Antithrombotic Therapy For VTE Disease Compendium and Review of CHEST Guidelines 2012 2021 March 2024

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Antithrombotic Therapy for VTE Disease: Compendium and Review of CHEST

Guidelines 2012-2021
Scott M. Stevens, MD, Scott C. Woller, MD, Lisa Baumann Kreuziger, MD, MS,
Kevin Doerschug, MD, Geert-Jan Geersing, MD, PhD, Frederikus A. Klok, MD PhD,
Christopher S. King, MD, Susan Murin, MD, Janine R.E. Vintch, MD, Philip S. Wells,
MD, Suman Wasan, MD, Lisa K. Moores, MD
PII: S0012-3692(24)00292-7
DOI: https://doi.org/10.1016/j.chest.2024.03.003
Reference: CHEST 6136
To appear in: CHEST
Received Date: 16 January 2024

Revised Date: 26 February 2024
Accepted Date: 3 March 2024
Please cite this article as: Stevens SM, Woller SC, Baumann Kreuziger L, Doerschug K, Geersing GJ,
Klok FA, King CS, Murin S, Vintch JRE, Wells PS, Wasan S, Moores LK, Antithrombotic Therapy for
VTE Disease: Compendium and Review of CHEST Guidelines 2012-2021, CHEST (2024), doi: https://
doi.org/10.1016/j.chest.2024.03.003.
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Physicians.
Antithrombotic Therapy for VTE Disease Page 1
Guidance Statement Compendium & Review
Antithrombotic Therapy for VTE Disease: Compendium and Review of CHEST Guidelines 2012-2021
Scott M. Stevens MD1, Scott C. Woller MD1, Lisa Baumann Kreuziger MD, MS2, Kevin Doerschug MD3,
Geert-Jan Geersing MD, PhD4, Frederikus A. Klok MD PhD5, Christopher S. King MD6, Susan Murin
MD7, Janine R.E. Vintch MD8, Philip S. Wells MD9, Suman Wasan, MD10, Lisa K. Moores MD11
Author Affiliations:
1. Department of Medicine, Intermountain Health, Murray, UT USA

2. Versiti, Blood Research Institute and Medical College of Wisconsin, Milwaukee, WI, USA
3. Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, IA, USA
4. Julius Center for Health Sciences and Primary Care, Dept. of General Practice and Nursing
Science, University Medical Center Utrecht, Netherlands
5. Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center,
Netherlands
6. Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA, USA
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7. University of California Davis School of Medicine, Davis, CA, USA
8. Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA,
USA
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9. Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute,
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Ottawa, Canada
10. Department of Medicine, University of North Carolina, Chapel Hill NC, USA
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11. Department of Medicine, F. Edward Hebert School of Medicine, The Uniformed Services
University of the Health Sciences, Bethesda MD, USA
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Abstract Word Count: 239

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Body Word Count: 4892
References: 20
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Keywords: venous thromboembolism; pulmonary embolism, deep venous thrombosis; treatment;

