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New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism

Huyen A Tran, Harry Gibbs, Eileen Merriman, Jennifer L Curnow, Laura Young, Ashwini Bennett, Chee Wee Tan, Sanjeev D Chunilal, Chris M Ward, Ross Baker and Harshal Nandurkar
Med J Aust 2019; 210 (5): . || doi: 10.5694/mja2.50004
Published online: 11 February 2019
Correction(s) for this article: Erratum | Published online: 17 February 2020

Abstract

Introduction: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease and, globally, more than an estimated 10 million people have it yearly. It is a chronic and recurrent disease. The symptoms of VTE are non‐specific and the diagnosis should actively be sought once considered. The mainstay of VTE treatment is anticoagulation, with few patients requiring additional intervention.

A working group of experts in the area recently completed an evidence‐based guideline for the diagnosis and management of DVT and PE on behalf of the Thrombosis and Haemostasis Society of Australia and New Zealand (www.thanz.org.au/resources/thanz-guidelines).

Main recommendations:

  • The diagnosis of VTE should be established with imaging; it may be excluded by the use of clinical prediction rules combined with D‐dimer testing.
  • Proximal DVT or PE caused by a major surgery or trauma that is no longer present should be treated with anticoagulant therapy for 3 months.
  • Proximal DVT or PE that is unprovoked or associated with a transient risk factor (non‐surgical) should be treated with anticoagulant therapy for 3–6 months.
  • Proximal DVT or PE that is recurrent (two or more) and provoked by active cancer or antiphospholipid syndrome should receive extended anticoagulation.
  • Distal DVT caused by a major provoking factor that is no longer present should be treated with anticoagulant therapy for 6 weeks.
  • For patients continuing with extended anticoagulant therapy, either therapeutic or low dose direct oral anticoagulants can be prescribed and is preferred over warfarin in the absence of contraindications.
  • Routine thrombophilia testing is not indicated.
  • Thrombolysis or a suitable alternative is indicated for massive (haemodynamically unstable) PE.

 

Changes in management as a result of the guideline: Most patients with acute VTE should be treated with a factor Xa inhibitor and be assessed for extended anticoagulation.


  • 1 Alfred Health, Melbourne, VIC
  • 2 Monash University, Melbourne, VIC
  • 3 Waitemata District Health Board, Auckland, New Zealand
  • 4 Haemophilia Treatment Centre, Westmead Hospital, Sydney, NSW
  • 5 Auckland District Health Board, Auckland, New Zealand
  • 6 Monash Medical Centre, Melbourne, VIC
  • 7 Royal Adelaide Hospital, Adelaide, SA
  • 8 Monash Health, Melbourne, VIC
  • 9  Royal North Shore Hospital, Sydney, NSW
  • 10 Perth Blood Institute, Perth, WA
  • 11 Australian Centre of Blood Diseases, Melbourne, VIC


Correspondence: huyen.tran@monash.edu

Competing interests:

No relevant disclosures.

