Importantly, these recommendations are not intended to apply to patients with VTE who have a contraindication to anticoagulant therapy, in whom placement of an IVC filter may be an important alternative. The EtD framework is shown online at: https://guidelines.gradepro.org/profile/A269DB76-A3AE-4994-A718-6F1E493D0A75. They completed disclosure-of interest-forms, which were reviewed by ASH and are available as Supplements 2 and 3. The certainties of the evidence were judged moderate because of imprecision. For patients with a contraindication to anticoagulation, insertion of a retrievable IVC filter may be indicated with retrieval as soon as the patient is able to receive anticoagulation. DVT. In health systems with poor primary care, home treatment may reduce equity. Our analysis showed a potential increase in mortality when using a longer course of anticoagulation than with a shorter course of anticoagulation, without statistical significance (RR, 1.38; 95% CI, 0.85-2.23; ARR, 7 more per 1000 patients; 95% CI, 3 fewer to 22 more; moderate-certainty evidence). Well-designed prospective studies that confirm the safety and efficacy of home treatment for selected patients with PE would be helpful, but the barriers listed above would need to be addressed prior to more widespread adoption of this recommendation. After completion of primary treatment for patients with unprovoked DVT and/or PE, the ASH guideline panel suggests indefinite antithrombotic therapy over stopping anticoagulation (conditional recommendation based on moderate certainty in the evidence of effects ⨁⨁⨁○). The EtD framework is shown online at: https://guidelines.gradepro.org/profile/64AF970C-9665-2F07-BFD3-EB4E658C5706. When using a DOAC for a longer course of anticoagulation, the risk of DVT was reduced in the study population (RR, 0.21; 95% CI, 0.11-0.41; ARR, 62 fewer per 1000 patients; 95% CI, 70 fewer to 46 fewer; high-certainty evidence), as well as in a low-risk population268  (ARR, 32 fewer per 1000 patients; 95% CI, 36 fewer to 24 fewer; moderate-certainty evidence). Other acquired variables that confer a very weak risk for recurrence (OR < 2), such as obesity, varicose veins, or laparoscopic surgery, are not considered significant risk factors individually, but they may have an additive effect when combined with other risk factors listed above. When using DOACs for indefinite anticoagulation, the risk of DVT in the study population was reduced (RR, 0.15; 95% CI, 0.10-0.23; ARR, 49 fewer per 1000 patients; 95% CI, 51 fewer to 44 fewer; high-certainty evidence), as well as for patients with chronic risk factors (ARR, 45 fewer per 1000 patients; 95% CI, 48 fewer to 41 fewer; high-certainty evidence).269,274  When using a VKA or LMWH for indefinite anticoagulation, a reduction in the risk of DVT for the study population was observed (RR, 0.17; 95% CI, 0.05-0.53; ARR, 54 fewer per 1000 patients; 95% CI, 61 fewer to 30 fewer), as well as for patients with chronic risk factors269,274  (ARR, 44 fewer per 1000 patients; 95% CI, 51 fewer to 25 fewer; high-certainty evidence). Four Markov model analyses of cost-effectiveness for extended antithrombotic therapy vs limited antithrombotic therapy for VTE treatment were identified. The certainty in the evidence was judged high for PE, DVT, and major bleeding but moderate for mortality because of imprecision given that the CI around the absolute estimates crossed thresholds that patients would likely consider important. PTS may develop in up to 30% to 50% of patients following the development of a proximal DVT,149,150  and this may be severe in 5% to 10% of patients.3,150  Thrombolytic therapy has been shown to result in a more rapid and complete lysis of thrombus than anticoagulant therapy alone, but relatively few studies have linked radiographic improvements to clinical outcomes. [Guideline] Ortel TL, Neumann I, Ageno W, et al. Finally, the certainty in the evidence for major bleeding was judged as high. Therefore, it was not possible to completely rule out a small difference between the alternatives on mortality. The analysis suggested that an unlimited duration of standard-intensity anticoagulation was always more cost-effective. In 4 trials,214-217  thrombolysis was catheter directed, whereas in 1,142  it was locoregionally infused. Second, the pooled CIs included the null, as well as appreciable benefit and harm. A longer course of anticoagulation also showed a potential reduction in the risk of PE in the study population, without statistical significance (RR, 0.66; 95% CI, 0.29-1.51; ARR, 17 fewer per 1000 patients; 95% CI, 35 fewer to 25 more; moderate-certainty evidence), and likely a small reduction in a low-risk population268  (ARR, 11 fewer per 1000 patients; 95% CI, 24 fewer to 17 more; moderate-certainty evidence). These patients need to undergo decisions about initial management (Recommendations 1 to 11) and primary treatment (Recommendations 12 to 14), just as with their initial event. BACKGROUND: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000 each year, corresponding to ∼300 000 to 600 000 events in the United States annually. Remarks: Although the majority of patients may not benefit from the use of stockings to reduce the risk of PTS, stockings may help to reduce edema and pain associated with acute DVT in selected patients. Different types of burdens are associated with both interventions. The use of a lower-dose DOAC compared with a standard-dose DOAC was associated with a nonsignificant increase in the risk of nonfatal PE (RR, 1.25; 95% CI, 0.54-2.91; ARR, 1 more per 1000 patients; 95% CI, 2 fewer to 10 more; moderate-certainty evidence). Remarks: Thrombolysis is reasonable to consider for younger patients with submassive PE at low risk for bleeding. These patients may have ≥1 nonenvironmental risk factor for recurrent VTE, such as inherited thrombophilia, older age, and/or male sex, but these variables would not affect this recommendation concerning the duration of the primary treatment phase for the thromboembolic event. The Botticelli DVT dose-ranging study, Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism, Einstein-DVT