Education Blog for Healthcare Professionals

New ACCP Guidelines – DVT and PE: Highlights and Summary

Stephan Moll, MD writes…  This month the American College of Chest Physicians (ACCP) published its new (2012) guidelines regarding anticoagulation and management of various thrombotic disorders, replacing the 2008 edition. The details of the new guidelines can be found here. A summary of the most important management issues regarding DVT and PE is listed below. The guidelines provide differentiated recommendations that are graded by

a)    their strength (either Grade 1 or 2; “grade 1” = strong recommendation; “grade 2” = weak recommendation) and

b)   the quality of data supporting the recommendations (Grade A, B, or C; “A” = high quality evidence (=solid, plenty, convincing supportive data); “B” = moderate quality evidence (=limited supportive data); “C” = low- or very-low quality evidence (=expert opinion or barely any supportive data).

When applying these guidelines to the management of an individual patient, these grades, obviously, need to be considered, as well as patient-individual factors, to avoid a rigid, black-and-white approach to a patient’s management. The key recommendations regarding DVT and PE are:

1.    Distal leg DVT

a)    Severe symptoms: Treat with anticoagulants. Length of treatment: 3 months (no matter whether DVT was associated with a transient risk factor (surgery, hospitalization, estrogen therapy, etc.) or was unprovoked (= idiopathic).

b)   No, mild or moderate symptoms (and no risk factors for clot extension – see below):

    • No anticoagulation needed.
    • Physician to obtain several (‘serial”) Doppler ultrasound leg examinations over the next 2 weeks to make sure the DVT has not extended (which it does in about 15 % of patients).
    • If DVT has extended: treat with anticoagulants for 3 months.

If extension of clot has not occurred within the first 2 weeks, it is unlikely to occur subsequently. Risk factors for extension: positive D-dimer, DVT that is extensive or close to the proximal veins, no reversible provoking factor for DVT present, active cancer, previous history of blood clots, and inpatient status.

2.    Proximal leg DVT

  • Should be treated with anticoagulants.
  • Suggestion is to not use thrombolytics or clot removal interventions (thrombectomy) routinely.
  • Treat as an outpatient, if feasible.
  • In the acute setting, i.e. the first few days: use once daily Dalteparin (Fragmin) or Tinzaparin (Innohep) or Fondaparinux (Arixtra) or twice daily Enoxaparin (Lovenox).
  • Preferred treatment beyond the first few days: warfarin, rather than Dabigatran (PradaxaÒ) or Rivaroxaban (XareltoÒ).
  • Length of treatment with blood thinners:
    • DVT triggered by surgery: 3 months, rather than 6 or 12 months.
    • DVT due to a mild risk factor (i.e. non-surgical risk factors such as estrogen therapy, long-distance travel, non-surgical hospital stay, etc): 3 months, rather than 6 or 12 months or long-term.
    • Unprovoked (idiopathic) DVT: long-term, if risk for bleeding not very high. Re-evaluation every so often (once per year?) to determine whether long-term treatment is still the right thing to do.

3.  Incidentally discovered (asymptomatic) DVT or PE

DVT (of the leg, arm, pelvis or abdominal/splanchnic) or PE that was asymptomatic and was discovered incidentally, for example because CT scans were done for other reasons:

a)    Leg, pelvic or IVC DVT: Treat with blood thinners. Length: same as discussed in proximal and distal DVT section (discussed above).

b)    Abdominal DVT (portal, splenic, mesenteric or hepatic vein thrombosis): Do not treat with blood thinners.

c)     PE: The CT should be reviewed with a good radiologist to determine whether the reported PE is really a PE. If there is uncertainty, then additional studies should be done (such as D-dimer, Doppler ultrasound of the legs, VQ scan, etc). If the conclusion is that the patient does, indeed, have a PE: Treat with anticoagulants. Length: same as discussed in the PE section below.

4.  Pulmonary Embolism

  • Should be treated with anticoagulants.
  • Suggestion is to not use thrombolytics routinely. However, if the PE is massive (i.e. combination of low blood pressure below 90 mm Hg systolic, heart rate above 100/min, poor perfusion of inner organs, low blood oxygen level, abnormal serum cardiac enzymes, abnormal right heart function on echo or CT) and the patient is at low risk for bleeding, tPA for 2 hours into a peripheral vein can be considered.
  • If the patient with PE is doing relatively well, outpatient treatment with discharge home from the emergency room is appropriate when feasible. “Doing relatively well” means clinically stable and with no impaired pre-existing heart and lung dysfunction.
  • In the acute setting, i.e. the first few days: use once daily Dalteparin (Fragmin) or Tinzaparin (Innohep) or Fondaparinux (Arixtra) or twice daily Enoxaparin (Lovenox).
  • Preferred treatment beyond the first few days: warfarin, rather than Dabigatran (PradaxaÒ) or Rivaroxaban (XareltoÒ).
  • Length of treatment with blood thinners (same treatment decision principles as in DVT):
    • PE triggered by surgery: 3 months, rather than 6 or 12 months.
    • PE due to a mild risk factor (i.e. non-surgical risk factors such as estrogen therapy, long-distance travel, non-surgical hospital stay, etc): 3 months, rather than 6 or 12 months or long-term.
    • Unprovoked (idiopathic) PE: long-term, if risk for bleeding not very high. Re-evaluation every so often (once per year?) to determine whether long-term treatment is still the right thing to do.

5.    Cancer associated DVT or PE

  • Treat for at least 3 months and preferably long-term, unless bleeding risk very high.
  • Low molecular weight heparin is the preferred treatment, rather than warfarin.

6.    Arm DVT

  • If DVT that involves the axillary or more proximal veins, anticoagulation therapy alone is suggested, rather than thrombolytic therapy. Length of anticoagulation: at least 3 months.
  • In upper extremity DVT not associated with a central venous catheter: 3 months of anticoagulation is recommended.
  • In upper extremity DVT associated with a central venous catheter:
    • Suggestion is to not remove the catheter if it is functional and there is an ongoing need for the catheter.  Anticoagulation should be given as long as the catheter is in place.
    • If the catheter is removed, anticoagulation should continue for 3 months thereafter.

 7.    Superficial thrombophlebitis

  • In patients with superficial thrombophlebitis of the leg of at least 5 cm in length, the suggestion is to give prophylactic dose of fondaparinux (preferred) or LMWH for 45 days, rather than no anticoagulation.

8.  Vena cava filter (=IVC filter)

  • Should only be placed in the patient with an acute DVT who cannot tolerate blood thinners because of active bleeding or a high risk for bleeding.
  • “We do not consider that a permanent IVC filter, of itself, is an indication for extended anticoagulation”.

9.    Compression stockings

  • Wear for at least 2 years (to prevent or minimize the occurrence of postthrombotic syndrome.
  • If at 2 years the patient has bothersome symptoms of postthrombotic syndrome (swelling, pain), continue to wear stockings for symptoms relief.
Disclosures: I have no financial disclosures relevant to this blog post.
Last updated: Feb 27th, 2012

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