Chest
Volume 133, Issue 6, Supplement, June 2008, Pages 454S-545S
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Antithrombotic and Thrombolytic Therapy, 8th ED: ACCP Guidelines
Antithrombotic Therapy for Venous Thromboembolic Disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

https://doi.org/10.1378/chest.08-0658Get rights and content

This chapter about treatment for venous thromboembolic disease is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see “Grades of Recommendation” chapter). Among the key recommendations in this chapter are the following: for patients with objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE), we recommend anticoagulant therapy with subcutaneous (SC) low-molecular-weight heparin (LMWH), monitored IV, or SC unfractionated heparin (UFH), unmonitored weight-based SC UFH, or SC fondaparinux (all Grade 1A). For patients with a high clinical suspicion of DVT or PE, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C). For patients with confirmed PE, we recommend early evaluation of the risks to benefits of thrombolytic therapy (Grade 1C); for those with hemodynamic compromise, we recommend short-course thrombolytic therapy (Grade 1B); and for those with nonmassive PE, we recommend against the use of thrombolytic therapy (Grade 1B). In acute DVT or PE, we recommend initial treatment with LMWH, UFH or fondaparinux for at least 5 days rather than a shorter period (Grade 1C); and initiation of vitamin K antagonists (VKAs) together with LMWH, UFH, or fondaparinux on the first treatment day, and discontinuation of these heparin preparations when the international normalized ratio (INR) is ≥ 2.0 for at least 24 h (Grade 1A). For patients with DVT or PE secondary to a transient (reversible) risk factor, we recommend treatment with a VKA for 3 months over treatment for shorter periods (Grade 1A). For patients with unprovoked DVT or PE, we recommend treatment with a VKA for at least 3 months (Grade 1A), and that all patients are then evaluated for the risks to benefits of indefinite therapy (Grade 1C). We recommend indefinite anticoagulant therapy for patients with a first unprovoked proximal DVT or PE and a low risk of bleeding when this is consistent with the patient's preference (Grade 1A), and for most patients with a second unprovoked DVT (Grade 1A). We recommend that the dose of VKA be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations (Grade 1A). We recommend at least 3 months of treatment with LMWH for patients with VTE and cancer (Grade 1A), followed by treatment with LMWH or VKA as long as the cancer is active (Grade 1C). For prevention of postthrombotic syndrome (PTS) after proximal DVT, we recommend use of an elastic compression stocking (Grade 1A). For DVT of the upper extremity, we recommend similar treatment as for DVT of the leg (Grade 1C). Selected patients with lower-extremity (Grade 2B) and upper-extremity (Grade 2C). DVT may be considered for thrombus removal, generally using catheter-based thrombolytic techniques. For extensive superficial vein thrombosis, we recommend treatment with prophylactic or intermediate doses of LMWH or intermediate doses of UFH for 4 weeks (Grade 1B).

Section snippets

Initial Anticoagulation of Acute DVT of the Leg

1.1.1. For patients with objectively confirmed DVT, we recommend short-term treatment with SC LMWH (Grade 1A), IV UFH (Grade 1A), monitored SC UFH (Grade 1A), fixed-dose SC UFH (Grade 1A), or SC fondaparinux (Grade 1A) rather than no such short-term treatment.

1.1.2. For patients with a high clinical suspicion of DVT, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C).

1.1.3. In patients with acute DVT, we recommend initial treatment with LMWH,

Initial Anticoagulation of Acute DVT of the Leg

Anticoagulation is the main therapy for acute DVT of the leg. The main objectives of anticoagulant therapy in the initial treatment of this disease are to prevent thrombus extension and early and late recurrences of VTE. The evidence for the need for anticoagulation in patients with DVT is based on studies performed > 40 years ago. The first and only trial1 that compared anticoagulant therapy with no anticoagulant therapy in patients with symptomatic DVT or PE was published in 1960 (Barritt and

LONG-TERM TREATMENT OF ACUTE DVT OF THE LEG

In this review, long-term treatment refers to treatments that are continued after initial therapy, such as with heparin or thrombolytic agents, has been completed. Long-term therapy has two goals: (1) to complete treatment of the acute episode of VTE; and (2) to prevent new episodes of VTE that are not directly related to the acute event. During the early phase of long-term treatment (ie, first 3 months), treatment of the acute episode of VTE predominates. During the late phase of long-term

POSTTHROMBOTIC SYNDROME

PTS is a cluster of leg symptoms and signs in patients with previous DVT. PTS occurs in 20 to 50% of patients after acute DVT.226 The initial treatment of acute DVT may influence the presence and severity of PTS, as discussed earlier (Section 2.0). The most prominent symptoms are chronic postural dependent swelling and pain, ambulatory discomfort, and skin pigmentation. The severity of symptoms may vary over time, and the most extreme manifestation is a venous ulcer of the lower leg. First, the

INITIAL TREATMENT OF ACUTE PE

Treatment regimens for DVT and PE are similar because the two conditions are manifestations of the same disease process. When patients with VTE are carefully studied, the majority of those with proximal DVT also have PE (symptomatic or asymptomatic) and vice versa.185 Furthermore, clinical trials of anticoagulant therapy have yielded similar estimates for efficacy and safety in patients with DVT alone, in those with both DVT and PE, and in patients with only PE. The risk of recurrence also

LONG-TERM TREATMENT OF ACUTE PE

In the following sections, studies that were performed exclusively in patients with PE will be emphasized. In addition, subgroup analyses of PE patients enrolled in studies that included patients who only presented with symptoms of DVT will be presented. As the findings of studies with DVT patients are relevant to PE patients, and as the findings of studies performed exclusively in patients with PE have been consistent with studies that included DVT patients, the recommendations for long-term

CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION

CTPH occurs much more frequently after acute PE than had previously been believed. The old teaching was that CTPH had a prevalence of not more than 1 in 500 cases of acute PE; however, data from prospective cohort studies indicate the frequency is approximately 3%.315, 316, 317 After acute PE initiates CTPH, pulmonary vascular remodeling may cause severe pulmonary hypertension out of proportion to pulmonary vascular thrombosis.318

Treatment of Infusion Thrombophlebitis

Peripheral vein infusion thrombophlebitis is estimated to occur in 25 to 35% of hospitalized patients who have peripheral IV catheters.326 In a three-arm randomized trial327 of 120 hospitalized patients with infusion thrombophlebitis, diclofenac emulsion gel used topically three times daily and oral diclofenac (75 mg bid) were superior to placebo in relieving local symptoms of thrombophlebitis at 48 h, with positive responses in 60% in both active treatment groups vs only 20% in the control

ACUTE UEDVT

Although most episodes of DVT occur in the lower limbs, it is estimated that 1 to 4% of cases involve the upper extremities. UEDVT can be classified into two etiologic groups: primary (includes unprovoked with or without thrombophilia, effort related, and thoracic outlet syndrome) and secondary (provoked by central venous catheters, pacemakers, or cancer); secondary UEDVT accounts for 75 to 80% of all cases.344, 345, 346

UEDVT may involve the subclavian, axillary or brachial veins. Clinical

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