An Update on the Treatment of Venous Thromboembolic Disease

Every four years the American College of Chest Physicians (ACCP) disseminates a new set of guidelines on the evaluation and management of venous thromboembolic disease (VTE).

The ACCP just released its updated guidelines for the treatment of VTE and I have attempted to summarize the main points of the guidelines below:

  • In patients with VTE and normal renal function and without cancer, the preferred order of anticoagulants are:
    • Novel oral anticoagulants (NOACs) such as dabigatran, rivaroxaban, apixaban, or edoxaban
    • Warfarin anticoagulation
    • Chronic low molecular weight heparin (LMWH) therapy
  • In patients with VTE and cancer, the preferred order of anticoagulants are:
    • LMWH therapy
    • Warfarin therapy
    • NOACs therapy
  • The recommended duration of anticoagulation for a provoked VTE is 3 months.
  • Recommend extended anticoagulation beyond 3 months for an unprovoked DVT with low-to-moderate risk of bleeding guided by D-dimer levels.
  • Patients with an unprovoked VTE should continue low-dose aspirin after their course of anticoagulation to reduce the chance of recurrent VTE.
  • Patients with a VTE and cancer should have extended LMWH anticoagulation
  • For unprovoked DVT with a high risk of bleeding, recommend 3 months anticoagulation.
  • For isolated distal DVT of the leg, recommend anticoagulation for 3 months
    • The choice of serial ultrasound at 2 weeks is an alternative for patients at very high risk for bleeding.
  • For low-risk, isolated, subsegmental pulmonary embolus (PE), we recommend clinical surveillance rather than anticoagulation.
  • The majority of patients with a proximal DVT should be treated with standard anticoagulation vs catheter-directed thrombolysis
  • Systemic thrombolysis should be reserved for hypotensive patients with a PE.
    • Thrombolysis for submassive PE remains controversial
  • Home treatment is recommended for patients with a low-risk PE.
  • No role for compression stocking to prevent post-thrombotic syndrome in patients with a proximal DVT.
  • Patients with a recurrent VTE on another therapy should be switched to long-term LMWH; patients with recurrent VTE on LMWH should have their dose increased.

Kearon C et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016 Jan 7; [e-pub]

Read all articles in Cardiovascular diseases, Hematology, Hospital Procedures, Medical General, Oncology
Tags: anticoagulation, cancer, Deep vein thrombosis, DVT, HPC updates, Updated guidelines, Venous Thromboembolic Disease, VTD

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