guideline; anticoagulant
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CIO Disclosures: SCW, SMS, KD, GJG, FAK, CSK, SM, JREV, PSW, SW and LMK report no potential COI
to disclose. LBK reports receiving research funding from CSL Behring and Takeda to her institution
for unrelated research
Acknowledgements: SCW and SMS drafted the initial manuscript. All authors participated in the
review, revision, and approval of the submitted manuscript. No funding was provided for this
manuscript. However CHEST at the discretion of the CHEST Guidelines Oversight Committee
provided material support and endorsement of the guidelines summarized herein.
Abstract
BACKGROUND The CHEST Antithrombotic Therapy for Venous Thromboembolism Disease evidencebased guidelines are now updated in a more frequent,
focused manner. Guidance statements from the most recent full guideline and two subsequent updates have not been gathered into a single source.
METHODS An international panel of experts with experience in prior Antithrombotic Therapy guideline development reviewed the 2012 CHEST
Antithrombotic Therapy guideline and its two subsequent updates. All guideline statements, and their associated Patient, Intervention, Comparator,
Outcome questions were assembled. A modified Delphi process was used to select statements considered relevant to current clinical care. The panel
further endorsed minor phrasing changes to match the standard language for guidance statements using the modified GRADE format endorsed by the
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CHEST Guidelines Oversight Committee. The panel appended comments following statements as deemed relevant, including suggesting which statements
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be updated in future guidelines due to interval evidence. RESULTS We include 58 guidance statements from prior versions of the antithrombotic therapy
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guidelines, with updated phrasing as needed to adhere to contemporary nomenclature. Statements are classified as strong or weak recommendations
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based on high, moderate, and low-certainty evidence, using GRADE methodology. The panel suggests that 5 statements are no longer relevant to current
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practice. CONCLUSION As CHEST continues to update guidance statements relevant to antithrombotic therapy for VTE disease, this manuscript serves as a
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unified collection of currently relevant statements from the preceding three guidelines. Suggestions are made to update specific statements in future
publications.
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Introduction
CHEST has been developing and publishing guidelines for the treatment of venous thromboembolism (VTE) for almost 40 years. Through 2012, CHEST’s
antithrombotic guidelines were published in a large, multi-section supplement covering multiple disease states and other aspects of antithrombotic
therapy.1 The last full edition of the Antithrombotic Therapy and Prevention of Thrombosis (9th edition): American College of Chest Physicians Evidence-
Based Clinical Practice Guidelines —“AT9” was published as a component of this supplement.2 Subsequently, two updates to AT9 have been published as
distinct manuscripts in 20163 (1st Update) and again in 2021 (2nd Update).4,5 AT9 and the updates are organized using the Patients, Interventions,
Comparators, Outcomes (PICO) framework from which formal guidance statements were created using explicit methodology. AT9 addressed 50 PICO
questions organized into 11 domains and contained 91 guidance statements. The 1st Update addressed 12 PICO questions from AT9, added 3 previously
unaddressed PICOs, and contained 29 guidance statements.3 The 2nd update addressed 14 PICOs contained in previous editions (two of these were merged
into a single PICO), added 4 previously unaddressed PICO and contained 32 guidance statements.5
Because the two updates included only selected PICO questions and guidance statements, clinicians seeking evidence-based guidance for specific clinical
questions may need to access multiple manuscripts to find the statements relevant to their enquiry. Further, it can be difficult to determine which
statements were updated from AT9 to the 1st Update, and subsequently to the 2nd Update. This complexity may reduce the utility of the guideline
publications.
In response to the advancing fields of guideline methodology and implementation science, CHEST has shifted its guideline activities to a new format.6
Forthcoming guidelines will emphasize more rapid updates to individual guidance statements based on meaningful advances in the medical literature. As
CHEST looks toward to the new format for future Antithrombotic Therapy guidance statements, a single source containing the current CHEST guidance
statements will be particularly useful to clinicians.
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This compendium and review aims to collect currently relevant guidance statements from AT9 and the two updates into a single publication, while updating
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nomenclature of older statements to adhere to the current modified GRADE nomenclature used by CHEST. Additionally, the authors have added remarks
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to existing statements to assist with clarification and have identified statements believed to no longer inform clinical care. Anticipating the next CHEST
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Guideline update, the authors have suggested PICO statements that are candidates for updating in the future.”
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Methods
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Two authors (SMS, SCW), who served as co-chairs for the Second Update, assembled a panel of internationally recognized experts in antithrombotic
therapy. The authors abstracted all guidance statements from AT9, the 1st Update and the 2nd Update, and aligned all statements according to the PICO
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addressed. Statements in the 1st and 2nd Updates that were specified as replacing preceding guidance statements were identified. Instances where
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guidance statements were combined were noted [e.g. otherwise identical separate statements for management of deep vein thrombosis (DVT) and
pulmonary embolism (PE) were combined in the 2nd Update to “Venous Thromboembolism” (VTE)]. A definitive list of all guidance statements was
assembled, utilizing the most recent version from the three publications. Detailed descriptions of the evidence selection, assessment, abstraction, pooling
and guidance statement creation for the guideline statements can be found in the original manuscripts.2-5
The collected statements were then reviewed by all panelists who voted regarding inclusion in this manuscript, using a modified Delphi technique. For
inclusion, 80% or more of the panel were required to vote in favor of the statement. An online tool was used for voting. Any statements receiving less than
80% approval, or individual statements requested by a panelist, were discussed during an online meeting of the panelists. The panel also voted on
statements to be identified as no longer relevant to inform clinical practice. A final vote was undertaken, including endorsement of the content of the
remarks.
The panel appended remarks following selected statements which provide further context, make note of interval new evidence, suggest updating of the
statement in a future guideline, or explain the rationale for considering a statement no longer applicable to current practice.
PICO questions and statements have been renumbered for this publication. The digit prior to the decimal refers to the PICO question addressed. Each
statement relevant to the PICO is denoted by the digit following the decimal. These numbers differ from those in the original manuscripts. When more
than one guidance statement is associated with a PICO, subsequent statements may depend on the decision made based on an earlier statement. For
example, statements in section 1.0 addressing anticoagulant management for isolated distal DVT are only applicable to those patients for whom treatment
is selected over serial observation.
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The order of presentation of the PICOs and guidance statements in this manuscript as well as terminology follows the system adopted in the 2nd Update:
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Phases of therapy:5
• Initiation Phase: (0-21 days) The initial provision of anticoagulants following VTE diagnosis.
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• Treatment Phase: (3 months) The period after initiation that completes treatment for the acute VTE event.
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• Extended Phase: (3 months – no planned stop date) The period of anticoagulant use at full or reduced dose for the goal of secondary prevention.
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Classification of precipitating Factors for VTE:7
• VTE Provoked by a Major Transient Risk Factor (present within 3 months prior to VTE diagnosis)
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• VTE Provoked by a Minor Transient Risk Factor (present within 2 months prior to VTE diagnosis)
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• VTE Provoked by a Persistent Risk Factor
• Unprovoked VTE
Direct-Acting Oral Anticoagulants (DOACs--apixaban, dabigatran, edoxaban, and rivaroxaban) are listed in alphabetical order. The order should not be
interpreted as the guideline panel’s order of preference for the use of these agents.
Colors have been added for ease of notation of the strength of the guidance statement. Dark green represents a strong statement “we recommend” in
favor of the Intervention. Light green indicates a weak statement “we suggest” in favor of the intervention. Dark red and light red represent strong and
weak statements against the intervention, respectively. Statements the panel deems no longer relevant are shaded in yellow.
Results
Collected Guidance Statements
The modified Delphi process resulted in evaluation of 58 collected guidance statements, addressing 20 PICO questions, (Table 1) and 5 statements felt to no
longer inform current practice. For each, an informal version of the PICO question is presented, followed by the statement and GRADE description. The 5
statements identified as no longer applicable are listed last. Remarks from the panel follow the statements.
Initial Management of VTE

Question 1: Whether to treat isolated distal DVT
Statement 1.0 (2021): In patients with acute isolated distal DVT of the leg and (i) without severe
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symptoms or risk factors for extension (see text)4, we suggest serial imaging of the deep veins for
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2 weeks over anticoagulation (weak recommendation, moderate-certainty evidence) or ii) with
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severe symptoms or risk factors for extension (see text), we suggest anticoagulation over serial
imaging of the deep veins (weak recommendation, low-certainty evidence).
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Panel Remarks: Distal DVT refers to veins in the leg below the popliteal vein. Serial ultrasound
refers to repeat ultrasound at approximately 1-week intervals for two weeks (e.g. days 0, 7, 14).
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New data informs this question in patients with cancer, favoring anticoagulation.8 The panel
suggests an update to this statement in a future guideline.
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Statement 1.1 (2021): In patients with acute isolated distal DVT of the leg who are managed with
serial imaging, we (i) recommend no anticoagulation if the thrombus does not extend (strong
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recommendation, moderate-certainty evidence), (ii) suggest anticoagulation if the thrombus
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extends but remains confined to the distal veins (weak recommendation, very low-certainty
evidence), and (iii) recommend anticoagulation if the thrombus extends into the proximal veins
(strong recommendation, moderate-certainty evidence).
Panel Remarks: See 1.0 remarks above.
Statement 1.2 (2012): In patients with acute isolated distal DVT of the leg who are managed with
initial anticoagulation, we recommend using the same approach as for patients with acute
proximal DVT (strong recommendation, moderate-quality evidence).
Panel Remarks: “Approach” refers to the choice and dose of agent for the initiation and treatment
phases of therapy.
Question 2: Whether to treat isolated subsegmental PE

