clinical assessment of deep-vein thrombosis |journal=Lancet |volume=345 |issue=8961 |pages=1326–30 |year=1995 |month=May |pmid=7752753 |doi= |url=}}</ref><ref name="pmid8257253">{{cite journal |author=Cogo A, Lensing AW, Prandoni P, Hirsh J |title=Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound |journal=Arch. Intern. Med. |volume=153 |issue=24 |pages=2777–80 |year=1993 |month=December |pmid=8257253 |doi= |url=}}</ref><ref name="pmid19718469">{{cite journal |author=Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I |title=Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study |journal=Thromb. Haemost. |volume=102 |issue=3 |pages=493–500 |year=2009 |month=September|pmid=19718469|doi=10.1160/TH09-01-0053 |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th09-01-0053&no_cache=1|accessdate=2011-12-14}}</ref><ref name="pmid8257253">{{cite journal| author=Cogo A, Lensing AW, Prandoni P, Hirsh J| title=Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound. | journal=Arch Intern Med | year= 1993 | volume= 153 | issue= 24 | pages= 2777-80 | pmid=8257253 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8257253  }} </ref><ref name="pmid15353493">{{cite journal |author=Joffe HV, Kucher N, Tapson VF, Goldhaber SZ |title=Upper-extremity deep vein thrombosis: a prospective registry of 592 patients |journal=[[Circulation]] |volume=110 |issue=12 |pages=1605–11 |year=2004 |month=September |pmid=15353493 |doi=10.1161/01.CIR.0000142289.94369.D7 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15353493 |accessdate=2012-10-07}}</ref><ref name="pmid20406709">{{cite journal| author=Isma N, Svensson PJ, Gottsäter A, Lindblad B| title=Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality. | journal=Thromb Res | year= 2010 | volume= 125 | issue= 6 | pages= e335-8 | pmid=20406709 | doi=10.1016/j.thromres.2010.03.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20406709  }} </ref><ref name="pmid17925416">{{cite journal| author=Muñoz FJ, Mismetti P, Poggio R, Valle R, Barrón M, Guil M et al.| title=Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. | journal=Chest | year= 2008 | volume= 133 | issue= 1 | pages= 143-8 | pmid=17925416 | doi=10.1378/chest.07-1432 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17925416  }} </ref>



Revision as of 19:01, 12 October 2017

Venous thromboembolism Microchapters

Patient Information

Deep vein thrombosis
Pulmonary embolism

Overview

Classification

Epidemiology

Risk Factors

Diagnosis

Treatment

Deep Vein Thrombosis
Pulmonary Embolism

Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]:Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [3]

Overiew

Classification

Venous thromboembolism (VTE) may be classified into:[1]

The following table further classifies DVT and PE:[2][3][4][5][4][6][7][8]

Classification of Venous thromboembolism
Clinical diagnosis Sub-classification Comments
Deep vein thrombosis Upper extremity
  • Uncommon and accounts for 1-5 % of all DVT
  • Most likely due to:
    • Central venous catheter
    • Cardiac pacemaker
    • Implantable cardioverter defibrillator
    • Effort thrombosis (Paget–Schroetter disease)
    • Cancer
Lower extremity
  • Proximal:
    • Popliteal veins
    • Femoral veins
    • Iliac veins
  • Isolated distal:
    • Calf veins (Peroneal, soleal, posterior tibial, gastrocnemial, soleal, gastrocnemial, peroneal, posterior tibial)
Pulmonary embolism (PE) Massive PE (High risk)
  • Sustained hypotension (systolic blood pressure <90 mm Hg), not due to arrhythmia, hypovolemia, sepsis, or left ventricular dysfunction, and either lasting for at least 15 minutes or necessitating the administration of inotropes

OR

  • Pulselessness

OR

  • Persistent profound bradycardia (heart rate < 40 bpm) plus findings of shock
Sub-massive PE (Intermediate risk PE)
  • Right ventricular dysfunction OR myocardial necrosis

AND

  • Absence of systemic hypotension (systolic blood pressure >90 mm Hg)
Low risk PE

Epidemiology

Incidence

  • The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.[9]
  • Subjects who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.[10]
  • In the United States, the annual incidence of VTE is estimated to be approximately 100 per 100,000 persons.[9]

Age

  • The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.[9]
  • Subjects who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.[10]

Gender

  • Studies about differences in the incidence of VTE by gender have mixed results.
    • Some reported a higher incidence of DVT among young females[11]
    • Some reported it higher among either older females[12]
    • Some reported it higher in men.[10][13]
  • In addition, the risk for DVT was reported to consistently increase with age across both genders.[10]

