danny hill pgy-5, hematology. vte acute management of vte risk stratification duration of...

Danny Hill PGY-5, Hematology

VTE Acute Management of VTE Risk Stratification Duration of Anticoagulation Bleeding Assessment Recurrence Assessment Upper Extremity Thrombosis Superficial Vein Thrombosis Post Thrombotic Syndrome IVC Filters CTEPH Splanchnic Vein Thrombosis

Incidence in total population ~ 70113 cases/100,000/year Age exponential increase in VTE with age, particularly after age 40 years 2535 years old 30 cases/100,000 persons 7079 years old 300500 cases/100,000 persons Relative incidence of PE vs DVT Absent autopsy diagnosis: 33% PE; 66% DVT With autopsy: 55% PE, 45% DVT

25% to 50% unprovoked 15% to 25% associated with cancer 20% following surgery 5% to 15%, misc

In 1938 Murray and Best described treating surgical patients with DVT/PE with UFH In 1947, Allen et.al described treating surgical patients with DVT/PE with UFH + Dicoumarol In 1960, Barritt and Jordan published RCT comparing UFH + nicoumalone vs expectant management Buller HR, Sohne M, Middeldorp S. J Thromb Haemost 2005; 3: 155460

Landmark RCT by Barritt and Jordan in 1960 conducted for 1 year before study closure ~ 25% will have a fatal recurrence (5/19) ~ 25% will experience recurrent not fatal PE (5/19) 0 fatalities or recurrent events in the AC arm (0/54) The estimated case-fatality rate of recurrent VTE without anticoagulant therapy is ~ 50% Barritt DW, Jordan SC. Lancet 1960; 1: 130912

Rate of recurrence ~ 50% Rate of fatal recurrence ~ 25% Case fatality rate ~ 50% Rate of recurrence ~ 5% Rate of fatal recurrence ~ 1% Case fatality rate ~ 20% LoveCoumadin

2008 For patients with a high clinical suspicion of DVT, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C) 2012 In patients with a high clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests (Grade 2C)

2012 In patients with an intermediate clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h (Grade 2C)

2012 In patients with a low clinical suspicion of acute VTE, we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (Grade 2C)

General Considerations

2008 For patients with objectively confirmed VTE, we recommend short-term treatment with SC LMWH, IV UFH, SC UFH, or SC fondaparinux (Grade 1A) rather than no such acute treatment 2012 In patients with acute VTE, we recommend initial treatment with parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) over no such initial treatment (Grade 1B)

2008 In patients with acute VTE, we recommend initiation of VKA together with LMWH, UFH, or fondaparinux on the first treatment day rather than delayed initiation of VKA (Grade 1A) 2012 In patients with VTE, we recommend early initiation of VKA (eg, same day as parenteral therapy is started) over delayed initiation (Grade 1B)

2008 In patients with acute VTE, we recommend initiation of VKA together with LMWH, UFH, or fondaparinux on the first treatment day rather than delayed initiation of VKA (Grade 1A). In patients with acute VTE, we recommend initial treatment with LMWH, UFH or fondaparinux for at least 5 days and until the INR is > 2.0 for at least 24 h (Grade 1C) 2012 In patients with acute VTE, we recommend early initiation of VKA (eg, same day as parenteral therapy is started) over delayed initiation, and continuation of parenteral anticoagulation for a minimum of 5 days and until the INR is > 2.0 for at least 24 h (Grade 1B)

Six options are available for the initial treatment of VTE: (1) SC LMWH without monitoring (2) IV UFH with monitoring (3) SC UFH given based on weight initially, with monitoring (4) SC UFH given based on weight initially, without monitoring (5) SC fondaparinux given without monitoring (6) PO Rivaroxaban

2008 In patients with acute VTE, we recommend initial treatment with LMWH, UFH, or fondaparinux for at least 5 days and until the INR is > 2.0 for 24 h (Grade 1C) 2012 In patients with acute VTE, we suggest LMWH or fondaparinux over IV UFH (Grade 2C) and over SC UFH (Grade 2B for LMWH; Grade 2C for fondaparinux) and continuation of parenteral anticoagulation for a minimum of 5 days and until the INR is > 2.0 for 24 h (Grade 1B)

20082012 In patients with acute VTE treated with LMWH, we suggest once- over twice-daily administration (Grade 2C)

2008 In patients with VTE, we recommend that the dose of VKA be adjusted to maintain a target INR of 2.5 (range, 2.0 to 3.0) for all treatment durations (Grade 1A) 2012 In patients with VTE who are treated with VKA, we recommend a therapeutic INR range of 2.0 to 3.0 (target INR of 2.5) over a lower (INR, 2) or higher (INR 3.0-5.0) range for all treatment durations (Grade 1B)

2008 For patients with unprovoked VTE who have a strong preference for less frequent INR testing to monitor their therapy, after the first 3 months of conventional-intensity anticoagulation (INR range, 2.0 to 3.0), we recommend low-intensity therapy (range, 1.5 to 1.9) with less frequent INR monitoring over stopping treatment (Grade 1A) We recommend against high-intensity VKA therapy (INR range, 3.1 to 4.0) compared to an INR range of 2.0 to 3.0 (Grade 1A)

Dabigatran: One completed study has directly compared dabigatran and VKA for the first 6 months of treatment of VTE This study suggests that treatment with dabigatran or VKA therapy is associated with a similar frequency of recurrent VTE, major bleeding, and death. Rivaroxaban: A single study has directly compared rivaroxaban (without initial parenteral anticoagulation) with parenteral anticoagulation and VKA in patients with acute DVT Results suggested that treatment with rivaroxaban and VKA therapy are associated with a similar frequency of recurrent VTE, major bleeding, and death.