Statement 2.0 (2021): In patients with subsegmental PE (no involvement of more proximal
pulmonary arteries) and no proximal DVT in the legs who have a (i) low risk for recurrent VTE (see
text), we suggest clinical surveillance over anticoagulation (weak recommendation, low-certainty
evidence) or (ii) high risk for recurrent VTE (see text4), we suggest anticoagulation over clinical
surveillance (weak recommendation, low-certainty evidence).
Panel Remarks: New data informs this question in patients that are age ≥ 65 years, and those that
have multiple (as opposed to single subsegmental PE), favoring anticoagulation.9 This guidance is
intended for patients without prior VTE, pregnancy, or cancer. The panel suggests an update to
this statement in a future guideline.
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Question 3: Whether to treat incidentally detected PE
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Statement 3.0 (2021): In patients who are incidentally found to have asymptomatic PE, we
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suggest the same initial and long-term anticoagulation as for comparable patients with
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symptomatic PE (weak recommendation, moderate-certainty evidence).
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Question 4: Whether to initiate empiric treatment while awaiting diagnostic tests in patients suspected of acute VTE
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Statement 4.0 (2012): In patients with a high clinical suspicion of acute VTE, we suggest treatment
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with parenteral anticoagulants compared with no treatment while awaiting the results of
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diagnostic tests (weak recommendation, low-quality evidence).
Panel Remarks: Author consensus suggests using a formal pretest probability assessment tool and
consideration of competing risks such as bleeding risk, duration of delay to diagnostic testing, and
patient clinical condition to inform treatment decision-making.
Statement 4.1 (2012): In patients with an intermediate clinical suspicion of acute VTE, we suggest
treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic
tests are expected to be delayed for more than 4 hours (weak recommendation, low-quality
evidence).
Statement 4.2 (2012): In patients with a low clinical suspicion of acute VTE, we suggest not
treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided
test results are expected within 24 hours (weak recommendation, low-quality evidence).
Interventional and adjunctive therapies

Question 5: Whether to use interventional therapy in acute DVT
Statement 5.0 (2021): In patients with acute DVT of the leg we suggest anticoagulant therapy
alone over interventional (thrombolytic, mechanical, or pharmacomechanical) therapy (weak
recommendation, moderate-certainty evidence).
Panel Remarks: Author consensus is that patients with phlegmasia cerulea dolens, characterized
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as DVT at risk for progression to critical limb ischemia and potential limb loss, are outside the
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scope of this guidance.
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Statement 5.1 (2012): In patients with acute DVT of leg who undergo thrombosis removal, we
recommend the same intensity and duration of anticoagulant therapy as in comparable patients
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who do not undergo thrombosis removal (strong recommendation, moderate-quality evidence).
Panel Remarks: Antithrombotic therapy selection may be influenced by whether a venous stent is
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placed during thrombosis removal, though limited evidence informs agent selection.10
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Question 6: Whether to use interventional therapy in acute PE
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Statement 6.0 (2021): In patients with acute PE associated with hypotension (e.g., systolic BP <90
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mm Hg) who do not have a high bleeding risk, we suggest systemically administered thrombolytic
therapy over no such therapy (weak recommendation, low-certainty evidence).
Panel Remarks: This statement should also be considered applicable to patients with a fall of
40mmHg from baseline systolic blood pressure and possibly for select patients with normotension
but signs of shock or respiratory failure.
Statement 6.1 (2021): In most patients with acute PE not associated with hypotension, we
recommend against systemically administered thrombolytic therapy (strong recommendation,
low-certainty evidence).
Panel Remarks: See 6.0 for remarks surrounding additional parameters of PE severity.
Statement 6.2 (2021): In selected patients with acute PE who deteriorate (see text4) after starting
anticoagulant therapy but have yet to develop hypotension and who have an acceptable bleeding
risk, we suggest systemically administered thrombolytic therapy over no such therapy (weak
recommendation, low certainty evidence).
Panel Remarks: See 6.0 remarks for guidance surrounding additional parameters of PE severity.
Statement 6.3 (2021): In patients with acute PE who are treated with a thrombolytic agent, we
suggest systemic thrombolytic therapy using a peripheral vein over catheter directed thrombolysis
(weak recommendation, low-certainty evidence).
Panel Remarks: The technology surrounding catheter-based strategies for PE treatment that may
represent an alternative to systemic thrombolysis has advanced rapidly. High quality trials with
patient-important endpoints are awaited, and may result in the need to update this statement.
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Statement 6.4 (2021): In patients with acute PE associated with hypotension who also have (i) a
high bleeding risk, (ii) failed systemic thrombolysis, or (iii) shock that is likely to cause death
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before systemic thrombolysis can take effect (e.g., within hours), if appropriate expertise and
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resources are available, we suggest catheter-assisted thrombus removal over no such intervention
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(weak recommendation, low-certainty evidence).
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Panel Remarks: Failure of thrombolysis has been better defined by an interval publication.11
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Additional interventions for severe PE include ECMO and surgical thrombectomy. Because high
quality evidence comparing CDT with thrombolysis among such patients does not exist, the panel
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suggests that systemic thrombolysis remain the first-line treatment until proper randomized trials
have confirmed the safety and efficacy of CDT in this setting. The panel suggests an update to this
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statement in a future guideline.
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Question 7: Whether to place IVC filter
Statement 7.0 (2021): In patients with acute DVT of the leg or PE, we recommend against the use
of an inferior vena cava (IVC) filter in addition to anticoagulants (strong recommendation,
moderate-certainty evidence).
Statement 7.1 (2021): In patients with acute proximal DVT of the leg or PE and a contraindication
to anticoagulation, we recommend the use of an IVC filter (strong recommendation, moderate-
certainty evidence).
Panel Remarks: “Acute” should be interpreted as approximately the first month after diagnosis. If
placed, IVC filter retrieval is advised once anticoagulation is started and tolerated.
Statement 7.2 (2012): In patients with acute proximal DVT of the leg or PE and an IVC filter
inserted as an alternative to anticoagulation, we suggest a conventional course of anticoagulant
therapy if their risk of bleeding resolves (weak recommendation, moderate-quality evidence).
Initiation Phase Anticoagulation
Panel Remarks: Note that when DOAC is selected for anticoagulation therapy for VTE, initiation is
achieved either with an initial high dose (apixaban, rivaroxaban) or an initial course of parenteral
LWMH (dabigatran, edoxaban), followed by the treatment phase dose of DOAC. See Statements
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11.0-11.2.
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Setting of initiation Phase
Question 8: Setting of initiation phase treatment
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Statement 8.0 (2012): In patients with acute DVT of the leg and whose home circumstances are
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adequate, we recommend initial treatment at home over treatment in hospital (strong
recommendation, moderate-quality evidence).
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Panel Remarks: The panel felt that “whose home circumstances are adequate” does not fully
embrace other important factors such as access to medications and ability to access outpatient
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follow-up, as phrased in 8.2. DVT severity including need for inpatient care or procedures must be
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considered.
Statement 8.1 (2012): In patients with acute DVT of the leg, we suggest early ambulation over
initial bed rest (weak recommendation, low-quality evidence).
Statement 8.2 (2021): In patients with low-risk PE we recommend outpatient treatment over
hospitalization provided access to medications, ability to access outpatient care, and home
circumstances are adequate (strong recommendation, low-certainty evidence).
Panel Remarks: “Low risk” should be defined through a validated classification model.12
Question 9: Choice and dosing of initiation phase of VKA anticoagulation

