Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315–52.
Clinical Practice Guideline
Included: Patients with VTE disease; age, gender and other medical comorbidity modifiers are unspecified.
Excluded: None stated.
History and physical exam; chest x-ray; electrocardiography (ECG); NT-proBNP and BNP; echocardiography; lung US; bioimpedance.
Adjudication of clinical data by independent reviewers blinded to the study’s primary index test results.
Acute heart failure.
Not clearly specified; presumably anyone who treats patients with VTE disease.
N = 17,893 patients in 57 studies.
CXR = chest x-ray; LR = likelihood ratio; QUADAS = Quality Assessment of Diagnostic Accuracy Studies; Sn = sensitivity; Sp = specificity.
Key Questions and Recommendations
Key Recommendations Recommendations: Strong (Grade 1); Weak (2). Quality of Evidence: High (Grade A); Moderate (B); Weak (C). Emergency Department (ED) Relevant Recommendations
- Treat patients with proximal DVT or PE with anticoagulants (AC) for ≥ 3 months (1B).
- If no cancer, suggest start with dabigatran, a direct thrombin inhibitor (DTI), or a factor Xa Inhibitor (FXaI: apixaban, rivoroxaban or edoxaban; all 2B) instead of a vitamin K antagonist (VKA: warfarin).
- If cancer thrombosis, then consider a low molecular weight heparin (LMWH), a DTI or a FXaI over VKA (all 2C).
- Treat patients with AC for ≥ 3 months if VTE related to surgery (1B) or some other transient risk factor (1B).
- Treat patients with AC for ≥ 3 months for first or second proximal DVT or PE, use regardless of bleeding risk (2B).
- Consider aspirin if AC stopped to avoid recurrent VTE (2B).
- If isolated distal DVT without extension risk factors or symptoms, consider serial ultrasound (US) every 2 weeks for resolution instead of AC use (2C). If high risk for extension or severe symptoms, then treat with AC.
- If using serial US to follow low risk distal DVT, initiate AC use if distal extension (2C) or proximal extension (1B).
- If acute proximal DVT, may consider catheter-directed thrombolysis (CDT) if cost, comorbidity or risk of post-thrombotic syndrome (PTS) warrant CDT over AC use (2C).
- In isolated DVT of leg, use of compression stockings to prevent PTS is NOT warranted (2B).
- In patients with subsegmental PE and distal DVT with low risk of VTE recurrence, AC may be deferred for clinical surveillance (2C).
- Patients with a low-risk PE and safe home environment need not be admitted (2B).
- In patients with PE and hypotension (sBP < 90), then patient should get thrombolysis vs. no treatment (2B).
- Thrombolysis not recommended if not hypotensive (1B).
- Patients on AC and deteriorating but not hypotensive, can receive thrombolysis if risk of bleeding risk is low (2C).
- Patients should receive thrombolysis through a peripheral intravenous (IV) line rather than CDT (2C).
- Hypotensive patients with failed thrombolysis, high bleeding risk, or impending death, warrant catheter-directed thrombectomy if resources and skilled personnel are available (2C).
- AC is recommended over thrombolysis for patients with acute upper extremity DVT (2C).
- Patients with recurrent VTE while on therapeutic OAC should be switched to LMWH temporarily (2C).
- Patients with recurrent VTE while compliant on long-term LMWH should have dose increased by 2,530% of original.
|Risk Factors for Bleeding on AC Therapy||Risk Factors for Extension of Distal DVT|
|Age > 65||Positive D-dimer|
|Previous bleeding,||Extensive thrombosis > 5cm/multiple veins/> 7mm diameter|
|Cancer (especially metastatic)||Thrombus close to proximal veins|
|Renal or liver failure||No reversible provoking factor for DVT|
|Prior cerebral vascular accident||Prior VTE|
|Anemia||Lower risk if leg DVT in muscular veins (soleus, gastrocnemius)|
|Antiplatelet treatment||No lower risk if DVT in axial veins (true deep, peroneal, tibial)|
|Poor AC control|
|Reduced functional capacity|
|Nonsteroidal anti-inflammatory drug use|
|0 = low risk of bleeding, 1 = moderate risk of bleeding, 2+ = high risk of bleeding|
Risk of Bias Assessment
|1||The research question is sensible and answerable.||Yes||Yes||Yes|
|2||The search included all languages, databases, abstracts, bibliographies, and expert contact.||No||No||No|
|3||The search for studies was unbiased and reproducible.||Maybe||Maybe||Maybe|
|4||The selection of studies was unbiased and reproducible.||Maybe||Maybe||Maybe|
|5||The data abstraction was unbiased (e.g., conducted independently by 2 researchers).||Yes||Yes||Yes|
|6||The quality assessment of the primary studies used QUADAS, was unbiased and reproducible.||Yes||Yes||Yes|
|7||The quality of the primary studies is high.||Yes||Yes||Yes|
|8||The populations, cut-off thresholds, and reference standards were similar for combined studies.||Yes||Yes||Yes|
|9||The subgroups were stated a priori and appropriate.||Yes||Yes||Yes|
|10||The methods of meta-analyses are valid (e.g., summary ROC or bivariate random effects).||Yes||Yes||Yes|
Funding & Conflicts of Interest
American College of Chest Physicians.
Conflicts of Interest
Potential Threats to Validity
Worster A; de Wit K; Updahye, S.
Competing Interest Disclosure
Dr. Upadhye - No conflicts of interest (ICMJE)