Clive Kearon1, Elie A Akl2, Anthony J Comerota3, Paolo Prandoni4, Henri Bounameaux5, Samuel Z Goldhaber6, Michael E Nelson7, Philip S Wells8, Michael K Gould9, Francesco Dentali10, Mark Crowther11, Susan R Kahn12. 1. Department of Medicine and Clinical Epidemiology and Biostatistics, Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada. 2. Department of Medicine, Family Medicine, and Social and Preventive Medicine, State University of New York at Buffalo, Buffalo, NY. Electronic address: elieakl@buffalo.edu. 3. Department of Surgery, Jobst Vascular Center, Toledo, OH. 4. Department of Cardiothoracic and Vascular Sciences, University of Padua, Padua, Italy. 5. Department of Medical Specialties, University Hospitals of Geneva, Geneva, Switzerland. 6. Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. 7. Department of Medicine, Shawnee Mission Medical Center, Shawnee Mission, KS. 8. Department of Medicine, University of Ottawa, Ottawa, ON, Canada. 9. Department of Medicine and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA. 10. Department of Medicine, University of Insubria, Varese, Italy. 11. Department of Medicine, Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada. 12. Department of Medicine and Clinical Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada.
Abstract
BACKGROUND: This article addresses the treatment of VTE disease. METHODS: We generated strong (Grade 1) and weak (Grade 2) recommendations based on high-quality (Grade A), moderate-quality (Grade B), and low-quality (Grade C) evidence. RESULTS: For acute DVT or pulmonary embolism (PE), we recommend initial parenteral anticoagulant therapy (Grade 1B) or anticoagulation with rivaroxaban. We suggest low-molecular-weight heparin (LMWH) or fondaparinux over IV unfractionated heparin (Grade 2C) or subcutaneous unfractionated heparin (Grade 2B). We suggest thrombolytic therapy for PE with hypotension (Grade 2C). For proximal DVT or PE, we recommend treatment of 3 months over shorter periods (Grade 1B). For a first proximal DVT or PE that is provoked by surgery or by a nonsurgical transient risk factor, we recommend 3 months of therapy (Grade 1B; Grade 2B if provoked by a nonsurgical risk factor and low or moderate bleeding risk); that is unprovoked, we suggest extended therapy if bleeding risk is low or moderate (Grade 2B) and recommend 3 months of therapy if bleeding risk is high (Grade 1B); and that is associated with active cancer, we recommend extended therapy (Grade 1B; Grade 2B if high bleeding risk) and suggest LMWH over vitamin K antagonists (Grade 2B). We suggest vitamin K antagonists or LMWH over dabigatran or rivaroxaban (Grade 2B). We suggest compression stockings to prevent the postthrombotic syndrome (Grade 2B). For extensive superficial vein thrombosis, we suggest prophylactic-dose fondaparinux or LMWH over no anticoagulation (Grade 2B), and suggest fondaparinux over LMWH (Grade 2C). CONCLUSION: Strong recommendations apply to most patients, whereas weak recommendations are sensitive to differences among patients, including their preferences.
BACKGROUND: This article addresses the treatment of VTE disease. METHODS: We generated strong (Grade 1) and weak (Grade 2) recommendations based on high-quality (Grade A), moderate-quality (Grade B), and low-quality (Grade C) evidence. RESULTS: For acute DVT or pulmonary embolism (PE), we recommend initial parenteral anticoagulant therapy (Grade 1B) or anticoagulation with rivaroxaban. We suggest low-molecular-weight heparin (LMWH) or fondaparinux over IV unfractionated heparin (Grade 2C) or subcutaneous unfractionated heparin (Grade 2B). We suggest thrombolytic therapy for PE with hypotension (Grade 2C). For proximal DVT or PE, we recommend treatment of 3 months over shorter periods (Grade 1B). For a first proximal DVT or PE that is provoked by surgery or by a nonsurgical transient risk factor, we recommend 3 months of therapy (Grade 1B; Grade 2B if provoked by a nonsurgical risk factor and low or moderate bleeding risk); that is unprovoked, we suggest extended therapy if bleeding risk is low or moderate (Grade 2B) and recommend 3 months of therapy if bleeding risk is high (Grade 1B); and that is associated with active cancer, we recommend extended therapy (Grade 1B; Grade 2B if high bleeding risk) and suggest LMWH over vitamin K antagonists (Grade 2B). We suggest vitamin K antagonists or LMWH over dabigatran or rivaroxaban (Grade 2B). We suggest compression stockings to prevent the postthrombotic syndrome (Grade 2B). For extensive superficial vein thrombosis, we suggest prophylactic-dose fondaparinux or LMWH over no anticoagulation (Grade 2B), and suggest fondaparinux over LMWH (Grade 2C). CONCLUSION: Strong recommendations apply to most patients, whereas weak recommendations are sensitive to differences among patients, including their preferences.
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