Narrative Review on Prevalence of Venous Thromboembolism and Public Awareness in India

Pritha Sarkar1 *, Sunita Srivastava1, Jayanta Das2, Anil Kumar3 1Amity College of Nursing, Amity University, 122413 Haryana, India 2AMRI Hospitals, Saltlake, Kolkata 700098, India

3School of Legal Studies, Central University of Kashmir, Tulmulla, Jammu and Kashmir 191131, India

*Corresponding Author’s Email:


Information regarding public knowledge about thrombosis in a broad sense and specifically venous thromboembolism (VTE) is not widely available. This review aims at understanding the true picture of venous thromboembolism prevalence among the Indian population over the last two decades. Although a majority of research studies had identified the occurrence of venous thromboembolism among Orthopaedic patients, it was not a rarity in neurosurgery, urology, burns, gynaecology, and critical care patients. The history of long travelling /flying had also proved a significant causative factor. Healthcare professionals should be alert to this hospital never event and follow best practice treatment algorithms based on international guidelines. Public awareness through social media should also be created to understand venous thromboembolism which can be fatal at times.

Keywords: Deep Vein Thrombosis, Pulmonary Embolism; Public Awareness; Prevalence; Venous Thromboembolism


About 10 million people around the world develop venous thromboembolism (VTE) each year. Although common among hospitalized patients, the occurrence of deep vein thrombosis (DVT) and pulmonary embolism (PE), together known as VTE, was often underdiagnosed, and the fatal consequences were an unknown fact. In an autopsy-based study conducted for about six years and three months in one of the tertiary hospitals in North India, 15.9% (159/1000) of adult autopsy cases were detected to develop pulmonary embolism. (Kakkar & Vasishta, 2008). Venous thromboembolism was even traced in healthy individuals who are often travelling for long hours (Choudhry & Upadhyay, 2009). The development of venous thromboembolism is having a high impact on the economic and humanitarian burden on society.


An extensive search of the research articles and review articles have been conducted using the PubMed and Scopus databases from 2003 to 2021.

Inclusion/Exclusion Criteria

Altogether 57 published original research studies and review articles were identified. Only those studies related to venous thromboembolism prevalence among the Indian population were included. The articles regarding the analysis of the clinical manifestations and exclusive treatment modalities were excluded. (Figure 1).

A flowchart of a research process

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Figure 1: PRISMA Flow Diagram for the Selection of Studies

Venous Thromboembolism Prevalence in India

Most of the researchers had chosen their expertise in acute care setups and tried to identify VTE cases retrospectively and a few prospectively (Agarwal et al., 2009) in single-center or multi center.

Orthopedic Surgery

Seven studies among orthopedic patients undergoing major surgical procedures in the lower extremities like THR (Total Hip Replacement) and TKR (Total Knee Replacement) and PFF (Proximal Femur Fractures) were identified. The study showed a high prevalence of VTE in 49/94 (52.1%) patients Agarwala, Bhagawat, & Modhe (2003). Compared to two studies by (Sen et al., 2011 and Singh et al., 2017), where venous thromboembolism prevalence was 16/56 (29%) and 62/301 (21%) patients respectively. (Figure 2)

Low prevalence was stated in studies by Jain et al. (2004); Bagaria et al. (2006); Dore et al. (2017) and Avulapati et al. (2019). In the prospective study by Jain et al there were a total of 2 patients who had developed venous thromboembolism out of 60 THR in 45 patients and 46 TKR in 26 patients (2.8%). Interestingly, in Bagaria et al. study out of 147 patients undergoing THR and TKR, 9 patients (6.12%) had VTE, out of which PE was 0.6%. Whereas among the total of 101 patients 8 patients (7.92%) had developed DVT and 2 of these patients had complications of PE (Dore et al. 2017; Avulapati et al., 2019) revealed a different aspect in their retrospective study, with the prevalence of symptomatic DVT as low as 0.22% (1 out of 447 patients) and PE 0%.

