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ACP's clinical practice guideline includes debut of Policy
Implication statement for this common, serious condition
Watch Video | Read
Guideline | Read Patient
PHILADELPHIA, November 1, 2011 -- In a new clinical practice
guideline published today in Annals of Internal Medicine, the
American College of Physicians (ACP) recommends that doctors assess
the risk of thromboembolism and bleeding in patients hospitalized
for medical illnesses, including stroke, before initiating therapy
to prevent venous thromboembolism (VTE).
VTE, comprised of pulmonary embolism (PE) and deep venous
thrombosis (DVT), is a serious, common clinical problem. Because
most hospitalized patients have at least one VTE risk factor, many
hospitals routinely give patients blood thinners. However, these
medications increase the risk of bleeding.
"The evidence does not support routine VTE prophylaxis in
patients hospitalized for medical illnesses, including stroke,"
said Amir Qaseem, MD, FACP, PhD, MHA, Director of Clinical Policy
at ACP. "If a patient is at risk for VTE, the American College of
Physicians recommends that physicians prescribe heparin or related
blood thinners, unless the assessed risk of bleeding outweighs
Benefits and Risks of Blood Thinners and Mechanical
In patients hospitalized for medical illnesses, including stroke,
prevention with heparin is associated with a statistically
significant reduction in PE events. In most cases, the clinical
benefit of reducing PE events will outweigh the harm of increased
risk of bleeding events, the guideline states. No differences in
benefits or harms were found between the types of heparin used.
If a patient is at risk for VTE and bleeding from blood
thinners, ACP does not recommend using graduated compression
stockings. The evidence showed that they were not effective in
preventing VTE or reducing death, and resulted in clinically
important lower extremity skin damage.
ACP's recommendations do not apply to patients hospitalized for
ACP Does Not Support Performance Measures that Encourage
Routine VTE Prevention
The guideline also includes a Policy Implication statement against
hospital performance measures that promote universal VTE prevention
regardless of a patient's individual risks for VTE and
"Because there is no standard, accepted risk-assessment formula
to identify which nonsurgical patients are likely to benefit from
VTE prophylaxis, this is best left to physician judgment and
performance measures encouraging routine prevention in all patients
are inappropriate," said Dr. Qaseem. "Until we can better identify
those patients who truly benefit, performance measures that
encourage VTE prophylaxis for patients hospitalized for medical
illnesses, including stroke, may encourage physicians to use
prevention in low risk patients for whom the risks may exceed the
More about Venous Thromboembolism
In VTE, blood clots often form in leg veins (DVT). Pieces of these
leg clots can break off and travel to the lungs, causing a serious
condition called pulmonary embolism. A large embolism may result in
acute heart failure or sudden death.
Twenty-six percent of patients with undiagnosed and untreated PE
will have a subsequent fatal embolism, and another 26 percent will
have a non-fatal recurrent embolism. Studies show that between 5
and 10 percent of all in-hospital deaths are a direct result of PE.
The incidence of PE in the United States accounts for 200,000 to
300,000 hospitalizations per year.
About the American College of Physicians
The American College of Physicians is the largest medical specialty
organization and the second-largest physician group in the United
States. ACP members include 132,000 internal medicine physicians
(internists), related subspecialists, and medical students.
Internists specialize in the prevention, detection, and treatment
of illness in adults. Follow ACP on Twitter and Facebook.