Venöse Thromboembolieprophylaxe bei nichtchirurgischen Patienten - Noch nicht ausreichend im klinischen Alltag implementiert

Venöse Thromboembolien sind vermeidbare, zum Teil tödliche Komplikationen bei hospitalisierten Patienten. Aus der Vielzahl der beschriebenen Risikofaktoren ist die Immobilisation im Krankenhaus aufgrund nichtchirurgischer Erkrankungen einer der wichtigsten zur Identifikation gefährdeter Patienten. Bei fehlenden Kontraindikationen sollte eine medikamentöse Thromboembolieprophylaxe mit niedermolekularem Heparin oder Fondaparinux erfolgen. Bestehen Kontraindikation gegen diese Medikamente, steht weiterhin unfraktioniertes Heparin als wirksame Therapieoption zur Verfügung. Der Stellenwert der nichtmedikamentösen Formen der Thromboembolieprophylaxe allerdings ist für nichtchirurgische Patienten weitgehend ungesichert. Dennoch muss ihr Einsatz empfohlen werden - insbesondere bei Kontraindikationen gegen den Einsatz medikamentöser Verfahren, wie zum Beispiel einem hohen Blutungsrisiko.

Venous thromboembolisms are avoidable and partly lethal complications occurring in inpatients. One of the most important of a great variety of reported risk factors is inpatient immobilisation of non-surgical patients. If there are no contraindications, it is urgently recommended to effect medicinal thromboembolism prophylaxis with low molecular heparin or fondaparinux. In case of contraindications against this medication, non-fractionated heparin is an effective alternative. However, the ranking of non-medicinal varieties of thromboembolism prophylaxis is far from being well established for non-surgical patients. Nevertheless, their use is recommended especially if there are contraindications against employing medicinal preparations, for example if there is a high risk of bleeding.

Key words

thromboembolism prophylaxis - non-surgical patients - risk factors - heparin - fondaparinux - non-medicinal prophylaxis

