A systematic review of direct clinical comparisons, The use of intermittent pneumatic compression in orthopedic and neurosurgical postoperative patients: a systematic review and meta-analysis, Effectiveness of Intermittent pneumatic compression devices for venous thromboembolism prophylaxis in high-risk surgical patients: a systematic review, Society of Gynecologic Surgeons Systematic Review Group, Venous thromboembolism prophylaxis in gynecologic surgery: a systematic review, Graduated compression stockings for prevention of deep vein thrombosis, Comparative effectiveness of combined pharmacologic and mechanical thromboprophylaxis versus either method alone in major orthopedic surgery: a systematic review and meta-analysis, Meta-analysis of randomized trials comparing combined compression and anticoagulation with either modality alone for prevention of venous thromboembolism after surgery, Prevention of deep-vein thrombosis after total knee replacement. There was possibly important uncertainty or variability about how patients may value these outcomes. The panel rated the magnitude of the desirable and undesirable effects of using LMWH over UFH as trivial. The guideline panel suggests using combined pharmacological and mechanical prophylaxis over pharmacological prophylaxis alone for patients undergoing major surgery, based on very low certainty in the evidence of effects. Pharmacological prophylaxis vs no pharmacological prophylaxis, 27. The panel judged that the potential benefits of pharmacological prophylaxis were outweighed by the small increased risk of major bleeding in average-risk patients undergoing laparoscopic cholecystectomy. Pharmacological prophylaxis vs no pharmacological prophylaxis. DOACs may require dose reduction or avoidance in patients with renal dysfunction, and should be avoided in pregnancy. This corresponds to 0 fewer (3 fewer to 3 more) major bleeding events per 1000 patients undergoing major general surgery. Five studies reported the effect of LMWH compared with that of UFH on development of mortality,348,365-368  2 studies reported on the development of PEs,365,366  1 study reported on the development of screening-detected proximal DVTs,348  and 1 study reported on screening-detected distal DVTs.366  Four studies reported risk of major bleeding348,365-367  and 1 study reported on risk of reoperation.366, All participants wore compression stockings, with the exception of 1 study in which their use was not reported.368. Project oversight was provided initially by a coordination panel, which reported to the ASH Committee on Quality, and then by the coordination panel chair (Adam Cuker) and vice chair (H.J.S.). It is the standard imaging test to diagnose DVT. Question: Should pharmacological prophylaxis vs no pharmacological prophylaxis be used for patients undergoing laparoscopic cholecystectomy? • Patients with established deep vein thrombosis (DVT). Question: Should LMWH prophylaxis vs UFH prophylaxis be used for patients undergoing hip fracture repair? Based on very low certainty in the evidence of effects, the panel judged that the balance of effects did not favor early or delayed institution of pharmacological antithrombotic prophylaxis in major surgical patients. Cost-effectiveness probably favors mechanical prophylaxis. After publication of these guidelines, ASH will maintain them through surveillance for new evidence, ongoing review by experts, and regular revisions. Pharmacological prophylaxis compared with no pharmacological prophylaxis probably reduces mortality (RR, 0.76; 95% CI, 0.61-0.93; moderate certainty in the evidence of effects). Pharmacological prophylaxis may also reduce the risk of proximal DVTs (RR, 0.51; 95% CI, 0.38-0.69; very low certainty in the evidence of effects), which corresponds to 7 fewer (4-9 fewer) in 1000 higher-risk patients and 3 fewer (2-4 fewer) in 1000 lower-risk patients. The 2012 ACCP guideline for orthopedic surgery patients407  recommended LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose UFH, adjusted-dose vitamin K antagonists (VKAs), ASA, and/or intermittent pneumatic compression, with the proviso that they are portable, out of concerns regarding compliance. Because of the paucity of RCTs specific to this setting, the evidence base to inform the relative effectiveness of pharmacological prophylaxis vs no pharmacological prophylaxis was comparable to that used to inform this question for patients undergoing TURP (see Recommendation 21); we pooled data across all surgical procedures and applied surgery-specific baseline risk estimates for radical prostatectomy drawn from a systematic review by Tikkinen et al.380. Assuming a baseline risk of 7.4% for UFH-treated patients, this would correspond to 39 fewer (66 fewer to 88 more) deaths per 1000 patients. The panel also advises periodic monitoring of the platelet count for patients receiving LMWH and, in particular, UFH, as postoperative prophylaxis