However, it should be noted that patients considered to have a “high risk of bleeding” were excluded from the randomized trial described in the analysis above.316 Decisions concerning anticoagulant therapy with warfarin for patients with a significant bleeding risk need to be individualized, and a VKA may not be the optimal anticoagulant in this setting. Clinical assessment and judgment are still required for identifying patients with PE who are appropriate for home management. The mean follow-up varied from 24 months to 28 months for different outcomes. These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. First, there was a lack of allocation concealment and blinding of study participants and personnel across the different studies. Patients placed a high value on the benefits of risk reduction in VTE recurrence and PTS.310 However, there is important variability in how individual patients may value the risk of thrombosis vs the risk of bleeding. One Markov model272 compared an unlimited duration of conventional-intensity anticoagulation (INR range, 2.0-3.0) vs low-intensity anticoagulation (INR range, 1.5-2.0) with warfarin. Recommendations 15 to 17 address the routine use of these strategies. Recommendations 18 to 22 address which patients should receive secondary prevention and with what antithrombotic therapies. Treating patients with DVT at home, rather than in the hospital, reduced the risk of PE (relative risk [RR], 0.64; 95% confidence interval [CI], 0.44-0.93; absolute risk reduction [ARR], 25 fewer per 1000 patients; 95% CI, 38 fewer to 5 fewer; moderate-certainty evidence) and the risk of subsequent DVT (RR, 0.61; 95% CI, 0.42-0.90; ARR, 29 fewer per 1000 patients; 95% CI, 43 fewer to 7 fewer; moderate-certainty evidence). For patients who will be treated with dabigatran or edoxaban, pretreatment with UFH or LMWH for up to 5 to 10 days is needed before switching to the DOAC. Assuming that 45% of the VTE events are PEs and 55% are DVTs,269 we estimated annualized risks of recurrent PE of 4.4 and of recurrent DVT of 5.3 per 100 patient-years for patients with a chronic risk factor. Deep vein thrombosis (DVT) is a medical condition that happens when a blood clot forms in a vein. In the case of D-dimer, we also rated down the certainty in the evidence for risk of bias (unblinded study) and imprecision (wide CIs around absolute estimates). We considered that avoidance of PE, DVT, and major bleeding was critical for patients. Individuals with significant renal impairment, as indicated by an estimated creatinine clearance <25 mL/min (apixaban) or 30 mL/min (all other DOACs) and patients at high risk for bleeding were excluded. Therefore, it was not possible to completely rule out a small difference between the alternatives on such outcomes. When using a DOAC for indefinite anticoagulation, the risk of DVT was reduced in the study population (RR, 0.15; 95% CI, 0.10-0.23; ARR, 49 fewer per 1000 patients; 95% CI, 51 fewer to 44 fewer; high-certainty evidence) as well as for patients with recurrent unprovoked VTE269,324 (ARR, 56 fewer per 1000 patients; 95% CI, 59 fewer to 51 fewer; high-certainty evidence). For baseline risks of VTE, we used a multicenter prospective cohort study274 that included 646 participants reporting a VTE recurrence rate of 9.7% per patient-year for patients with a chronic risk factor. The lower DOAC dose had little impact on the risk of DVT (RR, 0.75; 95% CI, 0.36-1.53; ARR, 2 fewer per 1000 patients; 95% CI, 6 fewer to 5 more; moderate-certainty evidence) or the risk of major bleeding (RR, 0.97; 95% CI, 0.12-1.95; ARR, 0 fewer per 1000 patients; 95% CI, 2 fewer to 7 more; moderate-certainty evidence). 2020 Oct 13;4(19):4693-4738. doi: 10.1182/bloodadvances.2020001830. The EtD framework is shown online at: https://guidelines.gradepro.org/profile/FFEF27C2-5C33-BB1B-B096-9624FCBB0456. You'll also have a physical exam so that your doctor can check for areas of swelling, tenderness or discoloration on your skin. An observational study suggested a higher level of patient satisfaction with a DOAC and a lower treatment burden than with LMWH or a VKA.273. The guidelines contain 10 chapters that focus on current areas of uncertainty and variation in clinical practice in the management of both deep vein thrombosis and pulmonary embolism.. To develop the new guidelines, ASH partnered with the McMaster University … For patients with DVT and/or PE who have completed primary treatment and will continue to receive secondary prevention, the ASH guideline panel suggests using anticoagulation over aspirin (conditional recommendation based on moderate certainty in the evidence of effects ⨁⨁⨁○). The ASH VTE treatment guideline panel has provided a conditional recommendation for the use of DOACs over VKAs as treatment for patients with a new diagnosis of VTE. Remarks: Patients who present with a new VTE event during therapeutic VKA treatment should be further investigated to identify potential underlying causes. For patients who develop DVT and/or PE provoked by a transient risk factor and have a history of a previous VTE also provoked by a transient risk factor, the ASH guideline panel suggests stopping anticoagulation after completion of primary treatment over indefinite antithrombotic therapy (conditional recommendation based on moderate certainty in the evidence of effects ⨁⨁⨁○). The panel considered that avoidance of PE, DVT, PTS, and major bleeding was critical for patients. Also, the number of patients studied was relatively small compared with the optimal information size, and the CIs around the absolute effect likely crossed the thresholds that patients would consider important. Some panelists disclosed new interests or relationships during the development process, but the balance of the majority was maintained. They are not intended to be taken as guidelines. Because only catheter-directed thrombolysis is available in the United States, implementing the procedure would probably result in large costs, which, in turn, will probably reduce equity and limit its acceptability and feasibility. Members of the VTE Guideline Coordination Panel reviewed the disclosures and judged which interests were conflicts and should be managed. For primary treatment of patients with DVT and/or PE, whether provoked by a transient risk factor (recommendation 12) or by a chronic risk factor (recommendation 13) or unprovoked (recommendation 14), the ASH guideline panel suggests using a shorter course of anticoagulation for primary treatment (3-6 months) over a longer course of anticoagulation for primary treatment (6-12 months) (conditional recommendations based on moderate certainty in the evidence of effects ⨁⨁⨁○). The panel rated the following outcomes as critical for clinical decision making across questions: mortality, PE, proximal DVT, and major bleeding. We considered that avoidance of PE, DVT, and major bleeding was critical for patients. We did not identify direct evidence on a cost-effectiveness comparison for unprovoked VTE. Therefore, it was not possible to completely rule out a small difference between the alternatives on such outcomes. Other factors, such as renal function, concomitant medications (eg, need for a concomitant drug metabolized through CYP3A4 enzymes or P-glycoprotein), and the presence of cancer, may also impact DOAC choice. Catheter-directed thrombolysis might increase the risk of PTS (RR, 2.59; 95% CI, 1.42-4.74; ARR, 223 more per 1000 patients; 95% CI, 76 more to 369 more; very-low-certainty evidence). The EtD table summarized the results of systematic reviews of the literature that were conducted for these guidelines. Other recommendations
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