Deep Venous Thrombosis and Pulmonary Embolism: Current Therapy

 

Pulmonary embolism and deep venous thrombosis are the two most important manifestations of venous thrombo-embolism (VTE), which is the third most common life-threatening cardiovascular disease in the United States. Anticoagulation is the mainstay of VTE treatment. Most patients with deep venous thrombosis or low-risk pulmonary embolism can be treated in the outpatient setting with low-molecular-weight heparin and a vitamin K antagonist (warfarin) or direct-acting oral anticoagulants. Inpatient treatment of VTE begins with parenteral agents, preferably low-molecular-weight heparin. Unfractionated heparin is used if a patient is hemodynamically unstable or has severe renal insufficiency, high bleeding risk, hemodynamic instability, or morbid obesity. Direct-acting oral anticoagulants are an alternative; however, concerns include cost and use of reversing agents (currently available only for dabigatran, although others are in development). If warfarin, dabigatran, or edoxaban is used, low-molecular-weight or unfractionated heparin must be administered concomitantly for at least five days and, in the case of warfarin, until the international normalized ratio becomes therapeutic for 24 hours. Hemodynamically unstable patients with a low bleeding risk may benefit from thrombolytic therapy. An inferior vena cava filter is not indicated for patients treated with anticoagulation. Current guidelines recommend anticoagulation for a minimum of three months. Special situations, such as active cancer and pregnancy, require long-term use of low-molecular-weight or unfractionated heparin. Anticoagulation beyond three months should be individualized based on a risk/benefit analysis. Symptomatic distal deep venous thrombosis should be treated with anticoagulation, but asymptomatic patients may be monitored with serial imaging for two weeks and treated only if there is extension.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are the two most important manifestations of venous thromboembolism (VTE), which is the third most common life-threatening cardiovascular disease, after myocardial infarction and stroke, in the United States.1 According to the Centers for Disease Control and Prevention, the annual incidence of VTE is one or two per 1,000 persons, and the overall mortality rate is between 60,000 and 100,000 annually.2 One-half of patients with DVT will have long-term complications, including postthrombotic syndrome and venous ulcers. One-third of patients with VTE will have a recurrence within 10 years.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Direct-acting oral anticoagulants are an alternative to vitamin K antagonist therapy (warfarin [Coumadin]) for VTE.

A

4, 19, 20

Most patients with deep venous thrombosis and selected patients with pulmonary embolism can be safely treated as outpatients.

B

8, 10, 11

Inferior vena cava filters should be avoided in patients with VTE treated with anticoagulation.

B

8, 9, 26, 27

If there are no contraindications, patients diagnosed with acute VTE should receive anticoagulation for a minimum of three months.

C

8, 9, 29


VTE = venous thromboembolism.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Direct-acting oral anticoagulants are an alternative to vitamin K antagonist therapy (warfarin [Coumadin]) for VTE.

A

4, 19, 20

Most patients with deep venous thrombosis and selected patients with pulmonary embolism can be safely treated as outpatients.

B

8, 10, 11

Inferior vena cava filters should be avoided in patients with VTE treated with anticoagulation.

B

8, 9, 26, 27

If there are no contraindications, patients diagnosed with acute VTE should receive anticoagulation for a minimum of three months.

C

8, 9, 29


VTE = venous thromboembolism.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN HEMATOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not recommend bed rest following diagnosis of acute deep venous thromboembolism after the initiation of anticoagulation therapy, unless significant medical concerns are present.

American Physical Therapy Association

Do not treat with an anticoagulant for more than three months in a patient

The Authors

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JASON WILBUR, MD, is an associate professor in the Department of Family Medicine at the University of Iowa Carver College of Medicine in Iowa City....

BRIAN SHIAN, MD, is an assistant professor in the Department of Family Medicine at the University of Iowa Carver College of Medicine.

Address correspondence to Jason Wilbur, MD, University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242 (e-mail: jason-wilbur@uiowa.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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