Prevention of venous thromboembolism: consensus, controversies, and challenges

The last 50 years have witnessed a multitude of publications evaluating the efficacy, safety and cost effectiveness of many different thromboprophylaxis interventions. There is widespread consensus that thromboprophylaxis safely reduces morbidity and mortality. More than 25 evidence-based guidelines, published since 1986, also recommend routine thromboprophylaxis in the majority of hospitalized patients. As a result, thromboprophylaxis is recognized as a key safety priority for hospitals. Some of the remaining areas of controversy that will be discussed in this paper include the role of individual risk assessments to determine thrombosis risk and prophylaxis, replacement of low-dose heparin by low-molecular-weight heparin (LMWH), the optimal duration of prophylaxis, the role of combined thromboprophylaxis modalities, the safety of anticoagulant prophylaxis with regional analgesia, the use of LMWHs in chronic renal insufficiency, and the emerging role of new oral anticoagulants as thromboprophylactic agents. Despite the overwhelming evidence supporting thromboprophylaxis, rates of thromboprophylaxis use remain far from optimal. Successful implementation strategies to bridge this knowledge:care gap are the most important current challenges in this area. These strategies must be multifaceted, utilizing local, systems-based approaches as well as legislation and incentives that reinforce best practices.