New venous thromboembolism treatment guidelines

The American College of Chest Physicians has just produced a treatment guideline for venous thromboembolism(VTE) and Pulmonary Embolism(PE). The primary push in this guideline is for the use of non-vitamin K oral anticoagulants over warfarin.

Here is a brief summary

DEEP VENOUS THROMBOSIS (DVT)

Isolated DVT with no severe symptoms or risk factors: suggest serial imaging over anticoagulation

In acute proximal DVT: anticoagulation alone is preferred to catheter directed thrombolysis

In acute DVT suggest no compression stockings to prevent post thrombotic syndrome

In recurrent VTE on vitamin K antagonist(VKA) treatment or other anticoagulants, suggest using low molecular weight heparin(LMWH)

Proximal Deep venous thrombosis(DVT) or PE – 3 months of  therapy is needed

In patients with no cancer, the treatment recommended is Dabigatran, Rivaroxaban, Apixaban, Edoxaban or VKA therapy over LMWH

In those patients with cancer, LMWH is recommended over VKA. Dabigatran, Rivaroxaban, Apixaban, Edoxaban are also recommended.

PULMONARY EMBOLISM (PE)

In subsegmental PE and no Proximal DVT, in patients with a low risk of VTE: clinical surveillance over anticoagulation is recommended.

Patients with low risk PE can have early discharge and treatment at home.

PE + HYPOTENSION (SBP <90mmHg) and not a high bleeding risk suggest thrombolytic therapy

PE and NORMAL BP suggest no thrombolysis, however if these patients deteriorate following anticoagulation, however still have no hypotension, suggest thrombolysis

In unprovoked DVT or PE, when stopping antigcoagulation, commence aspirin to prevent recurrent DVT

UPPER EXTREMITY DVT

In DVT that involves the axillary or more proximal veins, anticoagulant therapy is recommended over thrombolysis.

Reference

Clive Kearon, Elie A. Akl, Joseph Ornelas, Allen Blaivas, David Jimenez, Henri Bounameaux, Menno Huisman, Christopher S. King, Timothy Morris, Namita Sood, Scott M. Stevens, Janine R.E. Vintch, Philip Wells, Scott C. Woller, COL Lisa Moores. Antithrombotic Therapy for VTE Disease. Chest, 2016; DOI: 10.1016/j.chest.2015.11.026