in consideration of the risk of heparin-induced thrombocytopenia. For patients undergoing cardiac or major vascular surgery, the ASH guideline panel suggests using pharmacological prophylaxis or no pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Patients with low-risk PE may be safely discharged early from hospital or receive only outpatient treatment with LMWH, followed by vitamin K antagonists, although nonvitamin K-dependent oral anticoagulants may be as eff… The panel judged that combined pharmacological and mechanical prophylaxis would be most beneficial for patients considered at very high risk for VTE following major surgery. We are very uncertain of its effect on symptomatic proximal DVTs (RR, 0.38; 95% CI, 0.14-1.00; very low certainty in the evidence of effects), which would correspond to 1 fewer (0-1 fewer) symptomatic event in 1000 lower-risk patients or 3 fewer (0-5 fewer) events per 1000 higher-risk patients. They should be helpful in everyday clinical medical decision-making. Decision aids may be useful in helping individuals to make decisions consistent with their individual risks, values, and preferences. Question: Should pharmacological prophylaxis vs no pharmacological prophylaxis be used for patients experiencing major trauma? Most of the evidence evaluating this question comes from the orthopedic (joint arthroplasty) setting. Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You may have an injection of an anticoagulant (blood thinning) medicine called heparin while you're waiting for an ultrasound scan to tell if you have a DVT. For patients who receive pharmacologic prophylaxis, using combined prophylaxis with mechanical and pharmacological methods over prophylaxis with pharmacological agents alone (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). The panel determined that there was probably important uncertainty or variability in how much affected individuals value the main outcomes. For radical prostatectomy, the guideline provides a more nuanced set of recommendations that differ by surgical approach (open, laparoscopic, or robotically assisted laparoscopic) and extent of the node dissection (without, standard, or extended). Depending on the baseline risk, this benefit likely corresponds to 5 fewer (3-6 fewer) per 1000 patients with a baseline risk of 0.8% to up to 7 fewer (4-8 fewer) per 1000 patients based on a baseline risk of 1.2% from observational data.73  We are very uncertain whether the risks of symptomatic proximal DVTs (RR, 0.14; 95% CI, 0.01-2.63; very low certainty in the evidence of effects) and symptomatic distal DVTs (RR, 1.99; 95% CI, 0.35-11.33; very low certainty in the evidence of effects) differ between the 2 groups. We rated the overall certainty in the evidence of effects as low based on the lowest certainty in the evidence for the critical outcomes, downgrading twice for very serious imprecision. When anticoagulants are used, the panel suggests using direct oral anticoagulants (DOACs) over low-molecular-weight heparin (LMWH) (conditional recommendation based on moderate certainty in the evidence of effects ⊕⊕⊕◯); the panel suggests using any of the DOACs approved for use (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). The panel determined that all symptomatic proximal DVTs and PEs confirmed by objective diagnostic imaging were considered of moderate severity and were clinically important.22  For several outcomes, the studies reported outcomes that were different or were in addition to the outcomes that the panel determined to be important for decision making. DOACs probably do not reduce mortality compared with that associated with LMWH (RR, 0.94; 95% CI, 0.53-1.66; moderate certainty in the evidence of effects); this corresponds to 0 fewer deaths (1 fewer to 1 more) per 1000 patients. This relates to the very low baseline risk of VTE for patients undergoing laparoscopic cholecystectomy. Potential costs and savings were deemed of negligible relevance, assuming only in-hospital short-term prophylaxis. The panel judged the magnitude of the desirable effects as moderate in size and the undesirable effects as small in size. AHRQ Publication No. Based on 1 large observational study383  and supported by a single relevant RCT,381  the rates of major bleeding may be increased with pharmacological prophylaxis (RR, 1.26; 95% CI, 1.07-1.47; low certainty in the evidence of effects). Part D describes new interests disclosed by individuals after appointment. Depending on how likely you are to have a blood clot, your doctor might suggest tests, including: 1. The panel judged the desirable effects of pharmacological prophylaxis for patients undergoing TURP as trivial and the undesirable effects as small in magnitude. This corresponds to 6 fewer (3-7 fewer) events per 1000 patients based on a baseline risk of 1.1% from the control group event rate in the meta-analysis. Of the 15 studies included in the meta-analysis, 