New guidelines on preventing, diagnosing, and treating venous thromboembolism VTE were recently released by the American Society of Hematology. Among other recommendations, they strongly recommend pharmacological VTE prophylaxis in acutely or critically ill inpatients who have acceptable bleeding risk and mechanical prophylaxis when bleeding risk is too high. The guideline also strongly recommends against using direct oral anticoagulants during hospitalization or extending pharmacological prophylaxis after hospital discharge. Nonhospital recommendations in the guideline address patients in long-term care facilities, outpatients with minor injuries, and long-distance travelers.
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Although it is well-known that anticoagulation therapy is effective in the prevention and treatment of VTE events, these agents are some of the highest-risk medications a hospitalist will prescribe given the danger of major bleeding.
With the recent approval of several newer anticoagulants, it is important for the practicing hospitalist to be comfortable initiating, maintaining, and stopping these agents in a wide variety of patient populations. Image Credit: Shuttershock.
This 10th-edition guideline update is referred to as AT Now, the direct oral anticoagulants DOACs dabigatran, rivaroxaban, apixaban, or edoxaban are recommended over warfarin.
Although this is a weak recommendation based on moderate-quality evidence grade 2B , this is the first time that warfarin is not considered first-line therapy. It should be emphasized that none of the four FDA-approved DOACs are preferred over another, and they should be avoided in patients who are pregnant or have severe renal disease.
When it comes to duration of anticoagulation following a VTE event, the updated guideline continues to recommend three months for a provoked VTE event, with consideration for lifelong anticoagulation for an unprovoked event for patients at low or moderate bleeding risk.
However, it now suggests that the recurrence risk factors of male sex and a positive D-dimer measured one month after stopping anticoagulant therapy should be taken into consideration when deciding whether extended anticoagulation is indicated. AT10 also includes new recommendations concerning the role of aspirin for extended VTE treatment. Interestingly, the ACCP guideline gave a strong recommendation against the use of aspirin for VTE management in any patient population.
In the guideline, the role of aspirin was not addressed for VTE treatment. Now, AT10 states that low-dose aspirin can be used in patients who stop anticoagulant therapy for treatment of an unprovoked proximal DVT or PE as an extended therapy grade 2B. The significant change in this recommendation stems from two recent randomized trials that compared aspirin with placebo for the prevention of VTE recurrence in patients who have completed a course of anticoagulation for a first unprovoked proximal DVT or PE.
Another significant change in AT10 is the recommendation against the routine use of compression stockings to prevent postthrombotic syndrome PTS. This change was influenced by a recent multicenter randomized trial showing that elastic compression stockings did not prevent PTS after an acute proximal DVT. Thus, for patients with acute or chronic leg pain or swelling from DVT, compression stockings may be justified. A topic that was not addressed in the previous guideline was whether patients with a subsegmental PE should be treated.
Exceptions include patients at high risk for recurrent VTE e. If the decision is made to not prescribe anticoagulation for subsegmental PE, patients should be advised to seek reevaluation if their symptoms persist or worsen. This recommendation has now been modified to state that patients with low-risk PE may be treated entirely at home.
It is worth noting that outpatient management of low-risk PE has become much less complicated if using a DOAC, particularly rivaroxaban and apixaban as neither require initial treatment with parenteral anticoagulation. AT10 has not changed the recommendation for which patients should receive thrombolytic therapy for treatment of PE. It recommends systemic thrombolytic therapy for patients with acute PE associated with hypotension defined as systolic blood pressure less than 90 mmHg for 15 minutes who are not at high risk for bleeding grade 2B.
Likewise, for patients with acute PE not associated with hypotension, the guideline recommends against systemic thrombolytics grade 1B.
If thrombolytics are implemented, AT10 favors systemic administration over catheter-directed thrombolysis CDT due to the higher-quality evidence available. However, the authors state that CDT may be preferred for patients at higher risk of bleeding and when local expertise is available. Lastly, catheter-assisted thrombus removal should be considered in patients with acute PE and hypotension who have a high bleeding risk, who have failed systemic thrombolytics, or who are in shock and likely to die before systemic thrombolytics become therapeutic.
Although no prospective trials have evaluated the management of patients with recurrent VTE events while on anticoagulation therapy, AT10 offers some guidance. Guideline Analysis It is important to note that of the 54 recommendations included in the complete guideline update, only 20 were strong recommendations grade 1 , and none were based on high-quality evidence level A. It is obvious that more research is needed in this field.
Regardless, the ACCP antithrombotic guideline remains the authoritative source in VTE management and has a strong influence on practice behavior. With the recent addition of several newer anticoagulants, AT10 is particularly useful in helping providers understand when and when not to use them. Hospital Medicine Takeaways Despite the lack of randomized and prospective clinical trials, the updated recommendations from AT10 provide important information on challenging VTE issues that the hospitalist can apply to most patients most of the time.
Avoid compression stockings for the sole purpose of preventing postthrombotic syndrome. Do not admit patients with low-risk PE as determined by the PESI score to the hospital but rather treat them entirely at home.
Lastly, it is important to remember that VTE treatment decisions need to be individualized based on the clinical, imaging, and biochemical features of your patient.
CHEST Guideline for Antithrombotic Therapy in VTE
Although it is well-known that anticoagulation therapy is effective in the prevention and treatment of VTE events, these agents are some of the highest-risk medications a hospitalist will prescribe given the danger of major bleeding. With the recent approval of several newer anticoagulants, it is important for the practicing hospitalist to be comfortable initiating, maintaining, and stopping these agents in a wide variety of patient populations. Image Credit: Shuttershock. This 10th-edition guideline update is referred to as AT Now, the direct oral anticoagulants DOACs dabigatran, rivaroxaban, apixaban, or edoxaban are recommended over warfarin. Although this is a weak recommendation based on moderate-quality evidence grade 2B , this is the first time that warfarin is not considered first-line therapy. It should be emphasized that none of the four FDA-approved DOACs are preferred over another, and they should be avoided in patients who are pregnant or have severe renal disease.
Updated ACCP Guideline for Antithrombotic Therapy for VTE Disease
In regard to new oral anticoagulants, guideline authors recognize the recent clinical trials of apixaban and rivaroxaban, both direct factor Xa inhibitors, and dabigatran etexilate, a direct thrombin inhibitor, and offer recommendations for the new agents for select clinical conditions, including atrial fibrillation and orthopedic surgery. Innovations in Antithrombotic Guidelines The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines include innovations that have significantly impacted the more than recommendations for the prevention, diagnosis, and treatment of thrombosis. Two key advances are the more explicit and quantitative consideration of patient values and preferences and restriction of outcomes to only those deemed to be important for the patient. The latter innovation results in different interpretation of the body of evidence in thrombosis prevention that has previously focused on the detection of asymptomatic thrombosis by surveillance methods. Guideline authors also took a more critical look at the overall process of guideline development, providing more methodologically sophisticated scrutiny of all available evidence.
New guidelines cover VTE prophylaxis, diagnosis, anticoagulation, and HIT