Statement 9.0 (2012): In patients with acute VTE treated with VKA therapy, we recommend initial
treatment with parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) rather than
no such initial treatment (strong recommendation, moderate-quality evidence).
Statement 9.1 (2012): In patients with acute VTE initiated with a parenteral agent, we suggest
LMWH or fondaparinux over IV UFH (weak recommendation, low-quality evidence), and over SC
UFH (weak recommendation, moderate-quality evidence for LMWH; weak recommendation, low-
quality evidence for fondaparinux).
Panel Remarks: The DVT and PE statements were combined and minor edits made for clarity. See
11.0 for a comparative recommendation of anticoagulants.
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Statement 9.2 (2012): In patients with acute VTE treated with VKA, we recommend early initiation
(e.g., same day as parenteral therapy is started) over delayed initiation, and continuation of
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parenteral anticoagulation for a minimum of 5 days and until the INR is 2.0 or above for at least 24
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hours (strong recommendation, moderate-quality evidence).
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Panel Remarks: statement See 11.0 for a comparative recommendation of anticoagulants.
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Treatment Phase Anticoagulation
Question 10: Whether to use, and duration of, treatment phase anticoagulation in patients with acute VTE
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Statement 10.0 (2021): In patients with acute VTE who do not have a contraindication to
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anticoagulation we recommend a minimum 3-month treatment phase of anticoagulation (strong
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Panel Remarks: All patients should be assessed for the need for extended phase therapy at the
conclusion of the treatment phase. Note that patients with isolated distal DVT may be managed
with serial imaging, so this statement applies only to those managed with anticoagulation. Minor
phrasing changes made for clarity.
Question 11: Choice of treatment phase anticoagulation
Statement 11.0 (2021): In patients with an acute VTE (DVT of the leg or PE) we recommend
apixaban, dabigatran, edoxaban or rivaroxaban over VKA as treatment phase (first 3 months)
anticoagulant therapy (strong recommendation, moderate-certainty evidence).
Panel Remarks: The panel noted that rivaroxaban is listed by the AGS Beers criteria as potentially
inappropriate in elderly adults.13 Minor phrasing changes made for clarity.
Statement 11.1 (2021): In patients with acute VTE in the setting of cancer (“cancer-associated
thrombosis” -- CAT) we recommend an oral Xa inhibitor (apixaban, edoxaban, rivaroxaban) over
LMWH for the initiation and treatment phases of therapy (strong recommendation, moderate-
Panelist Remarks: Choice of anticoagulant in CAT is sensitive to patient factors that include drug-
drug interactions, oral medication tolerance and cancer-specific treatment variables.
Statement 11.2 (2012): In patients with VTE who are treated with VKA, we recommend a
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therapeutic INR range of 2.0-3.0 (target INR of 2.5) over a lower (INR < 2) or higher (INR 3.0-5.0)
range for all treatment durations (strong recommendation, moderate-quality evidence).
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Extended Phase Anticoagulation
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Question 12: Whether to offer extended phase anticoagulation
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Statement 12.0 (2021): In patients with VTE diagnosed in the setting of a major transient risk
factor (see text), we recommend against offering extended-phase anticoagulation (strong
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Statement 12.1 (2021): In patients with VTE diagnosed in the setting of a minor transient risk
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factor (see text), we suggest against offering extended-phase anticoagulation (weak
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Statement 12.2 (2021): In patients with VTE diagnosed in the absence of transient provocation
(unprovoked VTE) or VTE provoked by persistent risk factor, we recommend offering extended-
phase anticoagulation with a DOAC (strong recommendation, moderate-certainty evidence).
Panel Remarks: Minor phrasing changes made for clarity. See 12.3 and 20.0 for specific guidance
on the persistent provoking factors of cancer and antiphospholipid antibody syndrome (APS).
Statement 12.3 (2016): In patients with VTE and active cancer (CAT) who (i) do not have a high
bleeding risk, we recommend extended anticoagulant therapy (no scheduled stop date) over 3
months of therapy (strong recommendation, moderate-quality evidence), or (ii) have a high
bleeding risk, we suggest extended anticoagulant therapy (no scheduled stop date) over 3 months
of therapy (weak recommendation, moderate-quality evidence).
Question 13: Choice and dose of extended phase anticoagulation
Statement 13.0 (2021): In patients offered extended phase anticoagulation, we suggest the use of
reduced dose apixaban or rivaroxaban over full dose apixaban or rivaroxaban (weak
recommendation, very low-certainty evidence).
Panel Remarks: See 11.0.
Statement 13.1 (2021): In patients offered extended phase anticoagulation, we recommend
reduced dose DOAC (apixaban or rivaroxaban) over aspirin or no therapy (strong
recommendation, low-certainty evidence) and suggest rivaroxaban over aspirin (weak
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Panel Remarks: See 11.0. Rivaroxaban is specified in this statement due to a trial in which it was
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directly compared to aspirin.
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Statement 13.2 (2021): In patients with VTE diagnosed in the absence of transient risk factor
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(unprovoked VTE) or provoked by a persistent risk factor who cannot receive a DOAC, we suggest
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offering extended-phase anticoagulation with a VKA (weak recommendation, moderate-certainty
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evidence).
Panel Remarks: Minor phrasing changes made for clarity. In patients with CAT, LMWH is the
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preferred alternative to a DOAC. When VKA is used for extended phase anticoagulation,
continuing the same target INR as the treatment phase is favored.
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Statement 13.3 (2021): In patients with an unprovoked VTE who are stopping anticoagulant
therapy and do not have a contraindication to aspirin, we suggest aspirin over no aspirin to
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prevent recurrent VTE (weak recommendation, low-certainty evidence).
Panelist Remarks: Acknowledging that aspirin 100mg daily was used in the studies, low-dose
aspirin (i.e. aspirin 81mg daily) is believed to deliver an analogous therapeutic effect.
Complications of VTE
Question 14: Whether to offer graduated compression stockings
Statement 14.0 (2021): In patients with acute DVT of the leg, we suggest against using
compression stockings routinely to prevent PTS (weak recommendation, low-certainty evidence).
Panelist Remarks: This guidance pertains to compression stockings of 30-40mmHg. Interval

publications have added evidence in this domain. The panel suggests an update to this statement
in a future guideline.
Statement 14.1 (2012): In patients with PTS of the leg, we suggest a trial of compression stockings
(weak recommendation, low-quality evidence).
Panel Remarks: The purpose of a trial of compression would be to reduce pain and swelling.
Statement 14.2 (2012): In patients with severe PTS of the leg that is not adequately relieved by
compression stockings, we suggest a trial of an intermittent compression device (weak
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Panel Remarks: The panel noted that many devices are available, only some have been studied in
clinical trials. Revascularization procedures may also be of benefit in severe PTS.
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Statement 14.3 (2012): In patients with PTS of the leg, we suggest against using venoactive
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medications (weak recommendation, low-quality evidence).
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Panel Remarks: Minor phrasing changes made for clarity. There are ongoing RCTs addressing this
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situation. Their publication might prompt this statement to be updated.
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Question 15: Management of CTEPH
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Statement 15.0 (2012): In patients with CTEPH, we recommend extended anticoagulation over
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stopping therapy (strong recommendation, moderate-quality evidence).
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Panel Remarks: The panel noted ongoing controversy surrounding DOAC versus VKA in patients
with CTEPH, with some evidence suggesting VKA may be more effective.14
Thrombosis at Other Sites & Special Circumstances

