What are the new or revised recommendations in the updated ACCP guidelines on antithrombotic therapy and prevention of thrombosis?

Updated: Jun 06, 2019
  • Author: Daniel R Ouellette, MD, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Answer

In 2016, the American College of Chest Physicians (ACCP) updated recommendations on 12 topics that were in the 9th edition of their Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis guidelines, and address three new topics. [111]

Key new or revised recommendations include the following:

  • Dabigatran, rivaroxaban, apixaban, or edoxaban are preferred over vitamin K antagonist (VKA) therapy as long-term (first 3 months) anticoagulant therapy for noncancer patients (all grade 2B).
  • Low-molecular-weight heparin (LMWH) is recommended over VKA therapy, dabigatran, rivaroxaban, apixaban, or edoxaban as long-term (first 3 months) anticoagulant therapy for patients with cancer-associated thrombosis (all grade 2C).
  • Aspirin is recommended over no aspirin to prevent recurrent venous thromboembolism (VTE) in patients who are stopping anticoagulant therapy and do not have a contraindication to aspirin (grade 2B).
  • In most patients with acute pulmonary embolism (PE) not associated with hypotension, systemically administered thrombolytic therapy is recommended against (grade 1B).
  • In selected patients with acute PE who deteriorate after starting anticoagulant therapy but have yet to develop hypotension and who have a low bleeding risk, systemically administered thrombolytic therapy is preferred over no such therapy (grade 2C).

According to ACCP 9th edition guidelines, immediate therapeutic anticoagulation should be initiated for patients in whom deep venous thrombosis (DVT) or PE (grade 1B) is suspected. [5] Anticoagulation therapy reduces mortality rates from 30% to less than 10%. Diagnostic investigations should not delay empirical anticoagulant therapy in patients with high or intermediate risk of PE (grade 2C).

For acute PE, the ACCP guidelines recommend starting LMWH or fondaparinux, preferred over unfractionated heparin (UFH) (grade 2C for LMWH; grade 2B for fondaparinux) or subcutaneous heparin (grade 2B for LMWH; grade 2C for fondaparinux). [5] If patients are to be treated with LMWH, once-daily treatment is preferred to twice-daily treatment (grade 2C).

Patients who are considered to be low risk should be discharged early from hospital (grade 2B).

Patients should have an oral anticoagulant (warfarin) initiated at the time of diagnosis, and they should have UFH, LMWH, or fondaparinux discontinued only after the international normalized ratio (INR) is 2.0 for at least 24 hours but no sooner than 5 days after warfarin therapy has been started (grade 1B). The recommended duration of UFH, LMWH, and fondaparinux is based on evidence suggesting that the relatively long half-life of factor II, along with the short half-lives of protein C and protein S, may provoke a paradoxical hypercoagulable state if these agents are discontinued prematurely.


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