Antithrombotic Therapy for VTE:

CHEST Guidelines 2016

Jennifer Mah, MD
March 2016

Case
A 44-year-old man is evaluated in follow-up for an episode of
unprovoked left proximal leg deep venous thrombosis 3 months
ago. Following initial anticoagulation with low-molecular-weight
heparin, he began treatment with warfarin. INR testing done every
3 to 4 weeks has shown a stable therapeutic INR. He has mild left
leg discomfort after a long day of standing, but it does not limit his
activity level. He tolerates warfarin well. Family history is
unremarkable, and he takes no other medications.
Which of the following is the most appropriate management?
A. Continue anticoagulation indefinitely
B. Discontinue warfarin in another 3 months
C. Discontinue warfarin now
D. Discontinue warfarin and perform thrombophilia testing

Objectives

Recognize subgroups of VTE

Review medications for VTE anticoagulation
Learn guidelines for duration of therapy
Understand differences in therapy based on type
of VTE

Subgroups of VTE

Cancer-associated vs No cancer
Provoked vs Unprovoked
Proximal vs Distal DVT
Upper extremity vs Lower extremity DVT

VTE and No Cancer

Use NOAC preferred! (Grade 2B)
Rivaroxaban, apixaban
No bridging needed

Dabigatran, edoxaban
Start with parenteral anticoagulation x5 days

If contraindications to NOAC, then use VKA

therapy (warfarin) (Grade 2C)
Overlap with parenteral anticoagulation x5 days,
And INR >2 for 24 hours

Contraindications to NOACs
Extreme BMI (>40)
CrCl <30
Significant increased risk of bleeding

Cancer-Associated Thrombosis
Use LMWH (Grade 2C)
Enoxaparin 1 mg/kg/dose BID

Provoking Transient Risk Factors

for VTE

Surgery
Estrogen therapy
Pregnancy
Leg injury
Flight >8h

Location of VTE
Lower extremity DVT
Proximal Popliteal or more proximal veins
Distal Calf veins

Upper extremity DVT

Proximal Axillary or more proximal veins
Catheter-associated

Upper
Proximal
Isolated
Provoked
Severe
Extended
extremity
Distal
DVT
3
High
Serial
symptoms
or
DVT
months
therapy
DVT
PE
bleeding
imaging
Extended
3
Extending
months
risk
therapy
thrombus
for extension
Cancer-associated
Unprovoked
Mild
Anticoagulate
symptoms
Low
Mod
Anticoagulate
bleeding
bleeding
oror
high
Anticoagulate
risk
risk
bleeding
risk

Duration of Therapy

Proximal
Catheter-associated
Anticoagulate
Catheter
Catheter
Remove
Leave
functional?
and
still
catheter
needed?
in and anticoagulate
Special
Considerations
for

Yes

No

No

Yes

Risk Factors for Bleeding on Anticoagulant

Therapy

Age >65
Age >75
Previous bleeding
Cancer
Metastatic cancer
Renal failure
Liver failure
Thrombocytopenia
Previous stroke
Diabetes
Anemia
Antiplatelet therapy
Poor anticoagulant control
Comorbidity and reduced functional capacity
Recent surgery
Frequent falls
Alcohol abuse
NSAID use

Low risk

0 risk factors

Moderate risk

1 risk factor

High risk

2 risk factors

Risk Factors for Extension of

Distal DVT
Positive D-dimer
Extensive thrombus
>5cm long, involves multiple veins, >7mm
diameter

Thrombus close to proximal veins

No reversible provoking factor
Active cancer
History of VTE
Inpatient status

What if my patient stops anticoagulation?

Aspirin is NOT a reasonable alternative to
anticoagulation for extended therapy
Much less effective at preventing recurrent VTE

However, aspirin is better than nothing (Grade 2B)

Recurrent DVT on Anticoagulation

If on therapeutic warfarin or NOAC, then switch
to enoxaparin temporarily (minimum 1 month)
(Grade 2C)

Is this really recurrent VTE?

Is my patient compliant with therapy?
Is there underlying malignancy?

If on enoxaparin and compliant, then increase

the dose by 25-33% (Grade 2C)

Case Revisited
A 44-year-old man is evaluated in follow-up for an episode of
unprovoked left proximal leg deep venous thrombosis 3 months ago.
Following initial anticoagulation with low-molecular-weight heparin,
he began treatment with warfarin. INR testing done every 3 to 4 weeks
has shown a stable therapeutic INR. He has mild left leg discomfort
after a long day of standing, but it does not limit his activity level. He
tolerates warfarin well. Family history is unremarkable, and he takes
no other medications.
Which of the following is the most appropriate management?
A. Continue anticoagulation indefinitely
B. Discontinue warfarin in another 3 months
C. Discontinue warfarin now
D. Discontinue warfarin and perform thrombophilia testing

Upper
Isolated
Provoked
Mild
Extended
Anticoagulate
extremity
Distal
symptoms
3
Serial
Anticoagulate
DVT
months
therapy
DVT
imaging
Extended
3
months
oror
high
Anticoagulate
x2therapy
bleeding
weeks
risk
Proximal
Cancer-associated
Unprovoked
Severe
DVT
Low
High
symptoms
or
PE
to
bleeding
Extending
moderate
risk
risk
bleeding
thrombus
for extension
risk

Duration of Therapy

Case Revisited
A 44-year-old man is evaluated in follow-up for an episode of
unprovoked left proximal leg deep venous thrombosis 3 months ago.
Following initial anticoagulation with low-molecular-weight heparin,
he began treatment with warfarin. INR testing done every 3 to 4 weeks
has shown a stable therapeutic INR. He has mild left leg discomfort
after a long day of standing, but it does not limit his activity level. He
tolerates warfarin well. Family history is unremarkable, and he takes
no other medications.
Which of the following is the most appropriate management?
A. Continue anticoagulation indefinitely
B. Discontinue warfarin in another 3 months
C. Discontinue warfarin now
D. Discontinue warfarin and perform thrombophilia testing

Summary
NOACs are preferred over warfarin for
anticoagulation
Except if VTE is cancer-associated, then use
enoxaparin
Duration of therapy is usually 3 months, with
extended therapy based on risk factors for
recurrent VTE

References
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.
doi:10.1016/j.chest.2015.11.026.
MKSAP 17