ASH VTE Treatment_PDF

Treatment of Deep Vein Thrombosis and Pulmonary Embolism

Authors and Publication

  • Authors:

    • Zachary Liederman, MD MScCH (University of Toronto)

    • Eric K. Tseng, MD MScCH (University of Toronto)

    • Thomas L. Ortel, MD PhD (Duke University)

  • Published by: American Society of Hematology (ASH), 2020

Clinical Guidelines

  • ASH 2020 guidelines for management of venous thromboembolism (VTE):

    • Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE)

    • Key contributors include Thomas L. Ortel, Ignaci Barbarao Neumann, Walter Ageno, and others.

ASH Clinical Practice Guidelines on VTE

  1. Prevention of VTE in Surgical Hospitalized Patients

  2. Prevention of VTE in Medical Hospitalized Patients

  3. Treatment of Acute VTE (DVT and PE)

  4. Optimal Management of Anticoagulation Therapy

  5. Prevention and Treatment of VTE in Patients with Cancer

  6. Heparin-Induced Thrombocytopenia (HIT)

  7. Thrombophilia

  8. Pediatric VTE

  9. VTE in the Context of Pregnancy

  10. Diagnosis of VTE

  11. Anticoagulation in Patients with COVID-19

  12. Adaptation of ASH Management of VTE Guidelines for Latin America

Development of ASH Guidelines

  • Clinical Questions: Developed 20 to 30 clinically relevant questions in PICO format.

  • Evidence Synthesis: Evidence summaries incorporated into Evidence to Decision (EtD) frameworks.

    • Considerations included resource use, feasibility, and patient values.

    • Example PICO question: "Should thrombolytic therapy in addition to anticoagulation be used for patients with extensive proximal DVT?"

  • Making Recommendations: Recommendations formed by guideline panel members using EtD frameworks.

  • Panel Formation: Focused on expertise balance and conflict of interest management.

Patient and Clinician Recommendation Guidelines

  • Strong Recommendation: Defined as "The panel recommends…"

  • Conditional Recommendation: Defined as "The panel suggests…"

  • For Patients: Most would want the intervention vs. majority would want it, but many would not.

  • For Clinicians: Most individuals should receive the intervention, differing choices based on patient values and preferences.

Grading the Quality of Evidence

  • Evidence Quality Levels: Low (or Very Low), Moderate, Strong.

Objectives of Session

  1. Describe the initial management of patients with DVT and PE.

  2. Describe recommendations for duration of anticoagulation after VTE.

  3. Describe recommendations for management of recurrent VTE.

Incidence of VTE

  • Occurs in 1-2 per 1,000 people per year.

  • One-third of newly diagnosed VTE present with PE.

  • Common cause of morbidity and mortality.

  • Recurrence risk after completing primary treatment for unprovoked VTE is about 10% within two years.

  • Incidence increases with age, reaching as high as 1 in 100 for individuals over 80.

Management Stages of VTE Guidelines

  • Initial Stages: Within 2 weeks.

  • Primary Treatment: 3-6 months.

  • Secondary Prevention: Beyond 6 months.

Case Example: Unprovoked DVT

  • Patient Details: 48-year-old male presenting with leg pain and swelling.

  • Vital Signs: Heart rate 80, BP 130/80.

  • Evaluation: Left calf swelling, elevated D-dimer, ultrasound confirmed occlusive DVT.

Initial Management Recommendation for Unprovoked DVT

  • Options: A. Anticoagulation only B. Thrombolysis with anticoagulation C. Compression stockings with anticoagulation D. IVC filter with anticoagulation

Outcomes for Anticoagulation vs. Thrombolysis

  • Mortality: RR 0.77, indicating 2 fewer deaths per 1,000 with thrombolytic therapy.

  • Post-Thrombotic Syndrome (PTS): Reduced by 186 per 1,000 using thrombolytics.

  • Major Bleeding Risk: Elevated by 31 per 1,000 with thrombolytic therapy.

  • Recommendation: Anticoagulation therapy alone preferred for proximal DVT (low certainty).

Anticoagulation Options for DVT and PE

  • Direct Oral Anticoagulants (DOACs) vs. Vitamin K Antagonists (VKAs):

    • Mortality risk similar.

    • DOACs may have lower rates of DVT recurrence and PTS.

Home vs. Hospital Treatment

  • Recommendation: For uncomplicated DVT, home treatment is preferred to hospital treatment (low certainty).

Summary of Management Principles

  • Initial Management for Unprovoked VTE: Anticoagulation (DOAC preferred).

  • Duration for Secondary Prevention: Indefinite antithrombotic therapy suggested after primary treatment.

Case Example: Provoked DVT and PE

  • Patient Details: 76-year-old male post-hip replacement with new leg pain and shortness of breath, confirmed pulmonary embolism.

Risks and Management for Provoked Cases

  • Initial Management: Anticoagulation only, consideration of ASA suspension.

  • Recommendation against routine IVC filter insertion unless contraindicated to anticoagulation.

Provoking Risk Factors for VTE

  • Transient Risk Factors: Surgery, immobilization, pregnancy.

  • Chronic Risk Factors: Active cancer, autoimmune disorders, chronic immobility.

Further Management Decision Points

  • Recommendations favor short-term (3-6 months) anticoagulation over long-term (6-12 months) for provoked VTE due to transient risk factors.

Composite Cases and Recurrence Adjustments

  • Adjust recommendations based on previous thrombotic events and assess for secondary prevention strategies.

  • Indefinite therapy recommended for unprovoked events; reassessment needed with provoked events.

Conclusion on Case Studies

  • Emphasis on anticoagulation, DOACs over VKAs, and appropriate treatment duration based on risk factors.

Future Research Priorities

  • Identification of optimal patient populations for thrombolysis, prognostic scores, and long-term management strategies.

Summary Review Objectives Revisited

  1. Initial management description for DVT and PE.

  2. Duration of anticoagulation after VTE.

  3. Management of recurrent VTE recommendations.

Acknowledgements

  • ASH Guideline Panel Team and contributors for clinical practice guidance.

  • Visit ASH VTE guidelines at www.hematology.org/VTEguidelines for further resources.