Management of venous thromboembolism, DVT and pulmonary embolism: ASH guidelines

The American Society of Haematology has released very recent recommendations for the management of venous thromboembolism, treatment of deep vein thrombosis, and pulmonary embolism. The study was published in the journal "Blood Advances" in 2020.

Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE), which occurs in approximately 1 to 2 individuals per 1000 each year, thus corresponding to nearly 300 000 to 600 000 events in the United States annually. To prevent this American society of Haematology formed a multidisciplinary guideline panel with an intent to support patients, clinicians, and others in decisions about the treatment of venous thromboembolism.

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The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. They used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the evidence and make recommendations, which were subject to public comment. Clinical questions and outcomes were set up by the panel according to their importance for clinicians and adult patients.

Finally, the panel agreed upon 28 recommendations. Strong recommendations include the use of thrombolytic therapy for patients with PE and hemodynamic compromise, use of an international normalized ratio (INR) range of 2.0 to 3.0 over a lower INR range for patients with VTE who use a vitamin K antagonist (VKA) for secondary prevention, and use of indefinite anticoagulation for patients with recurrent unprovoked VTE. Conditional recommendations include the preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications and a preference for direct oral anticoagulants over VKA for primary treatment of VTE.

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Some of the recommendations are as follows:

• For patients with uncomplicated deep vein thrombosis (DVT), home treatment over hospital treatment was suggested.

• For patients with pulmonary embolism (PE) with a low risk for complications, the panel suggests offering home treatment over hospital treatment.

• For patients with DVT and/or PE, the panel suggests using direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs).

• For patients with DVT and/or PE, the guideline panel does not suggest 1 DOAC over another.

• In most patients with proximal DVT, the guideline panel suggests anticoagulation therapy alone over thrombolytic therapy in addition to anticoagulation.

• For patients with PE and hemodynamic compromise, the panel recommends using thrombolytic therapy followed by anticoagulation over anticoagulation alone.

• For patients with PE with echocardiography and/or biomarkers compatible with right ventricular dysfunction but without hemodynamic compromise (submassive PE), the panel suggests anticoagulation alone over the routine use of thrombolysis in addition to anticoagulation.

• For patients with extensive DVT in whom thrombolysis is considered appropriate, the panel suggests using catheter-directed thrombolysis over systemic thrombolysis.

• For patients with PE in whom thrombolysis is considered appropriate, the panel suggests using systemic thrombolysis over catheter-directed thrombolysis.

• For patients with proximal DVT and significant preexisting cardiopulmonary disease, as well as for patients with PE and hemodynamic compromise, the panel suggests anticoagulation alone rather than the anticoagulation plus insertion of an inferior vena cava (IVC) filter.

• After completion of primary treatment for patients with DVT and/or PE provoked by a chronic risk factor, the ASH guideline panel suggests indefinite antithrombotic therapy over stopping anticoagulation

• For patients with DVT, with or without an increased risk for Post Thrombotic Syndrome, the ASH guideline panel suggests against the routine use of compression stockings. 

The "conditional" recommendations include the following:

For patients with uncomplicated DVT or PE with a low risk for complications, the group suggests offering home treatment rather than hospital treatment.

The group suggests using direct oral anticoagulants instead of vitamin K antagonists for the initial treatment of DVT or PE.

The study titled " American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism" was published in the journal "Blood Advances." 

For further reading, click the following link: https://doi.org/10.1182/bloodadvances.2020001830