ASH Venous Thromboembolism Guidelines: Treatment of DVT and PE

Ortel TL, Neumann I, Ageno W, et al.
American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: Treatment of Deep Vein Thrombosis and Pulmonary Embolism. Blood Adv 2020;4:4693-4738.

The following are key points to remember from the American Society of Hematology (ASH) 2020 guidelines for the management of venous thromboembolism (VTE): treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE):

  1. The ASH assembled a multidisciplinary writing committee to provide evidence-based guidelines for management of DVT and PE, which occur 300,000-600,000 times annually in the United States.
  2. The ASH guidelines suggest home treatment over hospitalization for patients with uncomplicated acute DVT. This does not apply to patients who have other reasons for hospitalization, who lack support at home, who cannot afford medications, or who present with limb-threatening DVT or at high risk for bleeding.
  3. The ASH guidelines suggest offering home treatment instead of hospitalization for patients with acute PE at low risk for complications. This includes patients at low risk based on the Pulmonary Embolism Severity Index (PESI) or its simplified version. Patients with submassive (intermediate-high risk) or massive PE as well as patients at high risk for bleeding may benefit from hospitalization.
  4. Use of direct oral anticoagulants (DOACs) are recommended as first-line treatment of acute DVT or PE. DOAC therapy is preferred over vitamin K antagonists (VKAs) for most patients without severe renal insufficiency (creatinine clearance <30 ml/min), moderate-severe liver disease, or antiphospholipid antibody syndrome.
  5. For most patients with proximal DVT, the ASH guidelines suggest anticoagulation therapy alone over thrombolytic therapy. Thrombolysis is reasonable to consider in patients presenting with limb-threatening DVT (phlegmasia cerulea dolens) or for select younger patients at low bleeding risk with iliofemoral DVT.
  6. For patients with acute PE and evidence of right ventricular dysfunction (by echocardiography and/or biomarkers), the ASH guidelines suggest anticoagulation alone over routine use of thrombolysis. Thrombolysis is reasonable to consider for patients at low bleeding risk who are at high risk for decompensation.
  7. For patients with extensive DVT in whom thrombolysis is considered appropriate, the ASH guidelines suggest using catheter-directed thrombolysis over systemic thrombolysis. In contrast, for patients with acute PE in whom thrombolysis is considered appropriate, the ASH guidelines suggest using systemic thrombolysis over catheter-directed thrombolysis partially due to a paucity of randomized trial data.
  8. For patients with proximal DVT and significant pre-existing cardiopulmonary disease as well as patients with PE and hemodynamic compromise, the ASH guidelines suggest anticoagulation alone over anticoagulation plus inferior vena cava (IVC) filter placement. The use of retrievable IVC filters is appropriate for patients with a contraindication to anticoagulation.
  9. The ASH guidelines define the treatment period of acute DVT/PE as “initial management” (first 5-21 days), “primary treatment” (first 3-6 months), and “secondary prevention” (beyond the first 3-6 months). The guidelines favor shorter courses of anticoagulation (3-6 months) for acute DVT/PE associated with a transient risk factor. The guidelines suggest indefinite anticoagulation for most patients with unprovoked DVT/PE or a DVT/PE associated with a chronic risk factor.
  10. The ASH guidelines suggest against the routine use of prognostic scores, D-dimer testing, or venous ultrasound to guide the duration of anticoagulation.
  11. For patients with breakthrough DVT and/or PE while on therapeutic VKA treatment, the ASH guidelines suggest using low molecular weight heparin over DOAC therapy. This does not apply to patients who experience breakthrough DVT/PE due to poor international normalized ratio control.
  12. For patients with DVT/PE with stable cardiovascular disease, the ASH guidelines suggest suspending aspirin therapy when initiating anticoagulation. The combination of anticoagulation plus aspirin increases the risk of bleeding without clear evidence of benefit for patients with stable cardiovascular disease.
  13. For patients with acute DVT who are not at high risk for post-thrombotic syndrome, the ASH guidelines recommend against the routine use of compression stockings. However, select patients may benefit from compression stockings to help with edema and pain associated with acute DVT.

Clinical Topics: Anticoagulation Management, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism, Echocardiography/Ultrasound

Keywords: Anticoagulants, Antiphospholipid Syndrome, Aspirin, Echocardiography, Hematology, Hemorrhage, Heparin, Low-Molecular-Weight, Liver Diseases, Postphlebitic Syndrome, Postthrombotic Syndrome, Pulmonary Embolism, Renal Insufficiency, Vascular Diseases, Risk Factors, Secondary Prevention, Thrombolytic Therapy, Venous Thromboembolism, Venous Thrombosis, Ventricular Dysfunction, Right, Vitamin K

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