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Venous ThromboembolismAdvances in Diagnosis and Treatment

Educational Objective
To review the clinical management of patients with venous thromboembolism.
1 Credit CME
Key Points

Question  What advances in diagnosis and treatment of venous thromboembolism have occurred in the past 5 years?

Findings  Alternative approaches have been developed for improvement and simplification of currently recommended diagnostic algorithms and for assessment of specific subgroups. The introduction of direct oral anticoagulants has resulted in simplified treatment of venous thromboembolism with a lower risk of bleeding. Decisions on initiation and duration of therapy can now be more carefully implemented.

Meaning  Advances in diagnosis and treatment enabled more patient-specific management of venous thromboembolism.

Abstract

Importance  Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common and potentially fatal disease.

Objective  To summarize the advances in diagnosis and treatment of VTE of the past 5 years.

Evidence Review  A systematic search was conducted in EMBASE Classic, EMBASE, Ovid MEDLINE, and other nonindexed citations using broad terms for diagnosis and treatment of VTE to find systematic reviews and meta-analyses, randomized trials, and prospective cohort studies published between January 1, 2013, and July 31, 2018. The 10th edition of the American College of Chest Physicians Antithrombotic Therapy Guidelines was screened to identify additional studies. Screening of titles, abstracts, and, subsequently, full-text articles was performed in duplicate, as well as data extraction and risk-of-bias assessment of the included articles.

Findings  Thirty-two articles were included in this review. The application of an age-adjusted D-dimer threshold in patients with suspected PE has increased the number of patients in whom imaging can be withheld. The Pulmonary Embolism Rule-Out Criteria safely exclude PE when the pretest probability is low. The introduction of direct oral anticoagulants has allowed for a simplified treatment of VTE with a lower risk of bleeding regardless of etiology or extent of the VTE (except for massive PE) and has made extended secondary prevention more acceptable. Thrombolysis is best reserved for patients with massive PE or those with DVT and threatened limb loss. Insertion of inferior vena cava filters should be avoided unless anticoagulation is absolutely contraindicated in patients with recent acute VTE. Graduated compression stockings are no longer recommended to treat DVT but may be used when acute or chronic symptoms are present. Anticoagulation may no longer be indicated for patients with isolated distal DVT at low risk of recurrence.

Conclusions and Relevance  Over the past 5 years, substantial progress has been made in VTE management, allowing for diagnostic and therapeutic strategies tailored to individual patient characteristics, preferences, and values.

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Article Information

Corresponding Author: Philip S. Wells, MD, FRCPC, MSc, The Ottawa Hospital, 501 Smyth Rd, PO Box 206, Ottawa, ON K1H 8L6, Canada (pwells@toh.ca).

Accepted for Publication: September 7, 2018.

Correction: This article was corrected on December 18, 2018, for incorrect information in a figure.

Author Contributions: Drs Tritschler and Kraaijpoel had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Tritschler and Kraaijpoel contributed equally to this work.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Tritschler, Kraaijpoel, Wells.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Kraaijpoel.

Supervision: Kraaijpoel, Le Gal.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Tritschler’s research is supported by a grant from the Swiss National Science Foundation (SNSF P2ZHP3_177999) and he has received travel and congress fees from Pfizer. Dr Le Gal holds an Early Researcher Award from the Province of Ontario, a “CP Has Heart” Cardiovascular Award from the Heart and Stroke Foundation of Ontario, and is the University of Ottawa Department of Medicine Chair on Diagnosis of Venous Thromboembolism. Dr Wells has received honoraria for advisory board meetings from Bayer Healthcare, Sanofi, and Daiichi Sankyo, and research funding from Bristol-Myers Squibb/Pfizer. No other disclosures were reported.

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