Antithrombotic Therapy For VTE Disease

Publication Date: February 1, 2016
Last Updated: March 14, 2022

Recommendations

Choice of Long-Term (First 3 Months) and Extended (No Scheduled Stop Date) Anticoagulant

In patients with proximal DVT or pulmonary embolism (PE), we recommend long-term (3 months) anticoagulant therapy over no such therapy. (1, B)
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In patients with DVT of the leg or PE and no cancer, as long-term (first 3 months) anticoagulant therapy, we suggest dabigatran, rivaroxaban, apixaban, or edoxaban over vitamin K antagonist (VKA) therapy. (2, B)
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For patients with DVT of the leg or PE and no cancer who are not treated with dabigatran, rivaroxaban, apixaban, or edoxaban, we suggest VKA therapy over LMWH. (2, C)
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In patients with DVT of the leg or PE and cancer (“cancer-associated thrombosis”), as long-term (first 3 months) anticoagulant therapy,
  • we suggest LMWH over VKA therapy,
(2, B)
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  • dabigatran,
(2, C)
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  • rivaroxaban,
(2, C)
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  • apixaban
(, )
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  • or edoxaban
(2, C)
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In patients with DVT of the leg or PE who receive extended therapy, we suggest that there is no need to change the choice of anticoagulant after the first 3 months. (2, C)
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Duration of Anticoagulant Therapy

In patients with a proximal DVT of the leg or PE provoked by surgery, we recommend treatment with anticoagulation for 3 months over:
  • (i) treatment of a shorter period or
(1, B)
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  • (ii) treatment of a longer, time-limited period (eg, 6, 12, or 24 months) or
(1, B)
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  • (iii) extended therapy (no scheduled stop date).
(1, B)
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In patients with a proximal DVT of the leg or PE provoked by a nonsurgical transient risk factor, we recommend treatment with anticoagulation for 3 months over:
  • (i) treatment of a shorter period and
(1, B)
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  • (ii) treatment of a longer time-limited period (eg, 6, 12, or 24 months).
(1, B)
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  • We suggest treatment with anticoagulation for 3 months over extended therapy if there is a low or moderate bleeding risk and
(2, B)
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  • recommend treatment for 3 months over extended therapy if there is a high risk of bleeding.
(1, B)
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In patients with an isolated distal DVT of the leg provoked by surgery or by a nonsurgical transient risk factor,
  • we suggest treatment with anticoagulation for 3 months over treatment of a shorter period;
(2, C)
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  • we recommend treatment with anticoagulation for 3 months over treatment of a longer, time-limited period (eg, 6, 12, or 24 months);
(1, B)
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  • and we recommend treatment with anticoagulation for 3 months over extended therapy (no scheduled stop date).
(1, B)
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In patients with an unprovoked DVT of the leg (isolated distal or proximal) or PE,
  • we recommend treatment with anticoagulation for at least 3 months over treatment of a shorter duration,
(1, B)
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  • and we recommend treatment with anticoagulation for 3 months over treatment of a longer, time-limited period (eg, 6, 12, or 24 months).
(1, B)
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In patients with a first VTE that is an unprovoked proximal DVT of the leg or PE and who have a:
  • (i) low or moderate bleeding risk,we suggest extended anticoagulant therapy (no scheduled stop date) over 3 months of therapy,
(2, B)
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  • (ii) high bleeding risk (see text), we recommend 3 months of anticoagulant therapy over extended therapy (no scheduled stop date).
(1, B)
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In patients with a second unprovoked VTE and who have a:
  • (i) low bleeding risk, we recommend extended anticoagulant therapy (no scheduled stop date) over 3 months;
(1, B)
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  • (ii) moderate bleeding risk, we suggest extended anticoagulant therapy over 3 months of therapy;
(2, B)
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  • (iii) high bleeding risk, we suggest 3 months of anticoagulant therapy over extended therapy (no scheduled stop date).
(2, B)
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In patients with DVT of the leg or PE and active cancer (“cancer-associated thrombosis”) and who:
  • (i) do not have a high bleeding risk, we recommend extended anticoagulant therapy (no scheduled stop date) over 3 months of therapy, and
(1, B)
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  • (ii) have a high bleeding risk, we suggest extended anticoagulant therapy (no scheduled stop date) over 3 months of therapy.
(2, B)
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Aspirin for Extended Treatment of VTE

In patients with an unprovoked proximal DVT or PE who are stopping anticoagulant therapy and do not have a contraindication to aspirin, we suggest aspirin over no aspirin to prevent recurrent VTE. (2, B)
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Whether and How to Prescribe Anticoagulants to Patients With Isolated Distal DVT