Neurological Surgery

Among neurosurgical patients, 33 out of 273 patients (12%) developed VTE. (Borde et al., 2017)

Cardiology and Clinical Hematology

In a current retrospective observational study conducted in the departments of Cardiology and Clinical Hematology, at a tertiary care center, Punjab; a total of 330 admissions related to VTE were recruited over three years. The further diagnosis confirmed 303 patients (92%) having an acute episode of VTE at actual. (Singh et al., 2021)

Abdominal Surgery

Another retrospective descriptive study on 334 patients who underwent any sort of major abdominal surgery (>1hr duration) from Government Medical College, Thiruvananthapuram, for 2 years. Among them, only 4 patients (1.19%) developed deep venous thrombosis during the postoperative period (Kuttanchettiyar & Chisthi, 2018).

Venous Thromboembolism Risk in Intensive Care Patients

Pandey et al. (2009) found that 111 (94%) out of 117 patients (68 in wards and 49 in ICU) fall under the risk category of deep vein thrombosis development when assessed through Dr. Caprini’s risk score (Caprini, 2010). 100 % of the ICU patients (n=49) and 57.5% (n= 39) in the ward were at the highest risk for deep vein thrombosis development. A similar prospective study was conducted on a total of 210 patients over one year by Panda, Kumar & Ketkar (2017) where 150 (60%) patients were from intensive care units and 60 (40%) were from surgical wards. Using the same Caprini tool, VTE risk was found to be highest in 45.3%, higher in 33.3% and moderate in 21.3% among the 150 critical unit patients. However, among 60 post-surgical patients, 50% had the highest risk, 36.6% had the higher risk, and 13.3% had a moderate risk of venous thromboembolism.

Proximal and Distal Deep Vein Thrombosis

In one pioneering retrospective VTE prevalence study conducted in India, 60.7% of patients had proximal and 33.6% distal deep vein thrombosis out of 438667 admissions (Lee et al., 2009). Whereas in the retrospective study by (Naqvi et al., 2016), 215 patients (73.33%) had proximal, and 78 patients (26.26%) had distal deep vein thrombosis out of the total sample of 293 patients. In the study (Singh et al., 2017), 27.41% of patients were identified with symptomatic deep vein thrombosis, of which 58.06% had proximal and 37.09% had distal deep vein thrombosis. According to a study by Basavanthappa et al. (2019), further, out of 1024 medical records that were reviewed and analyzed, 812 (79%) medical records met the inclusion criteria. Here, 719 (88.5%) patients had proximal and 62 (7.6%) had distal deep vein thrombosis (Figure 3).

Pulmonary Embolism

Parakh et al. (2006) reflected a different overview of venous thromboembolism cases in their study by enrolling a total of 1552 inpatients and outpatientsbased on the initial clinical suspicion of lower limb DVT at Gangaram Hospital, Delhi. The study aims to determine the frequency of PE among Indian patients with symptomatic lower limb venous thrombosis. Out of these clinically assessed subjects, confirmed DVT was diagnosed through radionuclide venography in 744 patients. These patients had also undergone lung perfusion scans within 24 hours of presentation. The high probability of PE was among 294 (39.5%) patients and the intermediate probability was among 135 (18.1%) patients. Further, out of the total high probability scanned patients, 47% had no clinical manifestations of pulmonary embolism. In another study pulmonary embolism was observed in 14 out of a total of 100 AECOPD patients (Acute exacerbation of chronic obstructive pulmonary disease). Of these suspected PE patients, deep vein thrombosis in the lower extremity was diagnosed among 9 patients (Chaudhary et al., 2021).

Overall Venous Thromboembolism Prevalence

In the RAVS study 14.2 patients per 100,000 admissions were having VTE in comparison to the Lee et al. study conducted at Christian Medical College Vellore, where 17.46 patients per 10,000 admissions were detected with VTE (Lee et al., 2009). However, in a retrospective cross-sectional level II audit study (Pawar et al., 2020), there were a total of 518,111 admissions during the six-year study period, with a VTE prevalence of 19.49/10,000 cases. In the ARRIVE study there was an analysis of 949 medical records from three tertiary hospitals that confirmed 549/949 (57.8%) VTE cases after doppler ultrasonography for DVT and computed tomography, pulmonary angiography, and V/Q scan for PE (Kamerkar et al., 2016) from a period of 2006-2010. The total recorded patients having acute VTE without PE were 64% (352/549) and 23% (124/549) with PE, whereas only PE was 13% (73/549).

