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HAMILTON, ONTARIO -- With about 10 million cases of venous thromboembolism (VTE) worldwide each year, emergency physicians are constantly faced with finding the most appropriate ways to treat those patients.
Now, the American College of Chest Physicians has provided 53 updated recommendations in an effort to improve treatment. The 10th edition, “Antithrombotic Therapy for VTE Disease: CHEST Guideline, from the American College of Chest Physicians,” appeared recently in the journal Chest.
"This guideline article, another from CHEST living guidelines, provides the most up-to-date treatment options for patients with VTE,” said lead author Clive Kearon, MD, of McMaster University in Ontario. “The guideline presents stronger recommendations and weaker suggestions for treatment based on the best available evidence, and identifies gaps in our knowledge and areas for future research."
The guidelines include strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence.
Among the most significant new recommendations is the recommendation of non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin for initial and long-term treatment of VTE in patients without cancer. New research has shown that NOACs are as effective with reduced risk of bleeding and more convenience for patients and healthcare providers than warfarin, which requires routine bloodwork, according to the document.
“For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C),” guideline authors wrote. “For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B).”
The 10th edition also provides more specific information on subsegmental pulmonary embolism treatment recommendations, distinguishing which patients diagnosed with isolated subsegmental pulmonary embolism (SSPE) should receive anticoagulant therapy and which should not.
In terms of prevention, the guidelines recommend against the routine use of compression stockings to prevent patients with acute DVT from developing post-thrombotic syndrome, a chronic condition of the leg with swelling, pain, skin discoloration, and possibly ulcers.
The authors further noted that “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."