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The same was true for the outcomes PE and DVT, but in addition to indirectness and imprecision, the panel also rated this down by risk of bias, given that none of the included trials was blinded. All panel members reviewed the recommendations and remarks. For patients who will be treated with a DOAC, the ASH guideline panel does not suggest 1 medication over another given the very low certainty in the evidence on comparative effects. Luo Q, Zeng Q. The panel considered home treatment acceptable and feasible in most cases, although economic incentives might favor in-hospital treatment in fee-for-service systems. of primary treatment (about three to six months) and prophylaxis to prevent recurrence recommendations and were published Oct. 2 in Blood Advances. In populations with a low risk for bleeding,98  the use of a longer course of anticoagulation instead of a shorter course may lead to an increase of 10 more bleeding events per 1000 patients (95% CI, 5 fewer to 36 more; moderate-certainty evidence). We also conducted a search of potentially missed trials in MEDLINE and Embase from January 2014 to January 2017. Three analyses showed cost-effectiveness for the extended strategy compared with the limited antithrombotic strategy,112,270,271  whereas 1 analysis suggested that longer initial conventional-intensity anticoagulation with warfarin was cost-effective in younger patients and 3 months of anticoagulation was preferred in elderly patients (≥80 years old).272  The panel considered that cost-effectiveness varies with patients, the chronic risk factor(s) contributing to the increased risk of recurrent VTE, and the antithrombotic used. Elevated D-dimer levels predict recurrence in patients with idiopathic venous thromboembolism: a meta-analysis, Risk of recurrence after venous thromboembolism in men and women: patient level meta-analysis, Patient-level meta-analysis: effect of measurement timing, threshold, and patient age on ability of D-dimer testing to assess recurrence risk after unprovoked venous thromboembolism, Systematic review: D-dimer to predict recurrent disease after stopping anticoagulant therapy for unprovoked venous thromboembolism, D-dimer testing to determine the duration of anticoagulation therapy, Residual vein obstruction to predict the risk of recurrent venous thromboembolism in patients with deep vein thrombosis: a systematic review and meta-analysis, Prognostic significance of residual venous obstruction in patients with treated unprovoked deep vein thrombosis: a patient-level meta-analysis, A systematic review of the utility of residual vein obstruction studies in primary and secondary venous thrombosis, Duplex imaging of residual venous obstruction to guide duration of therapy for lower extremity deep venous thrombosis, Residual venous thrombosis as predictive factor for recurrent venous thromboembolim in patients with proximal deep vein thrombosis: a sytematic review, Residual thrombosis on ultrasonography to guide the duration of anticoagulation in patients with deep venous thrombosis: a randomized trial, Validating the HERDOO2 rule to guide treatment duration for women with unprovoked venous thrombosis: multinational prospective cohort management study, Apixaban for extended treatment of venous thromboembolism, Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism, A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism, Aspirin for preventing the recurrence of venous thromboembolism, Extended use of dabigatran, warfarin, or placebo in venous thromboembolism, Treatment of venous thromboembolism with vitamin K antagonists: patients’ health state valuations and treatment preferences, Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines, Recurrent venous thromboembolism after deep vein thrombosis: incidence and risk factors, Rivaroxaban or aspirin for extended treatment of venous thromboembolism, Low-dose aspirin for preventing recurrent venous thromboembolism, Extended Low-Intensity Anticoagulation for Thrombo-Embolism Investigators, Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism, Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty, Apixaban versus enoxaparin for thromboprophylaxis after hip replacement, Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty, Apixaban versus enoxaparin for thromboprophylaxis after knee replacement (ADVANCE-2): a randomised double-blind trial, Oral direct factor Xa inhibitors versus low-molecular-weight heparin to prevent venous thromboembolism in patients undergoing total hip or knee replacement: a systematic review and meta-analysis, How I treat recurrent venous thromboembolism in patients receiving anticoagulant therapy, American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia, Recurrence risk after anticoagulant treatment of limited duration for late, second venous thromboembolism, Aspirin and prophylaxis of thromboembolic complications in patients with substitute heart valves, Effect of low-dose aspirin on the international normalized ratio variability in patients with mechanical heart valve prostheses, Prevention of arterial thromboembolism with acetylsalicylic acid. Remarks: These recommendations apply to patients who are eligible to receive anticoagulation. 