Chest
Volume 149, Issue 2, February 2016, Pages 315-352
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Evidence-Based Medicine
Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report

https://doi.org/10.1016/j.chest.2015.11.026Get rights and content

Background

We update recommendations on 12 topics that were in the 9th edition of these guidelines, and address 3 new topics.

Methods

We generate strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence.

Results

For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C). For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B). For DVT, we suggest not using compression stockings routinely to prevent PTS (Grade 2B). For subsegmental pulmonary embolism and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C), and anticoagulation over clinical surveillance with a high risk (Grade 2C). We suggest thrombolytic therapy for pulmonary embolism with hypotension (Grade 2B), and systemic therapy over catheter-directed thrombolysis (Grade 2C). For recurrent VTE on a non-LMWH anticoagulant, we suggest LMWH (Grade 2C); for recurrent VTE on LMWH, we suggest increasing the LMWH dose (Grade 2C).

Conclusions

Of 54 recommendations included in the 30 statements, 20 were strong and none was based on high-quality evidence, highlighting the need for further research.

Key Words

antithrombotic therapy
evidence-based medicine
GRADE approach
venous thromboembolism

Abbreviations

AT9
9th Edition of the Antithrombotic Guideline
AT10
10th Edition of the Antithrombotic Guideline
CHEST
American College of Chest Physicians
CDT
catheter-directed thrombolysis
COI
conflict of interest
CTEPH
chronic thromboembolic pulmonary hypertension
CTPA
CT pulmonary angiogram
GOC
Guidelines Oversight Committee
INR
International Normalized Ratio
IVC
inferior vena cava
LMWH
low-molecular-weight heparin
NOAC
non-vitamin K oral anticoagulant
PE
pulmonary embolism
PTS
postthrombotic syndrome
RCT
randomized controlled trial
UEDVT
upper extremity deep vein thrombosis
US
ultrasound
VKA
vitamin K antagonist

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DISCLAIMER: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/CHEST-Guidelines.

FUNDING/SUPPORT: This guideline was supported solely by internal funds from The American College of Chest Physicians.

ENDORSEMENTS: This guideline is endorsed by the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the International Society for Thrombosis and Haemostasis, and the American Society of Health-System Pharmacists.

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