Chest
Volume 126, Issue 3, Supplement, September 2004, Pages 401S-428S
Journal home page for Chest

Antithrombotic Therapy for Venous Thromboembolic Disease: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

https://doi.org/10.1378/chest.126.3_suppl.401SGet rights and content

This chapter about antithrombotic therapy for venous thromboembolic disease is part of the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S–187S). Among the key recommendations in this chapter are the following: for patients with objectively confirmed deep vein thrombosis (DVT), we recommend short-term treatment with subcutaneous (SC) low molecular weight heparin (LMWH) or, alternatively, IV unfractionated heparin (UFH) [both Grade 1A]. For patients with a high clinical suspicion of DVT, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C+). In acute DVT, we recommend initial treatment with LMWH or UFH for at least 5 days (Grade 1C), initiation of vitamin K antagonist (VKA) together with LMWH or UFH on the first treatment day, and discontinuation of heparin when the international normalized ratio (INR) is stable and > 2.0 (Grade 1A). For the duration and intensity of treatment for acute DVT of the leg, the recommendations include the following: for patients with a first episode of DVT secondary to a transient (reversible) risk factor, we recommend long-term treatment with a VKA for 3 months over treatment for shorter periods (Grade 1A). For patients with a first episode of idiopathic DVT, we recommend treatment with a VKA for at least 6 to 12 months (Grade 1A). We recommend that the dose of VKA be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations (Grade 1A). We recommend against high-intensity VKA therapy (INR range, 3.1 to 4.0) [Grade 1A] and against low-intensity therapy (INR range, 1.5 to 1.9) compared to INR range of 2.0 to 3.0 (Grade 1A). For the prevention of the postthrombotic syndrome, we recommend the use of an elastic compression stocking (Grade 1A). For patients with objectively confirmed nonmassive PE, we recommend acute treatment with SC LMWH or, alternatively, IV UFH (both Grade 1A). For most patients with pulmonary embolism (PE), we recommend clinicians not use systemic thrombolytic therapy (Grade 1A). For the duration and intensity of treatment for PE, the recommendations are similar to those for DVT.

Section snippets

1.1 Initial treatment of acute DVT of the leg

Anticoagulation is the main therapy for acute DVT of the leg. The objectives of anticoagulant therapy in the initial treatment of this disease are to prevent thrombus extension and early and late recurrences of DVT and PE. The evidence for the need for anticoagulation in patients with DVT is based on studies performed > 40 years ago. The first and only trial1 evaluating heparin in patients with symptomatic PE that incorporated an untreated group was published in the 1960s. This trial1 showed a

1.1 Initial treatment of acute DVT of the leg

1.1.1. For patients with objectively confirmed DVT, we recommend short-term treatment with SC LMWH or IV UFH or SC UFH (all Grade 1A).

1.1.2. For patients with a high clinical suspicion of DVT, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C+).

1.1.3. In acute DVT, we recommend initial treatment with LMWH or UFH for at least 5 days (Grade 1C).

1.1.4. We recommend initiation of VKA together with LMWH or UFH on the first treatment day and

References (195)

  • CI Lagerstedt et al.

    Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis

    Lancet

    (1985)
  • JM Lohr et al.

    Lower extremity calf thrombosis: to treat or not to treat?

    J Vasc Surg

    (1991)
  • Research Committee of the British Thoracic Society

    Optimum duration of anticoagulation for deep-vein thrombosis and pulmonary embolism

    Lancet

    (1992)
  • S Schulman et al.

    Anticardiolipin antibodies predict early recurrence of thromboembolism and death among patients with venous thromboembolism following anticoagulant therapy: Duration of Anticoagulation Study Group

    Am J Med

    (1998)
  • SR Kahn et al.

    The post-thrombotic syndrome: current knowledge, controversies, and directions for future research

    Blood Rev

    (2002)
  • DP Brandjes et al.

    Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis

    Lancet

    (1997)
  • G Catania et al.

    Preliminary comparison of the clinical efficacy and tolerability of low-molecular-weight dermatan sulfate and calcium heparin in postthrombotic syndrome

    Curr Ther Res

    (1996)
  • SZ Goldhaber et al.

    Randomised controlled trial of recombinant tissue plasminogen activator versus urokinase in the treatment of acute pulmonary embolism

    Lancet

    (1988)
  • SZ Goldhaber et al.

    Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion

    Lancet

    (1993)
  • SZ Goldhaber et al.

    Reduced dose bolus alteplase vs conventional alteplase infusion for pulmonary embolism thrombolysis: an international multicenter randomized trial: The Bolus Alteplase Pulmonary Embolism Group

    Chest

    (1994)
  • DW Barrit et al.

