American College of Chest Physicians Guideline on Antithrombotic Therapy for VTE Disease

SUMMARY:

The decision whether to prescribe anticoagulation (AC) for deep vein thrombosis (DVT) or pulmonary embolism (PE), and for what duration, is a highly individualized one that must take into account several clinical variables as well as patient preferences. Recommendations for AC are tailored based on a patient’s bleeding risk profile, characteristics of DVT (proximal vs. distal) and the clinical context in which VTE has occurred (provoked vs. unprovoked, association with active cancer). The American College of Chest Physicians offers a comprehensive evidence-based guideline on how and when to treat VTE with anticoagulation.

Anticoagulation Choices

No Active Cancer

• Novel oral anticoagulants (NOAC) preferred over warfarin or low-molecular-weight heparin (LMWH)
  • NOACs (equivalent efficacy for treatment of VTE): dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa)
  • Dabigatran and edoxaban require initial parenteral therapy (unfractionated or LMWH) | Rivaroxaban and apixaban do not
  • If NOAC contraindicated: Use warfarin

With Active Cancer

• LMWH
• Inferior vena cava (IVC) filter
  • Reserved for patients with proximal DVT/PE who have an absolute contraindication to anticoagulation such as active bleeding
  • Not recommended in combination with AC

Proximal DVT or PE

• Provoked by surgery or a “nonsurgical transient risk factor” (e.g. pregnancy hormone therapy, long-distance air travel, leg injury)
  • 3 months AC
  • Duration is based on evidence that provoked VTE has a lower risk of recurrence
• Unprovoked (no surgery or identifiable transient risk factor)
  • While hereditary thrombophilia is associated with an increased VTE risk, there is little clinical benefit of testing for this condition, as its utility in decision making regarding anticoagulation is low

Without Active Cancer

• Low or moderate bleeding risk
  • “At least” 3 months vs extended (no stop date) AC
  • Decision to continue AC beyond 3 months influenced by patient sex and D-dimer (measured 1 month after stopping AC)
    • Men have 75% higher risk of recurrence than women
    • Positive D-dimer: Double risk of recurrence
• High bleeding risk
  • 3 months AC
  • “After 3 months of treatment, patients with unprovoked DVT of the leg or PE should be evaluated for the risk-benefit ratio of extended therapy.”

With Active Cancer

• Extended AC regardless of bleeding risk
• “In all patients who receive extended anticoagulant therapy, the continuing use of treatment should be reassessed at periodic intervals”
• If decision is made to stop AC for unprovoked VTE,
  • “suggest” aspirin to prevent recurrence | Not as effective as AC

Isolated Distal DVT

“It is anticipated that not all patients who are diagnosed with isolated distal DVT will be prescribed anticoagulants”

• Initiate AC (provoked or unprovoked)
  • 3 months AC or
  • Serial US imaging for 2 weeks if no severe symptoms or risk factors for extension
• Risk factors for extension include
  • Positive D-dimer | Extensive (>5 cm) thrombus | Thrombus close to proximal veins | No reversible provoking factor | Active cancer | Prior VTE | Inpatient status
• Initiate AC if
  • Thrombus has extended on repeat imaging (even if it remains isolated to distal veins)
  • Severe symptoms or risk factors for extension are present
    • Administer AC according to same rules as for proximal DVT

KEY POINTS:

Recurrent VTE

• Patient already on warfarin (with therapeutic INR) or NOAC with good compliance
  • Switch to LMWH for at least 1 month
  • Already on LMWH: Increase dose by 1/4 to 1/3
• Risk of recurrent VTE
  • Low risk: VTE is provoked by surgery
  • Intermediate risk: Provoked by a non-surgical risk factor
  • High risk: Unprovoked

Special Considerations

Upper Extremity DVT

• Commonly provoked by central venous catheter
• Axillary or more proximal veins
  • 3 months AC
• Consider thrombolysis for patient with
  • Severe symptoms lasting <14 days | Thrombus involving most of subclavian and axillary veins | Good functional status and life expectancy | Low bleeding risk

Subsegmental PE And No Proximal DVT

• Low risk of recurrence: Clinical surveillance
• High risk of recurrence: AC

Hemodynamically significant PE (causing hypotension)

• Low or moderate bleeding risk: systemic thrombolysis
• High bleeding risk, failed thrombolysis, or shock: catheter-directed thrombectomy

Anticoagulant Options for Acute VTE

• Apixaban
  • 10 mg oral twice daily for 7 days
  • 5 mg oral twice daily
  • Consider 2.5 mg twice daily beyond 6 months
• Rivaroxaban
  • 15 mg oral twice daily for 21 days
  • 20 mg once daily
  • Consider 10 mg daily beyond 6 months
• Warfarin
  • Start a parenteral anticoagulant and warfarin simultaneously
  • Continue LMWH for a minimum of 5 days and until the INR has reached ≥2 on 2 consecutive days then stop the parenteral anticoagulant and continue warfarin alone
  • Adjust warfarin dose to target INR 2.0 to 3.0
• LMWH
  • Dalteparin (CrCl ≥ 30 mL/min)
    • 200 units/kg subcutaneously once daily or 100 units/kg twice daily
  • Enoxaparin
    • CrCl ≥ 30 mL/min: 1.5 mg/kg subcutaneously once daily or 1 mg/kg twice daily
    • CrCl ≤ 30 mL/min: 1 mg/kg subcutaneously once daily

Learn More – Primary Sources

Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report