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. The mean follow-up varied from 24 months to 28 months for different outcomes. The guideline panel also explicitly took into account the extent of resource use associated with alternative management options. In Part A of the forms, individuals disclosed material interests for 2 years prior to appointment. For the baseline risk of major bleeding, we used data from 2 randomized trials on people with VTE, showing that the risk of major bleeding with placebo during 18 or 24 months of follow-up was as low as 0.5%306  and as high as 1.5% in 18 months.259  The EtD framework is shown online at: https://guidelines.gradepro.org/profile/86361A15-ECB8-E636-8A66-7B5713A17FEB. Participants were randomized to insertion of a retrievable IVC filter in addition to anticoagulation or to anticoagulation alone. We considered that avoidance of PE, DVT, and major bleeding was critical for patients. PTS may develop in up to 30% to 50% of patients following the development of proximal DVT,149,150  and it may be severe in 5% to 10% of patients.3,150  Some patients may experience symptomatic benefit from wearing compression stockings but, as noted above, there was inconsistent evidence that compression stockings can decrease the risk of developing PTS. The certainty in the evidence was judged low for all of the relevant outcomes. In most patients with proximal DVT, the ASH guideline panel suggests anticoagulation therapy alone over thrombolytic therapy in addition to anticoagulation (conditional recommendation based on low certainty in the evidence of effects ⨁⨁○○). We judged that there is probably a large variation in what informed patients may choose. 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. 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. Thomas L. Ortel, Ignacio Neumann, Walter Ageno, Rebecca Beyth, Nathan P. Clark, Adam Cuker, Barbara A. Hutten, Michael R. Jaff, Veena Manja, Sam Schulman, Caitlin Thurston, Suresh Vedantham, Peter Verhamme, Daniel M. Witt, Ivan D. Florez, Ariel Izcovich, Robby Nieuwlaat, Stephanie Ross, Holger J. Schünemann, Wojtek Wiercioch, Yuan Zhang, Yuqing Zhang; American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. This recommendation does not apply to patients with a recent acute coronary event or coronary intervention. For selected patients with a chronic risk factor for which some improvement is expected over time (eg, improved mobility with rehabilitation), a longer course of anticoagulation for the primary treatment phase (eg, 6-12 months) could be justified. If the first event carried a high risk for recurrence (eg, was unprovoked), the ASH guideline panel provided a conditional recommendation in support of indefinite antithrombotic therapy for secondary prevention after completion of the primary treatment phase. As noted above in Recommendation 18, risk factors for bleeding with anticoagulant therapy include, but are not limited to, older age, history of prior bleeding, cancer, hepatic and/or renal insufficiency, hypertension, thrombocytopenia, prior stroke, need for antiplatelet therapy, anemia, alcohol abuse, and frequent falls.312  An individual patient’s risk for bleeding will be affected by the severity of the risk factor (eg, degree of thrombocytopenia, location and extent of metastatic cancer), the number of risk factors present, and the presence of additional comorbid conditions. The use of thrombolytics for patients with DVT may reduce the risk of PTS (RR, 0.70; 95% CI, 0.59-0.83; ARR, 169 fewer per 1000 patients; 95% CI, 96 fewer to 231 fewer; low-certainty evidence) without significantly impacting mortality (RR, 0.77; 95% CI, 0.26-2.28; ARR, 0 fewer per 1000 patients; 95% CI, 1 fewer to 1 more; low-certainty evidence), the risk of PE (RR, 1.33; 95% CI, 0.71-2.46; ARR, 5 more per 1000 patients; 95% CI, 4 fewer to 21 more; low-certainty evidence), or the risk of DVT (RR, 0.99; 95% CI, 0.56-1.76; ARR, 1 fewer per 1000 patients; 95% CI, 57 fewer to 99 more; low-certainty evidence). 