Race

  • There is a significant difference in the incidence of DVT as it relates to race. African Americans characteristically have the highest incidence of DVT while Caucasians rank as the second highest incidence of DVT.[9]
  • When compared to African Americans and Caucasians, the incidence of DVT is noted to be two to four times lower in Hispanics and Asian-Pacific Islanders.[9]
  • Lower thrombosis incidences in non-Caucasians may be related to a lower prevalence of disorders like Factor V Leiden or Prothrombin 20210A mutation.[14][15]

Hospitalization for VTE

  • During 2007–2009, an estimated annual average of 547,596 hospitalizations had a diagnosis of VTE for adults aged ≥18 years. Estimates for DVT and PE diagnoses were not mutually exclusive. An estimated annual average of 348,558 adult hospitalizations had a diagnosis of DVT, and 277,549 adult hospitalizations had a diagnosis of PE. An estimated annual average of 78,511 adult hospitalizations (14% of overall VTE hospitalizations) had diagnoses of both DVT and PE.[16]
  • The estimated average annual number of hospitalizations with VTE was successively greater among older age groups: 54,034 for persons aged 18–39 years; 143,354 for persons aged 40–59 years; and 350,208 for persons aged ≥60 years. The estimated average annual number of hospitalizations with VTE was comparable for men (250,973) and women (296,623). Shown below is an image depicting the estimated average annual number of hospitalization with a diagnosis of DVT, PE, or VTE by age and sex.[16]
Estimated average annual number of hospitalizations with a diagnosis of deep thrombosis (DVT), pulmonary embolism (PE), or venous thromboembolism (VTE), by patient sex and age group — National Hospital Discharge Survey, United States, 2007–2009 - Source:CDC
  • The average annual rates of hospitalizations with a discharge diagnosis of DVT, PE, or VTE among adults were 152, 121, and 239 per 100,000 population, respectively. For VTE, the average annual rates were 60 per 100,000 population aged 18–39 years, 143 for persons aged 40–49 years, 200 for persons aged 50–59 years, 391 for persons aged 60–69 years, 727 for persons aged 70–79 years, and 1,134 for persons aged ≥80 years. The rates of hospitalization were similar for men and women, and the point estimates increased for both sexes by age.[16]
  • On average, 28,726 hospitalized adults with a VTE diagnosis died each year. Of these patients, an average of 13,164 had a DVT diagnosis and 19,297 had a PE diagnosis; 3,735 had both DVT and PE diagnoses.[16]

Recurrence of VTE

  • One-third (about 33%) of people with VTE will have a recurrence within 10 years.[17][18]
  • The risk of recurrence of VTE in patients diagnosed with first-time VTE is estimated to be around 7-8 percent per year during an average follow up period of 2.2 years of subsequent observation of 265 patients.[10]
  • Among patients with a first episode of VTE, the risk of recurrence of VTE is particularly elevated in the first 6 to 12 months following the first episode of VTE. The risk of recurrent VTE remains up to 10 years, with a estimated cumulative incidence of first overall VTE recurrence of 30 %. Predictors for recurrence of VTE include malignancy, neurological diseases, and paresis.[19]
  • In recent years, the increase in thrombosis incidence may be related to improved diagnostic modalities and increased awareness by clinicians.[9]

Complications of VTE

  • Estimates suggest that 60,000-100,000 Americans die of VTE, 10 to 30% of which will die within one month of diagnosis.[17][18]
  • Among people who have had a DVT, one-half will have long-term complications (post-thrombotic syndrome) such as swelling, pain, discoloration, and scaling in the affected limb.[17][18]

Risk Factors

Shown below is a list of predisposing factors for VTE.[20][21] The risk factors are classified as moderate or weak depending on how strongly they predispose for a VTE.

Moderate risk factors Weak risk factors
Chemotherapy
Obesity

Chronic heart failure
Respiratory failure
Hormone replacement therapy
Cancer
Oral contraceptive pills
Stroke
Pregnancy
Postpartum
❑ Prior history of VTE
Thrombophilia

Hospitalization

❑ Advanced age

Laparoscopic surgery
❑ Prepartum
Varicose veins

Risk factors of VTE may be categorized in to modifiable, non-modifiable, temporary and other risk factors.

