Taran The February conference will bring together an invited panel of approximately 90 guidelknes, who have developed the evidence review for the guidelines, in order to analyze this information and to come to a consensus on the recommendations for the guidelines. The ACCP is a medical professional society with antithrombofic 70 years of experience in conducting medical education conferences. This CHEST guideline series presents recommendations for the prevention, diagnosis, and treatment of thrombosis, addressing a comprehensive list of clinical conditions, including medical, surgery, orthopedic surgery, atrial fibrillation, stroke, cardiovascular disease, pregnancy, and neonates and children. Antithrombotic Therapy for Atrial Fibrillation: As the process of developing and publishing the guidelines takes three years, the ACCP is beginning in to develop the revision.
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Although it is well-known that anticoagulation therapy is effective in the prevention and treatment of VTE events, these agents are some of the highest-risk medications a hospitalist will prescribe given the danger of major bleeding. With the recent approval of several newer anticoagulants, it is important for the practicing hospitalist to be comfortable initiating, maintaining, and stopping these agents in a wide variety of patient populations. Image Credit: Shuttershock.
This 10th-edition guideline update is referred to as AT Now, the direct oral anticoagulants DOACs dabigatran, rivaroxaban, apixaban, or edoxaban are recommended over warfarin.
Although this is a weak recommendation based on moderate-quality evidence grade 2B , this is the first time that warfarin is not considered first-line therapy. It should be emphasized that none of the four FDA-approved DOACs are preferred over another, and they should be avoided in patients who are pregnant or have severe renal disease. When it comes to duration of anticoagulation following a VTE event, the updated guideline continues to recommend three months for a provoked VTE event, with consideration for lifelong anticoagulation for an unprovoked event for patients at low or moderate bleeding risk.
However, it now suggests that the recurrence risk factors of male sex and a positive D-dimer measured one month after stopping anticoagulant therapy should be taken into consideration when deciding whether extended anticoagulation is indicated. AT10 also includes new recommendations concerning the role of aspirin for extended VTE treatment. Interestingly, the ACCP guideline gave a strong recommendation against the use of aspirin for VTE management in any patient population.
In the guideline, the role of aspirin was not addressed for VTE treatment. Now, AT10 states that low-dose aspirin can be used in patients who stop anticoagulant therapy for treatment of an unprovoked proximal DVT or PE as an extended therapy grade 2B.
The significant change in this recommendation stems from two recent randomized trials that compared aspirin with placebo for the prevention of VTE recurrence in patients who have completed a course of anticoagulation for a first unprovoked proximal DVT or PE.
Another significant change in AT10 is the recommendation against the routine use of compression stockings to prevent postthrombotic syndrome PTS. This change was influenced by a recent multicenter randomized trial showing that elastic compression stockings did not prevent PTS after an acute proximal DVT. Thus, for patients with acute or chronic leg pain or swelling from DVT, compression stockings may be justified.
A topic that was not addressed in the previous guideline was whether patients with a subsegmental PE should be treated. Exceptions include patients at high risk for recurrent VTE e.
If the decision is made to not prescribe anticoagulation for subsegmental PE, patients should be advised to seek reevaluation if their symptoms persist or worsen. This recommendation has now been modified to state that patients with low-risk PE may be treated entirely at home. It is worth noting that outpatient management of low-risk PE has become much less complicated if using a DOAC, particularly rivaroxaban and apixaban as neither require initial treatment with parenteral anticoagulation.
AT10 has not changed the recommendation for which patients should receive thrombolytic therapy for treatment of PE. It recommends systemic thrombolytic therapy for patients with acute PE associated with hypotension defined as systolic blood pressure less than 90 mmHg for 15 minutes who are not at high risk for bleeding grade 2B.
Likewise, for patients with acute PE not associated with hypotension, the guideline recommends against systemic thrombolytics grade 1B. If thrombolytics are implemented, AT10 favors systemic administration over catheter-directed thrombolysis CDT due to the higher-quality evidence available. However, the authors state that CDT may be preferred for patients at higher risk of bleeding and when local expertise is available.
Lastly, catheter-assisted thrombus removal should be considered in patients with acute PE and hypotension who have a high bleeding risk, who have failed systemic thrombolytics, or who are in shock and likely to die before systemic thrombolytics become therapeutic. Although no prospective trials have evaluated the management of patients with recurrent VTE events while on anticoagulation therapy, AT10 offers some guidance.
Guideline Analysis It is important to note that of the 54 recommendations included in the complete guideline update, only 20 were strong recommendations grade 1 , and none were based on high-quality evidence level A. It is obvious that more research is needed in this field. Regardless, the ACCP antithrombotic guideline remains the authoritative source in VTE management and has a strong influence on practice behavior. With the recent addition of several newer anticoagulants, AT10 is particularly useful in helping providers understand when and when not to use them.
Hospital Medicine Takeaways Despite the lack of randomized and prospective clinical trials, the updated recommendations from AT10 provide important information on challenging VTE issues that the hospitalist can apply to most patients most of the time.
Avoid compression stockings for the sole purpose of preventing postthrombotic syndrome. Do not admit patients with low-risk PE as determined by the PESI score to the hospital but rather treat them entirely at home. Lastly, it is important to remember that VTE treatment decisions need to be individualized based on the clinical, imaging, and biochemical features of your patient.
Guidelines & Resources
Although it is well-known that anticoagulation therapy is effective in the prevention and treatment of VTE events, these agents are some of the highest-risk medications a hospitalist will prescribe given the danger of major bleeding. With the recent approval of several newer anticoagulants, it is important for the practicing hospitalist to be comfortable initiating, maintaining, and stopping these agents in a wide variety of patient populations. Image Credit: Shuttershock. This 10th-edition guideline update is referred to as AT
CHEST Guideline for Antithrombotic Therapy in VTE
VTE, the formation of blood clots in the vein, is a dangerous and potentially deadly medical condition and is a leading cause of death and disability worldwide. Key changes to recommendations in the 9th edition to the 10th edition include: Non-vitamin K antagonist oral anticoagulants NOACs are suggested over warfarin for initial and long-term treatment of VTE in patients without cancer. Since publication of the 9th edition, new studies show that NOACs are as effective as VKA therapy with reduced risk of bleeding and increased convenience for patients and health-care providers. Routine use of compression stockings is out to prevent postthrombotic syndrome in acute DVT. Based on recent evidence, the 10th edition suggests not to routinely use compression stockings to prevent postthrombotic syndrome in patients with acute DVT.
Updated ACCP Guideline for Antithrombotic Therapy for VTE Disease
Chest ; Anticoagulants should stop after 3 months of therapy in patients with an acute, proximal deep venous thrombosis DVT provoked by surgery rather than shorter or longer treatment courses Grade 1B. Anticoagulants should also be stopped after 3 months in patients with a proximal DVT or pulmonary embolism PE provoked by a nonsurgical transient risk factor over shorter or longer courses Grade 1B for high bleeding risk patients, Grade 2B for low or moderate bleeding risk patients. Anticoagulation should be given for 3 months in patients with a first unprovoked VTE and a high risk of bleeding Grade 1B , but should be extended without a scheduled stop date in patients with a low or moderate risk of bleeding Grade 2B. For patients with acute VTE who are treated with anticoagulation, the guideline recommends against the use of an inferior vena cava filter Grade 1B. For patients with an unprovoked proximal DVT or PE who are stopping anticoagulant therapy, the guideline suggests the use of aspirin over no aspirin to prevent recurrent VTE if there are no contraindications to aspirin therapy Grade 2B.
NEJM Journal Watch