20082012 In patients with VTE and no cancer, we suggest VKA therapy over LMWH for long- term therapy (Grade 2C). For patients with VTE and no cancer who are not treated with VKA therapy, we suggest LMWH over dabigatran or rivaroxaban for long-term therapy (Grade 2C)

~10-fold higher risk of dying and a threefold higher risk of recurrent VTE and major bleeding during the first 3 or 6 months of treatment Different mechanisms of thrombosis that may be associated with a poor response to VKA therapy

20082012 In patients with VTE and active cancer, if the risk of bleeding is not high, we recommend extended anticoagulant therapy over 3 months of therapy (Grade 1B), and if there is a high bleeding risk, we suggest extended anticoagulant therapy (Grade 2B)

2008 For patients with VTE and cancer, we recommend LMWH for the first 3 to 6 months of long-term anticoagulant therapy (Grade 1A) 2012 In patients with VTE and cancer, we suggest LMWH over VKA therapy (Grade 2B). In patients with VTE and cancer who are not treated with LMWH, we suggest VKA over dabigatran or rivaroxaban for long-term therapy (Grade 2B)

2008 For these patients, we recommend subsequent anticoagulant therapy with VKA or LMWH indefinitely or until the cancer is resolved. 2012 In patients with VTE who receive extended therapy, we suggest treatment with the same anticoagulant chosen for the first 3 months (Grade 2C)

Among patients with VTE and cancer, the advantages of LMWH over VKA therapy are expected to be greatest in the following patients: (1) with metastatic disease (2) being treated with aggressive chemotherapy (3) presenting with extensive VTE (4) with liver dysfunction (5) with poor or unstable nutritional status (6) who wish to avoid laboratory monitoring of coagulation

2008 In patients who are unexpectedly found to have asymptomatic VTE, we recommend the same initial and long-term anticoagulation as for comparable patients with symptomatic VTE (Grade 1C) 2012 In patients who are incidentally found to have asymptomatic of the leg, we suggest the same initial and long-term anticoagulation as for comparable patients with symptomatic VTE (Grade 2B)

isolated distal DVT = DVT of the peroneal, posterior tibial, anterior tibial veins without involvement of the popliteal or more proximal veins If all patients with suspected DVT have ultrasound examination of the calf veins (whole leg ultrasound), isolated distal DVT accounts for ~ 50% of all DVT diagnosed Natural history studies suggest that when left untreated, 15% of symptomatic distal DVT will extend into the proximal veins if extension does not occur within 2 weeks, it is unlikely to occur subsequently

A single controlled trial of 51 patients with symptomatic isolated distal DVT, all of whom were initially treated with heparin, found that 3 months of VKA therapy prevented DVT extension and recurrent VTE (29% vs 0%, P,.01)

2012 In patients with acute isolated distal DVT of the leg and severe symptoms or risk factors for extension, we suggest initial AC over serial imaging of the deep veins (Grade 2C)

2012 In patients with acute isolated distal DVT of the leg and without severe symptoms or risk factors for extension, we suggest serial imaging of the deep veins for 2 weeks over initial AC (Grade 2C)

+ Ddimer Thrombosis that is extensive or close to the proximal veins (eg, > 5 cm in length, involves multiple veins, >.7 mm in maximum diameter) Unprovoked DVT Active cancer History of VTE Inpatient status

2008 For patients with a first isolated distal DVT that is unprovoked, we suggest that 3 months of anticoagulant therapy is sufficient rather than indefinite therapy 2012 In patients with acute isolated distal DVT of the leg who are managed with initial anticoagulation, we recommend using the same approach as for patients with acute proximal DVT (Grade 1B)

2012 In patients with acute isolated distal DVT of the leg who are managed with serial imaging, we recommend no AC if the thrombus does not extend (Grade 1B); we suggest AC if the thrombus extends but remains confined to the distal veins (Grade 2C); we recommend AC if the thrombus extends into the proximal veins (Grade 1B)

2008 In patients with acute DVT, we recommend early ambulation in preference to initial bed rest when this is feasible (Grade 1A) 2012 In patients with acute DVT of the leg, we suggest early ambulation over initial bed rest (Grade 2C)

2008 In patients with acute DVT, we recommend initial treatment with LMWH once or twice daily, as an outpatient if possible (Grade 1C), or as an inpatient if necessary (Grade 1A), rather than treatment with IV UFH. 2012 In patients with acute DVT of the leg and whose home circumstances are adequate, we recommend initial treatment at home over treatment in hospital (Grade 1B)

Patients with DVT that involves the iliac and common femoral veins are at highest risk for PTS and therefore, are the subset with the greatest potential to benefit from thrombus removal strategies Thrombus removal strategies are indicated in patients with the very rare complication of impending venous gangrene despite optimal anticoagulant therapy Patients who are most likely to benefit from CDT have iliofemoral DVT, symptoms for 1 year, and a low risk of bleeding

2008 In selected patients with extensive acute proximal DVT (eg, iliofemoral DVT, symptoms for 1 year) who have a low risk of bleeding, we suggest that CDT may be used to reduce acute symptoms and postthrombotic morbidity (Grade 2B) 2012 In patients with acute proximal DVT of the leg, we suggest AC therapy alone over catheter-directed thrombolysis (Grade 2C)

2008 In selected patients with extensive proximal DVT (eg, symptoms for 1 year) who have a low risk of bleeding, we suggest that systemic thrombolytic therapy may be used to reduce acute symptoms and postthrombotic morbidity (Grade 2C) 2012 In patients with acute proximal DVT of the leg, we suggest AC therapy alone over systemic thrombolysis (Grade 2C)

2008 In selected patients with acute iliofemoral DVT (eg, symptoms for 1 year), we suggest that operative venous thrombectomy may be used to reduce acute symptoms and postthrombotic morbidity (Grade 2C) 2012 In patients with acute proximal DVT of the leg, we suggest AC therapy alone over operative venous thrombectomy (Grade 2C)

Of patients who are diagnosed with PE and start treatment, 5% die of the initial PE or another PE within the next 7 days Risk of dying of PE is ~ 70% if cardiopulmonary arrest occurs (1% of patients), 30% if there is shock requiring inotropic support (5% of patients), and 2% in patients who are not hypotensive.

