Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
BACKGROUND
This article addresses the treatment of VTE disease.


METHODS
We generated strong (Grade 1) and weak (Grade 2) recommendations based on high-quality (Grade A), moderate-quality (Grade B), and low-quality (Grade C) evidence.


RESULTS
For acute DVT or pulmonary embolism (PE), we recommend initial parenteral anticoagulant therapy (Grade 1B) or anticoagulation with rivaroxaban. We suggest low-molecular-weight heparin (LMWH) or fondaparinux over IV unfractionated heparin (Grade 2C) or subcutaneous unfractionated heparin (Grade 2B). We suggest thrombolytic therapy for PE with hypotension (Grade 2C). For proximal DVT or PE, we recommend treatment of 3 months over shorter periods (Grade 1B). For a first proximal DVT or PE that is provoked by surgery or by a nonsurgical transient risk factor, we recommend 3 months of therapy (Grade 1B; Grade 2B if provoked by a nonsurgical risk factor and low or moderate bleeding risk); that is unprovoked, we suggest extended therapy if bleeding risk is low or moderate (Grade 2B) and recommend 3 months of therapy if bleeding risk is high (Grade 1B); and that is associated with active cancer, we recommend extended therapy (Grade 1B; Grade 2B if high bleeding risk) and suggest LMWH over vitamin K antagonists (Grade 2B). We suggest vitamin K antagonists or LMWH over dabigatran or rivaroxaban (Grade 2B). We suggest compression stockings to prevent the postthrombotic syndrome (Grade 2B). For extensive superficial vein thrombosis, we suggest prophylactic-dose fondaparinux or LMWH over no anticoagulation (Grade 2B), and suggest fondaparinux over LMWH (Grade 2C).


CONCLUSIONS
Strong recommendations apply to most patients, whereas weak recommendations are sensitive to differences among patients, including their preferences.
Department of Medicine and Clinical Epidemiology and Biostatistics, Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada.
Clive
C
Kearon
Department of Medicine, Family Medicine, and Social and Preventive Medicine, State University of New York at Buffalo, Buffalo, NY. Electronic address: elieakl@buffalo.edu.
Elie A
EA
Akl
Department of Surgery, Jobst Vascular Center, Toledo, OH.
Anthony J
AJ
Comerota
Department of Cardiothoracic and Vascular Sciences, University of Padua, Padua, Italy.
Paolo
P
Prandoni
Department of Medical Specialties, University Hospitals of Geneva, Geneva, Switzerland.
Henri
H
Bounameaux
Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Samuel Z
SZ
Goldhaber
Department of Medicine, Shawnee Mission Medical Center, Shawnee Mission, KS.
Michael E
ME
Nelson
Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
Philip S
PS
Wells
Department of Medicine and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA.
Michael K
MK
Gould
Department of Medicine, University of Insubria, Varese, Italy.
Francesco
F
Dentali
Department of Medicine, Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada.
Mark
M
Crowther
Department of Medicine and Clinical Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada.
Susan R
SR
Kahn
D000284:Administration, Oral; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use; D003952:Diagnostic Imaging; D004334:Drug Administration Schedule; D019317:Evidence-Based Medicine; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D000077425:Fondaparinux; D006470:Hemorrhage / Q000097:blood / Q000139:chemically induced / Q000517:prevention & control; D006495:Heparin, Low-Molecular-Weight / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D007262:Infusions, Intravenous; D019934:International Normalized Ratio; D008134:Long-Term Care; D011134:Polysaccharides / Q000009:adverse effects / Q000627:therapeutic use; D011655:Pulmonary Embolism / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy / Q000517:prevention & control; D012307:Risk Factors; D012955:Societies, Medical; D014481:United States; D020246:Venous Thrombosis / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy* / Q000517:prevention & control*; D014812:Vitamin K / Q000037:antagonists & inhibitors
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D006495:Heparin, Low-Molecular-Weight; D011134:Polysaccharides; D014812:Vitamin K; D000077425:Fondaparinux