Thomas L Ortel1, Ignacio Neumann2, Walter Ageno3, Rebecca Beyth4,5, Nathan P Clark6, Adam Cuker7, Barbara A Hutten8, Michael R Jaff9, Veena Manja10,11, Sam Schulman12,13, Caitlin Thurston14, Suresh Vedantham15, Peter Verhamme16, Daniel M Witt17, Ivan D Florez18,19, Ariel Izcovich20, Robby Nieuwlaat19, Stephanie Ross19, Holger J Schünemann19,21, Wojtek Wiercioch19, Yuan Zhang19, Yuqing Zhang19. 1. Division of Hematology, Department of Medicine, Duke University, Durham NC. 2. Pontificia Universidad Catolica de Chile, Santiago, Chile. 3. Department of Medicine and Surgery, University of Insurbria, Varese, Italy. 4. Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL. 5. Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL. 6. Clinical Pharmacy Anticoagulation Service, Kaiser Permanente, Aurora, CO. 7. Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. 8. Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. 9. Harvard Medical School, Boston, MA. 10. University of California Davis, Sacramento, CA. 11. Veterans Affairs Northern California Health Care System, Mather, CA. 12. Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada. 13. Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia. 14. May-Thurner Syndrome Resource Network. 15. Division of Diagnostic Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO. 16. KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium. 17. Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT. 18. Department of Pediatrics, University of Antioquia, Medellin, Colombia. 19. Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada. 20. Internal Medicine Department, German Hospital, Buenos Aires, Argentina; and. 21. Department of Medicine, McMaster University, Hamilton, ON, Canada.
Abstract
BACKGROUND: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000 each year, corresponding to ∼300 000 to 600 000 events in the United States annually. OBJECTIVE: These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. METHODS: ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS: The panel agreed on 28 recommendations for the initial management of VTE, primary treatment, secondary prevention, and treatment of recurrent VTE events. CONCLUSIONS: Strong recommendations include the use of thrombolytic therapy for patients with PE and hemodynamic compromise, use of an international normalized ratio (INR) range of 2.0 to 3.0 over a lower INR range for patients with VTE who use a vitamin K antagonist (VKA) for secondary prevention, and use of indefinite anticoagulation for patients with recurrent unprovoked VTE. Conditional recommendations include the preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications and a preference for direct oral anticoagulants over VKA for primary treatment of VTE.
BACKGROUND: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000 each year, corresponding to ∼300 000 to 600 000 events in the United States annually. OBJECTIVE: These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. METHODS: ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS: The panel agreed on 28 recommendations for the initial management of VTE, primary treatment, secondary prevention, and treatment of recurrent VTE events. CONCLUSIONS: Strong recommendations include the use of thrombolytic therapy for patients with PE and hemodynamic compromise, use of an international normalized ratio (INR) range of 2.0 to 3.0 over a lower INR range for patients with VTE who use a vitamin K antagonist (VKA) for secondary prevention, and use of indefinite anticoagulation for patients with recurrent unprovoked VTE. Conditional recommendations include the preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications and a preference for direct oral anticoagulants over VKA for primary treatment of VTE.
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Authors: Gary H Lyman; Marc Carrier; Cihan Ay; Marcello Di Nisio; Lisa K Hicks; Alok A Khorana; Andrew D Leavitt; Agnes Y Y Lee; Fergus Macbeth; Rebecca L Morgan; Simon Noble; Elizabeth A Sexton; David Stenehjem; Wojtek Wiercioch; Lara A Kahale; Pablo Alonso-Coello Journal: Blood Adv Date: 2021-02-23