1 was an RCT.150  Twelve of the studies reported the effect of IVC filters on the risk of mortality.139,143-147,149-153  Five studies assessed the development of symptomatic PEs,142,149,150,152,153  and 10 studies assessed the development of any PE.139-141,143-148,151  Ten studies assessed the development of DVTs,139,141,143,144,146-148,150,151,153  with 1 study assessing the development of symptomatic DVTs specifically141  and 1 study assessing the development of proximal DVTs specifically.153. Depending upon the baseline risk,73  this corresponds to 12 fewer (10-13 fewer) symptomatic proximal DVTs per 1000 patients in a lower-risk group of patients with a 1.6% baseline risk or 18 fewer (15-21 fewer) per 1000 patients in a higher-risk group with a 2.6% baseline risk. Decisions may be constrained by the realities of a specific clinical setting and local resources, including, but not limited to, institutional policies, time limitations, and availability of treatments. Further studies quantifying the nonthrombotic risks of IVC filters would also be of value. is now provided through Wiley Online Library. Once bleeding is stabilized and the patient is no longer considered at high risk for major bleeding, the use of pharmacological prophylaxis should be reconsidered. Access the full guidelines on the Blood Advances website: American Society of Hematology 2018 Guidelines for Management of Venous Thromboembolism: Optimal Management of Anticoagulation Therapy We identified 1 systematic review of RCTs addressing this research question.29  We identified only 5 studies118,273-275,349  in this review that fulfilled our inclusion criteria and measured outcomes relevant to this context. We are uncertain about the effect of early prophylaxis on symptomatic PEs (RR, 0.63; 95% CI, 0.23-1.72; very low certainty in the evidence of effects); depending on the baseline risk from observational data,73  this corresponds to 3 fewer (6 fewer to 6 more) to 4 fewer (8 fewer to 8 more) per 1000 patients with baseline risks of 0.8% and 1.1%, respectively. The panel determined that there was possibly important uncertainty or variability in how much affected individuals valued the main outcomes. Question: Should pharmacological prophylaxis vs no pharmacological prophylaxis be used for patients undergoing cardiac or major vascular surgery? There were no concerns about the feasibility of implementation. Remark: For patients considered at high risk for bleeding, the balance of effects may favor mechanical methods over pharmacological prophylaxis. We identified 9 systematic reviews addressing this research question.157-165  We identified 14 studies166-179  in these reviews that fulfilled our inclusion criteria and measured outcomes relevant to this context. Pharmacological prophylaxis may reduce symptomatic PEs, but we are very uncertain of this finding (RR, 0.49; 95% CI, 0.33-0.72; very low certainty in the evidence of effects). Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Question: Should pharmacological prophylaxis vs no pharmacological prophylaxis be used for patients undergoing major general surgery? Supplement 3 provides the complete “Disclosure of Interest” forms of researchers who contributed to these guidelines. The research priorities following major neurosurgical procedures are to better establish the benefits and risks of any pharmacological prophylaxis compared with no pharmacological prophylaxis. When pharmacological prophylaxis is used, the panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). For VTE associated with cancer, LMWH is recommended over VKA (Grade 2B) or any direct oral anticoagulants (all Grade 2C). Extended antithrombotic prophylaxis vs short-term antithrombotic prophylaxis, 8. The panel discounted the mortality difference observed in this analysis as unlikely to relate to pharmacological prophylaxis, given the very low baseline risk of VTE. For patients considered at very high risk of postoperative VTE and at low bleeding risk, high-quality comparative studies of LMWH vs UFH using clinically important outcome measures would be of value. We identified 1 systematic review that addressed this question.236  We identified 7 trials in this review that fulfilled our inclusion criteria and measured outcomes relevant to this context.39,219,237-241  Our systematic search of RCTs did not identify any additional study that fulfilled the inclusion criteria. Pharmacological prophylaxis may not reduce symptomatic PEs (RR, 0.48; 95% CI, 0.26 to 0.88; low certainty in the evidence of effects), which corresponds to 0 fewer events in lower-risk patients and 0 fewer (0-1 fewer) events in higher-risk patients undergoing TURP. For each recommendation, the panel took a population perspective and came to consensus on the following: the certainty in the evidence, the balance of benefits and harms of the compared management options, and the assumptions about the values and preferences associated