Question 16: Choice and dose of therapy for SVT
Statement 16.0 (2021): In patients with superficial venous thrombosis (SVT) of the lower limb at
increased risk of clot progression to DVT or PE (see text4), we suggest the use of anticoagulation
for 45 days over no anticoagulation (Weak recommendation, moderate-certainty evidence).
Panel Remarks: The panel noted that treatment trials enrolled patients with SVT in the greater
saphenous vein of at least 5cm in length. SVT within about 3cm of the sapheno-femoral junction
is usually treated with the same approach as proximal DVT.
Statement 16.1 (2021): In patients with SVT who are treated with anticoagulation, we suggest
fondaparinux 2.5 mg daily over other anticoagulant treatment regimens such as (prophylactic or
therapeutic) dose of LMWH (weak recommendation, low-certainty evidence).
Statement 16.2 (2021): In patients with SVT who refuse or are unable to use parenteral
anticoagulation, we suggest rivaroxaban 10 mg daily as a reasonable alternative for fondaparinux
2.5 mg daily (weak recommendation, low-certainty evidence).
Panel Remarks: The panel made note of evidence disfavoring the use of NSAIDs or surgical
interventions for SVT.15,16
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Question 17: Management of UEDVT
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Statement 17.0 (2016): In patients with acute UEDVT that involves the axillary or more proximal
veins, we suggest anticoagulant therapy alone over thrombolysis (weak recommendation, low-
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Statement 17.1 (2016): In patients with UEDVT who undergo thrombolysis, we recommend the
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same intensity and duration of anticoagulant therapy as in patients with UEDVT who do not
undergo thrombolysis (strong recommendation, moderate-quality evidence).
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Statement 17.2 (2012): In most patients with UEDVT that is associated with a central venous
catheter, we suggest that the catheter not be removed if it is functional and there is an ongoing
ur
need for the catheter (weak recommendation, low-quality evidence).
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Statement 17.3 (2012): In patients with UEDVT that involves the axillary or more proximal veins,
we suggest a minimum duration of anticoagulation of 3 months over a shorter period (weak
Statement 17.4 (2012): In patients who have UEDVT that is associated with a central venous
catheter that is removed, we recommend 3 months of anticoagulation over a longer duration of
therapy in patients without cancer (strong recommendation, moderate-quality evidence), and we
suggest the same in patients with cancer (weak recommendation, low-quality evidence).
Panel Remarks: Minor phrasing changes made for clarity.
Statement 17.5 (2012): In patients who have UEDVT that is associated with a central venous
catheter that is not removed, we recommend that anticoagulation is continued as long as the
central venous catheter remains in place over stopping after 3 months of treatment in patients
with cancer (strong recommendation, low-quality evidence), and suggest the same in patients
without cancer (weak recommendation, low-quality evidence).
Panel Remarks: Minor phrasing changes made for clarity.
Statement 17.6 (2012): In patients who have UEDVT that is not associated with a central venous
catheter or with cancer, we recommend 3 months of anticoagulation over a longer duration of
therapy (strong recommendation, moderate-quality evidence).
Statement 17.7 (2012): In patients who have PTS of the arm, we suggest a trial of compression
bandages or sleeves to reduce symptoms (weak recommendation, low-quality evidence).
Statement 17.8 (2012): In patients with PTS of the arm, we suggest against treatment with
of
venoactive medications (weak recommendation, low-quality evidence).
o
Question 18: Management of Cerebral Vein/Venous Sinus Thrombosis
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Statement 18.0 (2021): In patients with cerebral vein/venous sinus thrombosis, we recommend
anticoagulation therapy for at least the treatment phase (first 3 months) over no anticoagulant
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therapy (strong recommendation, low-certainty evidence).
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Question 19: Management of Splanchnic Vein Thrombosis
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Statement 19.0 (2012): In patients with symptomatic splanchnic vein thrombosis (portal,
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mesenteric and/or splenic vein thromboses), we recommend anticoagulation over no
anticoagulation (strong recommendation, moderate-quality evidence).
Statement 19.1 (2012): In patients with incidentally detected splanchnic vein thrombosis (portal,
mesenteric and/or splenic vein thromboses), we suggest no anticoagulation over anticoagulation
Panel Remarks: The panel was concerned that this statement oversimplifies situations with
complex risk:benefit analyses, which includes bleeding risk associated with concomitant cirrhosis,
acute provoking factors (e.g. pancreatitis) and extent of thrombosis. The panel suggests an
update to this statement in a future guideline.
Statement 19.2 (2012): In patients with symptomatic hepatic vein thrombosis, we suggest
anticoagulation over no anticoagulation (weak recommendation, low-quality evidence).
Question 20: Anticoagulant management in patients with APS
Statement 20.0 (2021): In patients with confirmed APS being managed with anticoagulant
therapy, we suggest adjusted dose VKA (target INR 2.5) over DOAC therapy during the treatment
phase (weak recommendation, low-certainty evidence).
Panel Remarks: The panel noted that studies demonstrating lower efficacy of DOACs enrolled
patients with triple-positive serologic profiles. Management of patients with APS and other
antibody profiles is less clear.
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Statements no longer relevant to practice
o
The following statements were reviewed by the panel and after discussion and voting, were felt to no longer inform current clinical practice. Rationale for
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this assessment, along with the original publication’s reference number is listed for each.
(2012): 2.5.2. In patients with acute DVT of the leg treated with LMWH, we suggest once- over
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twice-daily administration.
5.4.2. In patients with acute PE treated with LMWH, we suggest once- over twice-daily
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administration.
Panel Remarks: This statement may cause confusion and according to an editorial, could result in
na
prescribing incorrect dosing of medications, especially enoxaparin.17
(2016): 4. In patients with DVT of the leg or PE who receive extended therapy, we suggest that
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there is no need to change the choice of anticoagulant after the first 3 months.
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Panel Remarks: The panel thought this statement may cause confusion and could be read to
contradict the statements in Question 13.
(2016): 26. In selected patients with chronic thromboembolic pulmonary hypertension (CTEPH)
who are identified by an experienced thromboendarterectomy team, we suggest pulmonary
thromboendarterectomy over no pulmonary thromboendarterectomy.
Panel Remarks: While not concerned about the statement’s contents, the panel felt that this
statement is out of scope of the antithrombotic guidelines and more completely addressed
elsewhere.18
(2012): 9.4. In patients with acute symptomatic UEDVT, we suggest against the use of
compression sleeves or venoactive medications.
Panel Remarks: The panel did not feel there is sufficient evidence to endorse any statement on
this specific issue.
(2012): 11.2 In patients with incidentally detected hepatic vein thrombosis, we suggest no
anticoagulation over anticoagulation.
Panel Remarks: The panelists universally disagreed with this statement, which is in conflict with
newer guidelines.19
Discussion & Conclusion