Modifiable Risk Factors Non-Modifiable Risk Factors Temporary Risk Factors Other Risk Factors

❑ Modifiable risk factors are reversible based upon lifestyle/behavior modification.
Obesity is defined as a body-mass index (BMI) above 30 kg/m2.[22] [23] [24]
Smoking:[22] Smoking significantly increases the risk of DVT, particularly among women who are taking oral contraceptive pills as well as among obese people.
❑ Use of oral contraceptives[25]
Hyperhomocysteinemia:[26] Hyperhomocysteinemia can be reduced with vitamin B supplementation.

❑ Advanced age
Heart failure
Thrombophilia or hypercoagulable state
Polycythemia vera

Factor V Leiden
Prothrombin G20210A mutation
Protein C deficiency
Protein S deficiency
Activated protein C resistance
Antithrombin III deficiency
Factor VIII mutation
Antiphospholipid syndrome
Heparin induced thrombocytopenia
Nephrotic syndrome
Paroxysmal nocturnal hemoglobinuria

Pregnancy and the peri-partum period
❑ Active cancer
Central venous catheter

❑ Other possible factors associated with VTE include:[27]

❑ Nutrition low in fish
Psychological stress
❑ Cardiovascular risk factors such as diabetes and hypercholesterolemia

Diagnosis

<nowiki>
 
 
 
 
 
 
 
 
Suspected pulmonary embolism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D-dimer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
 
 
 
 
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stop
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CXR
 
 
 
 
 
 
Ultrasound
If signs of DVT present
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
PE unlikely with positive D-dimer or PE likely
 
 
 
 
 
 
 
 
Abnormal
PE unlikely with positive D-dimer or PE likely
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
V/Q scan
 
 
 
 
 
 
 
CTPA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nnormal
 
Non diagnostic
 
High probability
 
PE present
 
PE absent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stop
 
 
 
 
 
 
Treat
 
Treat
 
Stop
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PE unlikely
 
 
 
PE likely
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serial ultrasound
 
 
 
CTPA or serial ultrasound
 
 
 

Treatment

Prevention

Patient population Sub-population Scoring criteria for risk assessment Major predisposing risk factors Prophylaxis options
Padua score

(Score≥ 4: High risk for VTE

Score< 4: Low risk for VTE)

IMPROVE score (0 0.5%

1 1.0%

2 1.7%

3 3.1%

4 5.4%

5-8 11%)

IMPROVE bleeding risk score

(Score ≥7: Elevated risk of bleeding

Score <7: Not elevated risk of bleeding)

IMPROVE Associative Score

(Score 0-1: Low risk for VTE

Score 2-3: Intermediate risk for VTE

Score 4-10: Hight risk for VTE)

Non-surgical patients Acutely ill patients
  • Active cancer 3
  • Previous VTE 3
  • Decreased mobility 3

Thrombophilia 3

Previous trauma or surgery within that last month 2

Age≥ 70 1

Heart and/or respiratory failure 1

Ischemic stroke or acute myocardial infarction 1

Acute rheumatologic disorder and/or acute infection 1

Obesity 1

Hormonal therapy

Critically ill patients
Cancer in outpatient  Does the patient have a solid tumor 

AND 

Additional risk factors for VTE?

Previous VTE

❑ Hormonal therapy

❑ Immobilization

❑ Angiogenesis inhibitors

❑ Thalidomide

❑ Lenalidomide

Chronically immobilized patients
Long travel
Asymptomatic thrombophilia
Non-hospitalized subjects
Surgical patients Orthopedic surgery patients
General and abdominal pelvic surgeries
Cardiac surgery
Thoracic surgery
Craniotomy
Spinal surgery
Trauma

Non-surgical patients

(i) Prevention in acutely ill hospitalized patients

Risk assessment in acutely ill patients

The following scoring systems can be used to assess the risk of VTE, based on risk factors:

(a) Padua prediction score for VTE

Shown below is a table depicting Padua predictive score for VTE among hospitalized medical patients. The interpretation of the score is as follows:

  • Score≥ 4: High risk for VTE
  • Score< 4: Low risk for VTE[28]
Variable Score
Active cancer 3
Previous VTE 3
Decreased mobility 3
Thrombophilia 3
Previous trauma or surgery within that last month 2
Age≥ 70 1
Heart and/or respiratory failure 1
Ischemic stroke or acute myocardial infarction 1
Acute rheumatologic disorder and/or acute infection 1
Obesity 1
Hormonal therapy 1

(b) IMPROVE predictive score for VTE

Calculation of the IMPROVE predictive score

Variable Score[29]
Prior episode of VTE 3
Thrombophilia 3
Malignancy 1
Age more than 60 years 1

Interpretation of the IMPROVE predictive score

Score Predicted VTE risk through 3 months[29]
0 0.5%
1 1.0%
2 1.7%
3 3.1%
4 5.4%
5-8 11%

(ii) Preventive approach in acutely ill hospitalized patients based on risk assessment

Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: Venous thromboembolism

 
 
 
 
 
What is the risk of thrombosis in the acutely ill patient?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High
 
Low
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient bleeding or at high risk of bleeding?
 