Dose-Ranging Study Investigators, A dose-ranging study evaluating once-daily oral administration of the factor Xa inhibitor rivaroxaban in the treatment of patients with acute symptomatic deep vein thrombosis: the Einstein-DVT Dose-Ranging Study, Oral rivaroxaban for the treatment of symptomatic pulmonary embolism, Apixaban for the treatment of Japanese subjects with acute venous thromboembolism (AMPLIFY-J Study). Recommendations 12 to 14 address the duration of the primary treatment phase of therapy. Remarks: A critical review of the indication for aspirin therapy is needed at the time anticoagulant therapy is initiated, considering the increased risk of bleeding vs the potential benefit in terms of cardiovascular prevention. Patients were randomized to receive placebo or continue treatment for ≥6 months. Also, catheter-directed thrombolysis is an expensive procedure, and its implementation would probably result in an increment of direct costs. The certainty in the evidence was judged low for all of the relevant outcomes. Three analyses showed that the longer course was cost-effective compared with the shorter course of antithrombotic therapy,112,270,271  whereas 1 analysis suggested that a longer course of anticoagulation with warfarin was cost-effective in younger patients and 3 months of anticoagulation was preferred in elderly patients (80-year-old subgroup).272, The panel considered that a longer course of treatment was probably acceptable and feasible. The certainty in the evidence was judged low for mortality because of the reasons mentioned above, as well as the large unexplained heterogeneity. DVT has an annual incidence of about 1–2 per 1000 people. In this study, participants were randomized to stop anticoagulation or to continue it for up to 18 months. For patients with PE with echocardiography and/or biomarkers compatible with right ventricular dysfunction but without hemodynamic compromise (submassive PE), the ASH guideline panel suggests anticoagulation alone over the routine use of thrombolysis in addition to anticoagulation (conditional recommendation based on low certainty in the evidence of effects ⨁⨁○○). We did find studies evaluating the prognostic performance of the different tools: an individual patient meta-analysis of observational studies and 1 RCT (n = 2527)300  showed an independent association of residual vein thrombosis and recurrent VTE (HR, 1.32; 95% CI, 1.06-1.65). This document may also serve as the basis for adaptation by local, regional, or national guideline panels. afford medications, or have a history of poor adherence. For the baseline risk of major bleeding, we used data from 2 randomized trials on people with VTE, showing that the risk of major bleeding with placebo during 18 or 24 months of follow-up was as low as 0.5%306  and as high as 1.5% in 18 months.259  The EtD framework is shown online at: https://guidelines.gradepro.org/profile/86361A15-ECB8-E636-8A66-7B5713A17FEB. The EtD framework is shown online at: https://guidelines.gradepro.org/profile/073BA619-F572-CFBA-9A07-8DC73ADB05FD. These guidelines may not include all appropriate methods of care for the clinical scenarios described. Active cancer is addressed in a future guideline document from ASH and is not considered in this article. Interpretation of strong and conditional recommendations. We considered that avoidance of PE, DVT, and major bleeding was critical for patients. Remarks: Indefinite anticoagulation is probably appropriate for the majority of patients with unprovoked VTE. Phase 1 results: a cooperative study, Tissue plasminogen activator for the treatment of acute pulmonary embolism. Remarks: This recommendation does not apply to patients who have a high risk for bleeding complications. Patients with limb-threatening DVT or a high risk for bleeding and those requiring IV analgesics may benefit from initial treatment in the hospital. Patients placed a high value on the benefits of risk reduction in VTE recurrence and PTS.311  However, there is important variability in how individual patients may value the risk of recurrent VTE vs the risk of bleeding. as well as for patients with PE and hemodynamic compromise, anticoagulation alone Review at 3 to 6 months according to clinical need. The certainty in the evidence was judged as low for mortality, PE, and DVT because of risk of bias (none of the included trials were blinded) and imprecision (CI around the absolute estimates likely crossed the thresholds that patients would consider important). Plasminogen activator Italian multicenter study 2, Streptokinase and heparin in the treatment of pulmonary embolism: a randomized comparison, Six-month echocardiographic study in patients with submassive pulmonary embolism and right ventricle dysfunction: comparison of thrombolysis with heparin, Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion, Urokinase pulmonary embolism trial. The panel estimated that the cost of a DOAC does not vary significantly with the dose. Lastly, and most importantly, an infrastructure to provide outpatient PE treatment needs to be established to ensure that patients can be followed closely. For primary treatment of the thromboembolic event, the ASH guideline panel has provided a conditional recommendation for a shorter course (3-6 months) of therapeutic anticoagulation over a longer course (6-12 months) of therapy, based on moderate certainty in the evidence of effects. An evaluation of the conditions and criteria (and the related judgments, research evidence, and additional considerations) that determined the conditional (rather than strong) recommendation will help to identify possible research gaps. The guideline does not cover pregnant women. Development of these guidelines was wholly funded by ASH, a nonprofit medical specialty society that represents hematologists. A high risk for bleeding or requiring IV analgesics may benefit from the original analysis this trial included 400 with... Phase reduces the risk of thrombosis vs the risk of thrombosis vs the risk bleeding. 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