**Emerging Issues in Thromboprophylaxis**

Pathophysiology and Clinical Aspects of 128 Venous Thromboembolism in Neonates, Renal Disease and Cancer Patients

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manage recurrent venous thromboembolic events despite systemic anticoagulation

**6** 

*United Kingdom* 

**Aetiology of Deep Venous Thrombosis -** 

Clinical research on deep venous thrombosis (DVT) and thromboembolism (VTE) has focused in recent years on the contributions of potentiating factors, alone and in combination, to the risk of contracting these conditions. Many such 'risk factors' have been identified (Geerts *et al*., 2004) and are discussed elsewhere in this book. The National Institute for Clinical Excellence (NICE) in the United Kingdom has exploited this knowledge to make the prevention of DVT its main focus for 2011. In his keynote lecture introducing the policy and procedures adopted by NICE, Arya (2011) described the tools for evaluating risk in various patient groups and emphasised 'anticoagulation' in the design and implementation of evidence-based prophylactic measures. He claimed that the frequency of VTE in hospital patients should be reduced by 2/3 if the agreed protocols are followed. An

Comparable views have been articulated elsewhere in Europe. Although NICE is distinctive in recommending assessment for thromboprophylaxis for all medical inpatients, the health services of other European Union countries offer broadly similar guidelines, especially for patients with acute medical conditions with expected durations of hospital stay longer than 3-4 days (Khoury *et al*., 2011). Similarly, in the USA, the Surgeon General issued a 'Call to Action to Prevent Deep Venous Thrombosis and Pulmonary Embolism' in 2008 (Sliwka & Fang, 2010), and the Joint Commission on Accreditation of Healthcare Organizations requires prophylaxis for patients at moderate or high risk of VTE (Rothberg *et al*., 2010). In all these cases, the emphasis is on anticoagulation, typically with unfractionated or low

However, despite the progress made in recent decades, the incidences of DVT-associated mortality and morbidity among hospital patients have declined only minimally (Kahn & Ginsberg, 2004; Heit, 2005), perhaps suggesting there is scope for improvement in our

Because of the range and variety of established risk factors, there is a widespread view that DVT is 'multifactorial' or 'multicausal' (e.g. Rosendaal, 1999, 2005; Lippi & Franchini, 2008; Khoury *et al.*, 2011). In a substantial minority of DVT patients, no known risk factor can be identified, and those cases are dubbed 'idiopathic'. While 'risk factors' determine the

understanding of the aetiology of DVT and *a fortiori* our approach to prophylaxis.

achievement of that magnitude would be most welcome.

molecular weight heparin or with Fondaparinux.

**1. Introduction** 

**Implications for Prophylaxis** 

Paul S. Agutter and P. Colm Malone *Theoretical Medicine and Biology Group,* 
