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CHEST Guideline on Antithrombotic Therapy for VTE

30 Jan, 2016 | 19:21h | UTC

Authors

Kearon C, Akl EA, Ornelas J et all

Citation

Antithrombotic Therapy for VTE Disease: CHEST Guideline. Published online January 07, 2016. Chest. 2016.

Context

The American College of Chest Physicians publishes periodically one of the most important guidelines on thrombosis and antithrombotic drugs. Full revision is undertaken every 3 to 4 years and since the last guideline (9th ed, 2012) a group of experts has been reviewing new evidence on a yearly basis to determine which recommendations require updating. This guideline updates include indications for the new oral anticoagulation drugs, the use of aspirin in patients with unprovoked proximal DVT or PE who are stopping anticoagulant therapy and the possibility of home treatment for low-risk pulmonary embolism.

10 Key points

1 – In patients with deep venous thrombosis (DVT) of the leg or pulmonary embolism (PE) provoked by surgery or by a nonsurgical transient risk factor (eg. estrogen therapy, leg injury or flight >8h) the guideline suggests anticoagulation for 3 months.

 

2 – In patients with an unprovoked DVT of the leg or PE the recommendation is to anticoagulate for at least 3 months. After 3 months of treatment these patients should be evaluated for the risk-benefit ratio of extended therapy. The bleeding risk, patient sex and D-dimer level measured after a month after stopping anticoagulant therapy are factors that will influence the decision. For more details on the complex decision regarding duration of treatment in these patients, please refer to the original article.

 

3 – In patients with and unprovoked proximal DVT or PE in whom a decision has been made to stop anticoagulant therapy and do not have a contraindication, aspirin is suggested as a less effective strategy to prevent recurrent venous thromboembolism (VTE).

 

4 – In patients with a second unprovoked VTE who have a low or moderate risk of bleeding, extended anticoagulant therapy (no scheduled stop date) is recommended. In patients with a high bleeding risk, 3 months of therapy is preferred.

 

5 – In patients with DVT of the leg or PE and active cancer who do not have a high bleeding risk, extended anticoagulant therapy (no scheduled stop date) is recommended.

 

6 – When anticoagulation for VTE is required in the long term in a patient without cancer, prefer dabigatran, rivaroxaban, apixaban or edoxaban over vitamin K antagonists (VKA) and VKA over low molecular weight heparin (LMWH).

 

7 – When anticoagulation for VTE is required in the long term in a patient with cancer, prefer LMWH over VKA, dabigatran, rivaroxaban, apixaban or endoxaban.

 

8 – In patients with low-risk PE whose home circumstances are adequate, treatment at home or early discharge is suggested.

 

9 – In patients with subsegmental PE and no proximal DVT in the legs who have a low risk for recurrent VTE (see original article), clinical surveillance is suggested over anticoagulation.

 

10 – In patients with acute PE with hypotension (e.g. systolic BP < 90 mmHg) who do not have high bleeding risk, systemic thrombolytic therapy is suggested.

 

Summary by

Euclides Cavalcanti, MD *

Revision by

Christian Morinaga, MD *

*The reviewers declare no conflicts of interest.

**This summary is for educational purposes only and is NOT endorsed by the American College of Chest Physicians. For the care of a given patient, please refer to the original article.


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