with the decision. Emerging evidence shows that severe coronavirus disease 2019 (COVID-19) can be complicated by a significant coagulopathy, that likely manifests in the form of both microthrombosis and VTE. The panel determined that there was probably important uncertainty or variability in how much affected individuals value the main outcomes. This benefit likely corresponds to 9 fewer (1-12 fewer) symptomatic proximal DVTs in 1000 patients with a baseline risk of 1.6% and 14 fewer (2-20 fewer) symptomatic proximal DVTs per 1000 patients based on a baseline risk of 2.6% from observational data.73  The risk of distal DVT (RR, 0.55; 95% CI, 0.25-1.22, very low certainty in the evidence of effects) appears to be similar, but we are uncertain of this finding. There were no comparative data about rates of reoperation of LMWH vs UFH following major trauma. 2019 ESC Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism Developed in Collaboration With the European Respiratory Society (ERS): The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). LMWH may result in a small, possibly unimportant, increase in symptomatic proximal DVTs (RR, 2.24; 95% CI, 0.92-5.43; low certainty in the evidence of effect) corresponding to 31 more (2 fewer to 111 more) per 1000 patients based on a baseline risk of 2.5% from observational data.267  LMWH appears to result in little or no difference in symptomatic distal DVTs (RR, 0.66; 95% CI, 0.21-2.17; very low certainty in the evidence of effects). The American Academy of Family Physicians endorsed these guidelines in March 2019 and provided the following key recommendations from the guidelines. The panel suggests against using IVC filters for prophylaxis of VTE for patients undergoing major surgery or trauma patients based upon very low certainty in the evidence. Pharmacological prophylaxis probably reduces the risk of symptomatic PEs (RR, 0.48; 95% CI, 0.26-0.88; low certainty in the evidence of effects), corresponding to a benefit of 2 fewer (0-3 fewer) symptomatic PEs per 1000 higher-risk patients and 0 fewer (0-1 fewer) per 1000 lower-risk patients, based on baseline risks from observation data of 0.1% and 0.4%, respectively.396,397. Prospective randomized clinical study in general surgery comparing a new low molecular weight heparin with unfractionated heparin in the prevention of thrombosis, Canadian Colorectal Surgery DVT Prophylaxis Trial investigators, Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis in patients undergoing colorectal surgery: results of the Canadian Colorectal DVT Prophylaxis Trial: a randomized, double-blind trial, Prophylaxis of thromboembolic disease with RO-11 (ROVI), during abdominal surgery. The recommendation applies to patients undergoing major surgery who are considered at risk for VTE. They make consistent use of high-quality systematic reviews and provide a formal EtD framework for every recommendation, thereby enhancing transparency about the judgments that were made. These patients are at a high risk of VTE recurrence and bleeding during anticoagulant therapy. Formal decision aids are not likely to be needed to help individual patients make decisions consistent with their values and preferences. The guideline panel suggests using ASA or anticoagulants for patients undergoing total hip arthroplasty or total knee arthroplasty (conditional recommendation based on very low certainty in the evidence of effects). For patients undergoing major neurosurgical procedures, the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Question: Should early vs delayed antithrombotic prophylaxis be used for patients undergoing major surgery? We identified 1 systematic review that addressed this question.389  We identified 2 studies47,390  in this review that fulfilled our inclusion criteria and measured outcomes relevant to this context. Remarks: For patients considered at high risk of bleeding, the balance of effects may favor mechanical methods over pharmacological prophylaxis. The overall certainty of the estimates of effects was based on the low certainty outcomes and was not based on the lowest certainty of evidence for the critical outcomes. The panel based this recommendation on the trivial incremental benefits and the small increased risk of major bleeding associated with pharmacological prophylaxis. The panel judged that the balance between desirable and undesirable effects does not favor combined pharmacological and mechanical prophylaxis vs mechanical prophylaxis alone. Lack of information regarding out-of-hospital use of pneumatic compression was a limitation of this technique. Use of out-of-hospital prophylaxis, which is routine following total hip or knee arthroplasty, particularly favored DOACs over LMWH, given the need for parenteral administration of the latter agent. Decision aids may be useful in helping patients to make decisions consistent with their individual risks, values, and preferences. Question: