VTE Risk in Medical Patients

VTE risk is a common, but preventable, complication

Although many associate venous thromboembolism (VTE) with recent trauma or surgery, 50% to 70% of symptomatic cases, as well as the majority of cases of fatal pulmonary embolism (PE), occur in medical (nonsurgical, nontrauma) patients.3, 61 Because of the often silent nature of VTE, the first sign of a problem may be a clinically significant event, such as PE.

Cancer and other medical illness are major contributors to VTE risk

Cancer, in particular, is a major risk factor, as one in five diagnosed cases of VTE occurs in a person with cancer.62

Immobilisation increases the risk of VTE

Hospitalised medical patients are often immobile because of weakness, reduced alertness, or nerve injury. In addition, patients in critical care settings are often bedridden. Even in the absence of medical illness, lack of mobility can lead to venous stasis and VTE, as can occur during long-distance air travel.1, 63

Conditions commonly associated with hospitalisation that increase risk of VTE

  • Stroke
  • Congestive heart failure (NYHA Class III-IV)
  • Acute respiratory disease
  • Acute myocardial infarction
  • Acute arthritis
  • Acute infection
  • Inflammatory bowel disease

Patient-related, predisposing characteristics that increase risk of VTE3, 64

  • Recent surgery or major trauma
  • Immobility or paralysis
  • Malignancy
  • Previous VTE
  • Older age, particularly >80 years
  • Oestrogen therapy (contraceptives or hormone replacement)
  • Obesity
  • Central vein catheterisation
  • Varicose veins
  • Inherited or acquired thrombophilia


Age, in particular, is a one of the most important risk factors for VTE. The risk increases exponentially over time, from a negligible rate in children under 15 (<5 per 100,000) to a rate of ~500 per 100,000 in those over 80.65, 66

Hospitalised patients often have multiple risk factors for VTE

Patients hospitalised because of medical illness often have multiple risk factors for VTE, and these risks are generally cumulative.3, 64 Accordingly, all patients should be evaluated for their risk of VTE at the time of hospital admission. This evaluation should be repeated whenever there is a significant change in a patient’s clinical status.64

Preventive treatment can reduce incidence of VTE

Prospective studies have shown that hospitalised medical patents at high risk who do not receive preventive anticoagulant therapy develop deep vein thrombosis (DVT) in the calf in 10% to 15% of cases. The same studies revealed an incidence of proximal DVT in 2% to 5% and of PE in 0.3% to 1.5%.64, 67, 68
Studies have also shown that anticoagulant prophylaxis reduces the risk of symptomatic VTE in hospitalised medical patients.69 Despite the clear need for prophylactic care to prevent VTE in high-risk medical patients, a recent multinational, cross-sectional audit57 revealed that fewer than 40% of hospitalised medical patients at risk received standard VTE prophylaxis. Therefore, timely risk assessment and preventive therapy is the optimal therapeutic approach.3

VTE risk associated with cancer

VTE is a leading cause of death in patients with cancer. The incidence of symptomatic VTE in patients with malignancies ranges from 4% to 20% depending on the study.62 Certain medications used to treat cancer, such as tamoxifen and erythropoietin, increase the risk of VTE. In addition, novel chemotherapeutic agents that suppress blood vessel formation (eg, thalidomide, lenalidomide, and bevacizumab) have been associated with a high rate of VTE.62, 70

Certain cancer malignancies are associated with higher VTE risk

The risk of thrombosis is greatest in the first year after the diagnosis of cancer malignancy.71, 72 Certain cancer malignancies are associated with a higher VTE risk (eg, pancreatic, gastric, colon, brain, kidney, ovarian, prostate, haematologic, and lung), and metastatic disease confers a greater risk than primary tumours.62 The same predisposing factors that elevate the risk of VTE in surgical patients and in hospitalised patients without cancer augment the overall risk in patients with cancer.62
Long Term Complications of VTE >
  • 3 - Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, and Colwell CW. Prevention of Venous Thromboembolism: American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008: 381S–453S.
  • 61 - Goldhaber SZ, Tapson VF; DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004;93(2):259-262.
  • 62 - Lyman GH, Khorana AA, Falanga A, et al; American Society of Clinical Oncology. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol. 2007;25(34):5490-5505.
  • 1 - Lapostolle F, Surget V, Borron SW, et al. Severe pulmonary embolism associated with air travel. N Engl J Med. 2001;345(11):779-783.
  • 63 - Goldhaber SZ. Pulmonary embolism. Lancet. 2004;363(9417):1295-1305.
  • 64 - Francis CW. Clinical practice. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med. 2007;356(14):1438-1444.
  • 65 - White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(23 suppl 1):I4-I8.
  • 66 - Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ 3rd. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med. 2000;160(6):809-815.
  • 67 - Cohen AT, Davidson BL, Gallus AS, et al; ARTEMIS Investigators. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. BMJ. 2006;332(7537):325-329.
  • 68 - Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999;341(11):793-800.
  • 69 - Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med. 2007;146(4):278-288.
  • 57 - Cohen AT, Tapson VF, Bergmann JF, et al; ENDORSE Investigators. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371(9610):387-394.
  • 70 - Levine MN, Lee AYY, Kakkar AK. Cancer and Thrombosis. In: Colman RW, Clowes AW, George JN, Goldhaber SZ, Marder VJ, eds. Hemostasis and Thrombosis: Basic Principles and Clinical Practice. 5th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2006:1251-1262.
  • 71 - Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Malignancies, prothrombotic mutations, and the risk of venous thrombosis. JAMA. 2005;293(6):715-722.
  • 72 - Chew HK, Wun T, Harvey D, Zhou H, White RH. Incidence of venous thromboembolism and its effect on survival among patients with common cancers. Arch Intern Med. 2006;166(4):458-464
Venous thromboembolism
A condition in which a blood clot (thrombus) forms in a vein, which in some cases then breaks free and enters the circulation as an embolus, finally lodging in and completely obstructing a blood vessel, e.g., in lungs causing a PE. The term encompasses both DVT and PE.
Venous stasis
The presence of an abnormally low rate of blood flow in the veins. This can be caused by, for example, the use of a tourniquet or prolonged immobility.
Prophylaxis
The prevention of a disease or pathological condition.

From the Image Library

Patient figure: major veins and deep vein thrombosis (DVT) Vein image 1: venous thrombus formation in cusps of veins Micrograph: deep vein thrombosis See all Venous Thrombosis

Did You Know?

The incidence of first-time VTE increases exponentially with age: a) Under 15 years of age: <5 cases per 100, 000 per year; b) Over 80 years of age: 450-600 cases per 100,000 per year (~0.5%/year)40, 147

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