20082012 In patients with low-risk PE and whose home circumstances are adequate, we suggest early discharge over standard discharge (eg, after first 5 days of treatment) (Grade 2B)

Several clinical prediction rules exist to identify patients with acute PE who have a low risk of serious complications and may be suitable for treatment at home. EKG BNP & Trops TTE CTPA Clinical Risk Scores The PE Severity Index (PESI) is best validated

Jimenez, D. et al. Arch Intern Med 2010;170:1383-1389

1) age > 80 2) cancer 3) Cardiopul disease 4) tachy 5) hypotension 6) hypoxia Patients with a score of 0 (ie, no variables present) are categorized as low risk; those with a score of > 1 (any variable present) are high risk.

OriginalSimplified Sensitivity 88.5 (81.4-95.5)96.1 (91.9-100.0) Specificity 38.4 (35.2-41.532.9 (29.9-36.0) LR + 1.44 (1.31-1.581.43 (1.35-1.53) LR - 0.30 (0.16-0.560.12 (0.04-0.36)

Patients with acute PE who meet the following criteria appear to be suitable for treatment out of the hospital: (1) Clinically stable with good cardiopulmonary reserve (eg, PESI score of, 8 h)

Whether DVT was confined to the distal veins (isolated distal DVT), which is estimated to be associated with about one-half of the risk of recurrence of proximal DVT and PE Whether the VTE was a second or subsequent episode of VTE, which is estimated to be associated with about a 50% higher risk of recurrence compared with a first VTE

1 year5 year Provoked surgery1%3% Provoked other (E2)5%15% Unprovoked10%30% Cancer-associated15%/year

Five trials have evaluated shortening the duration of oral anticoagulant therapy from 3 or 6 months to 4 or 6 weeks in patients with mostly first episodes of VTE The shorter duration of therapy, the absolute decrease in bleeding was small compared with the absolute increase in recurrent VTE

Six randomized comparisons found that 6 or 12 months of therapy did not convincingly lower risk of recurrence but increased major bleeding about 2.5-fold In a recent meta-analysis, treatment of 3 months compared with 6 months was associated with an HR of 1.19 (95% CI, 0.86- 1.65) in all patients and an HR of 1.39 (95% CI, 0.96-2.01) in patients with unprovoked DVT or PE during the 2 years after stopping anticoagulant therapy

Five trials compared extended anticoagulation with VKA with stopping VKA therapy at 3 or 6 months in patients who were judged to have a high risk of recurrence Indefinite treatment with conventional-intensity VKA (target INR 2.5) reduces recurrent VTE by about 90% (RR 0.12; 95% CI, 0.05-0.25)

Major bleeding (95% CI), %1.6 (1.32.0) Fatal Bleeds (95% CI), %0.2 (0.10.3) Case Fatality Rate (95% CI), %11.3 (7.515.9) Extended anticoagulant therapy was associated with about a 2.6-fold increase in major bleeding

Antiphospholipid antibody (RR, 2) Hereditary thrombophilia (RR, 1.5) Asian ethnicity (RR, 0.8) Male vs female sex (RR, 1.6) Negative D -dimer testing 1 month after withdrawal of VKA (RR, 0.4) BMI HER DOO2 Residual thrombosis in the proximal veins (RR, 1.5)

10% 1%

OBRI HAS-BLED HEMORR2HAGES REITE ATRIA

There is no validated prediction tool to stratify the risk of major bleeding during extended anticoagulant therapy specifically in patients with VTE

Age. >65 y Previous bleeding Cancer Renal failure Liver failure Thrombocytopenia Previous stroke Diabetes Anemia Antiplatelet therapy Poor anticoagulant control Comorbidity and reduced functional capacity Recent surgery Frequent falls Alcohol abuse

Low (0 RF)Int (1 RF)High (>1 RF) 3 months AC (%) Baseline Risk 0.61.24.8 Risk Increase 1.02.08.0 Total 1.63.212.8 > 3 months AC (%/y) Baseline Risk 0.3 0.6>2.5 Risk Increase 0.51.0>4.0 Total 0.81.6>6.5

Outcomes After 5 y of Treatment Risk of Bleeding LowIntermediateHigh First VTE provoked by surgery Recurrent VTE reduction per 1,000 26 (19-27) (1 fatal) 26 (19-27) (1 fatal) 26 (19-27) (1 fatal) Major bleeding increase per 1,000 24 (2-73) (3 fatal) 49 (1-173) (5 fatal) 98 (1-346) (11 fatal)

Outcomes After 5 y of Treatment Risk of Bleeding LowIntermediateHigh First VTE provoked by a nonsurgical factor Recurrent VTE reduction per 1,000 132 (93-137) (5 fatal) 132 (93-137) (5 fatal) 132 (93-137) (5 fatal) Major bleeding increase per 1,000 24 (2-73) (3 fatal) 49 (1-173) (5 fatal) 98 (1-346) (11 fatal)

Outcomes After 5 y of Treatment Risk of Bleeding LowIntermediateHigh First unprovoked VTE Recurrent VTE reduction per 1,000 264 (186-273) (10 fatal) 264(186-273) (10 fatal) Major bleeding increase per 1,000 24 (2-73) (3 fatal) 49 (1-173) (5 fatal) 98 (1-346) (11 fatal)

