Author: Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)
Venous thromboembolic (VTE) disease is a commonly managed condition in the ED and consists of DVT (deep venous thrombosis) and PE (pulmonary embolism). The American College of Chest Physicians (ACCP) released an update of the diagnosis and management of these conditions in January 2016. This post is a quick review of the updated ACCP Evidence-Based Clinical Practice Guidelines. A full link to the guidelines is provided below.
Choice of Therapy
In patients with proximal DVT or PE and no cancer, treatment for three months with dabigatran, rivaroxaban, apixaban, or edoxaban over vitamin K antagonist (VKA) therapy is recommended (all Grade 2B). If not treated with a new oral anticoagulant, VKA therapy is recommended over low molecular weight heparin (LMWH) (Grade 2C).
Patients with cancer and VTE should be treated with LMWH over other anticoagulants (all Grade 2C).
No change in choice of initial anticoagulant is suggested if treatment must extend over three months (Grade 2C).
Remarks: Initial parenteral anticoagulation is given before dabigatran and edoxaban, is not given before rivaroxaban and apixaban, and is overlapped with VKA therapy.
Length of Treatment
Anticoagulation for three months is recommended with proximal DVT or PE (Grade 1B). Three months of treatment is recommended for VTE associated with nonsurgical, transient risk factors, or in association with surgery (Grade 1B).
In patients with unprovoked DVT or PE, anticoagulation for at least three months over treatment of a shorter timeframe is suggested (Grade 1B).
If an unprovoked proximal DVT or PE with low or moderate bleeding risk is present, at least three months of treatment is recommended (Grade 2B). For patients with high risk of bleeding and unprovoked VTE, three months of treatment is recommended (Grade 1B). After three months of treatment, evaluation of the risks and benefits of further treatment is recommended. Reassessment at least annually is needed if therapy is continued.
For an isolated distal DVT of the leg provoked by surgery or a transient risk factor, treatment for three months is recommended over a shorter period (Grade 2C).
If a second unprovoked VTE occurs with low or moderate risk of bleeding, anticoagulation for over three months is recommended (Grade 1B for low risk of bleeding, Grade 2B for moderate). For patients with high risk of bleeding, three months of therapy is recommended (Grade 2B). Reassessment of need for treatment should be completed at regular intervals.
If active cancer and VTE is present, over three months of therapy is suggested in those who do not have high risk of bleeding (Grade 1B). If high risk of bleeding is present, anticoagulation for over three months is suggested, though at a lower recommendation (Grade 2B).
If stopping anticoagulants after three months of treatment, aspirin should be used daily if no contraindications exist (Grade 2C).
Distal leg DVT
If acute isolated distal DVT is present with no severe symptoms or risk factors for extension, serial imaging of the deep veins for 2 weeks is suggested over anticoagulation (Grade 2C). If severe symptoms or risk factors for extension are present, anticoagulation is suggested (Grade 2C).
If treating acute distal DVT, the same anticoagulation therapy is warranted as for patients with acute proximal DVT (Grade 1B).
If managed with serial imaging, no anticoagulation is suggested if the thrombus does not extend (Grade 1B). Anticoagulation is recommended if the thrombus extends but remains in the distal veins (Grade 2C) and if the thrombus extends into the proximal veins (Grade 1B).
Thrombolytic Therapy for DVT
In patients with acute proximal DVT, anticoagulation alone over catheter-directed thrombolysis is suggested (Grade 2C).
Compression stockings are not routinely recommended for prevention of post-thrombotic syndrome in patients with acute DVT (Grade 2B).
In patients with acute DVT or PE under current treatment with anticoagulation, no IVC filter is recommended (Grade 1B).
Anticoagulation of Subsegmental PE
In patients with subsegmental PE (no proximal pulmonary artery involvement), no proximal DVT, and low risk for recurrent VTE, clinical surveillance over anticoagulation is recommended (Grade 2C). If high risk for recurrent VTE, anticoagulation is recommended (Grade 2C).* In this setting, ultrasound of the lower extremities should be obtained to exclude proximal DVT.
*The following are at risk for recurrent VTE: patients who are hospitalized or have reduced mobility for another reason; have active cancer (metastatic or being treated with chemotherapy); or have no reversible risk factor for VTE such as recent surgery. A low cardiopulmonary reserve or marked symptoms that cannot be attributed to another condition favor anticoagulant therapy, whereas a high risk of bleeding favors no anticoagulant therapy.
Out of Hospital Treatment for PE
In patients with low-risk PE and adequate follow up/home circumstances, home treatment or early discharge (before hospital day 5) is suggested (Grade 2B).
Systemic Thrombolytic Therapy for PE
In patients with acute PE, systolic BP less than 90mmHg, and low to moderate risk of bleeding, thrombolytic therapy is recommended (Grade 2B).
In the majority of patients with acute PE and no hypotension, no thrombolytics should be given (Grade 1B).
Thrombolytic therapy is recommended for patients with acute PE who decompensate after starting anticoagulation and have low bleeding risk (Grade 2C).
*The guidelines do not propose that echocardiography or cardiac biomarkers should be measured routinely in patients with PE because, when measured routinely, the results do not have clear therapeutic implications.
Catheter Based Treatments
In patients with acute PE who are treated with thrombolysis, systemic therapy via peripheral vein is recommended over catheter directed treatment (Grade 2C).
In patients with acute PE with hypotension but who have high bleeding risk, failed systemic thrombolysis, or shock that is likely to lead to death before systemic thrombolysis can take effect, catheter-assisted thrombus removal is recommended (Grade 2C).
Upper Extremity DVT
For patients with upper DVT of the axillary or proximal arm veins, anticoagulation over thrombolysis is recommended (Grade 2C).
Recurrent VTE on Anticoagulation
In patients with recurrent VTE while on anticoagulation with warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban, LMWH should be used temporarily for at least one month (Grade 2C).
Reevaluation of compliance, malignancy, and risk factors should be completed.
Reference / Further Reading
Kearon C, Akl EA, Ornelas J, Blaivas A, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline. Chest 2016. DOI: 10.1016/j.chest.2015.11.026