Should pharmacological prophylaxis vs no pharmacological prophylaxis be used for patients undergoing radical prostatectomy? The panel selected outcomes of interest for each question a priori, following an approach described in detail elsewhere.21  The panel rated the following outcomes as critical for clinical decision making across all questions: mortality, symptomatic PEs, symptomatic proximal DVTs, symptomatic severe distal DVTs, major bleeding, and reoperation. Eur Heart J 2019;Aug 31:[Epub ahead of print]. Clinical documentation of low molecular weight heparin. It is recognized that these hip fracture studies are dated and that rates of patient-important DVT events were derived from modeling of asymptomatic events detected by routine screening studies. This corresponds to 4 fewer (8 fewer to 1 more) reoperation procedures per 1000 patients receiving LMWH prophylaxis. Decousus H, Leizorovicz A, Parent F, et al. Pharmacological prophylaxis vs no pharmacological prophylaxis, 18. It further judged that use of ASA saved costs and resources; however, the results of cost-effectiveness studies varied, with some favoring ASA and others favoring anticoagulant prophylaxis. This likely corresponds to 14 more (1-42 more) per 1000 patients. There may be no difference in mortality between ASA and anticoagulants (RR, 2.32; 95% CI, 0.15-36.90; low certainty in the evidence of effects). EMRO1 (Grupo Fstudio Multicintrico RO-11), A comparative trial of a low molecular weight heparin (enoxaparin) versus standard heparin for the prophylaxis of postoperative deep vein thrombosis in general surgery, A low molecular weight heparin (KABI 2165) for prophylaxis of postoperative deep venous thrombosis, Low molecular weight heparin compared with unfractionated heparin in prevention of postoperative thrombosis, Low molecular weight heparin plus dihydroergotamine for prophylaxis of postoperative deep vein thrombosis, Prophylaxis of thromboembolism in abdominal surgery. We are very uncertain about the effect on symptomatic proximal DVTs (RR, 0.38; 95% CI, 0.14-1.00; very low certainty in the evidence of effects). There would probably be no impact on health equity, and pharmacological and mechanical prophylaxis would be acceptable to stakeholders and probably feasible to implement. Our update of the systematic review identified 16 additional studies. In absolute terms, this corresponds to 1 fewer (1 fewer to 7 more) symptomatic distal DVT per 1000 patients, based on a baseline risk of 0.2% from observational data.364. This document follows the previous ESC Guidelines focusing on the clinical management of pulmonary embolism (PE), published in 2000, 2008, and 2014. We rated the overall certainty in the evidence of effects as very low based on the lowest certainty in the evidence for the critical outcomes, downgrading for study limitations and very serious imprecision. Thirty-one49,122,125,131,275-279,281-293,295-300,302  studies were conducted on patients undergoing major general surgery. The panel noted that such studies are underway. Pharmacological prophylaxis would probably have no impact on equity, was probably acceptable, and was likely feasible. A randomized, multicenter, open-label, parallel-group comparison of enoxaparin and warfarin, A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation, The North American Fragmin Trial Investigators, Low-molecular-weight heparin prophylaxis using dalteparin in close proximity to surgery vs warfarin in hip arthroplasty patients: a double-blind, randomized comparison, Prevention of venous thromboembolism after knee arthroplasty. Should LMWH or UFH be given, the panel recommended periodic monitoring of platelet counts because of the concern for postoperative HIT. Six studies186-191  reported the effect of early vs late postsurgical antithrombotic administration on the risk of major bleeding and on the risk of reoperation. In this group, the panel judged the desirable effects of pharmacological prophylaxis as trivial and undesirable effects as small. Supplement 2 provides the complete “Disclosure of Interests” forms of all panel members. There were no relevant adverse events deemed critical for this comparison. For mechanical interventions, such as graduated or mechanical compression devices or IVC filters, the effectiveness of these interventions was assessed across all surgical domains. Remark: For patients considered at high risk for VTE, combined prophylaxis is particularly favored over mechanical or pharmacological prophylaxis alone. Further high-quality research studies using clinically important outcomes to identify patients with high baseline risk for VTE in whom combined pharmacological and mechanical prophylaxis would be of value, particularly outside the orthopedic setting, are needed. Low-dose heparin versus graded pressure stockings, Comparison of warfarin and external pneumatic compression in prevention of venous thrombosis after total hip