Rational antithrombotic therapy and prophylaxis in elderly, immobile patients.

The aging process is associated with increased coagulation and fibrinolysis parameters, resulting in an overall 'prethrombotic state'. This probably explains the increased baseline susceptibility of elderly patients to the development of thromboembolic disease. Additional factors such as major surgery or malignant disease multiply the risk of thromboembolism in this population. Even when adequate antithrombotic therapy is instituted, the mortality associated with thromboembolic disease remains considerable; this underlines the importance of adequate thromboembolic prophylaxis. At present, the use of low molecular weight heparins (LMWHs) in elderly immobile patients appears to be the most effective approach to prophylaxis. The use of compression stockings seems to be effective in the prevention of venous thrombosis, at least in moderate risk surgical patients. In patients undergoing orthopaedic surgery, additional prophylaxis (e.g. with an LMWH) is necessary. In the management of venous thrombosis, patients can initially be treated with a bodyweight-adjusted dosage of an LMWH. In patients with deep vein leg thrombosis or pulmonary embolism, oral anticoagulant therapy should be started as soon as possible, and should be continued for 6 months. However, before starting prophylaxis or therapy, an individual risk assessment should be performed in which the benefits and disadvantages are balanced. Most of the large trials that have studied the effects of thromboembolic prophylaxis have focused on postsurgical patients. However, it will be of great interest to develop more specific prophylactic and therapeutic regimens for different nonsurgical high risk subgroups of patients, particularly the elderly.