CHEST 2008 Anti-Thrombotic Guidelines
High Clinical Suspicion of DVT or PE:
- Anticoagulate while awaiting the outcome of diagnostic tests (Grade 1C)
Acute DVT or PE-Initial Therapy:
- Initial treatment with LMWH/UFH/fondaparinux for >5 days rather than a shorter period (Grade 1C)
- Initiation of coumadin together with LMWH/UFH/fondaparinux on first treatment day
- Discontinuation of heparin when INR is >2.0 for at least 24 h (Grade 1A).
- Early evaluation of the risks to benefits of thrombolytic therapy (Grade 1C)
- PE + hemodynamic compromise: short-course thrombolytics (Grade 1B)
- Non-massive PE: we recommend against the use of thrombolytic therapy (Grade 1B)
Acute DVT or PE-Length of Therapy:
- DVT or PE Secondary to Transient (Reversible) Risk Factor: coumadin for 3 months over treatment for shorter periods (Grade 1A).
- Unprovoked DVT or PE: coumadin for at least 3 months (Grade 1A), and that all patients are then evaluated for the risks to benefits of indefinite therapy (Grade 1C).
- Indefinite anticoagulant therapy for patients with a first unprovoked proximal DVT or PE and a low risk of bleeding when this is consistent with the patient’s preference (Grade 1A), and for most patients with a second unprovoked DVT (Grade 1A).
Acute DVT or PE-Intensity of Anticoagulation:
- We recommend that the dose of coumadin be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations (Grade 1A).
Acute DVT or PE-DVT/PE and Cancer:
- We recommend at least 3 months of treatment with LMWH for patients with VTE and cancer (Grade 1A), followed by treatment with LMWH or coumadin as long as the cancer is active (Grade 1C). For prevention of postthrombotic syndrome (PTS) after proximal DVT, we recommend use of an elastic compression stocking (Grade 1A).
UE (Axillary/Subclavian) DVT:
- UE DVT: similar treatment as for DVT of the leg (Grade 1C)
- Selected patients with LE (Grade 2B) and UE (Grade 2C) DVT may be considered for thrombus removal, generally using catheter-based thrombolytic techniques.
Superficial Vein Thrombosis:
- For extensive superficial vein thrombosis, we recommend treatment with prophylactic or intermediate doses of LMWH or intermediate doses of UFH for 4 weeks (Grade 1B).