Health
Research
Medicine
Medical Guidelines
PE
Antithrombotic Therapy
VTE
Distal DVT
Recurrent VTE
Pulmonary
1/ A summary of the new @accpchest guidelines for VTE antithrombotic therapy (with strength of recommendation).
See full recommendations: bit.ly
See full recommendations: bit.ly
2/ For acute, isolated distal DVT:
🩸 - severe symptoms/extension risk: weekly serial imaging x 2 weeks > anticoagulation (weak)
🩸 + severe symptoms/extension risk: anticoagulation > serial imaging (strong)
🩸 - severe symptoms/extension risk: weekly serial imaging x 2 weeks > anticoagulation (weak)
🩸 + severe symptoms/extension risk: anticoagulation > serial imaging (strong)
3/
🩸 Isolated subsegmental PE + no proximal leg DVT + LOW risk for recurrent VTE: clinical surveillance > anticoagulation (weak)
🩸 Isolated subsegmental PE + no proximal leg DVT + HIGH risk for recurrent VTE: anticoagulation > surveillance (weak)
🩸 Isolated subsegmental PE + no proximal leg DVT + LOW risk for recurrent VTE: clinical surveillance > anticoagulation (weak)
🩸 Isolated subsegmental PE + no proximal leg DVT + HIGH risk for recurrent VTE: anticoagulation > surveillance (weak)
4/
🩸 Incidentally diagnosed, asymptomatic acute PE: same anticoagulation plan as for symptomatic (weak)
🩸 Cerebral vein/venous sinus thrombosis: anticoagulation for at least 3 months > no anticoagulation (strong)
🩸 Incidentally diagnosed, asymptomatic acute PE: same anticoagulation plan as for symptomatic (weak)
🩸 Cerebral vein/venous sinus thrombosis: anticoagulation for at least 3 months > no anticoagulation (strong)
5/
🩸 Acute leg DVT: anticoagulation > interventional (thrombolytic, mechanical, pharmacomechanical) therapy (weak)
🩸 Acute PE + hypotension + low bleeding risk: thrombolytics > no thrombolytics (weak)
🩸 Most acute PEs without hypotension: NO thrombolytics (strong)
🩸 Acute leg DVT: anticoagulation > interventional (thrombolytic, mechanical, pharmacomechanical) therapy (weak)
🩸 Acute PE + hypotension + low bleeding risk: thrombolytics > no thrombolytics (weak)
🩸 Most acute PEs without hypotension: NO thrombolytics (strong)
6/
🩸 Acute PE with deterioration on anticoagulation (not yet hypotensive) + acceptable bleeding risk): use systemic thrombolysis (weak)
🩸 Thrombolysis for acute PE: systemic > catheter-directed thrombolysis (weak)
🩸 Acute PE with deterioration on anticoagulation (not yet hypotensive) + acceptable bleeding risk): use systemic thrombolysis (weak)
🩸 Thrombolysis for acute PE: systemic > catheter-directed thrombolysis (weak)
7/
🩸 Acute PE + hypotension + high bleeding risk/failed systemic lysis/profound shock: catheter-directed removal > no such intervention (weak)
🩸 Acute DVT of leg: NO IVC filter in addition to anticoagulation (strong)
🩸 Acute PE + hypotension + high bleeding risk/failed systemic lysis/profound shock: catheter-directed removal > no such intervention (weak)
🩸 Acute DVT of leg: NO IVC filter in addition to anticoagulation (strong)
8/
🩸 Acute proximal DVT of leg + contraindication to anticoagulation: use IVC filter (strong)
🩸 Low-risk PE: outpatient treatment > hospitalization (strong)
🩸 For DVT/PE: apixaban/dabigatran/edoxaban/rivaroxaban > VKA for 1st 3 months of therapy (strong)
🩸 Acute proximal DVT of leg + contraindication to anticoagulation: use IVC filter (strong)
🩸 Low-risk PE: outpatient treatment > hospitalization (strong)
🩸 For DVT/PE: apixaban/dabigatran/edoxaban/rivaroxaban > VKA for 1st 3 months of therapy (strong)
9/
🩸 Acute cancer-associated VTE: oral Xa inhibitor > LMWH (strong)
🩸 Confirmed APLS: adjusted dose VKA (target INR 2.5) > DOAC (weak)
🩸 Superficial venous thrombosis (SVT) of leg at risk of progression to DVT/PE: anticoagulation x 45 days > no anticoagulation (weak)
🩸 Acute cancer-associated VTE: oral Xa inhibitor > LMWH (strong)
🩸 Confirmed APLS: adjusted dose VKA (target INR 2.5) > DOAC (weak)
🩸 Superficial venous thrombosis (SVT) of leg at risk of progression to DVT/PE: anticoagulation x 45 days > no anticoagulation (weak)
10/
🩸 SVT of leg at risk of progression to DVT/PE: fondaparinux 2.5 mg/d > other anticoagulants (weak)
🩸 SVT and unable to use parenteral anticoagulation: rivaroxaban 10 mg/d as an alternative to fondaparinux (weak)
🩸 SVT of leg at risk of progression to DVT/PE: fondaparinux 2.5 mg/d > other anticoagulants (weak)
🩸 SVT and unable to use parenteral anticoagulation: rivaroxaban 10 mg/d as an alternative to fondaparinux (weak)
11/
🩸 Acute VTE: 3 months of anticoagulation, then assess for extended-phase therapy (strong)
🩸 Acute VTE + major transient risk factor: NO extended-phase anticoagulation (strong)
🩸 Acute VTE + minor transient risk factor: NO extended-phase anticoagulation (weak)
🩸 Acute VTE: 3 months of anticoagulation, then assess for extended-phase therapy (strong)
🩸 Acute VTE + major transient risk factor: NO extended-phase anticoagulation (strong)
🩸 Acute VTE + minor transient risk factor: NO extended-phase anticoagulation (weak)
12/
🩸 Acute VTE that is unprovoked or due to persistent risk factor: extended-phase anticoagulation with DOAC (strong) or VKA if can't receive DOAC (weak)
🩸 Extended-phase anticoagulation: reduced-dose apixaban or rivaroxaban > full-dose of these agents (weak)
🩸 Acute VTE that is unprovoked or due to persistent risk factor: extended-phase anticoagulation with DOAC (strong) or VKA if can't receive DOAC (weak)
🩸 Extended-phase anticoagulation: reduced-dose apixaban or rivaroxaban > full-dose of these agents (weak)
13/
🩸 Extended-phase anticoagulation: reduced-dose DOAC > ASA or no therapy (strong) and reduced-dose rivaroxaban > ASA (weak)
🩸 Patients with unprovoked proximal DVT/PE who are stopping anticoagulation: ASA > no ASA (weak)
🩸 Extended-phase anticoagulation: reduced-dose DOAC > ASA or no therapy (strong) and reduced-dose rivaroxaban > ASA (weak)
🩸 Patients with unprovoked proximal DVT/PE who are stopping anticoagulation: ASA > no ASA (weak)
14/
🩸 Acute leg DVT, NO compression stockings to prevent post-thrombotic syndrome (weak)
Thanks to the many authors for these thoughtful recommendations.
@SCWollerMD @gjgeersing
/end
🩸 Acute leg DVT, NO compression stockings to prevent post-thrombotic syndrome (weak)
Thanks to the many authors for these thoughtful recommendations.
@SCWollerMD @gjgeersing
/end
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