replacement, Randomized clinical trial of intermittent pneumatic compression and low molecular weight heparin in trauma, Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty, Safety and efficacy of pneumatic compression with foot-pumps for prophylaxis against deep vein thrombosis after total hip joint replacement. Treatment of DVT. This recognition has led to the urgent need for practical guidance regarding prevention, diagnosis, and treatment of VTE. There is a need for high-quality randomized trials specific to patients undergoing radical prostatectomy, particularly those treated with robotically assisted laparoscopic prostatectomy, the most widely used surgical approach for clinically localized prostate cancer. A comparative randomized trial, Fraxiparine: Second International Symposium Recent Pharmacologic and Clinical Data, The European Fraxiparin Study (EFS) Group, Comparison of a low molecular weight heparin and unfractionated heparin for the prevention of deep vein thrombosis in patients undergoing abdominal surgery, Efficacy and tolerance of Fraxiparine in the prevention of deep vein thrombosis in general surgery performed with medullar conduction anesthesia [in French], Low dose heparin versus low molecular weight heparin (Kabi 2165, Fragmin) in the prophylaxis of thromboembolic complications of abdominal oncological surgery, Orgaran (Org 10172) or heparin for preventing venous thrombosis after elective surgery for malignant disease? The EtD framework is available online at https://guidelines.gradepro.org/profile/AEF71CF4-AB9F-1DDF-A08B-1F5E2484EA5F. In the very low risk setting, no specific pharmacological or mechanical prophylaxis is recommended other than early ambulation. The 2013 International Angiology guideline favors LMWH, fondaparinux, VKAs, rivaroxaban, apixaban, or dabigatran, along with use of intermittent pneumatic compression after total hip arthroplasty.403  The most current NICE guideline recommends LMWH or rivaroxaban after total hip arthroplasty and the same after total knee arthroplasty, with the additional option of ASA.401, For VTE prophylaxis after surgery for hip fractures, the 2012 ACCP guideline recommends LMWH for VTE prophylaxis vs fondaparinux and low-dose UFH over adjusted-dose VKAs or ASA.407  Concurrent use of an intermittent pneumatic compression device was also recommended. Although the panel rated symptomatic VTE end points as those upon which recommendations should be based, the panel recognized that most studies of VTE prophylaxis following surgery used asymptomatic DVTs detected by the routine performance of sensitive screening tests (eg, venography) as the primary study outcome. Cancer (known or undiagnosed). The EtD framework is available online at https://guidelines.gradepro.org/profile/61E7ADC1-4C91-8D58-9E3A-56BFEE3EAC20. The majority of radical prostatectomies performed by urologists in the United States are performed robotically, typically with no or only a limited lymph node dissection. LMWH may result in a small increase in major bleeding (RR, 2.4; 95% CI, 0.53-10.78; low certainty in the evidence of effects). They further judged that the balance between desirable and undesirable effects probably favors combined pharmacological and mechanical prophylaxis over pharmacological prophylaxis alone. Patients with other risk factors for VTE (eg, history of VTE, thrombophilia, or malignancy) may benefit from pharmacological prophylaxis. Depending on baseline risk, this corresponds to 1 more (1-2 more) major bleed per 1000 patients in a lower-risk population (baseline risk of 0.5% from observational data)267  or as many as 20 more (10-31 more) per 1000 patients in a higher-risk population (baseline risk of 8% from the control group event rate in the meta-analysis). For patients considered at high thrombosis risk and low bleeding risk, combined mechanical and pharmacological prophylaxis should be considered. The use of DOACs reduces symptomatic proximal DVTs slightly (RR, 0.56; 95% CI, 0.39-0.79; high certainty in the evidence of effects), which corresponds to 3 fewer (1-4 fewer) symptomatic proximal DVTs per 1000 patients, based on a baseline risk of 0.6% from observational data.202,203  This effect on symptomatic distal DVTs is probably not clinically relevant (RR, 0.56; 95% CI, 0.39-0.79; high certainty in the evidence of effects), which corresponds to 0 fewer symptomatic distal DVTs per 1000 patients based on a baseline risk of 0.049%, from observational data.202,203. And placebo, Ardeparin ( low-molecular-weight heparin and unfractionated heparin [ in German ] a. Of screening-detected proximal DVTs, and compression and aspirin, and the GRADE.. Treatment is tablets of an anticoagulant filter vs no pharmacological prophylaxis for patients considered moderate! That formed the basis of this recommendation, the panel recognized that mechanical methods over pharmacological more! 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