Chest
SupplementAntithrombotic and Thrombolytic Therapy, 8th ED: ACCP GuidelinesAntithrombotic Therapy for Venous Thromboembolic Disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Section snippets
Initial Anticoagulation of Acute DVT of the Leg
1.1.1. For patients with objectively confirmed DVT, we recommend short-term treatment with SC LMWH (Grade 1A), IV UFH (Grade 1A), monitored SC UFH (Grade 1A), fixed-dose SC UFH (Grade 1A), or SC fondaparinux (Grade 1A) rather than no such short-term treatment.
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 patients with acute DVT, we recommend initial treatment with LMWH,
Initial Anticoagulation of Acute DVT of the Leg
Anticoagulation is the main therapy for acute DVT of the leg. The main objectives of anticoagulant therapy in the initial treatment of this disease are to prevent thrombus extension and early and late recurrences of VTE. The evidence for the need for anticoagulation in patients with DVT is based on studies performed > 40 years ago. The first and only trial1 that compared anticoagulant therapy with no anticoagulant therapy in patients with symptomatic DVT or PE was published in 1960 (Barritt and
LONG-TERM TREATMENT OF ACUTE DVT OF THE LEG
In this review, long-term treatment refers to treatments that are continued after initial therapy, such as with heparin or thrombolytic agents, has been completed. Long-term therapy has two goals: (1) to complete treatment of the acute episode of VTE; and (2) to prevent new episodes of VTE that are not directly related to the acute event. During the early phase of long-term treatment (ie, first 3 months), treatment of the acute episode of VTE predominates. During the late phase of long-term
POSTTHROMBOTIC SYNDROME
PTS is a cluster of leg symptoms and signs in patients with previous DVT. PTS occurs in 20 to 50% of patients after acute DVT.226 The initial treatment of acute DVT may influence the presence and severity of PTS, as discussed earlier (Section 2.0). The most prominent symptoms are chronic postural dependent swelling and pain, ambulatory discomfort, and skin pigmentation. The severity of symptoms may vary over time, and the most extreme manifestation is a venous ulcer of the lower leg. First, the
INITIAL TREATMENT OF ACUTE PE
Treatment regimens for DVT and PE are similar because the two conditions are manifestations of the same disease process. When patients with VTE are carefully studied, the majority of those with proximal DVT also have PE (symptomatic or asymptomatic) and vice versa.185 Furthermore, clinical trials of anticoagulant therapy have yielded similar estimates for efficacy and safety in patients with DVT alone, in those with both DVT and PE, and in patients with only PE. The risk of recurrence also
LONG-TERM TREATMENT OF ACUTE PE
In the following sections, studies that were performed exclusively in patients with PE will be emphasized. In addition, subgroup analyses of PE patients enrolled in studies that included patients who only presented with symptoms of DVT will be presented. As the findings of studies with DVT patients are relevant to PE patients, and as the findings of studies performed exclusively in patients with PE have been consistent with studies that included DVT patients, the recommendations for long-term
CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION
CTPH occurs much more frequently after acute PE than had previously been believed. The old teaching was that CTPH had a prevalence of not more than 1 in 500 cases of acute PE; however, data from prospective cohort studies indicate the frequency is approximately 3%.315, 316, 317 After acute PE initiates CTPH, pulmonary vascular remodeling may cause severe pulmonary hypertension out of proportion to pulmonary vascular thrombosis.318
Treatment of Infusion Thrombophlebitis
Peripheral vein infusion thrombophlebitis is estimated to occur in 25 to 35% of hospitalized patients who have peripheral IV catheters.326 In a three-arm randomized trial327 of 120 hospitalized patients with infusion thrombophlebitis, diclofenac emulsion gel used topically three times daily and oral diclofenac (75 mg bid) were superior to placebo in relieving local symptoms of thrombophlebitis at 48 h, with positive responses in 60% in both active treatment groups vs only 20% in the control
ACUTE UEDVT
Although most episodes of DVT occur in the lower limbs, it is estimated that 1 to 4% of cases involve the upper extremities. UEDVT can be classified into two etiologic groups: primary (includes unprovoked with or without thrombophilia, effort related, and thoracic outlet syndrome) and secondary (provoked by central venous catheters, pacemakers, or cancer); secondary UEDVT accounts for 75 to 80% of all cases.344, 345, 346
UEDVT may involve the subclavian, axillary or brachial veins. Clinical
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