Clinical Question

What are the latest recommendations for anti-thrombotic therapy for patients with venous thromboembolism (VTE)?

Bottom Line

The guideline covers a lot of ground. Key updates include a clear preference for direct oral anti-coagulants, including in patients with cancer, and low-dose apixaban (Eliquis) or rivaroxaban (Xarelto) for extended-phase anticoagulation in patients with unprovoked VTE. There is greater leeway for observation only of selected patients with subsegmental pulmonary embolism (PE) or isolated distal lower extremity deep venous thrombosis (DVT), and outpatient treatment of selected patients with PE. (Level of Evidence = 1a)

Synopsis

The latest update to the American College of Chest Physicians guideline regarding antithrombotic therapy for VTE adds four new recommendations and updates eight others. The authors identified an initiation phase when anticoagulants are first given, a treatment phase of three months, and an extended phase for selected patients beyond three months. For patients with acute isolated distal DVT, the guidelines recommend two weeks of serial imaging, with anticoagulation only if the DVT extends or the patient has severe symptoms or risk factors for extension. For patients with subsegmental PE, no proximal DVT in the legs, and who are at low risk for recurrent VTE, clinical observation without anticoagulation is recommended. Outpatient therapy for PE is recommended if patients are clinically stable; there is no recent bleeding, thrombocytopenia, or severe liver or kidney disease; and they feel well enough to be treated at home and are likely to be adherent. For patients with asymptomatic PE incidentally diagnosed during computed tomography of the chest, anticoagulation is recommended because studies have shown a similar prognosis to symptomatic PE.