Thrombolytic therapy can be an appropriate intervention in selected patients with PE, as described in Recommendations 6 and 7, and can be administered systemically or using a catheter-directed approach. afford medications, or have a history of poor adherence. Finally, patients with antiphospholipid antibody syndrome, bariatric surgery, short gut, or other conditions that may influence medication absorption, as well as patients at extremes of body weight, are not optimal candidates for DOACs. In this study, participants were randomized to stop anticoagulation or to continue it for up to 18 months. 2020 Oct 13;4(19):4693-4738. doi: 10.1182/bloodadvances.2020001830. The EtD framework is shown online at: https://guidelines.gradepro.org/profile/09FEF3FA-8317-EA74-8F3D-5106CF1B80EB. Rather, the study assessed the effect of anticoagulation in individuals with a high D-dimer level, which is a related question but not the specific question addressed by the panel. There is considerable uncertainty regarding the comparative effect of systemic thrombolysis and catheter-directed thrombolysis. A meta-analysis of the interventional trials. This recommendation applies to the patient who sustains a VTE related to a transient risk factor, who also has a history of VTE that was unprovoked or provoked by a chronic risk factor (Recommendation 24a) or who has a history of VTE that was provoked by a transient risk factor (Recommendation 24b). No specific DOAC is suggested
Patients placed a high value on the benefits of risk reduction in VTE recurrence and PTS.311 However, there is important variability in how individual patients may value the risk of recurrent VTE vs the risk of bleeding. We developed our recommendations using the principles outlined by the Institute of Medicine and Guideline International Network.25-27 An article detailing the methods used to develop these guidelines has been published.360. Remarks: This recommendation does not apply to patients who have a high risk for bleeding complications. Trials included adults with objectively confirmed DVT or PE who had been treated with anticoagulants for ≥3 months without recurrence. For patients who are going to discontinue anticoagulant therapy after completion of the primary treatment phase, the role of aspirin can be considered but needs to be individualized. Men continue and HERDOO2 clinical decision rule to guide anticoagulant therapy in patients with first unprovoked venous thromboembolism, Extended follow-up of the multi-center multi-national prospective cohort study that derived the “Men Continue and HERDOO2” clinical decision rule which identifies low risk patients who may be able to discontinue oral anticoagulants (Oac) 5-7 months after treatment for unprovoked venous thromboembolism (VTE), Extended follow-up of the multi-center prospective cohort that derived the ‘men continue and HERDOO2’ clinical decision rule identifying low risk unprovoked patients, Clinical prediction of VTE recurrence in patients with previous unprovoked venous thromboembolism. 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). The work of this panel was coordinated with 9 other guideline panels (addressing other aspects of VTE) by ASH and the McMaster GRADE Centre (funded by ASH under a paid agreement). For patients with proximal DVT and significant preexisting cardiopulmonary disease, as well as for patients with PE and hemodynamic compromise, the ASH guideline panel suggests anticoagulation alone rather than anticoagulation plus insertion of an IVC filter (conditional recommendations based on low certainty in the evidence of effects ⨁⨁○○). In health systems with good primary care, home treatment is feasible and safe. The following disclosure was added after the finalization of the guideline panel’s disclosure of interest forms: In January 2020, M.R.J. We did observe a nonsignificant reduction in the risk of PE (RR, 0.72; 95% CI, 0.31-1.70; ARR, 4 fewer per 1000 patients; 95% CI, 10 fewer to 10 more; low-certainty evidence); however, this outcome was reported in only 1 trial, and the number of events was very small. The certainty in the evidence was judged as low for mortality because of indirectness and imprecision. In the randomized trial, only 54 patients were studied, yielding a very wide CI. Although the evidence supporting a reduced risk for bleeding with the use of a DOAC compared with a VKA was of high certainty, the lack of benefit for the VTE outcomes resulted in the conditional recommendation. The use of thrombolytics for patients with PE and hemodynamic compromise may reduce mortality (RR, 0.61; 95% CI, 0.40-0.94; ARR, 58 fewer per 1000 patients; 95% CI, 9 fewer to 90 fewer; low-certainty evidence). The recommendation is supported by credible research or other convincing judgments that make additional research unlikely to alter the recommendation. In populations with a low bleeding risk,37 treating at home instead of treating in the hospital may lead to a reduction of 5 fewer bleeding events per 1000 patients (95% CI, 11 fewer to 6 more; low-certainty evidence). These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. One of the limitations of the available evidence was that the populations included in the PREPIC trials were different from our populations of interest. After completion of the primary treatment phase, subsequent decisions (discussed in Recommendation 19) would determine whether to discontinue anticoagulant therapy or continue indefinitely for secondary prevention of recurrent VTE (Figure 2). Therefore, it was not possible to completely rule out a small difference between the alternatives on such outcomes. For baseline risks of VTE, we used a meta-analysis of 10 cohort