American College of Chest Physicians Offers New Guidelines on Antithrombosis for VTE — Physician’s First Watch

Medical News |
January 8, 2016

American College of Chest Physicians Offers New Guidelines on Antithrombosis for VTE

By Kelly Young

Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS

The American College of Chest Physicians has issued new guidelines on antithrombotic therapy for venous thromboembolism (VTE), including guidance on use of non-vitamin K antagonist oral anticoagulants.

Among the recently changed or added recommendations, published in Chest:

  • For patients without cancer who have deep vein thrombosis (DVT) of the leg or pulmonary embolism (PE), the guidelines suggest using dabigatran, rivaroxaban, apixaban, or edoxaban instead of vitamin K antagonists for the first 3 months' treatment and beyond.

  • Patients with unprovoked proximal DVT or PE who are stopping anticoagulation should receive aspirin to reduce the risk for recurrent VTE, assuming aspirin is not contraindicated.

  • For patients who have acute DVT of the leg, compression stockings are not recommended to prevent post-thrombotic syndrome (PTS). However, for patients with PTS symptoms, "a trial of graduated compression stockings is often justified."

  • Patients with low-risk PE may be treated at home or receive an early discharge.

Reader Comments (5)

rita Other Healthcare Professional, Obstetrics/Gynecology, hospital

My 58 year old husband just died suddenly of a massive saddle pulmonary embolus while in Maui on vacation. He had a proximal DVT of his superficial femoral and popliteal vein on his left leg last year (also while in Maui for our 30 year wedding anniversary). His only risk factor was being over 50 and being on a plane; otherwise a fit, healthy guy with normal blood pressure and weight. He was placed on Rivaroxaban for 8 months. His specialist then recommended to go off of blood thinners and to stay on daily baby Aspirin for life. We were told he had only a 3% chance of a DVT recurrence and to travel and enjoy life! Of course, he followed this advice and we watched his legs daily for any symptoms of swelling or pain of which there were none!! The autopsy showed a DVT in his right leg and a double pulmonary saddle embolus which killed him in his sleep. We were not informed that a large percentage of deep vein thrombosis symptoms are actually silent! In fact, "30% of apparently isolated episodes of pulmonary embolism are associated with silent deep vein thrombosis" and "venous thrombosis can recur and its recurrence rate (after stopping anticoagulant treatment) is 25% within 5 years "!!!(Braz J Med Biol Res 2012 Jan, Ribeiro,et al) This is a 22% higher rate than we were told! Also, there was no recommendations for a thrombophilia workup (or other clotting disorders) "as this is was a clearly provoked event (the airplane ride)". My questions are: Why aren't clients informed of this 25%recurrence rate? This would have made me change all of our future travel plans to only cruises (never again an airplane ride if it was the provoking factor only). Or at least doctors should perhaps recommend that patients go back on Rivaroxaban 2weeks prior to the flight, during the whole vacation and up to 2 weeks after the flight!! Also, all clients should be informed that having other clotting disorders increases their risk of future DVT's, so then we could have opted to get these tests done and if they were positive,it would have put my husband in the category for lifelong Rivaroxaban and thus, he would likely still be alive!

f.fallahian-intensivist

As you know spiral chest CT angiography may not detect subsegmental division involvement of pulmonary artery, and if a patient suspected to PTE with high Wells score; it is better receive PTE treatment. But in this text I suppose it was written subsegmental invovlement need no treatment.

HRobert Silverstein Physician, Cardiology, Preventive Medicine Center

The authors of the original article and this post need an education in clear communication: the caveats MAY be accurate (or not) but the language borders on the absurd. HRS, MD, FACC

f.fallahian-intensivist

For subjects resistance to warfarin as need more than one tablet to save INR =2.5 , or have a new thrombosis episode while on warfarin, meanwhile not completely stand in the category of thrombophilia and lupus anticoagulant Abs, do you recommend LMWH or cheking with ROTEM or other couagulation defects- and starting another drug?

Margaret A Rosenthal, D.O. Physician, Internal Medicine, retired

CONCLUSION OF ABSTRACT: Of 54 recommendations included in the 30 statements, 20 were strong and NONE was based on high quality evidence highlighting the need for further research.
QUESTION: 1)Should we really be changing our guidelines i.e. getting rid of VIt K antagonist based on NO high quality evidence?

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