Prevention of venous thromboembolism in high risk patients

Venous thromboembolism includes two closely related clinical manifestations: deep vein thrombosis (DVT), more commonly of the lower limbs, and pulmonary embolism. Pulmonary embolism is the most common cause of preventable death in hospitalized patients. The definition of the risk factors for venous thromboembolism should allow to adopt the most suitable prophylactic regimen. Determinants for the risk of venous thromboembolism are patient risk factors, both clinical and molecular, and the clinical setting. In this article the prophylactic regimens most widely employed in the prevention of venous thromboembolism in high-risk clinical settings with be reviewed. Then, the available guidelines for the management of thrombophilic patients will be given.

The authors have been working in this field contributing original papers. In addition, the material examined in this review article includes papers published in the journals covered by the Science Citation Index and Medline.

Pharmacological prophylaxis is an effective approach for reducing morbidity and mortality from venous thromboembolism. Nevertheless, prophylaxis for venous thromboembolism is under employed because the incidence of venous thromboembolism is underestimated and there is fear of bleeding side effects. Adopting the proper prophylactic strategy for venous thromboembolism requires defining the patient risk factor. Determinants for the risk of venous thromboembolism are patient risk factors, both clinical and molecular, and the clinical setting. The risk connected with the clinical setting is the only risk defined by properly performed epidemiological studies. High-risk clinical settings are major orthopedic surgery, elective neurosurgery, spinal cord injury, cancer surgery and multiple trauma. The most effective anticoagulant regimens in the prevention of venous thromboembolism in high-risk patients are adjusted-dose unfractionated heparin, low molecular weight heparins (LMWHs) and oral anticoagulants. LMWHs are as effective and safe as the other two agents, but they do not require laboratory monitoring. On the other hand, LMWHs are more expensive than unfractionated heparin and warfarin. The use of effective agents still leaves the patients with a high prevalence of venous thromboembolism. Hence the search for more effective agents such as selective thrombin inhibitors like hirudin and its analogues. In patients undergoing elective hip surgery, hirudin has been recently shown to be more effective than low-dose unfractionated heparin and the LMWH enoxaparin.