Topic	Recommendation	Comments
Aspirin	Suggest initiating aspirin to prevent future VTE in patients with an unprovoked DVT or PE who decide to stop anticoagulation (grade 2B)	Aspirin should not be considered a substitute for anticoagulation but is suggested for patients who wish to stop therapy and not pursue lifelong anticoagulation following an unprovoked DVT or PE
Direct oral anticoagulants	Recommended for outpatient treatment of non–cancer-associated provoked or unprovoked VTE over vitamin K antagonists (grade 2B) and LMWH (grade 2C)	Simplification of anticoagulation management: no need for frequent dosage adjustments or international normalized ratio monitoring Andexanet alfa (Andexxa) is available to reverse apixaban (Eliquis) and rivaroxaban (Xarelto), and idarucizumab (Praxbind) is available to reverse dabigatran (Pradaxa)
LMWH	Recommended for outpatient treatment of cancer-associated provoked or unprovoked VTE over direct oral anticoagulants (grade 2C) and vitamin K antagonists (grade 2B)	Two studies have demonstrated a reduction in recurrence of VTE in patients with cancer treated with a direct oral anticoagulant (e.g., rivaroxaban, edoxaban [Savaysa]) compared with LMWH (e.g., dalteparin [Fragmin]); however, the studies also demonstrated an increased risk of bleeding, specifically in patients with esophageal or gastroesophageal cancer 4,5 CHEST guidelines have not been updated in response to these studies*
Location of care	Suggest care at home or early discharge for patients with low-risk PE who have adequate home support (grade 2B)	Criteria: clinically stable; no recent bleeding, no advanced renal disease, no advanced hepatic disease, no thrombocytopenia (< 70 × 103 per μL [70 × 109 per L]); adequate support at home and ability to adhere to regimen; patient feels comfortable with home care; no evidence of right ventricular dysfunction; normal cardiac biomarkers Pulmonary Embolism Severity Index may be used to help stratify risk
Recurrent VTE	Suggest changing to LMWH if recurrence while on vitamin K antagonists or direct oral anticoagulants (grade 2C) If recurrence while on LMWH, suggest increasing dose by one-fourth to one-third (grade 2C)	If unable to increase intensity, consider insertion of an inferior vena cava filter
Subsegmental PE	Low-risk subsegmental PE without proximal DVT, suggest surveillance instead of anticoagulation (grade 2C), suggest anticoagulation if higher risk of recurrence (grade 2C)	Factors associated with true subsegmental PE compared with a false-positive result on computed tomography: high-quality imaging; multiple filling defects; defects in proximal subsegmental vessels; multiple images with same defect; defect surrounded by contrast; symptoms consistent with PE; multiple views with defect; high pretest probability for PE; positive unexplained d-dimer assay results Factors associated with high risk of progression or recurrence: hospitalized patients; immobility or reduced mobility; cancer; unprovoked; low cardiopulmonary reserve; severe symptoms that cannot be explained otherwise All patients should be evaluated for DVT by ultrasonography of lower extremities; additional testing to rule out DVT is indicated for patients with signs or risk of an upper extremity DVT or a central-line–associated DVT