Primary treatment

Recommendations 12 to 14 (moderate certainty). For DVT and/or PE provoked by a transient or chronic risk factor, as well as unprovoked DVT and/or PE, a shorter (3 to 6 months) vs longer (6 to 12 months) duration of primary anticoagulant treatment is recommended. The longer course may be indicated for certain patients.

Secondary prevention


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Recommendations 15 to 17 (very low certainty). In determining whether to discontinue anticoagulation after primary treatment for unprovoked DVT and/or PE, the guidelines recommended against routine use of prognostic scores, D-dimer testing, or ultrasound to assess for residual thrombosis. However, these methods may be appropriate in certain cases.

Recommendations 18 and 19 (moderate certainty). Indefinite antithrombotic therapy is recommended for patients with DVT and/or PE provoked by a chronic risk factor (such as autoimmune disease), and for patients with unprovoked DVT or PE, except for those with a high bleeding risk.

Recommendation 20 (moderate certainty). For DVT or PE patients who will receive secondary prevention, anticoagulation is recommended over aspirin.

Recommendation 21 (strong; moderate certainty). For patients receiving VKA therapy as secondary prevention, the guidelines recommend using an international normalized ratio (INR) range of 2.0 to 3.0 over a lower INR range.

Recommendation 22 (moderate certainty). For patients continuing a DOAC for secondary prevention, a standard-dose DOAC or lower-dose DOAC is recommended.

Treatment of recurrent VTE

Recommendation 23 (very low certainty). For breakthrough VTE during treatment with VKA, the use of low-molecular-weight heparin (LMWH) is recommended over DOAC therapy, except for patients with poor INR control.

Recommendation 24a (moderate certainty). For VTE provoked by a transient risk factor in patients with a history of unprovoked VTE or VTE provoked by a chronic risk factor, continuation of antithrombotic therapy after primary treatment is recommended.

Recommendation 24b (moderate certainty). For VTE provoked by a transient risk factor in patients with a history of the same, discontinuation of anticoagulant therapy following primary treatment is recommended over indefinite anticoagulation.

Recommendation 25 (strong; moderate certainty). For recurrent unprovoked VTE, indefinite antithrombotic therapy after primary treatment is recommended.

Additional management issues

Recommendation 26 (very low certainty). For VTE in patients with stable cardiovascular disease who were previously taking aspirin to modify cardiovascular risk, the guidelines recommend discontinuation of aspirin during anticoagulation therapy, except for patients with a recent acute coronary event or coronary intervention.

Recommendations 27 and 28 (very low certainty). The guidelines recommend against routine use of compression stockings for DVT patients with or without an increased risk for postthrombotic syndrome. However, stockings may reduce DVT-related edema and pain in some patients.

The panel acknowledges that the guidelines do not touch on every challenge that clinicians may encounter in treating VTE. However, additional recommendations can be easily added to future editions of the guidelines as new evidence emerges.  

“Areas that still remain unclear are low-risk APLS patients: Can they possibly be treated with a DOAC?” Dr Cromwell stated. “Another challenge is the patient with recurrent provoked VTE: Is there a role for a long-term prophylactic anticoagulation?”

References

  1. Centers for Disease Control and Prevention. Data and statistics on venous thromboembolism. Last Updated February 7, 2020. Accessed on November 4, 2020. https://www.cdc.gov/ncbddd/dvt/data.html
  2. Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolismBlood Adv. 2020;4(19):4693-4738. doi:10.1182/bloodadvances.2020001830