    Anticoagulant drugs in the treatment of pulmonary embolism: a controlled trial

    Lancet

    (1960)
  • JS Alpert et al.

    Mortality in patients treated for pulmonary embolism

    JAMA

    (1976)
  • JA Kanis

    Heparin in the treatment of pulmonary thromboembolism

    Thromb Diath Haemorrh

    (1974)
  • RD Hull et al.

    Heparin for 5 days as compared with 10 days in the initial treatment of proximal venous thrombosis

    N Engl J Med

    (1990)
  • L Harrison et al.

    Comparison of 5-mg and 10-mg loading doses in initiation of warfarin therapy

    Ann Intern Med

    (1997)
  • MA Crowther et al.

    A randomized trial comparing 5-mg and 10-mg warfarin loading doses

    Arch Intern Med

    (1999)
  • MJ Kovacs et al.

    Comparison of 10-mg and 5-mg warfarin initiation nomograms together with low-molecular-weight heparin for outpatient treatment of acute venous thromboembolism: a randomized, double-blind, controlled trial

    Ann Intern Med

    (2003)
  • P Brill-Edwards et al.

    Establishing a therapeutic range for heparin therapy

    Ann Intern Med

    (1993)
  • MN Levine et al.

    A randomized trial comparing activated thromboplastin time with heparin assay in patients with acute venous thromboembolism requiring large daily doses of heparin

    Arch Intern Med

    (1994)
  • RD Hull et al.

    Optimal therapeutic level of heparin therapy in patients with venous thrombosis

    Arch Intern Med

    (1992)
  • RA Raschke et al.

    The weight-based heparin dosing nomogram compared with a “standard care” nomogram: a randomized controlled trial

    Ann Intern Med

    (1993)
  • MK Cruickshank et al.

    A standard heparin nomogram for the management of heparin therapy

    Arch Intern Med

    (1991)
  • SS Anand et al.

    Recurrent venous thrombosis and heparin therapy: an evaluation of the importance of early activated partial thromboplastin times

    Arch Intern Med

    (1999)
  • DP Brandjes et al.

    Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal-vein thrombosis

    N Engl J Med

    (1992)
  • EW Salzman et al.

    Management of heparin therapy: controlled prospective trial

    N Engl J Med

    (1975)
  • RL Glazier et al.

    Randomized prospective trial of continuous vs intermittent heparin therapy

    JAMA

    (1976)
  • B Fagher et al.

    Heparin treatment of deep vein thrombosis: effects and complications after continuous or intermittent heparin administration

    Acta Med Scand

    (1981)
  • DW Hommes et al.

    Subcutaneous heparin compared with continuous intravenous heparin administration in the initial treatment of deep vein thrombosis: a meta-analysis

    Ann Intern Med

    (1992)
  • AW Lensing et al.

    Treatment of deep venous thrombosis with low-molecular-weight heparins: a meta-analysis

    Arch Intern Med

    (1995)
  • LR Dolovich et al.

    A meta-analysis comparing low-molecular-weight heparins with unfractionated heparin in the treatment of venous thromboembolism: examining some unanswered questions regarding location of treatment, product type, and dosing frequency

    Arch Intern Med

    (2000)
  • M Levine et al.

    A Comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis

    N Engl J Med

    (1996)
  • MM Koopman et al.

    Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home: the Tasman Study Group

    N Engl J Med

    (1996)
  • The Columbus Investigators

    Low-molecular-weight heparin in the treatment of patients with venous thromboembolism

    N Engl J Med

    (1997)
  • PS Wells

    Outpatient treatment of patients with deep-vein thrombosis or pulmonary embolism

    Curr Opin Pulm Med

    (2001)
  • L Harrison et al.

    Assessment of outpatient treatment of deep-vein thrombosis with low-molecular-weight heparin

    Arch Intern Med

    (1998)
  • G Merli et al.

    Subcutaneous enoxaparin once or twice daily compared with intravenous unfractionated heparin for treatment of venous thromboembolic disease

    Ann Intern Med

    (2001)
  • BA Charbonnier et al.

    Comparison of a once daily with a twice daily subcutaneous low molecular weight heparin regimen in the treatment of deep vein thrombosis

    Thromb Haemost

    (1998)
  • AW Lensing et al.

    Rationale and results of thrombolytic therapy for deep vein thrombosis

  • C Winter et al.

    Surgical treatment of iliofemoral vein thrombosis technical aspects: possible secondary interventions

    Int Angiol

    (1989)
  • AM Lansing et al.

    Five-year follow-up study of iliofemoral venous thrombectomy

    Ann Surg

    (1968)
  • Cited by (0)

    View full text