This chapter about treatment for venous thromboembolic disease is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see "Grades of Recommendation" chapter). Among the key recommendations in this chapter are the following: for patients with objectively confirmed
deep vein thrombosis (DVT) or
pulmonary embolism (PE), we recommend
anticoagulant therapy with subcutaneous (SC)
low-molecular-weight heparin (
LMWH), monitored IV, or SC
unfractionated heparin (UFH), unmonitored weight-based SC UFH, or SC
fondaparinux (all Grade 1A). For patients with a high clinical suspicion of DVT or PE, we recommend treatment with
anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C). For patients with confirmed PE, we recommend early evaluation of the risks to benefits of
thrombolytic therapy (Grade 1C); for those with hemodynamic compromise, we recommend short-course
thrombolytic therapy (Grade 1B); and for those with nonmassive PE, we recommend against the use of
thrombolytic therapy (Grade 1B). In acute DVT or PE, we recommend initial treatment with
LMWH, UFH or
fondaparinux for at least 5 days rather than a shorter period (Grade 1C); and initiation of
vitamin K antagonists (VKAs) together with
LMWH, UFH, or
fondaparinux on the first treatment day, and discontinuation of these
heparin preparations when the international normalized ratio (INR) is > or = 2.0 for at least 24 h (Grade 1A). For patients with DVT or PE secondary to a transient (reversible) risk factor, we recommend treatment with a VKA for 3 months over treatment for shorter periods (Grade 1A). For patients with unprovoked DVT or PE, we recommend treatment with a VKA for at least 3 months (Grade 1A), and that all patients are then evaluated for the risks to benefits of indefinite
therapy (Grade 1C). We recommend 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). We recommend that the dose of VKA be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations (Grade 1A). We recommend at least 3 months of treatment with
LMWH for patients with VTE and
cancer (Grade 1A), followed by treatment with
LMWH or VKA 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). For DVT of the upper extremity, we recommend similar treatment as for DVT of the leg (Grade 1C). Selected patients with lower-extremity (Grade 2B) and upper-extremity (Grade 2C). DVT may be considered for
thrombus removal, generally using
catheter-based thrombolytic techniques. 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).