Prophylaxis for Venous Thromboembolism in General Medical Patients: DISCUSSION

28 Sep


VTE is potentially preventable in general medical patients, but until recently the frequency of this condition in patients admitted to general medicine wards had not been established, because of the different methods used to diagnose deep vein thrombosis and the heterogeneity of the patient popula­tion studied. In 3 recent randomized trials (MEDENOX, PREVENT, and ARTEMIS) LMWH was compared with placebo in the general medical population; these studies helped to establish that VTE prophylaxis with LMWH can significantly and safely reduce the incidence of VTE in general medical patients admitted to hospital. In several randomized clinical trials (most recently the PRINCE trial) directly comparing LDUH and LMWH, there have been no significant differences in rates of deep vein thrombosis or bleeding between these 2 agents.

Many hospital inpatients have risk factors for VTE, and these risks appear to be cumulative1 The average age of this study population was 80 years, and most of the patients had acute infection or were confined to bed for more than 72 hours. More than 80% of the study population had at least 2 independent risk factors for VTE, which suggests that this population had multiple risk factors. The heterogeneity of the general medical population may make it challenging for health care professionals to determine the risk of VTE. However, some medical conditions such as CHF and COPD have been identified as independent risk factors for VTE, and patients with these conditions should receive prophylaxis until the risk factors have been reversed.

This study revealed poor rates of VTE prophylaxis for general medical patients admitted with exacerbations of CHF or COPD. Even after the poor rates of prophylaxis had been highlighted and health care professionals had been educated about the indications for VTE prophylaxis outlined in current practice guidelines, the rates of prophylaxis remained poor. Many barriers to the implementation and adherence of guidelines have been identified in the literature, including insufficient staff, oversight at the time of admission because of the focus on acute problems, existing outdated protocols, physician concerns regarding safety and cost, patient choice or refusal, and lack of physician cooperation or interest. At the authors’ institution, most physicians acknowledged oversight and lack of awareness of current guidelines as barriers to VTE prophylaxis for patients with CHF and COPD. Much improvement in initiating VTE prophylaxis is necessary, and literature is available to guide health care professionals in assessing the risk of VTE.