Outcomes After 5 y of Treatment Risk of Bleeding LowIntermediateHigh Second unprovoked VTE Recurrent VTE reduction per 1,000 396 (279-409) (14 fatal) Major bleeding increase per 1,000 24 (2-73) (3 fatal) 49 (1-173) (5 fatal) 98 (1-346) (11 fatal)

2012 In patients with an isolated distal DVT of the leg provoked by surgery or by a nonsurgical transient risk factor, we suggest treatment with anticoagulation for 3 months over treatment of a shorter period (Grade 2C) and recommend treatment with anticoagulation for 3 months over treatment of a longer time limited period (eg, 6 or 12 months) (Grade 1B) or extended therapy

2008 For patients with DVT secondary to a transient (reversible) risk factor, we recommend treatment with a VKA for 3 months over treatment for shorter periods (Grade 1A) 2012 In patients with a proximal DVT of the leg or PE provoked by surgery, we recommend treatment with anticoagulation for 3 months over: (i) treatment of a shorter period (Grade 1B), (ii) treatment of a longer time-limited period (eg, 6 or 12 months) (Grade 1B), or (iii) extended therapy (Grade 1B)

2012 In patients with a proximal DVT of the leg or PE provoked by a nonsurgical transient risk factor, we recommend treatment with AC for 3 months over (i) treatment of a shorter period (Grade 1B), (ii) treatment of a longer time limited period (eg, 6 or 12 months) (Grade 1B), and (iii) extended therapy

2008 For patients with a first isolated distal DVT that is unprovoked, we suggest that 3 months of anticoagulant therapy is sufficient rather than indefinite therapy (Grade 2B) 2012 In patients with a first VTE that is an unprovoked isolated distal DVT of the leg, we suggest 3 months of anticoagulant therapy over extended therapy in those with a low bleeding risk (Grade 2B), and recommend 3 months of anticoagulant treatment in those with a moderate or high bleeding risk

2008 For patients with unprovoked DVT or PE, we recommend treatment with a VKA for at least 3 months (Grade 1A). We recommend that after 3 months of anticoagulant therapy, all patients with unprovoked DVT or PE should be evaluated for the risk- benefit ratio of long-term therapy (Grade 1C) 2012 In patients with an unprovoked DVT of the leg (isolated distal or proximal) or PE, we recommend treatment with anticoagulation for at least 3 months over treatment of a shorter duration (Grade 1B). After 3 months of treatment, patients with unprovoked DVT of the leg or PE should be evaluated for the risk-benefit ratio of extended therapy.

2008 For patients with a first unprovoked VTE that is a proximal DVT or PE, and in whom risk factors for bleeding are absent and for whom good anticoagulant monitoring is achievable, we recommend long-term treatment (Grade 1A) 2012 In patients with a first VTE that is an unprovoked proximal DVT of the leg or PE and who have a low or moderate bleeding risk, we suggest extended anticoagulant therapy over 3 months of therapy (Grade 2B)

20082012 In patients with a first VTE that is an unprovoked proximal DVT of the leg or PE and who have a high bleeding risk, we recommend 3 months of anticoagulant therapy over extended therapy (Grade 1B)

2008 For patients with a second episode of unprovoked VTE, we recommend long-term treatment (Grade 1A) 2012 In patients with a second unprovoked VTE, we recommend extended anticoagulant therapy over 3 months of therapy in those who have a low bleeding risk (Grade 1B), and we suggest extended anticoagulant therapy in those with a moderate bleeding risk (Grade 2B)

20082012 In patients with a second unprovoked VTE who have a high bleeding risk, we suggest 3 months of anticoagulant therapy over extended therapy (Grade 2B)

About 5% to 10% of VTE involve the upper extremities. UEDVT involves the subclavian, axillary, or brachial veins and may include extension to the brachiocephalic vein, superior vena cava, or the internal jugular vein UEDVT may lead to complications, including symptomatic PE (5% of patients), recurrent UEDVT (8% at 5 years), and PTS of the arm (20% of patients)

UEDVT includes two etiologic groups: Primary (unprovoked with or without thrombophilia, effort- related and thoracic outlet syndrome) Paget-Schroetter Syndrome Secondary (provoked by central venous catheters, pacemakers, or cancer) Secondary UEDVT accounts for 75% of cases.

No randomized controlled studies have evaluated acute anticoagulation for initial treatment of UEDVT. Several small prospective cohort studies have reported low rates of recurrent DVT, PE, and major bleeding when UEDVT was treated similarly to leg DVT

2008 For patients with acute upper-extremity DVT (UEDVT), we recommend initial treatment with therapeutic doses of LMWH, UFH, or fondaparinux (Grade 1C) 2012 In patients with acute UEDVT that involves the axillary or more proximal veins, we recommend acute treatment with parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) over no such acute treatment (Grade 1B)

20082012 In patients with acute UEDVT that involves the axillary or more proximal veins, we suggest LMWH or fondaparinux over IV UFH (Grade 2C) and over SC UFH (Grade 2B)

2008 For most patients with acute UEDVT, we recommend against the routine use of systemic or catheter-directed thrombolytic therapy (Grade 1C) 2012 In patients with acute UEDVT that involves the axillary or more proximal veins, we suggest anticoagulant therapy alone over thrombolysis (Grade 2C)

2008 In selected patients with acute UEDVT (eg, in those with a low risk of bleeding and severe symptoms of recent onset), we suggest that CDT may be used for initial treatment if appropriate expertise and resources are available (Grade 2C)

20082012 In patients with UEDVT who undergo thrombolysis, we recommend the same intensity and duration of anticoagulant therapy as in similar patients who do not undergo thrombolysis (Grade 1B)