No VTE prophylaxis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
Mechanical VTE prophylaxis
For the period of immobilization or hospital stay only
Graduated compression stocking
Intermittent pneumatic compression
 
Pharmacological VTE prophylaxis
For the period of immobilization or hospital stay only
LMWH
LDUH, BID
LDUH, TID
Fondaparinux
 
 
 
 
 
 
 
 
 
 
 
Did the bleeding or bleeding risk subside
AND
the patient is still at increased risk of thrombosis?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
❑ Substitute mechanical prophylaxis by pharmacological prophylaxis
 
❑ Continue mechanical prophylaxis

(iii) Prevention in critically ill hospitalized patients

Risk assessment in critically ill patients

(a) IMPROVE bleeding risk score

Shown below is a table depicting the IMPROVE risk score for bleeding among hospitalized medical patients. The scores can be interpreted as such:[30]

  • Score ≥7: Elevated risk of bleeding
  • Score <7: Not elevated risk of bleeding
Variable Score
Active gastric or duodenal ulcer 4.5
Prior bleeding within the last 3 months 4
Thrombocytopenia (<50x109/L) 4
Age ≥ 85 years 3.5
Liver failure (INR>1.5) 2.5
Severe kidney failure (GFR< 30 mL/min/m2) 2.5
Admission to ICU or CCU 2.5
Central venous catheter 2
Rheumatic disease 2
Active malignancy 2
Age: 40-84 years 1.5
Male 1
Moderate kidney failure (GFR: 30-59 mL/min/m2) 1

(iv) Preventive approach in critically ill hospitalized patients

Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: Venous thromboembolism

 
 
 
Is the critically ill patient bleeding or at risk for major bleeding?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
Mechanical VTE prophylaxis
 
Pharmacological VTE prophylaxis
LMWH
LDUH
 
 
 
 
 
 
 
 
 
 
 
Did the bleeding or bleeding risk subside?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
❑ Substitute mechanical prophylaxis by pharmacological prophylaxis
 
❑ Continue mechanical prophylaxis

Shown below is an algorithm depicting VTE prophylaxis among cancer patients. Note that, cancer patients with indwelling central venous catheters do not require VTE prophylaxis with neither low molecular weight heparin, low dose unfractionated heparin or vitamin K antagonists.[31]

Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: Venous thromboembolism

 
 
Does the patient have a solid tumor
AND
Additional risk factors for VTE?
❑ Previous VTE
Hormonal therapy
❑ Immobilization
Angiogenesis inhibitors
Thalidomide
Lenalidomide
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
Pharmacological VTE prophylaxis
LMWH
LDUH
 
❑ No VTE prophylaxis
 
  1. Moheimani F, Jackson DE (2011). "Venous thromboembolism: classification, risk factors, diagnosis, and management". ISRN Hematol. 2011: 124610. doi:10.5402/2011/124610. PMC 3196154. PMID 22084692.
  2. Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS (1998). "Does this patient have deep vein thrombosis?". JAMA. 279 (14): 1094–9. PMID 9546569. Unknown parameter |month= ignored (help)
  3. Wells PS, Hirsh J, Anderson DR; et al. (1995). "Accuracy of clinical assessment of deep-vein thrombosis". Lancet. 345 (8961): 1326–30. PMID 7752753. Unknown parameter |month= ignored (help)
  4. 4.0 4.1 Cogo A, Lensing AW, Prandoni P, Hirsh J (1993). "Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound". Arch. Intern. Med. 153 (24): 2777–80. PMID 8257253. Unknown parameter |month= ignored (help)
  5. Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I (2009). "Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study". Thromb. Haemost. 102 (3): 493–500. doi:10.1160/TH09-01-0053. PMID 19718469. Retrieved 2011-12-14. Unknown parameter |month= ignored (help)
  6. Joffe HV, Kucher N, Tapson VF, Goldhaber SZ (2004). "Upper-extremity deep vein thrombosis: a prospective registry of 592 patients". Circulation. 110 (12): 1605–11. doi:10.1161/01.CIR.0000142289.94369.D7. PMID 15353493. Retrieved 2012-10-07. Unknown parameter |month= ignored (help)
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