Brevity is the Soul of Wit: How to Use Comprehensive VTE Guidelines

The American College of Chest Physicians publishes an evidence-based, comprehensive guideline on the prevention and treatment of thrombosis; the 9th edition was published in 2012.¹ Anything the reader wants to know about antithrombosis, it can be found here. 

This months’ Top Paper² took Polonius’ advice to Laertes in Hamlet and penned a succinct review of the guideline. Since the primary document is meant to serve as a reference source,¹ consider this as quick go-to guide. 
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Here are some highlights:

• The diagnosis of thrombosis relies first on clinical evaluation. That evaluation can be accomplished by applying the Wells score, which can be accessed online.³ It calculates the pretest probability for a thrombotic event based on clinical findings (eg, leg swelling, history of immobilization, diagnosis of cancer, and calf tenderness).

• Fibrin D-dimer and duplex ultrasound are incorporated next in the algorithm. A low Wells score probability plus a negative D-dimer, for example, means the workup is complete and the risk for thrombosis is very low. On the other hand, in the same setting, a positive D-dimer warrants an ultrasound.

• Venous thromboembolism (VTE) treatment is unpacked with a summary of unfractioned and fractioned heparins, fondaparinux, warfarin, and a wealth of evidence incorporating the novel oral anticoagulants (eg, dabigatran, rivaroxaban, and apixaban) with indications for ambulatory versus inpatient treatment.

• Perplexing clinical scenarios are included as well, including situations where you may use oral anticoagulation or heparin in persons with cancer and VTE. The CLOT study found that recurrent VTE occurred in 17% of the patients on warfarin, but only 9% of those on dalteparin after 6 months.⁴

• What do you do if you discover superficial thrombophlebitis? Note: 25% of patients with superficial thrombophlebitis will have a deep vein thrombosis, so ultrasound is definitely warranted. 

• Inferior vena cava filters are overused.

• Perioperative prevention is discussed for both non- and orthopedic procedures. 

• The authors extend anticoagulation as prophylaxis in patients heterozygous for the factor V Leiden mutation, prothrombin 20210A, and protein C and S deficiencies as well as antiphospholipid antibody syndrome. 

• Upper extremity catheter thrombosis requires therapeutic anticoagulation for 3 months. 

There is a wealth of additional data in both the original guidelines and this laudable summary. Depending on the situation, either can serve as a handy reference when further information is needed in the setting of VTE workup and treatment. ■

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.

References:

1. Guyatt GH, Aki EA, Crowther M, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):7S-47S.

2. Pollak AW, McBane RD 2nd. Succinct review of the new VTE prevention and management guideline. Mayo Clin Proc. 2014;89(3):394-408.

3.Wells PS, Anderson DR, Bormanis J,
et al. Value of assessment of pre-test probability of deep venous thrombosis in clinical management. Lancet. 1997;
350(9094):1795-1798.

4.Lee AY, Levine MN, Baker RI, et al. Randomized comparison of low-molecular weight heparin versus oral anticoagulant therapy for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 2003;
349(2):146-153.