A graph of blood vessels

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Figure 2: Prevalence of Venous Thromboembolism among Major Patient Group

A graph of different types of data

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Figure 3: Proximal and Distal Deep Vein Thrombosis in Major India Study Findings

Common Risk Factors Identified

Many original studies conducted in the Indian scenario stated the various risk factors that might be the reason for the development of venous thromboembolism (Stephen et al., 2017).

Naqvi et al. (2016) conducted a major study to discover the prevalence of deep vein thrombosis over the past 25 years and its underlying risk factors. There was a significant record of 126 (43%) post-partum patients with deep vein thrombosis within the age group of 30 years. Apart from this, there was a previous history of lower limb trauma (14.3%), advanced malignancy (10.3%), and a history of major surgery (8.8 %). However, in 19.4% of cases, no definite risk factor was found. In the Kamerkar et al. 2016 study, among the total 549 diagnosed venous thromboembolism cases, 34% had a history of deep vein thrombosis, 28% had surgery, including orthopedic surgery, 16% suffered trauma, 14% of patients were immobilized for >3 days, 7% were detected with malignancy, 2% were pregnant /postpartum patients and 0.9% had a history of long-distance travel, including air travel. Ramakrishnan & Detect-DVT Investigators (2017) conducted a prospective observational study from 23 hospitals in India to assess the prevalence of symptomatic deep vein thrombosis in Indian patients with acute sepsis. A total of 275 patients were recruited from six hospitals in North India, seven from the South, three from the East, and seven from West India.

The prevalence of symptomatic deep vein thrombosis in patients among whom the majority (n = 127, 46.2%) did not have severe sepsis and were not in septic shock, followed by a few cases of severe sepsis (n = 94, 34.2%) and septic shock (n = 54, 19.6%). Whereas cardiovascular risk was found among 16.2% of patients who were at the highest deep vein thrombosis risk in the study by Pandey et al., (2009) along with 35.5% of patients having respiratory disease and 25.6% of patients having sepsis and septicemia as risk factors.

Malignancy, being one of the major factors provoking venous thromboembolism, was identified to be 6.8% (n= 8) in Parakh et al., (2006), 31% in Lee et al., (2009), 10.3% (n= 30) in Naqvi et al., (2016), 13% (n= 72) Men and 29% (n= 133) Women in Pawar et al., (2020) and 16% (n=11) in Singh et al., (2017).

Table 1: Major Research Articles of Inia








Agarwala S.

et al. (2003)

Prospective randomized study


P. D. Hinduja National Hospital and Medical Research Centre, Mumbai

104 enrolled 94 evaluated (patients with major

orthopedic lower limb surgery)

49 patients (52.1%)

  • Distal calf DVT was found commonest which significantly lead to PE in many cases.

  • LMWH has reduced DVT frequency to 47%.

  • Recommended to use LMWH for Indian patients undergoing major joint surgery.

Jain V.

et al. (2004)

Retrospective study

Jan 2015-

Jan 2016

Faridabad, Haryana,

60 hips in 45 patients

and 46 kneesin 26 patients undergoing THA and TKA

2 patients

(undergone THA)

  • Diagnosis of acute PE among suspected clinical profile of patients was confirmed based on CT pulmonary angiography.

  • About 58.5% ofpatient had at least one risk factor for PE.

  • Smoking was the major risk factor found in 22 (41.5%).

Bagaria V.

et al. (2006)

Prospective study


KEM Hospital, Mumbai

147 patients undergone TKR,THR and PFF

VTE - 6.12%

(PE - 0.6%)

  • Between 6-10 days post- operatively all cases were screened with ultra-duplex

  • VTE prevalence was found low.

study and clinical observation

Parakh R et al. (2007)

Prospective cohort study

January 2001 -

July 2004

Sir Ganga Ram Hospital, New Delhi

1552 inpatient & out patient with

suspected lower limb DVT

DVT- 744 patients

  • Presented at the VI th Asian Vascular Society Conference, November 2004, Bangalore, India.

