BACKGROUND: We update recommendations on 12 topics that were in the 9th edition of these guidelines, and address 3 new topics.
METHODS: We generate strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence.
RESULTS: For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C). For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B). For DVT, we suggest not using compression stockings routinely to prevent PTS (Grade 2B). For subsegmental pulmonary embolism and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C), and anticoagulation over clinical surveillance with a high risk (Grade 2C). We suggest thrombolytic therapy for pulmonary embolism with hypotension (Grade 2B), and systemic therapy over catheter-directed thrombolysis (Grade 2C). For recurrent VTE on a non-LMWH anticoagulant, we suggest LMWH (Grade 2C); for recurrent VTE on LMWH, we suggest increasing the LMWH dose (Grade 2C).
CONCLUSIONS: Of 54 recommendations included in the 30 statements, 20 were strong and none was based on high-quality evidence, highlighting the need for further research.
OBJECTIF: Fournir un examen des données probantes et résumé clinique du syndrome post-thrombotique (PTS). SOURCES DES DONNÉES: Une revue de littérature a été réalisée via MEDLINE (1950-Juillet 1, 2009) et International Pharmaceutical Abstracts (1970-Juin 2009) des recherches en utilisant les termes syndrome post-thrombotique, syndrome post-phlébitique, une thrombose veineuse profonde, et des bas de compression. Synthèse des données: PTS est le mieux caractérisé comme un syndrome chronique des signes et des symptômes cliniques, y compris douleur, gonflement, paresthésies, et une ulcération dans le membre affecté suite à la thrombose veineuse profonde (TVP). Il survient chez jusqu'à la moitié des patients présentant une TVP symptomatique, généralement dans les 2 premières années. Bien que la physiopathologie de la PTS n'est pas bien comprise, un thrombus peut causer l'hypertension veineuse et insuffisance valvulaire traduisant par un oedème, une hypoxie tissulaire, et dans les cas graves, l'ulcération. Les facteurs de risque pour PTS comprennent récurrente TVP ipsilatérale, l'obésité et la mauvaise qualité du traitement anticoagulant. Diagnostic PTS est basée sur la présence de signes et symptômes typiques et peuvent être faites en utilisant l'un des nombreux systèmes de notation cliniques. Prévention de la PTS devrait se concentrer sur la prévention TVP et l'utilisation de bas de contention élastiques qui suivent la TVP, alors que la fibrinolyse est toujours sous enquête comme une méthode efficace pour la prévention PTS. Le traitement du SPT peuvent inclure soit pharmacologique ou mécanique modalités, bien qu'aucun de ces régimes a été rigoureusement testé. Les pharmaciens ont la possibilité de fournir plus complète de gestion antithrombotique en éduquant les patients et les fournisseurs sur le STP, en recommandant une thérapie appropriée de prévention, d'aider les patients à obtenir et à adhérer à cette thérapie, et aider les fournisseurs à la gestion de PTS. CONCLUSIONS: Les fournisseurs devraient être proactif dans la prévention de PTS, avec les pharmaciens jouent un rôle actif dans la prévention des TVP optimale, l'identification des patients à risque de PTS, et de conseiller et de diriger les thérapies préventives.
BACKGROUND: New treatments are available for treatment of venous thromboembolism. PURPOSE: To review the evidence on the efficacy of interventions for treatment of deep venous thrombosis (DVT) and pulmonary embolism. DATA SOURCES: MEDLINE, MICROMEDEX, the Cochrane Controlled Trials Register, and Cochrane Database of Systematic Reviews from the 1950s through June 2006. STUDY SELECTION: Randomized, controlled trials; systematic reviews of trials; and observational studies; all restricted to English-language articles. DATA EXTRACTION: Paired reviewers assessed study quality and abstracted data. The authors pooled results about optimal duration of anticoagulation. DATA SYNTHESIS: This review includes 101 articles. Low-molecular-weight heparin (LMWH) is modestly superior to unfractionated heparin at preventing recurrent DVT and is at least as effective as unfractionated heparin for treatment of pulmonary embolism. Outpatient treatment of venous thromboembolism is likely to be effective and safe in carefully chosen patients, with appropriate services available. Inpatient or outpatient use of LMWH is cost-saving or cost-effective compared with unfractionated heparin. In observational studies, catheter-directed thrombolysis safely restored vein patency in select patients. Moderately strong evidence supports early use of compression stockings to reduce postthrombotic syndrome. Limited evidence suggests that vena cava filters are only modestly efficacious for prevention of pulmonary embolism. Conventional-intensity oral anticoagulation beyond 12 months may be optimal for patients with unprovoked venous thromboembolism, although patients with transient risk factors benefit little from more than 3 months of therapy. High-quality trials support use of LMWH in place of oral anticoagulation, particularly in patients with cancer. Little evidence is available to guide treatment of venous thromboembolism during pregnancy. LIMITATIONS: The authors could not address all management questions, and excluded non-English-language literature. CONCLUSIONS: The strength of evidence varies across the study questions but generally is strong.
We update recommendations on 12 topics that were in the 9th edition of these guidelines, and address 3 new topics.
METHODS:
We generate strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence.
RESULTS:
For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C). For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B). For DVT, we suggest not using compression stockings routinely to prevent PTS (Grade 2B). For subsegmental pulmonary embolism and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C), and anticoagulation over clinical surveillance with a high risk (Grade 2C). We suggest thrombolytic therapy for pulmonary embolism with hypotension (Grade 2B), and systemic therapy over catheter-directed thrombolysis (Grade 2C). For recurrent VTE on a non-LMWH anticoagulant, we suggest LMWH (Grade 2C); for recurrent VTE on LMWH, we suggest increasing the LMWH dose (Grade 2C).
CONCLUSIONS:
Of 54 recommendations included in the 30 statements, 20 were strong and none was based on high-quality evidence, highlighting the need for further research.