In patients with acute isolated distal DVT of the leg and
  • (i) without severe symptoms or risk factors for extension, we suggest serial imaging of the deep veins for 2 weeks over anticoagulation and
(2, C)
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  • (ii) with severe symptoms or risk factors for extension, we suggest anticoagulation over serial imaging of the deep veins.
(2, C)
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In patients with acute, isolated, distal DVT of the leg who are managed with anticoagulation, we recommend using the same anticoagulation as for patients with acute proximal DVT. (1, B)
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In patients with acute, isolated, distal DVT of the leg who are managed with serial imaging, we
  • (i) recommend no anticoagulation if the thrombus does not extend,
(1, B)
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  • (ii) suggest anticoagulation if the thrombus extends but remains confined to the distal veins, and
(2, C)
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  • (iii) recommend anticoagulation if the thrombus extends into the proximal veins.
(1, B)
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CDT for Acute DVT of the Leg

In patients with acute proximal DVT of the leg, we suggest anticoagulant therapy alone over CDT. (2, C)
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Role of IVC Filter in Addition to Anticoagulation for Acute DVT or PE

In patients with acute DVT or PE who are treated with anticoagulants, we recommend against the use of an IVC filter. (1, B)
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Compression Stocking to Prevent PTS

In patients with acute DVT of the leg, we suggest not using compression stockings routinely to prevent PTS. (2, B)
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Whether to Treat Subsegmental PE

In patients with subsegmental PE (no involvement of more proximal pulmonary arteries) and no proximal DVT in the legs who have a:
  • (i) low risk for recurrent VTE, we suggest clinical surveillance over anticoagulation, and
(2, C)
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  • (ii) high risk for recurrent VTE, we suggest anticoagulation over clinical surveillance.
(2, C)
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Treatment of Acute PE Out of the Hospital

In patients with low-risk PE and whose home circumstances are adequate, we suggest treatment at home or early discharge over standard discharge (eg, after the first 5 days of treatment). (2, B)
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Systemic Thrombolytic Therapy for PE

In patients with acute PE associated with hypotension (eg, systolic BP <90 mm Hg) who do not have a high bleeding risk, we suggest systemically administered thrombolytic therapy over no such therapy. (2, B)
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In most patients with acute PE not associated with hypotension, we recommend against systemically administered thrombolytic therapy. (1, B)
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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, we suggest systemically administered thrombolytic therapy over no such therapy. (2, C)
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Catheter-Based Thrombus Removal for the Initial Treatment of PE

In patients with acute PE who are treated with a thrombolytic agent, we suggest systemic thrombolytic therapy using a peripheral vein over CDT. (2, C)
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In patients with acute PE associated with hypotension and who have:

(i) a high bleeding risk,
(ii) failed systemic thrombolysis, or
(iii) shock that is likely to cause death before systemic thrombolysis can take effect (eg, within hours),

if appropriate expertise and resources are available, we suggest catheter-assisted thrombus removal over no such intervention. (2, C)
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Pulmonary Thromboendarterectomy in for the Treatment of Chronic Thromboembolic Pulmonary Hypertension

In selected patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are identified by an experienced thromboendarterectomy team, we suggest pulmonary thromboendarterectomy over no pulmonary thromboendarterectomy. (2, C)
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Thrombolytic Therapy in Patients With Upper Extremity DVT

In patients with acute upper extremity DVT (UEDVT) that involves the axillary or more proximal veins, we suggest anticoagulant therapy alone over thrombolysis. (2, C)
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In patients with UEDVT who undergo thrombolysis, we recommend the same intensity and duration of anticoagulant therapy as in patients with UEDVT who do not undergo thrombolysis. (1, B)
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Management of Recurrent VTE on Anticoagulant Therapy

In patients who have recurrent VTE on VKA therapy (in the therapeutic range) or on dabigatran, rivaroxaban, apixaban, or edoxaban (and are believed to be compliant), we suggest switching to treatment with LMWH at least temporarily. (2, C)
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In patients who have recurrent VTE on long-term LMWH (and are believed to be compliant), we suggest increasing the dose of LMWH by about one-quarter to one-third. (2, C)
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Recommendation Grading

Overview

Title

Antithrombotic Therapy For VTE Disease

Authoring Organization

American College of Chest Physicians

Publication Month/Year

February 1, 2016

Last Updated Month/Year

July 27, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

We update recommendations on 12 topics regarding antithrombotic therapy for VTE disease that were in the 9th edition of these guidelines, and address 3 new topics.

Target Patient Population

Patients with risk of DVT

Inclusion Criteria

Male, Female, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Home health, Hospice, Hospital, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D054556 - Venous Thromboembolism, D020246 - Venous Thrombosis, D000925 - Anticoagulants, D056824 - Upper Extremity Deep Vein Thrombosis

Keywords

anticoagulation, Antithrombotic Agents, Venous Thromboembolism, deep venous thrombosis, Anticoagulation

Methodology

Number of Source Documents
227
Literature Search Start Date
August 1, 2014
Literature Search End Date
November 30, 2020