20082012 In patients with UEDVT that involves the axillary or more proximal veins, we suggest a minimum duration of anticoagulation of 3 months over a shorter period (Grade 2B)

20082012 In patients who have UEDVT that is not associated with a central venous catheter or with cancer, we recommend 3 months of anticoagulation over a longer duration of therapy (Grade 1B)

20082012 In most patients with UEDVT that is associated with a central venous catheter, we suggest that the catheter not be removed if it is functional and there is an ongoing need for the catheter (Grade 2C)

20082012 In patients who have UEDVT that is associated with a central venous catheter that is not removed, we recommend that anticoagulation is continued as long as the central venous catheter remains over stopping after 3 months of treatment (Grade 1C)

20082012 In patients who have UEDVT that is associated with a central venous catheter that is removed, we recommend 3 months of anticoagulation over a longer duration of therapy (Grade 1B)

It usually affects the lower limbs; often involves a varicose vein; is associated with chronic venous insufficiency, malignancy, thrombophilia, pregnancy or estrogen therapy, obesity, sclerotherapy, long-distance travel, and a history of VTE; or may be unprovoked. The long saphenous vein is involved in ~ 2/3 of lower-limb SVT

Although traditionally considered a benign disease, a number of studies indicate that the consequences of SVT may be more serious. Proximal DVT & PE A prospective study of 844 patients with acute SVT of 5 cm found that at initial presentation, 4% of patients had symptomatic PE, and routine ultrasound detected proximal DVT in 10% and distal DVT in an additional 13% of patients.

proximal DVT + PE @ 47d = 1.3 vs 0.2%

2008 For patients with symptomatic infusion thrombophlebitis as a complication of IV infusion, we suggest oral diclofenac or another NSAID (Grade 2B), topical diclofenac gel (Grade 2B), or heparin gel (Grade 2B) until resolution of symptoms or for up to 2 weeks. We recommend against the use of systemic anticoagulation

2008 For patients with SVT, we suggest prophylactic or intermediate doses of LMWH (Grade 2B) or intermediate doses of UFH (Grade 2B) for at least 4 weeks. We suggest that as an alternative to 4 weeks of LMWH or UFH, VKA (target INR, 2.5; range, 2.0 to 3.0) can be overlapped with 5 days of UFH and LMWH and continued for 4 weeks (Grade 2C) 2012 In patients SVT of the lower limb of at least 5 cm in length, we suggest the use of a prophylactic dose of fondaparinux or LMWH for 45 days over no anticoagulation (Grade 2B)

20082012 In patients with SVT who are treated with anticoagulation, we suggest fondaparinux 2.5 mg daily over a prophylactic dose of LMWH (Grade 2C)

PTS is a cluster of leg symptoms and signs attributable to previous DVT. The most prominent symptoms are chronic dependent swelling and pain, discomfort on walking, and skin discoloration; the most severe manifestation is a venous ulcer of the lower leg. PTS occurs in ~ one-third of patients after acute DVT and up to two-thirds who have had an iliofemoral DVT

2008 For a patient who has had a symptomatic proximal DVT, we recommend the use of an elastic compression stocking with an ankle pressure gradient of 30 to 40 mm Hg if feasible (Grade 1A) 2012 In patients with acute symptomatic DVT of the leg, we suggest the use of compression stockings (Grade 2B)

2008 Compression therapy should be started as soon as feasible after starting anticoagulant therapy and should be continued for a minimum of 2 years, and longer if patients have symptoms of PTS

2008 For patients with mild edema of the leg due to PTS, we suggest the use of elastic compression stockings (Grade 2C) For patients with severe edema of the leg due to PTS, we suggest a course of intermittent pneumatic compression (Grade 2B) 2012 In patients with PTS of the leg, we suggest a trial of compression stockings (Grade 2C) In patients with severe PTS of the leg that is not adequately relieved by compression stockings, we suggest a trial of an intermittent compression device (Grade 2B)

2008 In patients with persistent venous ulcers, we suggest that rutosides, or sulodexide be added to local care and compression (Grade 2B) 2012 In patients with PTS of the leg, we suggest that venoactive medications (eg, rutosides, defibrotide, and hidrosmin) not be used (Grade 2C)

2008 For patients at risk for PTS after UEDVT, we do not suggest routine use of elastic compression or venoactive medications (Grade 2C) 2012 In patients with acute symptomatic UEDVT, we suggest against the use of compression sleeves or venoactive medications (Grade 2C)

2008 In patients with UEDVT who have persistent edema and pain, we suggest elastic bandages or elastic compression sleeves to reduce symptoms of PTS of the upper extremity (Grade 2C) 2012 In patients who have PTS of the arm, we suggest a trial of compression bandages or sleeves to reduce symptoms (Grade 2C)

20082012 In patients with PTS of the arm, we suggest against treatment with venoactive medications (Grade 2C)

No randomized trial or prospective observational study has evaluated IVC filters as sole therapy (ie, without concurrent anticoagulation) in patients with DVT IVC filters can be used instead of initial anticoagulant therapy in patients with acute PE if there is an unacceptable risk of bleeding or as an adjunct to anticoagulation The PREPIC study, which evaluated IVC filters as an adjunct to anticoagulation in 400 high-risk patients with proximal DVT, showed that filters reduced PE, increased DVT, and did not change overall frequency of VTE (DVT and PE combined) or mortality

2008 For patients with proximal DVT or PE, we recommend against the routine use of a IVC filter in addition to anticoagulants (Grade 1A) 2012 In patients with acute DVT of the leg or PE, we recommend against the use of an IVC filter in addition to anticoagulants (Grade 1B)

2008 For patients with acute proximal DVT or PE, if anticoagulant therapy is not possible because of the risk of bleeding, we recommend placement of an IVC filter (Grade 1C) 2012 In patients with acute proximal DVT of the leg or PE and contraindication to anticoagulation, we recommend the use of an IVC filter (Grade 1B)

