Venous thromboembolism (VTE) affects up to 900,000 individuals each year in the United States, with an estimated 60,000 to 100,000 related deaths. Approximately 10% to 30% of people with VTE will die within 1 month after diagnosis, and roughly one-third of patients experience a recurrence within 10 years.1 Such findings underscore the critical importance of adequate management of this disorder.
To that end, the American Society of Hematology released evidence-based guidelines for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients without cancer in the October 2020 issue of Blood Advances. The 28 recommendations were developed and graded by a multidisciplinary panel using the Grading of Recommendations Assessment, Development and Evaluation approach.2
“These guidelines will serve as an excellent resource to help support clinicians and others in the treatment of patients with VTE,” said Caroline Cromwell, MD, assistant professor of medicine in the division of hematology and medical oncology and the Icahn School of Medicine at Mount Sinai in New York. In addition to re-emphasizing direct oral anticoagulants (DOACs) as first-line treatment for VTE except in special circumstances, an “important point in the guidelines is that duration of anticoagulation is based mainly on the circumstance of the thrombotic episode — provoked or unprovoked.”
The recommendations are summarized below; all are conditional except for 3 strong recommendations as noted.
Recommendations 1 and 2 (low and very low certainty of evidence, respectively). Home treatment is recommended over hospital treatment for patients with uncomplicated DVT or PE, except for those with comorbid conditions requiring hospitalization, lack of adequate home support, history of poor treatment adherence, or inability to pay for medications. Hospital treatment may also be warranted for patients who have limb-threatening DVT, submassive or massive PE, high bleeding risk, or the need for IV analgesics.
Recommendations 3 and 4 (moderate and very low certainty, respectively). For DVT and/or PE, the guidelines recommended the use of DOACs over vitamin K antagonists (VKAs), with no preference for one DOAC over another. Factors such as renal insufficiency, liver disease, and cost may influence medication choice.
Recommendation 5 (low certainty). Anticoagulation therapy alone is recommended for most cases of proximal DVT, and the addition of thrombolytic therapy is not indicated. However, thrombolysis may be considered for patients with limb-threatening DVT and some younger patients.
Recommendation 6 (strong; low certainty). Thrombolytic therapy followed by anticoagulation over anticoagulation alone is suggested for patients with PE and hemodynamic compromise. Despite low certainty of evidence, the panel graded this as a strong recommendation due to the high mortality risk in this population and the potential lifesaving effect of thrombolytic therapy.
Recommendation 7 (low certainty). Anticoagulation alone (over routine use of thrombolysis in addition to anticoagulation) is recommended for patients with PE with echocardiography and/or biomarkers indicating right ventricular dysfunction in the absence of hemodynamic compromise.
Recommendation 8 (very low certainty). When thrombolysis is deemed appropriate for extensive DVT, catheter-directed thrombolysis is recommended over systemic thrombolysis.
Recommendation 9 (very low certainty). When thrombolysis is deemed appropriate for PE, systemic thrombolysis is recommended over catheter-directed thrombolysis.
Recommendations 10 and 11 (low certainty). Anticoagulation alone, without insertion of an inferior vena cava (IVC) filter, is recommended for proximal DVT with significant cardiopulmonary disease and for PE with hemodynamic compromise. If anticoagulation is contraindicated, a retrievable IVC filter may be warranted until anticoagulation is feasible.