Guidance for the treatment of deep vein thrombosis and pulmonary embolism

Abstract

This guidance document focuses on the diagnosis and treatment of venous thromboembolism (VTE). Efficient, cost effective diagnosis of VTE is facilitated by combining medical history and physical examination with pre-test probability models, D dimer testing and selective use of confirmatory imaging. Clinical prediction rules, biomarkers and imaging can be used to tailor therapy to disease severity. Anticoagulation options for acute VTE include unfractionated heparin, low molecular weight heparin, fondaparinux and the direct oral anticoagulants (DOACs). DOACs are as effective as conventional therapy with LMWH and vitamin K antagonists. Thrombolytic therapy is reserved for massive pulmonary embolism (PE) or extensive deep vein thrombosis (DVT). Inferior vena cava filters are reserved for patients with acute VTE and contraindications to anticoagulation. Retrievable filters are strongly preferred. The possibility of thoracic outlet syndrome and May-Thurner syndrome should be considered in patients with subclavian/axillary and left common iliac vein DVT, respectively in absence of identifiable triggers. The optimal duration of therapy is dictated by the presence of modifiable thrombotic risk factors. Long term anticoagulation should be considered in patients with unprovoked VTE as well as persistent prothrombotic risk factors such as cancer. Short-term therapy is sufficient for most patients with VTE associated with transient situational triggers such as major surgery. Biomarkers such as D dimer and risk assessment models such the Vienna risk prediction model offer the potential to customize VTE therapy for the individual patient. Insufficient data exist to support the integration of bleeding risk models into duration of therapy planning.

Thrombin Receptor Agonist Peptide–Induced Platelet Aggregation Is Reduced in Patients Receiving Dabigatran

“…Thrombin is not only a key protein in the cascade of fibrin clot formation but also a potent inducer of platelet aggregation. [17][18][19] Dabigatran is a competitive reversible nonpeptide antagonist of thrombin. Most of the actions of thrombin are inhibited in vitro by dabigatran.…”

Secondary prevention of systemic arterial and recurrent venous thromboembolic events, through extended time anticoagulation with apixaban, in an elderly patient with multiple comorbidities

“…In patients with DVT of the leg or PE who receive extended therapy, no need to change the choice of anticoagulant after the first 3 months (Grade 2C) Phase III studies indicated that dabigatran, rivaroxaban, apixaban or edoxaban ["novel" NOACs/"direct" DOACs/"target-specific" TSOAs -all the names, being "La même Jeannette, mais autrement coiffée"] are a more convenient alternative with practical advantages, as effective as the conventional therapy with LMWH and vitamin K antagonists (warfarin, acenocumarol) for the acute VTE [6][7][8][9][10] and for extended prophylaxis.…”

“…This class of new discovered oral anticoagulants brings consistent efficacy (reduced recurrent VTE or VTE-related death compared to placebo) [11], relative safety (significantly reducing the risks of major bleeding) [6,12] and convenience, compared with antivitamin K (acenocumrol or warfarin) [13].…”

Screening for MPN Mutations in Cases of Deep Vein Thrombosis and/or Pulmonary Embolism: What We have learnt from Studies

“…The diagnoses can be made with a good clinical exam evaluating the Wells score (or assimilated) plus quantification of D-dimers and realization of duplex ultrasound for lower legs DVT and/ or CT angiography for PE [3]. These sites have been widely studied for the presence of hidden or obvious cancers, such as MPNs.…”