2008 For patients with acute DVT who have an IVC filter inserted as an alternative to anticoagulation, we recommend that they should subsequently receive a conventional course of anticoagulant therapy if their risk of bleeding resolves (Grade 1C) 2012 In patients with acute proximal DVT of the leg or PE and an IVC filter inserted as an alternative to anticoagulation, we suggest a conventional course of anticoagulant therapy if their risk of bleeding resolves (Grade 2B)

20082012 In patients with CTPH, we recommend extended anticoagulation over stopping therapy (Grade 1B)

20082012 In selected patients with CTPH, such as those with central disease under the care of an experienced thromboendarterectomy team, we suggest pulmonary thromboendarterectomy over no pulmonary thromboendarterectomy (Grade 2C)

20082012 In patients with symptomatic splanchnic vein thrombosis (portal, mesenteric, and/or splenic vein thromboses), we recommend anticoagulation over no anticoagulation (Grade 1B)

20082012 In patients with incidentally detected splanchnic vein thrombosis (portal, mesenteric, and/or splenic vein thromboses), we suggest no anticoagulation over anticoagulation (Grade 2C)

20082012 In patients with symptomatic hepatic vein thrombosis, we suggest anticoagulation over no anticoagulation (Grade 2C)

20082012 In patients with incidentally detected hepatic vein thrombosis, we suggest no anticoagulation over anticoagulation (Grade 2C)

Outcomes No. of Participants (Studies), Follow-up Quality of the Evidence (GRADE) Relative Effect (95% CI) Anticipated Absolute Effects Risk With No Fondaparinux Risk Difference With Fondaparinux (95% CI) Mortality 3,002 (1 study), 3 mo Moderate d-g due to imprecision dg RR 1.99 (0.18- 21.87) 4 per 1,000 h h 4 more per 1,000 (from 3 fewer to 83 more) VTE 3,002 (1 study), 3 mo High d d RR 0.18 (0.06- 0.53) 33 per 1,000 h h 27 fewer per 1,000 (from 16 fewer to 31 fewer) SVT recurrence 3,002 (1 study), 3 mo High d d RR 0.31 (0.14- 0.68) 19 per 1,000 h h 13 fewer per 1,000 (from 6 fewer to 16 fewer) Major bleeding 2,987(1 study), 47 d Moderate d,e,i due to imprecision dei RR 0.99 (0.06- 15.86) e e 1 per 1,000 0 fewer per 1,000 (from 1 fewer to 10 more)

Age > 65 y 17-25 Age > 75 y 17-21,23,25-34 Previous bleeding 18,24,25,30,33-36 Cancer 20,24,30,37 Metastatic cancer 36.38, Renal failure 18,24,25,28,30,33 Liver failure 19,21,27,28 Thrombocytopenia 27,36 Previous stroke 18,25,27,39 Diabetes 18,19,28,32,34 Anemia 18,21,27,30,34 Antiplatelet therapy 19,27,28,34,40 Poor anticoagulant control 22,28,35 Comorbidity and reduced functional capacity 24,28,36 Recent surgery 21,41,bb Frequent falls 27 Alcohol abuse 24

Estimated Absolute Risk of Major Bleeding, % Categorization of Risk of Bleeding c c Low Risk d (0 Risk Factors) d Moderate Risk d (1 Risk Factor) d High Risk d ( 2 Risk Factors) d Anticoagulation 0-3 mo e e Baseline risk (%)0.61.24.8 Increased risk (%)1.02.08.0 Total risk (%)1.6 e e 3.212.8 f f Anticoagulation after first 3 mo g g Baseline risk (%/y)0.3 h h 0.6 2.5 Increased risk (%/y)0.51.0 4.0 Total risk (%/y)0.8 i i 1.6 i i 6.5

Outcomes No. of Participants (Studies), Follow-up Quality of the Evidence (GRADE) Relative Effect (95% CI) Anticipated absolute effects Risk With No Parenteral Anticoagulat ion Risk Difference With Parenteral Anticoagulat ion (95% CI) Mortality 120 (1 study), 6 mo Moderate b,c due to imprecision bc RR 0.5 (0.05-5.37) 33 per 1,000 16 fewer per 1,000 (from 31 fewer to 144 more) VTE symptomatic extension or recurrence 120 (1 study), 6 mo Moderate b,d due to imprecision bd RR 0.33 (0.11-0.98) 200 per 1,000 134 fewer per 1,000 (from 4 fewer to 178 fewer) Major bleeding 120 (1 study), 6 mo Moderate b,c due to imprecision bc RR 0.67 (0.12-3.85) 50 per 1,000 16 fewer per 1,000 (from 44 fewer to 142 more)

Outcomes No. of Participants (Studies), Follow-up Quality of the Evidence (GRADE) Relative Effect (95% CI) Anticipated Absolute Effects Risk With No CDT Risk Difference With CDT (95% CI) Mortality 153 (2 studies), 3 mo Low c,d due to imprecision cd RR 0.14 (0.01-2.71) 39 per 1,000 e e 34 fewer per 1,000 (from 39 fewer to 67 more) Nonfatal recurrent VTE 153 (1 study), 3 mo Low c,d due to imprecision cd RR 0.35 (0- 8.09) 48 per 1,000 f f 31 fewer per 1,000 (from 48 fewer to 340 more) Nonfatal major bleeding 153 (2 studies), 7 d Low c,d due to imprecision cd RR 2.00 (0.19-19.46) 29 per 1,000 6,7 29 more per 1,000 (from 23 fewer to 535 more) PTS (complete lysis on venography [Elsharawy et al 73 ]; patency on ultrasound and air plethysmogr aphy [Enden et al 74 ]) 138 (2 studies), 2 y Moderate c,g due to indirectness cg RR 0.46 (0- 0.79) 588 per 1,000 h h 318 fewer per 1,000 (from 123 fewer to 588 fewer) i i