The CHEST guidelines for Antithrombotic Therapy for Venous Thromboembolism are a longstanding, highly-referenced resource to inform best clinical care
of complex clinical conditions and use of therapies that carry significant risks. The utility of the guidelines may be decreased by statements spanning three
manuscripts, with interval updates of some statements and addition of new ones.2-4 This compendium strove to identify the relevant current guidance
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statements from across the three publications and collect them into a single location for easier reference to clinicians and other readers. In addition,
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guidance statements were re-organized into a sequence that follows the path of clinical care (an improvement introduced in the 2nd update)4, updated with
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the current GRADE nomenclature, and underwent minor phrasing improvements when the original statement language was unclear. The panel also
identified statements it suggests should be updated due to interval evidence and noted 5 statements that it considered no longer applicable to
-
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contemporary practice. Finally, the panel added comments to place statements into better clinical context or to add additional explanatory or interpretive
information.
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While this review is not an officially endorsed guideline of the American College of Chest Physicians, the panel utilized key practices of trustworthy
guidelines20 creation, such as use of a modified Delphi process. The intention of this effort is to provide a compendium that will be useful to readers as a
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single source to locate the most contemporary statements from the three preceding official guidelines.2-4 This work will inform future CHEST Guideline
publications.
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References
1. Guyatt GH, Akl EA, Crowther M, et al. Introduction to the ninth edition: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American
College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):48S-52S.
2. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e419S-494S.
3. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315-352.
4. Stevens SM, Woller SC, Baumann Kreuziger L, et al. Executive Summary: Antithrombotic Therapy for VTE Disease: Second Update of the CHEST
Guideline and Expert Panel Report. Chest. 2021;160(6):2247-2259.
5. Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel
Report. Chest. 2021;160(6):e545-e608.
6. Heffner JE. Update of Antithrombotic Guidelines: Medical Professionalism and the Funnel of Knowledge. Chest. 2016;149(2):293-294.
7. Kearon C, Ageno W, Cannegieter SC, et al. Categorization of patients as having provoked or unprovoked venous thromboembolism: guidance from
the SSC of ISTH. J Thromb Haemost. 2016;14(7):1480-1483.
8. Yamashita Y, Morimoto T, Muraoka N, et al. Edoxaban for 12 Months Versus 3 Months in Cancer Patients With Isolated Distal Deep Vein
Thrombosis (ONCO DVT study): An Open-label, Multicenter, Randomized Clinical Trial. Circulation. 2023.
9. Le Gal G, Kovacs MJ, Bertoletti L, et al. Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed
Without Anticoagulation : A Multicenter Prospective Cohort Study. Ann Intern Med. 2022;175(1):29-35.
of
10. Lee Cervi A, Applegate D, Stevens SM, et al. Antithrombotic management of patients with deep vein thrombosis and venous stents: an international
registry. Journal of Thrombosis and Haemostasis.
o
11. Pruszczyk P, Klok FA, Kucher N, et al. Percutaneous treatment options for acute pulmonary embolism: a clinical consensus statement by the ESC
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Working Group on Pulmonary Circulation and Right Ventricular Function and the European Association of Percutaneous Cardiovascular
-
Interventions. EuroIntervention. 2022;18(8):e623-e638.
re
12. de Wit K, D'Arsigny CL. Risk stratification of acute pulmonary embolism. J Thromb Haemost. 2023;21(11):3016-3023.
lP
13. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc.
2023;71(7):2052-2081.
14. Ishisaka Y, Watanabe A, Takagi H, Steiger D, Kuno T. Anticoagulation in chronic thromboembolic pulmonary hypertension: A systematic review and
na
meta-analysis. Thromb Res. 2023;231:91-98.
ur
15. Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2018;2(2):Cd004982.
16. Duffett L, Kearon C, Rodger M, Carrier M. Treatment of Superficial Vein Thrombosis: A Systematic Review and Meta-Analysis. Thromb Haemost.
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2019;119(3):479-489.
17. Miesner AR, Trewet CB. Clarification of once-daily low-molecular-weight heparin dosing in pulmonary embolism. Chest. 2012;142(4):1074-1075.
18. Klinger JR, Elliott CG, Levine DJ, et al. Therapy for Pulmonary Arterial Hypertension in Adults: Update of the CHEST Guideline and Expert Panel
Report. Chest. 2019;155(3):565-586.
19. Di Nisio M, Valeriani E, Riva N, Schulman S, Beyer‐Westendorf J, Ageno W. Anticoagulant therapy for splanchnic vein thrombosis. Journal of
Thrombosis and Haemostasis. 2020;18(7):1562-1568.
20. Laine C, Taichman DB, Mulrow C. Trustworthy clinical guidelines. Ann Intern Med. 2011;154(11):774-775.
Table: Active Guidance Statements and informal PICO Questions

