New NICE guideline NG89: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism

Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism


This guideline covers assessing and reducing the risk of venous thromboembolism (VTE or blood clots) and deep vein thrombosis (DVT) in people aged 16 and over in hospital. It aims to help healthcare professionals identify people most at risk and describes treatments and interventions that can be used to reduce the risk of VTE.


Published  March 2018
Next Review 2020


Full guidance available at https://www.nice.org.uk/guidance/ng89

Venous thromboembolism (VTE) risk assessment data: Q1 2017/18

NHS Improvement has released the official statistics for venous thromboembolism (VTE) risk assessment in England for quarter 1 (Q1) 2017/18 (April to June 2017).

Point of care ultrasound VS CT pulmonary angiogram in suspected pulmonary embolus

The ability of a multiorgan POCUS approach to help risk-stratify patients with clinical signs and symptoms of PE appears very promising, but more data are needed to make a definitive statement regarding validity in clinical practice.

Stroke patients in England set to receive revolutionary new treatment

NHS England has announced that it will commission mechanical thrombectomy so it can become more widely available for patients who have certain types of acute ischaemic stroke.

See the RCR response.

Thromboprophylaxis after miscarriage

Answer to the question What thromboprophylaxis is recommended after first trimester miscarriage? posted to the RCOG query bank.

Thromboprophylaxis at gynaecological surgery

Answer to the question What is the evidence for thromboprophylaxis in gynaecological surgeries and early pregnancy? posted to the RCOG query bank.

People prefer shorter compression stockings to prevent blood clots

People having surgery prefer wearing knee length to thigh length compression stockings to prevent deep vein thrombosis (DVT). They are more likely to wear knee length stockings correctly and for the recommended time.

From the NIHR Dissemination Centre

CEU Statement: Combined hormonal contraception and venous thromboembolism

Statement from the Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists' Clinical Effectiveness Unit about some fatal cases of venous thrombosis that were associated with use of combined hormonal contraception.

Ticagrelor for preventing atherothrombotic events after myocardial infarction

New NICE technology appraisal guidance on on ticagrelor (Brilique) for preventing atherothrombotic events after myocardial infarction in adults.

Rapid blood test helps exclude pulmonary embolism for low risk patients

An inexpensive blood test can help quickly rule out pulmonary embolism for low risk patients attending hospital outpatient or emergency departments, especially in people with early symptoms.

This review looked at the accuracy of a simple blood test called a D-dimer added to the usual diagnostic pathway and a clinical prediction rule. The test is already used to indicate the likelihood of related blood clots in the legs.

From the NIHR Dissemination Centre

International clinical practice guidelines including guidance for direct oral anticoagulants in the treatment and prophylaxis of venous thromboembolism in patients with cancer

Venous thromboembolism (VTE) is the second leading cause of death in patients with cancer. These patients are at an increased risk of developing VTE and are more likely to have a recurrence of VTE and bleeding while taking anticoagulants. Management of VTE in patients with cancer is a major therapeutic challenge and remains suboptimal worldwide. In 2013, the International Initiative on Thrombosis and Cancer (ITAC-CME), established to reduce the global burden of VTE in patients with cancer, published international guidelines for the treatment and prophylaxis of VTE and central venous catheter-associated thrombosis. The rapid global adoption of direct oral anticoagulants for management of VTE in patients with cancer is an emerging treatment trend that needs to be addressed based on the current level of evidence. 

In this Review, we provide an update of the ITAC-CME consensus recommendations based on a systematic review of the literature ranked according to the Grading of Recommendations Assessment, Development, and Evaluation scale. These guidelines aim to address in-hospital and outpatient cancer-associated VTE in specific subgroups of patients with cancer.

Request article form the library.

Safety Notice: Air embolism following CVC port being left open

NHS Improvement have been alerted via the coroner’s court to an incident where a patient died following a clamp on a central venous catheter port being briefly left open, resulting in air embolisation and cerebral infarction. The coroner was particularly concerned that:

• nursing staff were not aware of the risk of air embolisation when leaving a central venous catheter port uncapped and unclamped
• they were unable to locate any literature or guidance regarding the risk of air entry if the clamp is left open during use of the catheter.

The SITS-UTMOST: A registry-based prospective study in Europe investigating the impact of regulatory approval of intravenous Actilyse in the extended time window (3–4.5 h) in acute ischaemic stroke

European Stroke Journal,  Vol 1, Issue 3, 2016

The SITS-UTMOST (Safe Implementation of Thrombolysis in Upper Time window Monitoring Study) was a registry-based prospective study of intravenous alteplase used in the extended time window (3–4.5 h) in acute ischaemic stroke to evaluate the impact of the approval of the extended time window on routine clinical practice..

UHCW Research: Anthony Kenton

New and emerging angioplasty technologies in development for severe lower limb ischaemia

HSRIC has completed a review of new and emerging angioplasty-related technologies for arterial revascularisation in patients with severe lower limb ischaemia due to femoro-popliteal artery disease (PAD). Peripheral artery disease (PAD) is a condition in which the peripheral arteries of the body, particularly those in the legs, are narrowed or blocked by a build-up of fatty deposits (atheroma). The most common initial symptom of lower limb PAD is leg pain, usually in the calf, while walking (intermittent claudication). Severe or critical limb ischaemia is a seriously disabling, life and limb threatening, condition. It is characterised by severely diminished circulation, ischaemic pain at rest and tissue loss (ulceration and/or gangrene).

We identified thirty-one new and emerging technologies; 22 thought to be emerging and 9 that we believed to have been CE marked since 2015 and logged links to clinical trials and other key sources.

Bleeding risk with anticoagulants in atrial fibrillation or venous thromboembolism

New Eyes on Evidence from NICE:

A systematic review and meta-analysis found that, compared with warfarin, non-vitamin K antagonist oral anticoagulants were associated with a reduction in fatal bleeding in people with atrial fibrillation or venous thromboembolism.

Mechanical clot removal may offer better outcomes for people with stroke

Mechanical clot removal alongside standard clot-busting drug treatment may offer better functional outcomes for people who have suffered a stroke caused by a blood clot than drug treatment alone. This review found that 44% of patients receiving mechanical clot removal had a good functional outcome after 90 days, compared to 33% of those who didn’t.

However, these benefits only apply to a subset of patients. Prior brain scan is essential in order to identify if the clot is amenable to mechanical removal. Also, newer technology was associated with better outcomes.

Given these implementation challenges, the cost-effectiveness of the approach remains unknown. Mechanical clot removal is a highly skilled operation that should be performed within six to eight hours after the stroke. Patients would need early access to stroke units with the necessary diagnostics, technology and specialist expertise. Therefore a pragmatic NHS trial and cost-effectiveness analysis would be informative.

From the NIHR Dissemination Centre

An anticoagulant, bivalirudin, may not be safer than the alternative, heparin, when unblocking arteries in the heart

Bivalirudin is currently recommended as an alternative option to heparin to prevent clotting during percutaneous coronary intervention. This is a common procedure to unblock the heart’s arteries. It is more costly but may have advantages relative to heparin, such as a more rapid action and less risk of lowering the platelet count.

This review found that bivalirudin reduced risk of major bleeding compared with heparin. However, this was only when heparin was combined with a higher dose of another anti-clotting drug, a glycoprotein platelet IIb/IIIa inhibitor. When there was equivalent use of these inhibitors, there was no difference in bleeding. Bivalirudin was also associated with very small increased risks of heart attack and re-blockage of the blood vessel being treated.

For now, bivalirudin remains an alternative option to heparin, but individual patient characteristics should guide the best drug to use.
From the NIHR Dissemination Centre