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.
