Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Two thirds of patients with DVT or PE are associated with recent hospitalization. In review of evidence based safety practices, the Agency for Healthcare Research and Quality defined thromboprophylaxis against VTE as the number one patient safety practice for hospitalized patients. Because of the importance of VTE prevention it has been added as a core measure in 2013. VTE orders are in most admission and post op order sets. Additionally there is a “VTE Prophylaxis Module” in Paragon. See here for a complete list of order sets.
What are the key points
- For acute DVT or PE  initial parenteral anticoagulation therapy or anticoagulation with rivaroxaban is recommended. Early initiation of Vitamin K antagonist (VKA) i.e. warfarin (Coumadin) on the same day as parenteral therapy is recommended. Continuation of parenteral therapy for a minimum of 5 days and until the INR is 2.0 or above for at least 24h is recommended. The early increase in the PT/INR often reflects the initial reduction in clotting factors of the extrinsic pathway of coagulation while the patient may still be at risk for thromboembolic events due to the levels of the intrinsic and common pathways of coagulation. 
- Low molecular weight heparin (LMWH) or fodaparinux is preferred over unfractionated heparin or subcutaneous unfractionated heparin.
- Thrombolytic therapy for PE with hypotension.  
- Proximal DVT or PE a 3 month course of anticoagulation is preferred over shorter courses. 
- For proximal DVT or PE provoked by surgery or by non surgical transient risk factor 3 months of therapy is recommended. Unprovoked DVT extended therapy is recommended if bleeding risk is low to moderate. A 3 month therapy is recommended if risk of bleeding is high.  
- DVT associated with active cancer should receive extended therapy with LMWH over vitamin K antagonists. Vitamin K antagonists or LMWH are preferred over dabigatran or rivaroxaban. 
- Compression stockings to prevent post thrombotic syndrome. 
- For extensive superficial vein thrombosis; prophylactic dose fondaparinux or LMWH is recomended over no anticoagulation. Fondaparinux is preferred over LMWH.  
- Antithrombotic Therapy For VTE Disease, Kearon C, Akl EA, Comerota AJ, et al. Chest. 2012;141(2_suppl):e419S-e494S.
- Rivaroxaban – drugs.com information
- Low Molecular Weight Heparin – NEJM review
- Management of Venous Thromboembolism: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians; Ann Intern Med. 2007;146(3):204–210.
- Fodaparinux – drugs.com information
- Prevention of VTE in Orthopedic Surgery Patients. Chest. 2012; 141(2_suppl):e278S-e325S. doi:10.1378/chest.11–2404
- Oral anticoagulation therapy. Chest. 2012; 141(2_suppl):e44S-e88S. doi:10.1378/chest.11–2292
- Prevention of VTE in Nonorthopedic Surgical Patients. Chest. 2012; 141(2_suppl):e227S-e277S. doi:10.1378/chest.11–2297
- VTE, Thrombophilia, Antithrombotic Therapy and Pregnancy. Chest. 2012; 141(2_suppl):e691S-e736S. doi:10.1378/chest.11–2300
- Preventing Hospital- Aquired Venous Thromboembolism, Agency for Healthcare Research and Quality
- Overview of acute PE ↩
- Evidence-Based Management of Anticoagulant Therapy; Chest. 2012; 141(2_suppl):e152S-e184S. doi:10.1378/chest.11–2295 ↩
- Fibrinolytic therapy for acute DVT or PE ↩
- Treatment of Acute Pulmonary Embolism ↩
- Treatment of lower extremity DVT ↩
- Prevention of DVT in surgical patients ↩
- Management of anticoagulation before and after surgery ↩
- Treatment of VTE in patients with malignancy ↩
- Post thrombotic syndrome – Circulation ↩
- Superficial thrombophlebitis of the lower extremity ↩
- Catheter induced upper extremity venous thrombosis ↩