Literatur

• 1 Ageno W, Squizzato A, Ambrosini F. et al. . Thrombosis prophylaxis in medical patients: a retrospective review of clinical practice patterns.  Haematologica. 2002;  87 746-750
• 2 Agu O, Hamilton G, Baker D.. Graduated compression stockings in the prevention of venous thromboembolism.  Br J Surg. 1999;  86 992-1004
• 3 Albers GW, Amarenco P, Easton JD. et al. . Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.  Chest. 2004;  126
• 4 Alikhan R, Cohen AT, Combe S. et al. . Risk factors for venous thromboembolism in hospialized patients with acute medical illness: analysis of the MEDENOX Study.  Arch Intern Med. 2004;  164 963-968
• 5 Amaragiri SV, Lees TA.. Elastic compression stockings for prevention of deep vein thrombosis.  Cochrane Database Syst Rev. 2000;  3
• 6 Anderson Jr FA, Wheeler HB, Goldberg RJ. et al. . A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism: the Worcester DVT Study.  Arch Intern Med. 1991;  151 933-938
• 7 Anderson Jr FA, Wheeler HB, Goldberg RJ. et al. . Physician practices in the prevention of venous thromboembolism.  Ann Intern Med. 1991;  115 591-595
• 8 Anderson Jr FA, Wheeler HB, Goldberg RJ. et al. . Changing clinical practice: prospective study of the impact of continuing medical education and quality assurance programs on use of prophylaxis for venous thromboembolism.  Arch Intern Med. 1994;  154 669-677
• 9 Baglin TP, White K, Charles A.. Fatal pulmonary embolism in hospitalised medical patients.  J Clin Pathol. 1997;  50 609-610
• 10 Bergmann JF, Caulin C.. Heparin prophylaxis in bedridden patients.  Lancet. 1996;  348 205-206
• 11 Cade JF.. High risk of critically ill for venous thromboembolism.  Crit Care Med. 1982;  19 448-450
• 12 Cohen AT, Alikhan R, Arcelus JI. et al. . Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients.  Thromb Haemost. 2005;  94 750-759
• 13 Cohen AT, Gallus AS, Lassen MR. et al. .Fondaparinux vs placebo for the prevention of acutely ill patients (ARTEMIS). Paper presented at: The XIX Congress of the International Society on Thromb Haemost;. Abstract P 2003
• 14 Cohen AT, Davidson BL, Gallus AS. et al. . Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial.  BMJ. 2006;  332 325-329
• 15 Collins R, MacMahon S, Flather M. et al. . Clinical effects of anticoagulant therapy in suspected acute myocardial infarction: systematic overview of randomised trials.  BMJ. 1996;  313 652-659
• 16 Collins R, Scrimgeour A, Yusuf S, Peto R.. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic, and urologic surgery.  N Engl J Med. 1988;  318 1162-1173
• 17 Dentali F, Douketis JD, Gianni M. et al. . Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients.  Ann Intern Med. 2007;  146 278-288
• 18 Dexter PR, Perkins S, Overhage JM. et al. . A computerized reminder system to increase the use of preventive care for hospitalized patients.  N Engl J Med. 2001;  345 965-970
• 19 Diener HC, Ringelstin EB, von R Kummer. et al. . Prophylaxis of thrombotic and embolic events in acute ischaemic stroke with the low-molecualar-weight heparin certoparin: results of the PROTECT Trial.  Stroke. 2006;  37 139-144
• 20 Emerson PA, Marks P.. Prevention thromboembolism after myocardial infarction: effect of low-dose heparin or smoking.  BMJ. 1977;  1 18-20
• 21 Fraisse F, Holzapfel L, Coulaud J-M. et al. . Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD.  Am J Respir Crit Care Med. 2000;  161 1109-1114
• 22 Gardlund B.. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases.  Lancet. 1996;  347 1357-1361
• 23 Geerts WH, Pineo GF, Heit JA. et al. . Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.  Chest. 2004;  126
• 24 Goldhaber SZ, Dunn K, MacDougall RC.. New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than by withholding treatment.  Chest. 2000;  118 1680-1684
• 25 Goldhaber SZ, KettDH, Cusomano CJ. et al. . Low molecular weight heparin versus minidose unfractionated heparin for prophylaxis against venous thromboembolism in medical intensive care unit patients: a randomized controlled trial.  J Am Coll Cardiol. 2000;  35
• 26 Goldhaber SZ, Tapson VF.. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis.  Am J Cardiol. 2004;  93 259-262
• 27 Gubitz G, Sandercock P, Counsell C.. Anticoagulants for acute ischaemic stroke.  Cochrane Database Syst Rev. 2004;  3
• 28 Haas SB, Tribus CB, Insall JN. et al. . The significance of calf thrombi after total knee arthroplasty.  J Bone Joint Surg Br. 1992;  74 799-802
• 29 Haas SK.. Venous thromboembolic risk and its prevention in hospitalized medical patients.  Semin Thromb Hemost. 2002;  28 577-584