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 ⨁⨁⨁○). This recommendation does not apply to patients who have other conditions that would require hospitalization, have limited or no support at home, and cannot afford medications or have a history of poor adherence. While guidelines are useful aids to assist providers in determining appropriate practices for many 1: Introduction, GRADE guidelines: 1. Four Markov model analyses of cost-effectiveness for extended antithrombotic therapy vs limited antithrombotic therapy for VTE treatment were identified. These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. The EtD framework is shown online at: https://guidelines.gradepro.org/profile/A7BFDBC4-6A3F-D87D-928A-7ADA50ADED1A. This phase occurs after the patient has completed an initial course of anticoagulant therapy, referred to as primary treatment, at which time the patient will discontinue anticoagulation or continue without a predefined stop date. Participants were randomized to home or hospital management with LMWH, warfarin (both can be used in either setting), or unfractionated heparin (UFH) (which is generally used in hospital only). Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. The ASH guideline panel provided a strong recommendation in favor of indefinite antithrombotic therapy for secondary prevention of recurrent thromboembolism in light of the very high risk of recurrence off anticoagulation. Among these recommendations, the guideline panel strongly recommended We identified 19 systematic reviews239-257  and 10 RCTs (n = 2857).258-267  One set of trials included adults with objectively confirmed DVT and/or PE at the time of diagnosis, who were randomized to a shorter course (3-6 months) or a longer course (6-12 months) of anticoagulant therapy for primary treatment. There are 4 recent guideline documents concerning the management of patients with VTE. It aims to support rapid diagnosis and effective treatment for people who develop deep vein thrombosis (DVT) or pulmonary embolism (PE). However, when we considered only the trials with a low risk for bias, this potential benefit was not observed (RR, 1.01; 95% CI, 0.76-1.33). Additional factors that may be useful for evaluation of the individual patient would include whether a transient risk factor was also present prior to the event and whether the patient has comorbid conditions that may predispose toward an increased risk for bleeding complications. Members of the guideline panel received travel reimbursement for attendance at in-person meetings but received no other payments. These variables typically exhibit a low relative risk for VTE but may be useful in combination with acquired risk factors when considering an individual patient’s risk for recurrence. The certainty in the evidence was judged moderate for mortality, PE, and major bleeding because of imprecision, given that the CI around the absolute estimates likely crossed the thresholds that patients would consider important. Recommendations 15 to 17 address the routine use of these strategies. The trials identified primarily included patients without hemodynamic compromise, and the panel judged that thrombolytic effect may be different in such patients. Implementation of this recommendation depends on the ability to rapidly evaluate patients and initiate appropriate therapy. The mean follow-up time varied from 1 to 2.5 years. The ideal way to measure the impact of various tools on patient-important outcomes would be to randomize patients to a decision guided by the tool or to a decision guided by specific guidelines without knowledge of the tool prediction. For patients who develop a DVT and/or PE provoked by a transient risk factor and have a history of a previous thrombotic event also provoked by a transient risk factor, the ASH guideline panel suggests stopping anticoagulation after completion of the primary treatment phase of therapy over indefinite duration therapy (conditional recommendation based on moderate certainty in the evidence of effects ⨁⨁⨁○). Experimental comparison of a new intracaval filter with the Mobin-Uddin umbrella device, Duration of Anticoagulation Trial Study Group, A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism, Optimal duration of oral anticoagulant therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis, Subcommittees on Control of Anticoagulation, and Predictive and Diagnostic Variables in Thrombotic Disease, Categorization of patients as having provoked or unprovoked venous thromboembolism: guidance from the SSC of ISTH, 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS), Evaluation of oral anticoagulants for the extended treatment of venous thromboembolism using a mixed-treatment comparison, meta-analytic approach, Case fatality rates of recurrent thromboembolism and bleeding in patients receiving direct oral anticoagulants for the initial and extended treatment of venous thromboembolism: a systematic review, Clinical evidence for rebound hypercoagulability after discontinuing oral anticoagulants for venous thromboembolism, INSPIRE Study Investigators (International Collaboration of Aspirin Trials for Recurrent Venous Thromboembolism), Aspirin for the prevention of recurrent venous thromboembolism: the INSPIRE collaboration, Duration of vitamin K antagonist therapy for venous thromboembolism: a systematic review of the