The ACCP Chest Guidelines have been the main guide over the last more than 2 decades for evidence-based recommendations on best management of anticoagulants for various indications, including DVT and PE. The 10th edition of the chapter on DVT and PE management was published in Jan 2016 [ref 1]. Unfortunately, the guideline is not available for non-subscribers.
What this publication is NOT
It appears that Chest is not publishing any more the > 1000 page comprehensive 22 chapter structure of the ACCP Guidelines of the past, dealing with all possible indications for anticoagulant drugs (venous thromboembolism prevention and treatment, arterial occlusive disease, atrial fibrillation), the discussion of the various drugs and special patient populations (such as pregnancy women).
What this publication is
This 38 page document focusses on the best management of VTE. It provides 30 individual recommendations (page 7-19) and data-driven discussions of the evidence behind the guidance. It uses the terms “suggest” and “recommend” for its guidance, depending on the strength of published evidence. Unfortunately, the guideline is not available for non-subscribers.
- Outpatient management:
In patients with low-risk PE, outpatient treatment or early discharge are suggested, rather than hospitalization.
- Choice of anticoagulant drug:
In patients with DVT of the leg or PE (and no cancer) the suggestion is to use one of the direct oral anticoagulants (DOAC; apixaban, dabigatran, edoxaban, or rivaroxaban) rather than warfarin therapy!
- Sub-segmental PE:
Patients with sub-segmental PE (no involvement of more proximal pulmonary arteries) and no proximal DVT:
- Anticoagulation is suggested for patients at higher risk for recurrence, i.e. patients who are hospitalized, have reduced mobility, have cancer, had unprovoked sub-segmental PE, have low pulmonary reserve, or marked respiratory symptoms.
- No anticoagulation is suggested but simply surveillance in patients who are at low risk of VTE recurrence (e.g. patients with recent surgery or other transient risk factor
- Cancer patients with VTE:
In cancer patients with DVT of the leg or PE LMWH is suggested rather than a DOAC.
- How long to treat with Anticoagulants?
- VTE (proximal DVT or PE) provoked by surgery: recommend 3 months.
- VTE (proximal DVT or PE) provoked by non-surgical transient risk factor (e.g. estrogens, pregnancy, leg injury, flight > 8 hrs): suggest 3 months.
- Unprovoked VTE (proximal DVT or PE): suggest long-term.
- Distal DVT:
- if not severely symptomatic : suggest no anticoagulation, but f/u Doppler ultrasound;
- if severely symptomatic: suggest 3 months.
In patients with unprovoked venous thromboembolism (VTE) who stop anticoagulation, aspirin is suggested.
Kearon C et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016; 149(2):315-352
Conflict of interest: None
Last updated: Oct 27th, 2016