  • Lung Scan suggestive of high- probability PE in

70% (521/744) had suprapopliteal DVT,

39.5%(294/744) and

intermediate–probability PE in 18.5% (135/744) patients

Kakkar N

Necropsy study

7 Year


7- Jan


PGIMER, Chandigarh

1000 autopsy

in Medical patients

PE - 159 patients


  • Autopsy cases were classified into three groups based on fatal

PE, PE associated with other pathology and incidental PE.

32.07% (51/159) of PE cases had a primary diagnosis of


Lee A.D.

et al.(2009)



10 Year



Vellore, Tamilnadu

438 667


17.46 per



  • General surgical operations were the major predisposing

  • PE cases in 14.9 % of patients

  • Correct use of prophylaxis would bring down the mortality rates and reduce the DVT prevalence in India.

factor for postoperative DVT (40.3%), while malignancy was for secondary VTE.

Sen RK

et al. (2011)

Prospective study

Two year (Jan


Dec 2009)

Level I Trauma Centre, PGIMER; Chandigarh


Postoperative patients (pelviacetabular injury)

underwent Open

Reduction and Internal Fixation

16 patients (28.6%)

  • Clinical Observation still six weeks’ post-surgery and radiological findings identified VTE cases

  • Proximal DVT (12/16) is high

  • Pulmonary Embolism

developed among 10 patients

Naqvi S.E.

et al. (2016)

Retrospective study

31 years

(1983 -


JN Medical

College, Aligarh Muslim University, Aligarh,

Uttar Pradesh

93 patients

Proximal DVT 215 (73.33%)

Distal DVT 78 (26.26%)

  • Majority of VTE cases were young primigravida,

  • Post Thrombotic Syndrome detected in 25% of the cases

postpartum females

  • Efficacy of Administration of unfractionated heparin is




et al.(2016)


retrospective registry

5 years



Ruby Hall Clinic,

Pune; CMC,

Ludhiana; MS Ramaiah, Bangalore

949 Medical


549 patients


A total of 64% (352/549) patients had acute DVT without PE

  • 23% (124/549) of patients had acute DVT with PE

  • 13% (73/549) of patients had PE.


K Dore et al. (2017)





Hospital, Madurai


8 (7.92%)

  • The total joint replacement cases include 51 cases of total

hip arthroplasties, 40 cases of knee arthroplasties and 10 cases of hip hemiarthroplasty

Borde T.D et

al. (2017)


cohort based study

Nov 2013

-Dec 2014

NIMHANS, Bangalore


Neurosurgical patients

33 (12.08%)


  • Position (Supine/Lateral) and duration (> 5 hrs) during

  • Suggested algorithm for elective neurosurgery focusing on initial Doppler screening and effective prophylactic regimen (mechanical/ chemical)

neurosurgery results high DVT rates.

Singh R et




cohort based study



Dec 2016

Government Medical

College Jammu

301 Ortho


(Major Lower extremity)

62 (21%) Patients

  • High DVT rates observed among elderly post-operative females with comorbities and

had undergone periarticular knee surgeries



et al. (2019)



Jan 2017-

July 2018

BIRRD (T) Hospital,


447 post-

THA patients

1 patient

  • Low prevalence proves the effectiveness of customized chemoprophylaxis

administration after THA among poor socio-economic rural group.


pa R.P. et al.(2019)


single center study

Jan 2007-

March 2018

Ramaiah Medical

College, Bangalore

1024 patients

14.2 VTE / 10,000


  • Primary care Physicians/ surgeons,of South India should

be updated about VTE.

Pawar P et al.(2020)

Retrospective cross sectional Level II audit study

Jan 2012


Dec 2017

Sri Ramachandra Medical College, Chennai

518111 Patients


(19.49/ 10,000


  • Acute DVT (<14 days) contributed to 66% of the patient mostly at lower limb.

  • The mortality rate was 50 /170 patients with PE.

