Updated American College of Chest Physicians guideline on antithrombotic therapy for venous thromboembolism

Reference

Stevens SM, Woller SC, Kreuziger LB, et al. Executive summary: antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report. Chest 2021;160(6):2247-2259.

Synopsis

The latest update to the American College of Chest Physicians guideline regarding antithrombotic therapy for venous thromboembolism (VTE) adds 4 new recommendations and updates 8 others. The authors identify an initiation phase when anticoagulants are first given, a treatment phase of 3 months, and an extended phase for selected patients beyond 3 months. For patients with acute isolated distal deep vein thrombosis (DVT), the guidelines recommend 2 weeks of serial imaging, with anticoagulation only if it extends or if the patient has severe symptoms or risk factors for extension. Similarly, for patients with subsegmental pulmonary embolism (PE), no proximal DVT in the legs, and who are at low risk for recurrent VTE, clinical observation without anticoagulation is recommended. Outpatient therapy for PE is recommended if patients are clinically stable; there is no recent bleeding, thrombocytopenia, or severe liver or kidney disease; and they feel well enough to be treated at home and are likely to be adherent. For patients with asymptomatic PE incidentally diagnosed during computed tomography of the chest, anticoagulation is still recommended as studies have shown a similar prognosis to symptomatic PE. With regard to the choice of medication, a direct oral anticoagulant (such as apixaban, dabigatran, edoxaban, or rivaroxaban) is recommended as first-line therapy. An exception should be made for patients with antiphospholipid syndrome, for whom warfarin is recommended during the treatment phase. For patients with cancer, apixaban, edoxaban, and rivaroxaban are recommended over low-molecular-weight heparin for treatment of VTE. For patients with superficial venous thrombosis of the lower leg, the authors make a weak recommendation for 45 days of fondaparinux 2.5 mg daily or rivaroxaban 10 mg daily. Extended-phase low-dose anticoagulation with apixaban 2.5 mg twice daily or rivaroxaban 10 mg once daily is recommended for all patients with unprovoked VTE. This has only been studied for 2 to 4 years, so extending anticoagulation beyond that is of uncertain benefit. Aspirin is recommended when patients discontinue extended-phase anticoagulation. For patients with PE, thrombolytics are only recommended for patients with hypotension initially or who deteriorate clinically, assuming they do not have high bleeding risk. For those with a high bleeding risk and those who have failed thrombolysis, catheter-assisted thrombus removal is recommended. Inferior vena cava filters are only recommended for patients with DVT who have a contraindication to anticoagulation. For patients with cerebral vein or venous sinus thrombosis, anticoagulation is recommended. Finally, compression stockings are not recommended for patients with acute DVT.