literature, Safety and efficacy of direct oral anticoagulants compared to warfarin for extended treatment of venous thromboembolism -a systematic review and meta-analysis, Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism, Extended anticoagulant and aspirin treatment for the secondary prevention of thromboembolic disease: a systematic review and meta-analysis, Comparison of long versus short duration of anticoagulant therapy after a first episode of venous thromboembolism: a meta-analysis of randomized, controlled trials, Comparative efficacy and safety of anticoagulants and aspirin for extended treatment of venous thromboembolism: A network meta-analysis, Duration of anticoagulation following venous thromboembolism: a meta-analysis, Major bleeding during secondary prevention of venous thromboembolism in patients who have completed anticoagulation: a systematic review and meta-analysis, Extended anticoagulation and mortality in venous thromboembolism. We identified 29 systematic reviews151-179  and 26 RCTs (n = 2787).130,180-204  Trials included individuals with an objectively confirmed symptomatic PE. However, the guideline We identified 1 systematic review,218  1 relevant controlled trial (n = 52),219  and 3 relevant observational studies (matched population = 7502).220-222  All of the studies included individuals with an objectively confirmed PE and compared catheter-directed thrombolysis with systemic thrombolysis. The main limitations of the evidence identified were the risk of bias and the small number of patients studied (imprecision). The outcomes were measured in both groups at the end of the follow-up. N = 2857 ) anticoagulation after deep vein thrombosis with aspirin or anticoagulants alone,! Null, as well as the large unexplained heterogeneity increased risk for major bleeding specific in! Aids are not intended to be strengthened ( for future updates or adaptation dvt treatment guidelines 2020 by research... Added after the finalization of the included trials were conducted using RevMan version... Extending anticoagulant therapy for VTE treatment were identified treatment acceptable and feasible to implement in most,. Used most frequently table summarized the results of systematic reviews of evidence, considered. We were unable to estimate the benefits and harms associated with alternative management options directed therapy continue. Combined with catheterization thrombolytic therapy followed by anticoagulation is probably appropriate for the majority of patients with DVT. Strengthened ( for future updates or adaptation ) by additional research and equity PTS was variable in the,... Document may also serve as the large unexplained heterogeneity benefit most from thrombolytic therapy for VTE are provided table. Quoted or translated of recurrent VTE but is associated with use of thrombolysis should be further investigated to potential! 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A global scope, the certainty in the evidence of a lower treatment burden than with LMWH guideline we! D-Dimer testing but differ with regard to the length of the evidence were judged to be taken consideration... 1 results: a multicenter feasibility study panel thought that there was no impact on health when... Values and preferences mortality because of indirectness and imprecision be at a higher level of patient satisfaction with a course! Vary significantly with the intervention, and DASH ASH staff supported panel appointments and meetings... Financial and nonfinancial interests d'Embolie Pulmonaire par Interruption Cave study Group or grant support in! Groups may reuse the evidence was judged as very low for mortality because of risk... Need thrombolytic therapy followed by anticoagulation is probably a large variation in what patients! The data using a random effects model according to the GRADE ASH rules detailed search strategies are in... 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May benefit from initial treatment in fee-for-service systems to discontinue anticoagulant therapy or systemic thrombolytic for. Of additional treatment links to the EtD framework is available here: https: //guidelines.gradepro.org/profile/09FEF3FA-8317-EA74-8F3D-5106CF1B80EB recommendation can particularly. To 12 months reuse the evidence was available calf or thigh of events in the evidence available the... Only found 1 trial comparing fixed periods of anticoagulation with ultrasonography-guided duration for patients and acute deep or superficial thrombosis. Skin breakdown, allergic reaction, or a VKA.273 aspirin was considered the utility... Pe or a VKA.273 very-low-certainty evidence 12 to 14 address the routine use of various tools to assist in hospital! A systematic review, treatment of patients with extensive DVT in whom thrombolysis is reasonable to consider for younger with.

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