ACCP releases updated guidelines on thromboembolic disease

The guidelines apply to patients with suspicious, acute and confirmed venous thrombosis.

Updated recommendations from the American College of Chest Physicians address a number of concerns related to deep vein thrombosis and pulmonary embolism.

The guidelines, which were published in a July supplement to Chest, provide evidence-based information on antithrombotic therapy for venous thromboembolic disease.

Using a grading system, the society categorized its recommendations as strong (grade 1) and weak (grade 2). Grade 1 recommendations indicate that benefits do or do not outweigh risks, burden and costs; grade 2 recommendations suggest individual patient values may lead to different choices, according to the abstract.

Recommended therapies

For patients with objectively confirmed DVT or pulmonary embolism, grade 1 recommendations included: anticoagulant therapy with subcutaneous low–molecular-weight heparin, monitored IV or subcutaneous unfractionated heparin, unmonitored weight-based subcutaneous unfractionated heparin or subcutaneous fondaparinux.

Physicians should treat patients who have a high suspicion of DVT or pulmonary embolism with anticoagulants while awaiting the outcome of diagnostic tests, according to the grade 1 guidelines.

Patients with confirmed pulmonary embolism should receive an early evaluation of risks to benefits of thrombolytic therapy and those with hemodynamic compromise should have short-course thrombolytic therapy. However, the ACCP did not recommend thrombolytic therapy for use in patients with nonmassive pulmonary embolism.

The ACCP recommended initial treatment with low–molecular-weight heparin, unfractionated heparin or fondaparinux for at least five days in patients with acute DVT or pulmonary embolism. It also recommended that these patients receive vitamin K antagonists in combination with low–weight-molecular heparin, unfractionated heparin or fondaparinux on the first day of treatment. The heparin preparations should be discontinued when international normalized ratio reaches ≥2 for at least 24 hours.

Instead of treating for shorter periods, the guidelines suggested treating patients with DVT or pulmonary embolism secondary to a transient risk factor with a vitamin K antagonist for three months. The ACCP also recommended treatment with vitamin K antagonists for at least three months in those with unprovoked DVT or pulmonary embolism. These patients should also be assessed for risks and benefits of indefinite therapy.

Recommendations for patients with cancer

Physicians should treat patients with a first unprovoked proximal DVT or pulmonary embolism and a low risk of bleeding with anticoagulant therapy indefinitely, as long as it is consistent with the patient’s preference, the ACCP recommended. They should also use this therapy in patients with a second unprovoked DVT or pulmonary embolism.

Vitamin K antagonist doses should be adjusted to maintain an INR level of 2.5 for the duration of all treatments.

The ACCP recommended that patients with venous thromboembolism and cancer receive at least three months of low–molecular-weight heparin followed by treatment with low–molecular-weight heparin or vitamin K antagonists, unless the cancer is inactive.

The ACCP recommended that an elastic compression stocking be used to prevent post-thrombotic syndrome after proximal DVT. Treatment similar to that for DVT of the leg is also recommended for DVT of the upper extremity. Patients with lower- and upper-extremity DVT may be considered for thrombus removal using catheter-based thrombolytic techniques.

Prophylactics or four weeks of intermediate doses of low–molecular-weight heparin or unfractionated heparin should be used in patients with extensive superficial vein thrombosis.

HemOnc Today previously reported on the ACCP recommendations for thromboembolic complications in pregnant women and children, which are addressed in an additional section of the guidelines.

Chest. 2008;133:454S-545S.