PICO # Informal Statement Guidance Statement
Question #
Initial Management
1 Whether to 1 In patients with acute isolated distal DVT of the leg and (i) without severe symptoms or risk factors for
treat isolated extension (see text)1, we suggest serial imaging of the deep veins for 2 weeks over anticoagulation (weak
distal DVT recommendation, moderate-certainty evidence) or ii) with severe symptoms or risk factors for extension (see
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text), we suggest anticoagulation over serial imaging of the deep veins (weak recommendation, low-certainty
evidence).
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1.1 In patients with acute isolated distal DVT of the leg who are managed with serial imaging, we (i) recommend
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no anticoagulation if the thrombus does not extend (strong recommendation, moderate-certainty evidence),
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(ii) suggest anticoagulation if the thrombus extends but remains confined to the distal veins (weak
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recommendation, very low-certainty evidence), and (iii) recommend anticoagulation if the thrombus extends
lP
into the proximal veins (strong recommendation, moderate-certainty evidence).
1.2 In patients with acute isolated distal DVT of the leg who are managed with initial anticoagulation, we
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recommend using the same approach as for patients with acute proximal DVT (strong recommendation,
moderate-quality evidence).
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2 Whether to 2 In patients with subsegmental PE (no involvement of more proximal pulmonary arteries) and no proximal DVT
treat isolated in the legs who have a (i) low risk for recurrent VTE (see text), we suggest clinical surveillance over
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subsegmental anticoagulation (weak recommendation, low-certainty evidence) or (ii) high risk for recurrent VTE (see text1),
PE we suggest anticoagulation over clinical surveillance (weak recommendation, low-certainty evidence).
3 Whether to 3 In patients who are incidentally found to have asymptomatic PE, we suggest the same initial and long-term
treat anticoagulation as for comparable patients with symptomatic PE (weak recommendation, moderate-certainty
incidentally evidence).
detected PE
4 Whether to 4 In patients with a high clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants
initiate empiric compared with no treatment while awaiting the results of diagnostic tests (weak recommendation, low-
treatment quality evidence).
while awaiting 4.1 In patients with an intermediate clinical suspicion of acute VTE, we suggest treatment with parenteral
diagnostic tests anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for
in patients more than 4 hours (weak recommendation, low-quality evidence).
suspected of 4.2 In patients with a low clinical suspicion of acute VTE, we suggest not treating with parenteral anticoagulants
acute VTE while awaiting the results of diagnostic tests, provided test results are expected within 24 hours (weak
recommendation, low-quality evidence).
5 Whether to 5 In patients with acute DVT of the leg we suggest anticoagulant therapy alone over interventional
use (thrombolytic, mechanical, or pharmacomechanical) therapy (weak recommendation, moderate-certainty
interventional evidence).
therapy in 5.1 In patients with acute DVT of leg who undergo thrombosis removal, we recommend the same intensity and
acute DVT duration of anticoagulant therapy as in comparable patients who do not undergo thrombosis removal (strong
of
6 Whether to 6 In patients with acute PE associated with hypotension (e.g., systolic BP <90 mm Hg) who do not have a high
use bleeding risk, we suggest systemically administered thrombolytic therapy over no such therapy (weak
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interventional recommendation, low-certainty evidence).
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therapy in 6.1 In most patients with acute PE not associated with hypotension, we recommend against systemically
-
acute PE administered thrombolytic therapy (strong recommendation, low-certainty evidence).
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6.2 In selected patients with acute PE who deteriorate (see text1) after starting anticoagulant therapy but have
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yet to develop hypotension and who have an acceptable bleeding risk, we suggest systemically administered
thrombolytic therapy over no such therapy (weak recommendation, low certainty evidence).
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6.3 In patients with acute PE who are treated with a thrombolytic agent, we suggest systemic thrombolytic
therapy using a peripheral vein over catheter directed thrombolysis (CDT) (weak recommendation, low-
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6.4 In patients with acute PE associated with hypotension who also have (i) a high bleeding risk, (ii) failed systemic
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thrombolysis, or (iii) shock that is likely to cause death before systemic thrombolysis can take effect (e.g.,
within hours), if appropriate expertise and resources are available, we suggest catheter-assisted thrombus
removal over no such intervention (weak recommendation, low-certainty evidence).
7 Whether to 7 In patients with acute DVT of the leg or PE, we recommend against the use of an inferior vena cava (IVC) filter
place IVC filter in addition to anticoagulants (strong recommendation, moderate-certainty evidence).
7.1 In patients with acute proximal DVT of the leg or PE and a contraindication to anticoagulation, we recommend
the use of an IVC filter (strong recommendation, moderate-certainty evidence).
7.2 In patients with acute proximal DVT of the leg or PE and an IVC filter inserted as an alternative to
anticoagulation, we suggest a conventional course of anticoagulant therapy if their risk of bleeding resolves
(weak recommendation, moderate-quality evidence).
8 Setting of 8 In patients with acute DVT of the leg and whose home circumstances are adequate, we recommend initial
initial phase treatment at home over treatment in hospital (strong recommendation, moderate-quality evidence).
treatment
8.1 In patients with acute DVT of the leg, we suggest early ambulation over initial bed rest (weak
8.2 In patients with low-risk PE we recommend outpatient treatment over hospitalization provided access to
medications, ability to access outpatient care, and home circumstances are adequate (strong
recommendation, low-certainty evidence).
9 Choice and 9 In patients with acute VTE treated with VKA therapy, we recommend initial treatment with parenteral
of
dosing of anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) rather than no such initial treatment (strong
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initiation phase recommendation, moderate-quality evidence).
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anticoagulation 9.1 In patients with acute VTE initiated with a parenteral agent, we suggest LMWH or fondaparinux over IV UFH
(weak recommendation, low-quality evidence), and over SC UFH (weak recommendation, moderate-quality
-
evidence for LMWH; weak recommendation, low-quality evidence for fondaparinux).
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9.2 In patients with acute VTE, we recommend early initiation of VKA (e.g., same day as parenteral therapy is
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started) over delayed initiation, and continuation of parenteral anticoagulation for a minimum of 5 days and
until the INR is 2.0 or above for at least 24 hours (strong recommendation, moderate-quality evidence).
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Treatment Phase Anticoagulation
10 Whether to 10 In patients with acute VTE who do not have a contraindication we recommend a minimum 3-month treatment
use treatment
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phase of anticoagulation (strong recommendation, moderate-certainty evidence).
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phase
anticoagulation
in patients wit
acute VTE
11 Choice of 11 In patients with an acute VTE (DVT of the leg or PE) we recommend apixaban, dabigatran, edoxaban or
treatment rivaroxaban over VKA as treatment phase (first 3 months) anticoagulant therapy (strong recommendation,
phase moderate-certainty evidence).
anticoagulation 11.1 In patients with acute VTE in the setting of cancer (“cancer-associated thrombosis”) we recommend an oral Xa
inhibitor (apixaban, edoxaban, rivaroxaban) over LMWH for the initiation and treatment phases of therapy
(strong recommendation, moderate-certainty evidence).
11.2 In patients with VTE who are treated with VKA, we recommend a therapeutic INR range of 2.0-3.0 (target INR