  • 61 patients underwent IVC filter insertions

10.7% (13/117) DVT cases from recent General and Ortho surgery had received any prophylaxis.

Singh S et



observational study

Jan 2017

-Jan 2020

DMC Hospital,


330 patients

303 patients


  • Recent Surgery and malignancy were highlighted risk factors

  • In hospital mortality rate is 8.9

  • Unprovoked DVT in 76% of patients


Table 2: Common Risk Factors Detected in Indian Studies












Agarwala, Bhagwat & Modhe, (2003)


Gr I - 51

with prophyla xis,

Gr II- 53

without prophyla xis





yea rs

Gr I


58%Wom en)



70%Wom en)


- TKR 37(35.6%)









Pandey A

et al.




[68 in wa rds


49 in



patients (75 %)

[39 in

wards and 49 in ICU]



yea rs


)-Men; 45(38.5%

) -







Respira tory-


Cardiovascul ar- 20(17.1%)

Diabetes 20(17.1%)

A.D. Lee

et al.



Admissio ns




yea rs

48% Men








Another medica l

conditions- 21%


al condition- 12%

Sen R.K.

et al.








yea rs


) - Men 8 (14.3%)








acetabula r


11 patients

had 13

a ssocia ted injuries

Naqvi SE

et al.




Proxima l




Dista l DVT- 78


34.5 ±


yea rs



Men 210(71.6













History of estrogen

intake - 12(4%)

Kamerkar DR

et al.





Acute DVT


PE; 124


Acute DVT with PE;

47 ± 16

yea rs

70% Men













Pa st History DVT- 189(34.4%)

Past history PE -


Immobiliza ti on >3days - 76(13.8%)


73(13%) - PE

e - 2(0.4%)

Varicose vein- 59


Long- distance travel

including a ir travel- 5 (0.9


Dore N.K

et al.




8 (7.92%)



yea rs



Men; 58(57.4%

)- Women



Joint surgery






Borde TD

et al.








yea rs


%)- Men 102(37%)

- Women





(11 /33)



Hypertensio n, Frequent alcohol take, smoking and obesity

Singh R

et al.








yea rs


%)- Men; 123(40.9










Avulapati SK

et al.




1 patient (symptoma tic)


yea rs


%) Men 149(33.3










Pawar P

et al.




1010 (19.49/ 10,000

ca ses) patients

± 42

yea rs

55% (551


Men 45% (459/101 0)


47% (259/1010

) Men

29% (133/1010

) Women

13% (60/1010

) Women

13% (72/101

0) Men

29% (133/10 10)




Medica l Specia lties 40% (220

/1010) Men 29% (459/



Singh S et al. (2021)



303 (92%)



yea rs

60.7% (184/303)

Men 39.3% (119/303)



(41/ 303)

2.3% (7/303)

16% (11/ 303)



Pa st History VTE- 22.4% (68/303)

Prolonged Immobility- 8 /303


Travel - 2/ 303


Thrombophil ia – 22 /303


Venous thromboembolism is one of the quality indicators as per the study involving 358 hospitals across 32 countries (Cohen et al., 2008). It was revealed that the proportion of Indian patients considered at risk for VTE is 53.6%, like that of the global patients at risk for VTE (51.8%). However, unlike the Global ENDORSEstudy, where 50.2% of at-risk patients received ACCP-recommended prophylaxis(Kearon et al., 2012), in India, a deficient proportion of at-risk patients (17.4%) received ACCP-recommended prophylaxis (Pinjala, 2012). VTE Core Group Leaders from all major medical-surgical fields– Gastrointestinal, General and Vascular, Hematology, Critical Care, Orthopedics, Gynae & Obstetrics and Oncology in India held a series of meetings from August 2005 to January 2006, to identify the significant prevalence of DVT among the Indian population as compared with Western World data. To address this matter of concern, an in-depth analysis of the guidelines of the American College of Chest Physicians (ACCP), the International Union of Angiology (IUA), and the Royal College of Obstetricians and Gynecologists (RCOG) was done, and their relevancy with respect to Indian patients was judged, as mentioned in the review article. An outline was framed and concluded (Parakh, Kakkar & Kakkar, 2007). Ramakrishnan et al., (2022) had also suggested adherence to ACCP guidelines in VTE prevention. Shirol et al. (2017) conducted a survey, where the majority of plastic surgeons admitted the usage of low molecular heparin after considering the patient’s age, comorbidities, degree and percentage of burn and lower limb involvement. A similar questionnaire-based survey on 100 active general surgeons was taken by Venkataram et al., (2013). The survey result showed that 97% knew about VTE, and 49% of surgeons had experienced patient deaths due to PE. Noticeably, 64% of surgeons do not practice preoperative DVT risk scoring, while 33% of surgeons practice institute –based protocol.

