Venous Thromboembolism: Management Guidelines from the American Society of Hematology
Am Fam Physician. 2021 Oct ;104(4):429-431.
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Key Points for Practice
• In-hospital and home treatment of PE provide similar outcomes, although home treatment of DVT produces better outcomes.
• After primary DOAC treatment for three to six months, decisions for indefinite anticoagulation depend on risk factors associated with initial VTE.
• When VTE is unprovoked or associated with chronic factors, indefinite anticoagulation reduces recurrent VTE with a slightly increased risk of major bleeding.
• Aspirin is less effective than anticoagulants at reducing VTE risk but has similar major bleeding risk.
From the AFP Editors
Every year, up to two in every 1,000 people in the United States experience venous thromboembolism (VTE). The American Society of Hematology has updated recommendations for management of VTE, which includes deep venous thrombosis (DVT) and pulmonary embolism (PE).
Initial Management of VTE
Treating VTE at home often produces better outcomes than treating in the hospital. In patients with uncomplicated DVT, treating at home reduces the likelihood of PE development. The risk of a subsequent DVT is also less (number needed to treat [NNT] = 29; 95% CI, 24 to 143). Mortality and bleeding rates with DVT are similar between treatment settings. For patients with clinically stable PE, home treatment produces outcomes similar to those with hospital treatment.
In the absence of threat to the limb or high risk of severe postthrombotic syndrome, thrombolytic therapy is not recommended for DVT. Up to one-half of patients with proximal DVT develop postthrombotic syndrome, although only 10% will experience severe symptoms. Thrombolysis reduces postthrombotic syndrome (NNT = 6; 95% CI, 5 to 11) but increases major bleeding (number needed to harm [NNH] = 33; 95% CI, 20 to 63), with similar mortality and subsequent VTE risks. Systemic, regional, and catheter-directed thrombolysis have similarly elevated bleeding risks. With extensive DVT, the benefits of catheter-directed thrombolysis to prevent PE are uncertain.
In patients with PE and hemodynamic compromise demonstrated by systolic blood pressure reduction of at least 40 mm Hg from baseline or systolic blood pressure measurement below 90 mm Hg, the guideline strongly recommends thrombolytic therapy to reduce mortality despite a significant risk of major bleeding that includes intracranial bleeding. In PE with right ventricular dysfunction but no hemodynamic compromise, also called submassive PE, the decision is complicated by poor evidence quality. Mortality may slightly improve after thrombolysis, and catheter-directed thrombolysis may be better than systemic thrombolysis, but evidence is insufficient to recommend these treatments and anticoagulation alone is suggested.
Although direct oral anticoagulant (DOAC) treatment has similar effects on mortality and subsequent VTE risk as vitamin K antagonists, the risk of major bleeding is lower using DOACs (NNT = 167; 95% CI, 112 to 334). DOAC treatment appears to reduce cost by eliminating monitoring requirements. Patients who have antiphospholipid antibody syndrome or morbid obesity, or who have had bariatric surgery, are poor candidates for DOAC treatment. No particular DOAC is recommended.
INFERIOR VENA CAVA FILTERS
Inferior vena cava filters are not recommended with anticoagulation because they do not reduce PE or mortality and commonly cause adverse effects.
Primary VTE Treatment
Treatment of initial VTE is most effective for three to six months. Although longer treatment reduces the likelihood of recurrence, this benefit may be offset by increases in bleeding and mortality. After primary treatment, secondary VTE prevention is recommended for patients with a chronic persistent risk factor (Table 1) without a high risk of bleeding complications. There are separate recommendations for patients with cancer.
Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.
This series is coordinated by Michael J. Arnold, MD, contributing editor.
A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.
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