Latest Updates to Guidance on Prevention and Management of VTE

Neil Skolnik, MD


December 17, 2021

This transcript has been edited for clarity.

I'm Dr Neil Skolnik. Today I am going to talk about the American College of Chest Physician's guidelines on treatment of venous thromboembolic disease (VTE).  

Before we discuss the specific recommendations, it is worth knowing that the language used in the guidelines is very specific, with "suggested" being a weak recommendation and "recommended" being a strong recommendation.

Isolated distal deep vein thrombosis (DVT). This is defined as a DVT below the popliteal vein. Distal DVT is less worrisome than proximal DVT because distal DVT has a low risk of causing a pulmonary embolus (PE), but around 15% of the distal DVT extends proximally to become a proximal DVT.

Weekly ultrasounds for 2 weeks are suggested over immediate anticoagulation in patients who are at low risk for recurrent DVT. If repeat ultrasound shows that the thrombus has propagated, the patient should be treated.

Subsegmental PE. I want to touch on the recommendations for subsegmental PE. The guidelines give the option of not treating patients at low risk for recurrence of VTE, but I'm going to suggest that we ask for expert help because there are a lot of nuances as well as some new data that have come out since the guidelines were published.

If we find a PE incidentally when doing a CT for another reason, the guidelines recommend that it be managed the same as any other PE.

Where to treat PE — outpatient or inpatient? For low-risk PE, the guidelines make a strong recommendation for outpatient management over hospitalization.

For superficial thrombosis, we used to not treat at all, or we might treat with an NSAID. Now, based on the increased risk for extension to DVT, the guidelines suggest 45 days of anticoagulation.

Agent Choice and Duration of Therapy

With respect to choice of anticoagulation for patients with VTE, direct-acting oral anticoagulants (DOACs) are recommended over warfarin, mainly based on the lower risk for intracranial bleeding with DOACs.

The next decision is duration of treatment. The guidelines recommend 3 months of anticoagulation, after which we need to consider whether "extended therapy" is indicated. Long-term anticoagulation lowers the risk for recurrence by about 80%.

For decisions about extended anticoagulation, there are three subgroups:

  • Patients with a major transient risk factor (eg, surgery, cast): The guidelines recommend against extended therapy because the risk for recurrence is low — about 3% over 5 years.

  • Patients with a minor risk factor (eg, estrogen therapy, bedrest for fewer than 3 days, VTE after long car or airplane ride): The guidelines do not recommend extended anticoagulation. The risk for recurrence is about 6% in these patients.

  • For unprovoked DVT or for DVT with a persistent risk factor, long-term anticoagulation is recommended. The rationale for extended anticoagulation is that approximately 30% of people with an unprovoked DVT have recurrence of the VTE within 5 years.

Long-term anticoagulation comes with significant bleeding risk. To mitigate this risk, when extended therapy is indicated for long-term treatment and prevention of recurrence, the guidelines suggest the use of reduced-dose apixaban (2.5 mg twice daily) or rivaroxaban (10 mg daily) rather than the full dose of these agents. Reduced dosing brings the risk into the same range as using aspirin for long-term therapy but has the benefit of anticoagulation. Although not indicated for treatment or prevention of recurrence of VTE, aspirin therapy should be used if anticoagulation therapy is not instituted, and it reduces risk for recurrence by about 30% — not as good as the 80% achieved with long-term anticoagulation.

Finally, for prevention of postthrombotic syndrome, we used to recommend graduated compression hose. The guidelines now suggest that compression hose should not be used, based on a randomized trial showing no benefit.

These are some important updates on a high-risk condition that we see often.

I'm Neil Skolnik, and this is Medscape.

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