The fourth and final monograph in this series on venous thromboembolic disease addresses the most essential aspect of all: prevention of the disease. The preceding monographs in this series have covered the complex epidemiology, risk factors, natural history, invasive and noninvasive diagnostic approaches, and treatment of patients with suspected or established deep venous thrombosis or pulmonary embolism. Of all the conundrums facing clinicians engaged in recognition and management of venous thromboembolism (VTE), prevention is most amenable to successful implementation given the expanding array of effective prophylactic strategies available. Successful preventive management must take into account the relative efficacy and toxicity of various alternative approaches and pertinent economic factors and apply these astutely to the individual patient or population at hand in the context of the intrinsic risk profile in a given clinical situation.
Although effective prophylaxis against VTE is available in the form of a variety of antithrombotic agents, these drugs carry a risk of bleeding that make judicious use dependent on appropriate assessment of patient-specific risk. The differential risk of bleeding during anticoagulant therapy in patients with acute or chronic medical illness and those in perioperative surgical settings requires distinct preventive strategies, and these are separately addressed in this issue. Patients with previous VTE are at higher risk of recurrent thromboembolism than those without previous episodes, particularly when no reversible cause can be identified and eliminated. Whereas the conventional therapeutic approach involved administration of anticoagulant medication for 3 to 6 months after an acute episode of VTE, a new paradigm has emerged that calls for secondary prophylaxis over a much longer term in appropriate cases. In most, this can be effectively achieved with a lower intensity of anticoagulation than used during the acute phase of treatment for established thromboembolism.
Consistent with the objective of these supplements to provide current reviews applicable to primary care practice, the premise underlying this final issue is that prevention of VTE is mainly in the hands of the primary physician. Keeping in mind the needs of the practitioner, the goal was to provide comprehensive practical information based on the highest level of evidence available and recommendations consistent with accepted practice guidelines. Unsettled areas are highlighted as controversial, and pragmatic approaches are offered when consensus about optimum management is lacking. As in previous issues, the guest editor for this monograph is a widely recognized specialist in the topic, and the authors of each clinical review have been carefully selected according to similar criteria. A board jointly selected by the Society for Vascular Medicine and Biology and the editors of Circulation has approved each manuscript.
We hope this series of monographs will serve as a lasting and comprehensive resource for primary care physicians and specialists regarding strategies for diagnosis, management, and prevention of this common and debilitating disease. Because improving patient care is a continuous process, the reader is urged to use this as a foundation for updating clinical knowledge through regular contact with the literature of this rapidly developing clinical science.