ࡱ> -/,a :jbjb11 &[[:FFFFFFF|  |*2,\RFmFFmmmFFmZnFFFFmmV@FF K"W 0*cxJmJmF||||(Topic ID 1747): Management of VTE: Acute and Long-Term Clive Kearon Dr. Kearon will present an update on the acute and long-term treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), highlighting new recommendations in emphasis in the 8th Edition of the Antithrombotic and Thrombolytic Therapy ACCP Evidence-Based Clinical Practice Guidelines. His presentation will be confined to anticoagulant and thrombolytic therapy for lower limb DVT and for PE, rather than covering the full scope of the Antithrombotic Thereapy for Venous Thromboembolic Disease chapter (i.e., will not include the post-thrombotic syndrome, upper extremity DVT and superficial phlebitis). Acute Treatment of DVT and PE Fondaparinux is now included as a recommended acute treatment for VTE (Grade IA) and is judged non-inferior to previously recommended therapies (Grade IA for evidence supporting non-inferiority). Subcutaneous unfractionated heparin, either in a fixed weight-based dose or an initial weight-based dose followed by adjustment in response to APTT testing, is now included as a recommended acute treatment (Grade IA) and is judged non-inferior to previously recommended therapies (Grade IB for evidence supporting non-inferiority). Catheter-directed thrombolysis is now accepted (i.e. may be used) as an alternative to anticoagulant therapy alone in selected patients with extensive DVT who have a low risk of bleeding, provided appropriate expertise and resources are available (Grade 2B). While the 8th Edition does not encourage use of catheter-directed thrombolysis in such patients, nor does it actively discourage its use in the absence of critical limb ischemia as was the position of the 7th Edition of these guidelines. Stratification of severity is recommended in patients with acute PE in order to identify patients for whom thrombolytic therapy may be indicated (Grade 1C). In addition to recommending thrombolytic therapy for PE patients with hemodynamic compromise (Grade 1B), thrombolytic therapy is now suggested for selected high-risk patients without hypotension who have a low risk of bleeding (Grade 2B). Inferior vena caval (IVC) filters are recommended for patients with acute proximal DVT and PE who cannot receive anticoagulant therapy (Grade 1C), but are not recommended for other indications. After insertion of an IVC filter, if it subsequently becomes safe to anticoagulate the patient (e.g., risk of bleeding resolves), it is recommended that patients should receive acute and long-term anticoagulation (i.e., the same duration of therapy) as if the same patient had not had an IVC filter inserted (Grade 1C). Long-term treatment of DVT and PE The presence or absence of a reversible provoking risk factor is the most important determinant of the risk of recurrent VTE and the optimal duration of anticoagulation. VTE provoked by a major reversible factor, such as recent surgery, should generally be treated for 3 months (Grade IA). VTE provoked by active cancer should generally be treated independently (Grade1C) and include treatment with LMWH for at least the first 3 months (Grade IA). Unprovoked proximal DVT or PE should be treated for at least 3 months (Grade IA) and indefinitely (Grade IA) if: a) there is a low risk of bleeding, b) good anticoagulation is achievable; and c) this is acceptable to patients. Bibliography: Kearon, C., S. R. Kahn, G. Agnelli, S. Goldhaber, G. Raskob, and A. J. Comerota. 2008. Antithrombotic Thereapy for Venous Thromboembolic Disease. ACCP Evidence-Based Clinical Practice Guidelines (Eight Edition). Chest 133:454S-545S.  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