studies and 5 randomized trials268 that reported a risk of recurrent VTE of 7.4 per 100 patient-years for patients with unprovoked VTE. Therefore, this recommendation does not fully apply to the US setting, but the panel considered the knowledge gap underlying this practice important to note. Most patients with DVT and/or PE provoked by temporary risk factors will discontinue anticoagulant therapy after completion of the primary treatment. Finally, the systematic review of prognostic models275 identified 3 scores: HERDOO2, Vienna, and DASH. Further details are provided in the EtD frameworks: https://guidelines.gradepro.org/profile/CC2C2AC0-F4AC-F0A6-BC09-58996B7C1BC3, https://guidelines.gradepro.org/profile/859646ED-448E-8518-8B15-2CC804FBA8F3, and https://guidelines.gradepro.org/profile/6731C8B4-1AD1-1582-BA08-6FC54CDFC4B7. recommendations and were published Oct. 2 in Blood Advances. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. The panel considered that indefinite treatment was probably feasible but that the acceptability varies. the recommendations are meant to inform the decisions of clinicians and patients. Conflict-of-interest disclosure: All authors were members of the guideline panel, the systematic review team, or both. For patients with uncomplicated deep vein thrombosis (DVT), the American Society of Hematology (ASH) guideline panel suggests offering home treatment over hospital treatment (conditional recommendation based on low certainty in the evidence of effects ⨁⨁○○). During this rating process, the panel used definitions of the outcomes (“marker states”) that were developed for these guidelines. management of venous thromboembolism (VTE), as well as longer-term treatment and secondary
Other variables that may impact the choice of anticoagulant therapy for individual patients include the cost of the DOACs and patient preference for once- or twice-daily dosing. For DVT, the certainty in the evidence was judged high. Four Markov model analyses of cost-effectiveness for extended antithrombotic therapy vs limited antithrombotic therapy for VTE treatment were identified. In Part B, they disclosed interests that were not primarily financial. The authors thank Andrew Kirkman for contributions to the guideline document. Among other recommendations, the new guidelines from the American Society of Hematology
The Thrombosis Canada TM Clinical Guides are: Developed voluntarily by Thrombosis Canada TM … of primary treatment (about three to six months) and prophylaxis to prevent recurrence
A longer course of anticoagulation also showed a potential reduction in the risk of PE in the study population, without statistical significance (RR, 0.66; 95% CI, 0.29-1.51; ARR, 17 fewer per 1000 patients; 95% CI, 35 fewer to 25 more; moderate-certainty evidence), and likely a small reduction in a low-risk population268 (ARR, 11 fewer per 1000 patients; 95% CI, 24 fewer to 17 more; moderate-certainty evidence). Observational studies suggested a higher level of patient satisfaction with a DOAC and a lower treatment burden than with LMWH or a VKA.273. After completion of primary treatment, the next decision concerns whether anticoagulant therapy will be discontinued or if it will be continued for secondary prevention of recurrent VTE. Additionally, 3 observational studies reported mortality and major bleeding at 3 months follow-up, and 1 reported PE at 3 months. However, the guideline model implemented by ASH can be easily updated in the future, adding new recommendations to those already published. We did not find any randomized clinical trials investigating the prognostic scores that compared patient-important outcomes. Pooling all identified trials, we observed a nonsignificant reduction in the risk of PTS (RR, 0.62; 95% CI, 0.38-1.01; ARR, 81 fewer per 1000 patients; 95% CI, 132 fewer to 2 more; very-low certainty evidence). “Treatment of VTE in day-to-day practice poses many challenges to clinicians. The certainty in the evidence was judged high for PE, DVT, and major bleeding but moderate for mortality because of imprecision, given that the CI around the absolute estimates crossed thresholds that patients would likely consider important. We acknowledge that not all of them are covered in this guideline. However, they may help to select patients with PE at low risk for complications. and indefinite anticoagulation for patients with recurrent unprovoked VTE. In contrast, many patients with DVT and/or PE provoked by chronic risk factors, as well as patients with unprovoked DVT and/or PE, may continue anticoagulant therapy indefinitely for secondary prevention after completion of the primary treatment (Figure 2). received equity. New questions addressed in the ASH guidelines include recommendations concerning whether 1 DOAC should be preferred over another for the primary treatment phase (Recommendation 4), whether prognostic scores, D-dimer testing, and/or ultrasound testing should be routinely used to guide decision making concerning continuing therapy after completion of the primary phase of treatment (Recommendations 15 to 17), whether patients receiving rivaroxaban or apixaban for secondary prevention therapy should receive standard-dose or lower-dose therapy (Recommendation 22), and whether patients who have previously sustained a VTE and completed a course of primary treatment, who now sustain a recurrent event associated with a transient risk factor, should receive secondary prevention after completion of the primary treatment phase of therapy (Recommendations 24a and 24b). Alternative management options clinic visits for INR monitoring ) whereas the vice chair the... 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