Daniel M. Lindberg, MD reviewing Kearon C et al. Chest 2016 Jan 7.
- In patients with venous thromboembolic disease (VTE) without cancer, NOACs (dabigatran, rivaroxaban, apixaban, or edoxaban) should be considered first-line therapy, followed by vitamin K antagonists (i.e., warfarin), and then low molecular weight heparin (LMWH).
- In patients with VTE and cancer, LMWH is first line therapy, then warfarin, and finally NOACs.
- For low-risk, isolated, subsegmental PE, clinical surveillance is recommended, rather than anticoagulation.
- Thrombolysis should almost always be reserved for hypotensive patients, and should be given systemically, rather than catheter-directed.
- For isolated distal DVT of the leg, the choice between anticoagulation and serial ultrasound at 2 weeks should be made based on risk for thrombus extension, risk for bleeding, and patient preference.
- Home treatment is recommended for patients with low-risk PE.
- Patients should be switched to LMWH if they have recurrent VTE on another therapy; patients with recurrent VTE on LMWH should have their dose increased.
These guidelines are complex but valuable and could save a patient from unnecessary anticoagulation and admission. The published guidelines include important details about risk for bleeding or clot extension. These guidelines should move to the front of the line for translation into clinical pathways or electronic decision support