New Guidelines for Venous Thromboembolism Treatment

The American College of Chest Physicians recently released new guidelines for the treatment of venous thromboembolism (VTE).

Using a grade approach, each of the guidelines’ recommendations is presented as strong (Grade 1) or weak (Grade 2) based on high- (Grade A), moderate- (Grade B) or low-quality (Grade C) clinical evidence.

None of the 54 recommendations included the new guidelines were based on high-quality evidence. As a result, additional research is warranted.

In the meantime, key recommendations are as follows:

• For patients with VTE in the leg or pulmonary embolism without cancer, the guidelines recommend long-term anticoagulant therapy (first 3 months) such as dabigatran, rivaroxaban, apixaban, or edoxaban (all Grade 2B) over vitamin K antagonists (VKA) such as warfarin.
• In patients with DVT in the leg or pulmonary embolism and cancer, the guidelines recommend low-molecular-weight heparin (LMWH) over VKA, dabigatran, rivaroxaban, apixaban, and edoxaban (all Grade 2C).
• In patients with DVT in the leg or pulmonary embolism who receive extended therapy, the guidelines suggest that there is no need for a change in anticoagulant therapy after the first 3 months (Grade C).
• In patients with an unprovoked proximal DVT or pulmonary embolism who are stopping anticoagulant therapy and do not have a contraindication to aspirin, the guidelines recommend aspirin over no aspirin to prevent recurrent VTE (Grade 2C).
• In patients with DVT, the guidelines recommend against using compression stockings routinely to prevent post-thrombotic syndrome (Grade 2B).
• In patients with subsegmental pulmonary embolism—which is defined as no involvement of more proximal pulmonary—and no proximal DVT in the legs, the guidelines recommend clinical surveillance over anticoagulation when there is a low risk of recurrent VTE (Grade 2C), but they recommend anticoagulation over clinical surveillance when there is a high risk (Grade 2C).
• In patients with low-risk PE and whose home circumstances are adequate, the guidelines recommend treatment at home or early discharge over standard discharge (eg, after the first 5 days of treatment) (Grade 2B).
• In most patients with acute pulmonary embolism not associated with hypotension, the guidelines recommend against systemically administered thrombolytic therapy (Grade 1B).
• In selected patients with acute pulmonary embolism who deteriorate after starting anticoagulant therapy but have yet to develop hypotension and have a low bleeding risk, the guidelines recommend systemically administered thrombolytic therapy over no such therapy (Grade 2C).
• In patients with acute pulmonary embolism who are treated with a thrombolytic agent, the guidelines recommend systemic thrombolytic therapy using a peripheral vein over catheter-directed thrombolysis (Grade 2C).
• In patients with acute pulmonary embolism associated with hypotension and who have (i) a high bleeding risk, (ii) failed systemic thrombolysis, or (iii) shock that is likely to cause death before systemic thrombolysis can take effect (eg, within hours), the guidelines recommend catheter-assisted thrombus removal, if appropriate expertise and resources are available, over no such intervention (Grade 2C).
• In selected patients with chronic thromboembolic pulmonary hypertension who are identified by an experienced thromboendarterectomy team, the guidelines recommend pulmonary thromboendarterectomy over no such procedure (Grade 2C).
• In patients who have recurrent VTE while on VKA therapy (in the therapeutic range) or dabigatran, rivaroxaban, apixaban or edoxaban (and are believed to be compliant), the guidelines recommend switching to treatment with LMWH at least temporarily (Grade 2C).
• In patients who have recurrent VTE while on long-term LMWH (and are believed to be compliant), the guidelines recommend increasing the dose of LMWH by about one-quarter to one-third (Grade 2C).
• In patients with VTE who are treated with anticoagulants, the guidelines recommend against an inferior vena cava filter (Grade 1B).