Antithrombotic Therapy for VTE Disease

Kearon, Clive; Akl, Elie A.; Ornelas, Joseph; Blaivas, Allen; Jimenez, David; Bounameaux, Henri; Huisman, Menno; King, Christopher S.; Morris, Timothy A.; Sood, Namita; Stevens, Scott M.; Vintch, Janine R.E.; Wells, Philip; Woller, Scott C.; Moores, Lisa

doi:10.1016/j.chest.2015.11.026

Cited by 4,830Venous Thromboembolism Diagnosis and ManagementBlood Coagulation and Thrombosis MechanismsAtrial Fibrillation Management and Outcomes

Antithrombotic Therapy for VTE Disease

Kearon, Clive, Akl, Elie A., Ornelas, Joseph, Blaivas, Allen, Jimenez, David, Bounameaux, Henri, Huisman, Menno, King, Christopher S. +7 more·2016·Chest

DOI 10.1016/j.chest.2015.11.026

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Abstract

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.

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Direct-acting oral anticoagulants such as dabigatran, apixaban, rivaroxaban, and edoxaban are becoming the preferred agents for acute VTE compared with vitamin K antagonists.
“Direct-acting oral anticoagulants (DOACs) such as dabigatran, apixaban, rivaroxaban, and edoxaban are becoming the preferred agents for use in acute venous thromboembolism (VTE; deep vein thrombosis and pulmonary embolism) compared with vitamin K antagonists (VKAs). 1”
From Systematic review and meta-analysis of the efficacy and safety of apixaban compared to rivaroxaban in acute VTE in the real world (2019) · cites this paper as [1]
Current guidelines suggest extended (ie, indefinite) anticoagulation in patients with unprovoked proximal deep vein thrombosis or pulmonary embolism who have a non-high bleeding risk.
“current guidelines suggest extended (ie, indefinite) anticoagulation in patients with unprovoked proximal deep vein thrombosis or pulmonary embolism who have a non-high bleeding risk.6 7 8”
From Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis (2019) · cites this paper as [6]
It is unlikely that patients with a major bleeding risk that exceeds 3% a year would ever experience a net long term mortality benefit from indefinite anticoagulation.
“as suggested by current guidelines,6 7 it is unlikely that patients with a major bleeding risk that exceeds 3% a year would ever experience a net long term mortality benefit from indefinite anticoagulation.”
From Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis (2019) · cites this paper as [6]

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Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association
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Diagnosis and management of acute deep vein thrombosis: a joint consensus document from the European Society of Cardiology working groups of aorta and peripheral vascular diseases and pulmonary circulation and right ventricular function
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Racial, ethnic, and socioeconomic inequities in the prescription of direct oral anticoagulants in patients with venous thromboembolism in the United States.
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Authors: Kearon, C., Akl, E. A., Ornelas, J., Blaivas, A., Jimenez, D., Bounameaux, H., Huisman, M., King, C. S., Morris, T. A., Sood, N., Stevens, S. M., Vintch, J. R. E., Wells, P., Woller, S. C., & Moores, L.
Affiliations: McMaster University (CA)
American College of Chest Physicians (US)
VA New Jersey Health Care System (US)
University of Geneva (CH)
Leiden University Medical Center (NL)
Virginia Commonwealth University (US)
University of California San Diego (US)
The Ohio State University (US)
University of Utah (US)
Harbor–UCLA Medical Center (US)
University of Ottawa (CA)
Uniformed Services University of the Health Sciences (US)
Corresponding author: Akl, Elie A.
ORCID: Akl, Elie A.
Bounameaux, Henri
Huisman, Menno
King, Christopher S.
Morris, Timothy A.
Sood, Namita
Stevens, Scott M.
Vintch, Janine R.E.
Woller, Scott C.
Moores, Lisa
Venue: Chest
Publisher: Elsevier BV
Published: 2016-02
Volume: 149
Issue: 2
Pages: 315-352
ISSN: 0012-3692 (ISSN-L)
DOI: 10.1016/j.chest.2015.11.026
OpenAlex: W2225937646
Cited by: 4,830
References: 610
Citations by year: 2026: 173 · 2025: 244 · 2024: 270 · 2023: 321 · 2022: 420 · 2021: 630 · 2020: 697 · 2019: 607 · 2018: 621 · 2017: 530 · 2016: 244 · 2015: 18 · 2014: 23 · 2013: 15 · 2012: 9
FWCI: 627.82
Type: journal article
Language: en
Update notices: erratum (2016-10-01)
Open access: closed
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations: CHEST Journal (publishedVersion)
PubMed (publishedVersion)
Funders: American College of Chest Physicians
Topics: Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
Health Sciences › Medicine › Hematology › Blood Coagulation and Thrombosis Mechanisms
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
Keywords: venous thromboembolism, antithrombotic therapy, anticoagulation, dabigatran, rivaroxaban, apixaban, edoxaban, vitamin K antagonists, low molecular weight heparin, cancer-associated thrombosis, inferior vena cava filter, post-thrombotic syndrome, compression stockings, subsegmental pulmonary embolism, thrombolysis, recurrent venous thromboembolism, catheter-directed thrombolysis
MeSH terms: Drug Administration Schedule, Fibrinolytic Agents, Humans, Societies, Medical, Evidence-Based Medicine, International Normalized Ratio, Venous Thrombosis

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