Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

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Prevention of Venous Thromboembolism
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7th ACCP Conference on Antithrombotic
Thrombolytic Therapy

• Developed by a panel of 87 physicians
• Published CHEST Sept 2004 supplement
• Introduces novel therapies for prevention/treatmen
  t of thrombosis
• Emphasizes need for stronger implementation in
  the clinical setting

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Grade 1 Recommendations
RCT randomized controlled trial
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Grade 2 Recommendations
RCT randomized controlled trial
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General Recommendations

• Use mechanical methods of prophylaxis primarily
  in patients at high risk of bleeding (Grade 1C),
  or as an adjunct to anticoagulant-based
  prophylaxis (Grade 2A)
• Direct careful attention toward ensuring proper
  use of, and optimal compliance with, the
  mechanical device (Grade 1C)
• We recommend against the use of aspirin alone as
  prophylaxis of VTE for any patient group (Grade
  1A)

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General Surgery (1)
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General Surgery (2)
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General Surgery (3)
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Vascular Surgery

• In patients with no additional risk factors for
  thromboembolism, we suggest clinicians do not
  routinely use thromboprophylaxis (Grade 2B)
• For patients with additional thromboembolic risk
  factors who are undergoing major vascular
  surgery, we recommend low-dose unfractionated
  heparin (LDUH) or LMWH (Grade 1C)

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Gynecologic Surgery (1)
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Gynecologic Surgery (2)
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Gynecologic Surgery (3)
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Orthopaedic Surgery - Hip
Usual high-risk dose, started 12 h before
surgery or 12 to 24 h after surgery or, half the
usual high-risk dose, started 4 to 6 h after
surgery, and then the usual high-risk dose the
following day 2.5 mg, started 6 to 8 h after
surgery Target INR 2.5 range, 2.0 to 3.0,
started before surgery or the evening after
surgery
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Orthopaedic Surgery - Knee
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Orthopaedic Surgery hip fracture
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Orthopaedic Surgery duration

• Total hip or knee replacement, or hip-fracture
  surgery
• LMWH (high-risk dose), fondaparinux (2.5 mg/d),
  or a VKA (target INR 2.5 range, 2.0 to 3.0) for
  10 d (Grade 1A)
• Total hip replacement or hip-fracture surgery
• extended prophylaxis ( 28 to 35 d) after surgery
  (Grade 1A), as follows
• total hip replacement LMWH (Grade 1A), a VKA
  (Grade 1A), or fondaparinux (Grade 1C)
• hip-fracture surgery fondaparinux (Grade 1A),
  LMWH (Grade 1C), or a VKA (Grade 1C)

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Orthopaedic Surgery - other

• We recommend basing a decision about when to
  initiate pharmacologic prophylaxis on the
  efficacy-to-bleeding tradeoffs for that agent
  (Grade 1A). LMWH therapy can be started
  preoperatively or postoperatively (Grade 1A)
• We recommend against routine duplex
  ultrasonography screening at hospital discharge
  in asymptomatic patients after major orthopedic
  surgery (Grade 1A)

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Elective Spinal Surgery
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Neurosurgery
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Trauma
eg, spinal cord injury, fracture of lower
extremity or pelvis, major head injury,
indwelling femoral venous line
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Acute Spinal Cord Injury
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Other Conditions
We suggest clinicians not routinely administer
therapy to prevent thrombosis related to
long-term indwelling central venous catheters in
cancer patients (Grade 2B) specifically, we
suggest that clinicians not use LMWH (Grade 2B),
and recommend against fixed-dose warfarin for
this indication (Grade 1B).
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Application of the ACCP Guidelines

• In theory, dissemination of evidence-based
  guidelines derived from systematic reviews should
  result in more-informed decision-making and
  improved patient outcomes
• Despite their widespread dissemination, however,
  the application of the ACCP antithrombotic
  guidelines in practice remains incomplete

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Implementation Strategies to increase uptake of
guidelines
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Implementation Strategies to increase uptake of
guidelines
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Implementation StrategiesAdditional
recommendations

• We recommend devoting appreciable resources to
  distributing educational material to encourage
  the use of guidelines to reduce thrombosis (Grade
  2B)
• We suggest that few resources be devoted to
  educational meetings (Grade 2B), to audit and
  feedback (Grade 2B), and to educational outreach
  visits (Grade 2B) to encourage implementation of
  the guidelines
• We suggest devoting appreciable resources to
  computer reminders (Grade 2A) and to
  patient-mediated interventions (Grade 2B)