Achieving Victory Over Venous Thromboembolism: Reviewing CHEST Guidelines

Volume 16, Issue 2

Venous thromboembolism (VTE) has an estimated prevalence of over 600,000 people in the United States, with approximately 60,000 to 100,000 people dying from this condition every year.

While oral anticoagulation has long been the standard of care for patients with VTE, and direct acting oral anticoagulants (DOACs) have supplanted warfarin as the standard of care, there is still sufficient new evidence to warrant a guideline update from the American College of Chest Physicians.

In this week’s issue of Talking Therapeutics, we cover the most salient updates to guidelines for VTE.

#1 For low-risk pulmonary embolism, outpatient treatment is adequate for initiation phase over hospitalization.

Patients must meet the following criteria to be treated for acute pulmonary embolism outside the hospital setting:

• clinically stable with cardiopulmonary reserve;
• no contraindications such as recent bleeding, severe renal or liver disease, or severe thrombocytopenia (ie, < 50,000/mm³);
• the patient can adhere to the proposed treatment regimen; and
• the patient’s preference and comfort with initiation of therapy at home.

The main reason for this new recommendation is to minimize the harms associated with hospitalization, such as contraction of a nosocomial infection.

As with most kinds of VTE, DOACs are recommended as first-line therapy for outpatient treatment of acute pulmonary embolism. This preference is based on a reduction in the risk of hemorrhage with DOAC therapy.

#2 Acute deep vein thrombosis of the leg can be managed with anticoagulation therapy alone without additional interventions, such as thrombolytic therapy or mechanical extraction.

The treatment phase should last 3 months and DOACs should be used preferentially over warfarin.

In patients with transient risk factors (such as recent surgery or a long flight), extended-phase anticoagulation is not recommended. Additionally, patients with unprovoked VTE or persistent risk factors should be offered extended-phase anticoagulation with a DOAC.

#3 For patients with antiphospholipid antibody syndrome, warfarin is preferred over DOAC therapy in light of recent evidence suggesting inferior outcomes with DOACs for this disease state.

#4 In patients with cancer-associated thrombosis, oral Xa inhibitors such as apixaban, rivoroxaban, or edoxaban are recommended over low-molecular weight heparin for both initiation and treatment phases.