Summary of Updated VTE Treatment Guidelines

Venous thromboembolism (VTE) is a common disease that affects nearly 10 million individuals worldwide annually.

VTE includes deep venous thrombosis (DVT), which is the formation of blood clots deep in the vein, and pulmonary embolism (PE), which occurs when blood clots break off and eventually get trapped in the lungs. Anticoagulation works in the fibrinolytic system to break these formed blood clots apart.

Earlier this year, the American College of Chest Physicians (CHEST) updated its guidelines for “Antithrombotic Therapy for VTE Disease."

CHEST now recommends novel oral anticoagulants (NOACs) like apixaban, dabigatran, edoxaban, and rivaroxaban over vitamin k antagonists (VKAs) for long-term anticoagulant treatment (3 months) of noncancer VTE patients. For those who are intolerant or can’t be treated with the NOACs, the guidelines recommend VKAs over low-molecular-weight heparins (LMWHs). For VTE patients with cancer, however, LMWHs remain the recommended choice for long-term antithrombotic therapy.

According to the updated guidelines, NOACs have significantly lower bleeding risks than VKAs. To date, no clinical trials have directly compared the NOACs with one another, and indirect comparisons have failed to suggest that 1 NOAC is more advantageous than another.

Aspirin is now recommended for the prevention of recurrent VTE in unprovoked proximal DVT or PE patients who have discontinued anticoagulant therapy. CHEST concluded that aspirin reduces VTE recurrence by one-third, and the benefits outweigh the risks of bleeding. However, the updated guidelines discourage the use of aspirin as an alternative to anticoagulant therapy.

The CHEST panelists determined that earlier recommendations limited optimal therapeutic results in patients with chronic thromboembolic pulmonary hypertension (CTEPH). With recent advances in surgery, thrombi can now be removed from the peripheral pulmonary artery, and so pulmonary thromboendarterectomy is now recommended for patients with CTEPH.

There are also new recommendations for patients with isolated subsegmental PE and no proximal DVT. For those at low risk for recurrent VTE, clinical surveillance is recommended, but for those at high risk, anticoagulation is recommended.

The new guidelines also recommend against the routine use of compression stockings for the prevention of postthrombotic syndrome (PTS). In recent clinical studies, compression stockings routinely failed to decrease PTS risk and leg pain or show any significant benefit.

Finally, the updated guidelines include recommendations that remain unchanged from the previous edition, but are now supported by stronger evidence. For instance, CHEST still recommends against inferior vena cava filter in patients taking anticoagulants, and it also still recommends against systemic thrombolytic therapy in PE patients without hypotension or degeneration while on anticoagulant therapy. However, CHEST continues to support the use of anticoagulant treatment indefinitely after the first unprovoked PE.