informative

1. ANTITHROMBOTIC THERAPY
FOR VTE DISEASE
KERLEYSE DOMOND
PRIMARY CARE 1: ACUTE AND CHRONIC HEALTH PROBLEM
PALM BEACH ATLANTIC UNIVERSITY

2. OBJECTIVES
• Practice Guidelines & the Professional Organization
• Definition of Disease/Wellness state
• Purpose of the guideline
• Diagnostic Criteria
• Recommende3d Diagnostic Testing
• Management Recommendations
• Differences from previous version
• Difference from other professional organization

3. PRACTICE GUIDELINES & THE PROFESSIONAL ORGANIZATION
• Name
• CHEST Guideline and Expert Panel Report
• Affiliation
• McMaster University Hamilton, ON
• American University of Beirut Beirut, Lebanon
• CHEST Glenview, IL
• VA New Jersey Health Care System Newark, NJ
• Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcala Madrid, Spain
• University of Geneva, Switzerland
• Leiden University Medical Center Leiden, Netherlands
• Virginia Commonwealth Univeristy Falls Church, VA
• University of California San Diego, CA
• The Ohio State University Columbus, OH
• Intermountain Medical Center and the University of Utah Murray, UT
• HARBOR-UCLA Medical Center Torrance, CA
• The University of Ottawa and Ottawa Hospital Research Institute Ottawa, ON
• Uniformed Services University of the Health Sciences Bethesda, MD
• Authors
• Clive Kearon, Elie Alk, Joseph Ornelas, Allen Blaivas, David Jimenez, Henri Bounameaux, Menno Huisman, Christopher S. King, Timothy A. Morris, Namita Sood, Scott M. Stevens,
Janine R. E. Vintch, Phillips Wells, Scott C. Woller, Lisa Moores
• Year
• 2016

4. DEFINITION OF DISEASE/WELLNESS STATE
• Venous thromboembolism (VTE) is a blood clot that starts in a vein usually with inflammation of vessel
wall (Guercini, Mommi, Camporese, Tonello, Imberti, Benedetti, & Di Lecce, 2016)
• Venous thromboembolism (VTE) is the third most common cardiovascular disease after acute coronary
syndromes and stroke (Guercini, et., al. 2016)
• Affects more than 750, 000 people every year
• Long-term complications include: pulmonary embolism (PE) , deep vein thrombosis (DVT), cancer-
associated thrombosis, postthrombotic syndrome (PTS) 20-50% of patients, and chronic
thromboembolitic pulmonary hypertension (CTEPH) 1-4%, (Kearon, Akl, Ornelas, Blaivas, Jimenez,
Bounameaux, & Moores, 2016)
• Most common causes are surgery, cancer, immobilization, hospitalization, pregnancy, and use of oral
contraceptive or estrogen for menopause (Guercini, et., al. 2016). Also, old age (with no discrimination),
obesity, autoimmune disease such as Lupus
Guercini, F., Mommi, V., Camporese, G., Tonello, C., Imberti, D., Benedetti, R., & ... Di Lecce, L. (2016). The management of patients with venous thromboembolism in Italy: insights from the
PREFER in VTE registry. Internal & Emergency Medicine, 11(8), 1095-1102. doi:10.1007/s11739-016-1507-6

5. PURPOSE OF THE GUIDELINE
• To update evidence-based recommendations for the use of antithrombotic therapy for the
management of venous thromboembolism (VTE) disease

6. DIAGNOSTIC CRITERIA
• Diagnosis of VTE starts with an assessment of Clinical pretest probability (CPTP)
• CPTP is higher if: (1) symptoms and signs are typical for DVT or PE; (2) there are risk factors for VTE; (3) VTE is thought to be
the most likely diagnosis; and (4) symptoms and signs are more severe
• CPTP assessment is facilitated by use of clinical prediction rules, of which:
• The Wells DVT score (A score of ≥2 has been termed “DVT likely.” This group makes up ∼40% of patients and has a
prevalence of DVT of ∼33%. A score of ≤1 has been termed “DVT unlikely.” This group makes up ∼75% of patients and has a
prevalence of DVT of ∼10%. The original Wells DVT model was for a first suspected DVT and, therefore, did not include a
score for previous VTE)
• The Wells PE score (A score of ≥4.5 (moderate and high probability groups combined) has been termed “PE likely.” This group
makes up ∼40% of patients and has a prevalence of PE of ∼33%. Is also termed “PE unlikely.” In the original derivation of the
Wells PE model, patients were required to have a score of ≤1.5 to be categorized as low probability, but a score of ≤4 has
subsequently been used for low probability)
• The Geneva PE score are the most widely used and best validated.The Wells PE and Geneva PE scores, and a modified
version of the Wells DVT score are suitable for suspected first or recurrent PE. CPTP prediction rules are also available for
DVT in pregnancy and upper-extremity DVT.CPTP is usually categorized as low, intermediate, or high, or as unlikely or likely
• Although CPTP alone cannot rule-in VTE and generally does not rule-out VTE, it: (1) guides the selection of further testing
(confirmatory test if high CPTP; exclusionary test if low CPTP); and (2) is often rules-out or rules-in VTE when combined with
other test results. Not using CPTP as part of the diagnostic process wastes information and, therefore, reduces the accuracy
of diagnostic testing (increases false-positives and false-negatives)
Kearon, C. (2017). Diagnosis of suspected venous thromboembolism. American Society of Hemotology, 2016(1), 397-403. December 2, 2016. doi: 10.1182/asheducation-2016.1.397