Major contraindications a a Structural intracranial disease Previous intracranial hemorrhage Ischemic stroke within 3 mo Active bleeding Recent brain or spinal surgery Recent head trauma with fracture or brain injury Bleeding diathesis Relative contraindications b b Systolic BP > 180 mm Hg Diastolic BP > 110 mm Hg Recent bleeding (nonintracranial) Recent surgery Recent invasive procedure Ischemic stroke more that 3 mo previously Anticoagulation (eg, VKA therapy) Traumatic cardiopulmonary resuscitation Pericarditis or pericardial fluid Diabetic retinopathy Pregnancy Age > 75 y Low body weight (eg, < 60 kg) Female sex Black race

Outcomes No. of Participants (Studies), Follow-up Quality of the Evidence (GRADE) Relative Effect (95% CI) Anticipated Absolute Effects Risk With No Systemic Lysis Risk Difference With Systemic Lysis (95% CI) Mortality 688 (5 studies), 3 mo a a Low b-e due to imprecision be RR 0.86 (0.27-2.68) 21 per 1,000 3 fewer per 1,000 (from 16 fewer to 36 more) Nonfatal recurrent VTE 687 (3 studies), 3 mo f f Low d,e,g due to imprecision deg RR 1.28 (0.25-6.68) 48 per 1,000 h h 13 more per 1,000 (from 36 fewer to 273 more) Nonfatal major bleeding 688 (10 studies), 3 mo f f Moderate c,d,i due to imprecision cdi RR 1.84 (0.94-3.59) 29 per 1,000 h,j hj 24 more per 1,000 (from 2 fewer to 75 more) PTS 678 (2 studies), 2 y k k Low d,e,l,m due to risk of bias and imprecision delm RR 0.71 (0.49-1.04) 588 per 1,000 n n 171 fewer per 1,000 (from 300 fewer to 24 more)

Outcomes No. of Participants (Studies), Follow-up Quality of the Evidence (GRADE) Relative Effect (95% CI) Anticipated Absolute Effects Risk With No vena cava Filters Risk Difference With Vena cava Filters (95% CI) Mortality 400 (1 study), 8 y Moderate c,d due to imprecision cd RR 0.95 (0.78- 1.16) e e 515 per 1,000 26 fewer per 1,000 (from 113 fewer to 82 more) Symptomati c PE 304 (1 study), 8 y Moderate c,f due to imprecision cf RR 0.41 (0.2-0.86) g g 151 per 1,000 89 fewer per 1,000 (from 21 fewer to 121 fewer) Recurrent DVT 310 (1 study), 8 y Moderate c,f due to imprecision cf RR 1.3 (0.93-1.82) h h 273 per 1,000 82 more per 1,000 (from 19 fewer to 224 more) Major bleeding 337 (1 study), 8 y Moderate c,d due to imprecision cd RR 0.83 (0.52-1.34) i i 185 per 1,000 31 fewer per 1,000 (from 89 fewer to 63 more) PTS 308 (1 study), 8 y Low d,j due to risk of bias and imprecision dj RR 0.87 (0.66-1.13) 699 per 1,000 91 fewer per 1,000 (from 238 fewer to 91 more)

Outcomes No. of Participants (Studies), Follow-up Quality of the Evidence (GRADE) Relative Effect (95% CI) Anticipated Absolute Effects Risk With Control Risk Difference With 4 or 6 wk vs 3 or 6 mo Months of Anticoagulat ion (95% CI) Recurrent VTE 2,185 (5 studies c ), 1- 2 y d c d High e-g eg RR 1.83 (1.39-2.42) 64 per 1,000 53 more per 1,000 (from 25 more to 91 more) Major bleeding 2,185 (5 studies), 1-2 y High f f RR 0.54 (0.22-1.32) 12 per 1,000 5 fewer per 1,000 (from 9 fewer to 4 more) Mortality 2,098 (5 studies), 1-2 y High e,f,h efh RR 0.97 (0.68-1.38) 55 per 1,000 2 fewer per 1,000 (from 18 fewer to 21 more)

Outcomes No. of Participants (Studies), Follow-up Quality of the Evidence (GRADE) Relative Effect (95% CI) Anticipated Absolute Effects Risk With 3 mo Risk Difference With 6 or 12 mo (95% CI) Recurrent VTE 2,061 (6 studies), 1-3 y Moderate c-e due to imprecision ce RR 0.89 (0.69-1.14) 115 per 1,000 13 fewer per 1,000 (from 36 fewer to 16 more) Major bleeding 2,061 (6 studies), 1-3 y High f f RR 2.49 (1.2-5.16) 9 per 1,000 13 more per 1,000 (from 2 more to 37 more) Mortality g g 1,331 (5 studies), 1-3 y Moderate d due to imprecision d RR 1.3 (0.81-2.08) 44 per 1,000 13 more per 1,000 (from 8 fewer to 47 more)