of 2.5) over a lower (INR < 2) or higher (INR 3.0-5.0) range for all treatment durations (strong
Extended Phase Anticoagulation
12 Whether to 12 In patients with VTE diagnosed in the setting of a major transient risk factor (see text), we recommend against
offer extended offering extended-phase anticoagulation (strong recommendation, moderate-certainty evidence).
phase 12.1 In patients with VTE diagnosed in the setting of a minor transient risk factor (see text), we suggest against
anticoagulation offering extended-phase anticoagulation (weak recommendation, moderate-certainty evidence).
of
12.2 In patients with VTE diagnosed in the absence of transient provocation (unprovoked VTE) or VTE provoked by
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persistent risk factor, we recommend offering extended-phase anticoagulation with a DOAC (strong
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-
12.3 In patients with VTE and active cancer (“cancer-associated thrombosis”) who (i) do not have a high bleeding
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risk, we recommend extended anticoagulant therapy (no scheduled stop date) over 3 months of therapy
lP
(strong recommendation, moderate-quality evidence), or (ii) have a high bleeding risk, we suggest extended
anticoagulant therapy (no scheduled stop date) over 3 months of therapy (weak recommendation, moderate-
na
quality evidence).
13 Choice and 13 In patients offered extended phase anticoagulation, we suggest the use of reduced dose apixaban or
dose of
extended ur
rivaroxaban over full dose apixaban or rivaroxaban (weak recommendation, very low-certainty evidence).
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13.1 In patients offered extended phase anticoagulation, we recommend reduced dose DOAC (apixaban or
phase rivaroxaban) over aspirin or no therapy (strong recommendation, low-certainty evidence) and suggest
anticoagulation rivaroxaban over aspirin (weak recommendation, moderate-certainty evidence).
13.2 In patients with VTE diagnosed in the absence of transient risk factor (unprovoked VTE) or provoked by a
persistent risk factor who cannot receive a DOAC, we suggest offering extended-phase anticoagulation with a
VKA (weak recommendation, moderate-certainty evidence).
13.3 In patients with an unprovoked VTE who are stopping anticoagulant therapy and do not have a
contraindication to aspirin, we suggest aspirin over no aspirin to prevent recurrent VTE (weak
Complications of VTE
14 Whether to 14 In patients with acute DVT of the leg, we suggest against using compression stockings routinely to prevent PTS
offer (weak recommendation, low-certainty evidence).
graduated 14.1 In patients with PTS of the leg, we suggest a trial of compression stockings (weak recommendation, low-
compression quality evidence).
stockings 14.2 In patients with severe PTS of the leg that is not adequately relieved by compression stockings, we suggest a
trial of an intermittent compression device (weak recommendation, moderate-quality evidence).
14.3 In patients with PTS of the leg, we suggest against using venoactive medications (weak recommendation, low-
quality evidence).
15 Management 15 In patients with CTPH, we recommend extended anticoagulation over stopping therapy (strong
of CTEPH recommendation, moderate-quality evidence).
Thrombosis at Other Sites & Special Circumstances
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16 Choice and 16 In patients with superficial venous thrombosis (SVT) of the lower limb at increased risk of clot progression to
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dose of DVT or PE (see text1), we suggest the use of anticoagulation for 45 days over no anticoagulation (Weak
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therapy for SVT recommendation, moderate-certainty evidence).
16.1 In patients with SVT who are treated with anticoagulation, we suggest fondaparinux 2.5 mg daily over other
-
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anticoagulant treatment regimens such as (prophylactic or therapeutic) dose of LMWH (weak
lP
16.2 In patients with SVT who refuse or are unable to use parenteral anticoagulation, we suggest rivaroxaban 10
mg daily as a reasonable alternative for fondaparinux 2.5 mg daily (weak recommendation, low-certainty
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evidence).
17 Management 17 In patients with acute UEDVT that involves the axillary or more proximal veins, we suggest anticoagulant
of UEDVT
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therapy alone over thrombolysis (weak recommendation, low-quality evidence).
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17.1 In patients with UEDVT who undergo thrombolysis, we recommend the same intensity and duration of
anticoagulant therapy as in patients with UEDVT who do not undergo thrombolysis (strong recommendation,
17.2 In most patients with UEDVT that is associated with a central venous catheter, we suggest that the catheter
not be removed if it is functional and there is an ongoing need for the catheter (weak recommendation, low-
quality evidence).
17.3 In patients with UEDVT that involves the axillary or more proximal veins, we suggest a minimum duration of
anticoagulation of 3 months over a shorter period (weak recommendation, moderate-quality evidence).
17.4 In patients who have UEDVT that is associated with a central venous catheter that is removed, we recommend
3 months of anticoagulation over a longer duration of therapy in patients with no cancer (strong
recommendation, moderate-quality evidence), and we suggest this in patients with cancer (weak
17.5 In patients who have UEDVT that is associated with a central venous catheter that is not removed, we
recommend that anticoagulation is continued as long as the central venous catheter remains in place over
stopping after 3 months of treatment in patients with cancer (strong recommendation, low-quality evidence),
and we suggest this in patients with no cancer (weak recommendation, low-quality evidence).
17.6 In patients who have UEDVT that is not associated with a central venous catheter or with cancer, we
recommend 3 months of anticoagulation over a longer duration of therapy (strong recommendation,
17.7 In patients who have PTS of the arm, we suggest a trial of compression bandages or sleeves to reduce
symptoms (weak recommendation, low-quality evidence).
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17.8 In patients with PTS of the arm, we suggest against treatment with venoactive medications (weak
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pr
18 Management 18 In patients with cerebral vein/venous sinus thrombosis, we recommend anticoagulation therapy for at least
of Cerebral the treatment phase (first 3 months) over no anticoagulant therapy (strong recommendation, low-certainty
-
re
Vein/Venous evidence).
Sinus
lP
Thrombosis
19 Management 19 In patients with symptomatic splanchnic vein thrombosis (portal, mesenteric and/or splenic vein thromboses),
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of Splanchnic we recommend anticoagulation over no anticoagulation (strong recommendation, moderate-quality
Vein evidence).
Thrombosis 19.1
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In patients with incidentally detected splanchnic vein thrombosis (portal, mesenteric and/or splenic vein
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thromboses), we suggest no anticoagulation over anticoagulation (weak recommendation, low-quality
evidence).
19.2 In patients with symptomatic hepatic vein thrombosis, we suggest anticoagulation over no anticoagulation
20 Anticoagulant 20 In patients with confirmed antiphospholipid syndrome being managed with anticoagulant therapy, we suggest
management adjusted dose VKA (target INR 2.5) over DOAC therapy during the treatment phase (weak recommendation,
in patients low-certainty evidence).
with APS
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Antithrombotic Therapy for VTE Disease: Compendium and Review of CHEST

To appear in: CHEST

Received Date: 16 January 2024

1. Department of Medicine, Intermountain Health, Murray, UT USA

Abstract Word Count: 239

Body Word Count: 4892

Keywords: venous thromboembolism; pulmonary embolism, deep venous thrombosis; treatment;

Initial Management of VTE

Question 2: Whether to treat isolated subsegmental PE

Panel Remarks: See 4.0 remarks above.

Interventional and adjunctive therapies

Initiation Phase Anticoagulation

Question 9: Choice and dosing of initiation phase of VKA anticoagulation

Question 11: Choice of treatment phase anticoagulation

Panelist Remarks: This guidance pertains to compression stockings of 30-40mmHg. Interval

Thrombosis at Other Sites & Special Circumstances

Discussion & Conclusion

Table: Active Guidance Statements and informal PICO Questions

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