7. RECOMMENDED DIAGNOSTIC TESTING
• PE rule-out criteria (PERC)
• D-dimer
• Venous ultrasound
• Venography
• CT and MRI
• CTPA
• V/Q lung
• Pulmonary angiography
Kearon, C. (2017). Diagnosis of suspected venous thromboembolism. American Society of Hemotology, 2016(1), 397-403. December 2, 2016. doi: 10.1182/asheducation-2016.1.397

8. MANAGEMENT RECOMMENDATIONS
• Non-vitamin K antagonist oral anticoagulants are suggested over Warfarin for initial and long term
treatment of VTE in patients without cancer
• Aspirin use for extended treatment of DVT
• New isolated subsegmental pulmonary embolism treatment for DVT
Kearon, C., Akl, E. A., Ornelas, J., Blaivas, A., Jimenez, D., Bounameaux, H., & ... Moores, L. (2016). Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel
Report. Chest, 149(2), 315-352. doi:10.1016/j.chest.2015.11.026

9. DIFFERENCES FROM PREVIOUS VERSION
• Warfarin is no longer considered as first line therapy for VTE disease
• Recurrence risk factors for male with a positive D-dimer obtained one month after stopping anticoagulant
therapy should be taken into consideration when deciding whether extended anticoagulation is needed
• Low dose Aspirin can be used in patients who stop anticoagulant therapy for treatment of an unprovoked DVT
or PE as an extended therapy
• Compression stockings is no longer used to prevent PTS
Kearon, C., Akl, E. A., Ornelas, J., Blaivas, A., Jimenez, D., Bounameaux, H., & ... Moores, L. (2016). Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel
Report. Chest, 149(2), 315-352. doi:10.1016/j.chest.2015.11.026

10. DIFFERENCE FROM OTHER PROFESSIONAL
ORGANIZATION
• Considering that American College of Chest Physicians (CHEST) is the global leader in advancing best
patient outcomes, no other differences were able to be obtained
• To date, the update guideline has been endorsed by several other professional organization such as
American Association for Clinical Chemistry, American College of Clinical Pharmacy, International
Society for Thrombosis and Haemostasis, and American Society of Health-System Pharmacists
Chestnet.org, (2016)

11. CONCLUSION
• There are many ways to test for DVT and no single approach is better than the other
• Sometimes the given tests are not definitive due to contraindications or test results are simply
inconclusive
• Do what it is best and appropriate for your patients

12. REFERENCES
• CHEST issues new antithrombotic guideline update for treatment of VTE disease. (2016). Retrieved from
http://www.chestnet.org/News/Press-Releases/2016/01/AT10-VTE
• Guercini, F., Mommi, V., Camporese, G., Tonello, C., Imberti, D., Benedetti, R., & ... Di Lecce, L. (2016).
The management of patients with venous thromboembolism in Italy: insights from the PREFER in VTE
registry. Internal & Emergency Medicine, 11(8), 1095-1102. doi:10.1007/s11739-016-1507-6
• Kearon, C. (2017). Diagnosis of suspected venous thromboembolism. American Society of Hemotology,
2016(1), 397-403. December 2, 2016. doi: 10.1182/asheducation-2016.1.397
• Kearon, C., Akl, E. A., Ornelas, J., Blaivas, A., Jimenez, D., Bounameaux, H., & ... Moores, L. (2016).
Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest, 149(2), 315-
352. doi:10.1016/j.chest.2015.11.026