OutcomesNo. of Participants (Studies), Follow-upQuality of the Evidence (GRADE)Relative Effect (95% CI) Anticipated Absolute Effects Risk With No Extended Duration Oral AnticoagulationRisk Difference With Extended Duration Oral Anticoagulation (95% CI) Mortality1,184 (4 studies), 10-36 moModerate c-e due to imprecision ceRR 0.57 (0.31-1.03)63 per 1,00027 fewer per 1,000 (from 44 fewer to 2 more) Recurrent VTE at 1 y1,184 (4 studies), 10-36 moHighRR 0.12 (0.09-0.38) First VTE provoked by surgery f-j fj 10 per 1,00010 fewer per 1,000 (from 6 fewer to 9 fewer) First proximal DVT or PE provoked nonsurgical/first unprovoked distal DVT f-j fj 50 per 1,00044 fewer per 1,000 (from 31 fewer to 45 fewer) First unprovoked VTE f-j fj 100 per 1,00088 fewer per 1,000 (from 62 fewer to 91 fewer) Second unprovoked VTE f-j fj 150 per 1,000132 fewer per 1,000 (from 93 fewer to 137 fewer) Major bleeding at 1 y1,184 (4 studies), 10-36 moModerate due to imprecisionRR 2.63 (1.02-6.76) Low k,l (see Table 2) kl 3 per 1,0005 more per 1,000 (from 0 more to 15 more) Moderate k,l (see Table 2) kl 6 per 1,00010 more per 1,000 (from 1 more to 29 more) High k,l (see Table 2) kl 25 per 1,00040 more per 1,000 (from 3 more to 122 more) Recurrent VTE at 5 y1,184 (4 studies), 10-36 moHighRR 0.12 (0.09-0.38) First VTE provoked by surgery f-j fj 30 per 1,00026 fewer per 1,000 (from 19 fewer to 27 fewer) First proximal DVT or PE provoked nonsurgical/first unprovoked distal DVT f-j fj 150 per 1,000132 fewer per 1,000 (from 93 fewer to 137 fewer) First unprovoked VTE f-j fj 300 per 1,000264 fewer per 1,000 (from 186 fewer to 273 fewer) Second unprovoked VTE f-j fj 450 per 1,000396 fewer per 1,000 (from 279 fewer to 409 fewer) Major bleeding at 5 y1,184 (4 studies), 10-36 moModerate due to imprecisionRR 2.63 (1.02-6.76) Low k,l (see Table 2) kl 15 per 1,00024 more per 1,000 (from 2 more to 73 more) Moderate k,l (see Table 2) kl 30 per 1,00048 more per 1,000 (from 4 more to 146 more) High k,l (see Table 2) kl 125 per 1,000199 more per 1,000 (from 17 more to 609 more) Burden of anticoagulation not reportedWarfarin: daily medication, dietary and activity restrictions, frequent blood testing/monitoring, increased hospital/ clinic visits m m

Outcomes No. of Participants (Studies), Follow-up Relative Effect (95% CI) Anticipated Absolute Effects Risk With No Extended Duration Oral Anticoagulation Risk Difference With Extended Duration Oral Anticoagulation (95% CI) Mortality 1,184 (4 studies), 10-36 mo RR 0.57 (0.31-1.03)63 per 1,000 27 fewer per 1,000 (from 44 fewer to 2 more) Recurrent VTE at 1 y 1,184 (4 studies), 10-36 mo RR 0.12 (0.09-0.38) First VTE provoked by surgery f-j fj 10 per 1,000 10 fewer per 1,000 (from 6 fewer to 9 fewer) First proximal DVT or PE provoked nonsurgical/first unprovoked distal DVT f-j fj 50 per 1,000 44 fewer per 1,000 (from 31 fewer to 45 fewer) First unprovoked VTE f-j fj 100 per 1,000 88 fewer per 1,000 (from 62 fewer to 91 fewer) Second unprovoked VTE f-j fj 150 per 1,000 132 fewer per 1,000 (from 93 fewer to 137 fewer)

Outcomes No. of Participants (Studies), Follow-up Relative Effect (95% CI) Anticipated Absolute Effects Risk With No Extended Duration Oral Anticoagulation Risk Difference With Extended Duration Oral Anticoagulation (95% CI) Major bleeding at 1 y 1,184 (4 studies), 10-36 mo RR 2.63 (1.02-6.76) Low k,l (see Table 2) kl 3 per 1,000 5 more per 1,000 (from 0 more to 15 more) Moderate k,l (see Table 2) kl 6 per 1,000 10 more per 1,000 (from 1 more to 29 more) High k,l (see Table 2) kl 25 per 1,000 40 more per 1,000 (from 3 more to 122 more)

Outcomes No. of Participants (Studies), Follow-up Relative Effect (95% CI) Anticipated Absolute Effects Risk With No Extended Duration Oral Anticoagulation Risk Difference With Extended Duration Oral Anticoagulation (95% CI) Recurrent VTE at 5 y 1,184 (4 studies), 10-36 mo RR 0.12 (0.09-0.38) First VTE provoked by surgery f-j fj 30 per 1,000 26 fewer per 1,000 (from 19 fewer to 27 fewer) First proximal DVT or PE provoked nonsurgical/first unprovoked distal DVT f-j fj 150 per 1,000 132 fewer per 1,000 (from 93 fewer to 137 fewer) First unprovoked VTE f-j fj 300 per 1,000 264 fewer per 1,000 (from 186 fewer to 273 fewer) Second unprovoked VTE f-j fj 450 per 1,000 396 fewer per 1,000 (from 279 fewer to 409 fewer)

Outcomes No. of Participants (Studies), Follow-up Relative Effect (95% CI) Anticipated Absolute Effects Risk With No Extended Duration Oral Anticoagulation Risk Difference With Extended Duration Oral Anticoagulation (95% CI) Major bleeding at 5 y 1,184 (4 studies), 10-36 mo RR 2.63 (1.02-6.76) Low k,l (see Table 2) kl 15 per 1,000 24 more per 1,000 (from 2 more to 73 more) Moderate k,l (see Table 2) kl 30 per 1,000 48 more per 1,000 (from 4 more to 146 more) High k,l (see Table 2) kl 125 per 1,000 199 more per 1,000 (from 17 more to 609 more)

danny hill pgy-5, hematology. vte acute management of vte risk stratification duration of...

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