To achieve institutional accreditation from national and international quality bodies, it is not the physician’s duty alone to identify patients at VTE risk and follow up for treatment protocol. Antony emphasizes that nurses are equally responsible for early detection of the risk of DVT along with implementing the right prescribed prophylaxis as a part of the hospital patient safety protocol. Daily assessment through risk assessment tools like Wells Score should be practiced attending nursing care excellence. Effective training for the nursing team should also be imparted (Antony, Moly & Dharan, 2016).

Public Awareness

Modern hospital care style emphasizes patients’ and their relatives’ involvement by sharing information about their health condition and making them participate in the decision-making process (Vahdat et al., 2014). Hence social media is a crucial messenger to thepublic (Lavall, 2014). On Post-World Thrombosis Day, in Economic Times Health World Dr. Suviraj John had emphasized the perception of an unrecognized multiple risk factor preventive stratagem following Asian Venous Thromboembolism Guidelines (Akter, 2016). A case was reported about India’s cricketer-commentator and politician, Mr. Navjot Singh Sidhu, being hospitalized with DVT in his leg, and later, he recovered from it (PTI, 2015). India Today reported Dr. Jyoti B. Sharma’s statement (India Today Web Desk, 2015) that “Sitting for a long period every day may cause this disease. People taking long flights are often diagnosed with DVT”. ACCP guidelines recommend walking, calf muscle exercises, and sitting in an aisle seat for long-distance travelers.

In his interview to ET Healthworld (Akter 2019), Dr R. Sekhar believed, people should know that the primary threat to DVT is sudden cardiac arrest due to the clots that can get broken loose and travel to the lungs. He mentioned some high-risk factors like fractures, hip and pelvic surgery and

cancer patients, as well as moderate risk factors like old age and long overseas flights of more than 4hrs, which can aggravate the condition. Times of India (Sinha Kounteya, 2010) reported a case of a UK-based lecturer who had taken a long-haul flight from London to Delhi. He had ignored his left leg swelling which had gradually turned pale over time during the journey. However, soon after his landing, he had to rush to the nearest hospital due to the sudden deterioration in his condition. Brar and Saha (2019) stressed the urgency that the airlines have moral responsibilities towards their customers exposed to DVT risk as they opt for flight travel, especially when it is more than 4 hrs. Passenger awareness should be conducted through in-flight announcements, and leaflets should be distributed with the importance of VTE, which might be aggravated due to existing risk factors (Brar & Saha, 2019).

Corporate employees are susceptible to developing venous thromboembolism as a result of frequent flying or extensive travel obligations for job-related requirements, a condition often referred to as travelers' thrombosis (Dimberg et al., 2001; Johnston & Hudson, 2014). Even constant desktop jobs can lead to such conditions, called e-thrombosis (Healy et al., 2010; Suadicani et al., 2012). Future studies among corporate employees in India can be an eye-opener.


There is need to endeavor towards maximizing the impact of the VTE campaign by intensifying public awareness efforts. This is essential to sensitize individuals about this inconspicuous yet perilous condition and its corresponding risk factors. In contemporary times, numerous hospitals in India have taken the initiative to collaborate with various organizations in commemorating World Thrombosis Day, aimed at offering benefits to citizens. Through such initiatives, we aspire to effectively tackle this significant clinical challenge.

Conflict of Interest

The authors declare that they have no competing interests.


The authors are thankful to the Pro-Vice Chancellor and Vice Chancellor of Amity University, Haryana.


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