• 30 Handley AJ.. Low-dose heparin after myocardial infarction.  Lancet. 1972;  2 623-624
• 31 Halkin H, Goldberg J, Modan M, Modan B.. Reduction of mortality in general medical in-patients by low-dose heparin prophylaxis.  Ann Intern Med. 1982;  96 561-565
• 32 Heit JA, Silverstein MD, Mohr DN. et al. . Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study.  Arch Intern Med. 2004;  160 809-815
• 33 Hilbom M, Erila T, Sotaniemi K. et al. . Enoxaparin vs heparin for prevention of deep-vein thrombosis in acute ischaemic stroke: a randomized, double-blind study.  Acta Neurol Scand. 2002;  106 84-92
• 34 Hirsch DR, Ingenito EP, Goldhaber SZ.. Prevalence of deep venous thrombosis among patients in medical intensive care.  JAMA. 1995;  274 335-337
• 35 Kakkar VV, Howe CT, Flanc C, Clarke MB.. Natural history of postoperative deep-vein thrombosis.  Lancet. 1969;  2 230-232
• 36 Kamphuisen PW, Agnelli G, Sebastianelli M.. Prevention of venous thromboembolism after acute ischemic stroke.  J Thromb Haemost. 2005;  3 1187-1194
• 37 Keane MG, Ingenito EP, Goldhaber SZ.. Utilization of venous thromboembolism prophylaxis in the medical intensive care unit.  Chest. 1994;  106 13-14
• 38 Kearon C.. Natural history of venous thromboembolism.  Circulation. 2003;  107
• 39 Kelly J, Rudd A, Lewis R. et al. . Venous thromboembolism after acute stroke.  Stroke. 2001;  32 262-267
• 40 Khorana AA, Francis CW, Culakova E. et al. . Thromboembolism in hospitalized neutropenic cancer patients.  J Clin Oncol. 2006;  24 484-490
• 41 Kirwan CC, Nath E, Byrne GJ, McCollum CN.. Prophylaxis for venous thromboembolism during treatment for cancer: questionnaire survey.  BMJ. 2003;  327 597-598
• 42 Kleber FX, Witt C, Vogel G. et al. . Randomized comparison of enoxaparin with unfractionated heparin for the prevention of venous thromboembolism in medical patients with heart failure of severe respiratory disease.  Am Heart J. 2003;  145 614-621
• 43 Kucher N, Koo S, Quiroz R. et al. . Electronic alerts to prevent venous thromboembolism among hospitalized patients.  N Engl J Med. 2005;  352 969-977
• 44 Kucher N, Leizorovicz A, Valtkus PT. et al. . Efficacy and safety of fixed low-dose dalteparin in preventing venous thromboembolism among obese or elderly hospitalized patients: a subgroup analysis of the PREVENT trial.  Arch Intern Med. 2005;  165 341-345
• 45 Leizorovicz A, Cohen AT, Turpie AG. et al. . Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients.  Circulation. 2004;  110 874-879
• 46 Leizorovicz A, Mismetti P.. Preventing venous thromboembolism in medical patients.  Circulation. 2004;  110
• 47 Lindblad B, Eriksson A, Bergqvist D.. Autopsy-verified pulmonary embolism in a surgical department: analysis of the period from 1951 to 1988.  Br J Surg. 1991;  78 849-852
• 48 Mismetti P, Laporte-Simitsidis S, Tardy B. et al. . Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: a meta-analysis of randomised clinical trials.  Thromb Haemost. 2000;  83 14-19
• 49 Moser KM, LeMoine JR.. Is embolic risk conditioned by location of deep venous thrombosis?.  Ann Intern Med. 1981;  94 439-444
• 50 Collaborative overview of randomised trials of antiplatelet therapy. III. Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. Antiplatelet Trialists' Collaboration.  BMJ. 1994;  308 235-246
• 51 International Stroke Trial Collaborative Group The International Stroke Trial (IST). A randomised trail of aspirin, subcutaneous heparin, both or neither among 19435 patients with acute ischaemic stroke.  Lancet. 1997;  349 1569-1581
• 52 Prevention of fatal postoperative pulmonary embolism by low doses of heparin: an international multicentre trial.  Lancet. 1975;  2 45-51
• 53 Risk of and prophylaxis for venous thromboembolism in hospital patients. Thromboembolic Risk Factors (THRIFT) Consensus Group.  BMJ. 1992;  305 567-574
• 54 Samama MM, Cohen AT, Darmon J-Y. et al. . A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients.  N Engl J Med. 1999;  341 793-800
• 55 Sandler DA, Martin JF.. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis?.  J R Soc Med. 1989;  82 203-205
• 56 Stein PD, Henry JW.. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy.  Chest. 1995;  108 978-981
• 57 Warlow C, Terry G, Kenmure AC. et al. . A double-blind trial of low doses of subcutaneous heparin in the prevention of deep-vein thrombosis after myocardial infarction.  Lancet. 1973;  2 934-936

1 prophylaxis in MEDical patients with ENOXaparin

2 PRospective EValuation of dalteparin Efficacy for prevention of VTE in immobilized patieNts Trial

3 ARixtra in ThromboEmbolism prevention in a Medical Indications Study

Korrespondenz