  • 1. Raskob GE, Angchaisuksiri P, Blanco AN, et al. Thrombosis: a major contributor to global disease burden. SeminThromb Hemost 2014; 40: 724–735.
  • 2. Ho WK, Hankey GJ, Eikelboom JW. The incidence of venous thromboembolism: a prospective, community‐based study in Perth, Western Australia. Med J Aust 2008; 189: 144–147. https://www.mja.com.au/journal/2008/189/3/incidence-venous-thromboembolism-prospective-community-based-study-perth-western
  • 3. Fletcher J, Baker R, Fisher C, et al. The burden of venous thromboembolism in Australia. Access Economics, 2008. https://www.safetyandquality.gov.au/wp-content/uploads/2018/10/Access-Economics_The-burden-of-VTE-in-Australia_2008.pdf (viewed Jan 2019).
  • 4. Connors JM. Thrombophilia Testing and Venous Thrombosis. N Engl J Med 2017; 377: 1177–1187.
  • 5. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline. Chest 2016; 149: 315–352.
  • 6. Kearon C, Ageno W, Cannegieter SC, et al. Categorization of patients as having provoked or unprovoked venous thromboembolism: guidance from the SSC of ISTH. J Thromb Haemost 2016; 14: 1480–1483.
  • 7. van Es N, Le Gal G, Otten HM, et al. Screening for occult cancer in patients with unprovoked venous thromboembolism: a systematic review and meta‐analysis of individual patient data. Ann Intern Med 2017; 167: 410–417.
  • 8. Mos IC, Klok FA, Kroft LJ, et al. Safety of ruling out acute pulmonary embolism by normal computed tomography pulmonary angiography in patients with an indication for computed tomography: systematic review and meta‐analysis. J Thromb Haemost 2009; 7: 1491–1498.
  • 9. Mitchell AM, Jones AE, Tumlin JA, Kline JA. Prospective study of the incidence of contrast‐induced nephropathy among patients evaluated for pulmonary embolism by contrast‐enhanced computed tomography. Acad Emerg Med 2012; 19: 618–625.
  • 10. Di Nisio M, van Es N, Buller HR. Deep vein thrombosis and pulmonary embolism. Lancet 2016; 388: 3060–3073.
  • 11. Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta‐analysis. Ann Intern Med 2003; 139: 893–900.
  • 12. Righini M, Robert‐Ebadi H, Le Gal G. Diagnosis of acute pulmonary embolism. J Thromb Haemost 2017; 15: 1251–1261.
  • 13. Wells P, Anderson D, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D‐dimer. Thromb Haemost 2000; 83: 416–420.
  • 14. Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004; 2: 1247–1255.
  • 15. Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA 2006; 295: 199–207.
  • 16. Freund Y, Cachanado M, Aubry A, et al. Effect of the Pulmonary Embolism Rule‐Out Criteria on Subsequent Thromboembolic Events Among Low‐Risk Emergency Department Patients: the PROPER randomized clinical trial. JAMA 2018; 319: 559–566.
  • 17. Righini M, Perrier A, De Moerloose P, Bounameaux H. D‐Dimer for venous thromboembolism diagnosis: 20 years later. J Thromb Haemost 2008; 6: 1059–1071.
  • 18. Bernardi E, Camporese G, Buller HR, et al. Serial 2‐point ultrasonography plus D‐dimer vs whole‐leg color‐coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial. JAMA 2008; 300: 1653–1659.
  • 19. Carrier M, Rodger MA, Wells PS, et al. Residual vein obstruction to predict the risk of recurrent venous thromboembolism in patients with deep vein thrombosis: a systematic review and meta‐analysis. J Thromb Haemost 2011; 9: 1119–1125.
  • 20. Sostman HD, Stein PD, Gottschalk A, et al. Acute pulmonary embolism: sensitivity and specificity of ventilation‐perfusion scintigraphy in PIOPED II study. Radiology 2008; 246: 941–946.
  • 21. Anderson DR, Kahn SR, Rodger MA, et al. Computed tomographic pulmonary angiography vs ventilation‐perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA 2007; 298: 2743–2753.
  • 22. Cahill AG, Stout MJ, Macones GA, Bhalla S. Diagnosing pulmonary embolism in pregnancy using computed‐tomographic angiography or ventilation–perfusion. Obstet Gynecol 2009; 114: 124–129.
  • 23. Palareti G, Schellong S. Isolated distal deep vein thrombosis: what we know and what we are doing. J Thromb Haemost 2012; 10: 11–19.
  • 24. Pengo V, Denas G, Zoppellaro G, et al. Rivaroxaban vs warfarin in high‐risk patients with antiphospholipid syndrome. Blood 2018; 132: 1365–1371.
  • 25. Young AM, Marshall A, Thirlwall J, et al. Comparison of an oral factor xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: results of a randomized trial (SELECT‐D). J Clin Oncol 2018; 36: 2017–2023.
  • 26. Raskob GE, van Es N, Verhamme P, et al. Edoxaban for the treatment of cancer‐associated venous thromboembolism. N Engl J Med 2018; 378: 615–624.
  • 27. Agnelli G, Prandoni P, Santamaria MG, et al. Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. Warfarin Optimal Duration Italian Trial Investigators. N Engl J Med 2001; 345: 165–169.
  • 28. Agnelli G, Buller HR, Cohen A, et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med 2013; 368: 699–710.
  • 29. Weitz JI, Lensing AWA, Prins MH, et al. Rivaroxaban or aspirin for extended treatment of venous thromboembolism. N Engl J Med 2017; 376: 1211–1222.
  • 30. Boutitie F, Pinede L, Schulman S, et al. Influence of preceding length of anticoagulant treatment and initial presentation of venous thromboembolism on risk of recurrence after stopping treatment: analysis of individual participants’ data from seven trials. BMJ 2011; 342: d3036.
  • 31. McRae S, Tran H, Schulman S, et al. Effect of patient's sex on risk of recurrent venous thromboembolism: a meta‐analysis. Lancet 2006; 368: 371–378.
  • 32. Coppens M, Reijnders JH, Middeldorp S, et al. Testing for inherited thrombophilia does not reduce the recurrence of venous thrombosis. J Thromb Haemost 2008; 6: 1474–1477.
  • 33. Segal JB, Brotman DJ, Necochea AJ, et al. Predictive value of factor V Leiden and prothrombin G20210A in adults with venous thromboembolism and in family members of those with a mutation: a systematic review. JAMA 2009; 301: 2472–2485.
  • 34. Ageno W, Mantovani LG, Haas S, et al. Safety and effectiveness of oral rivaroxaban versus standard anticoagulation for the treatment of symptomatic deep‐vein thrombosis (XALIA): an international, prospective, non‐interventional study. Lancet Haematol 2016; 3: e12–e21.
  • 35. Brighton TA, Eikelboom JW, Mann K, et al. Low‐dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med 2012; 367: 1979–1987.
  • 36. Barco S, Corti M, Trinchero A, et al. Survival and recurrent venous thromboembolism in patients with first proximal or isolated distal deep vein thrombosis and no pulmonary embolism. J Thromb Haemost 2017; 15: 1436–1442.
  • 37. Nieto JA, Bruscas MJ, Ruiz‐Ribo D, et al. Acute venous thromboembolism in patients with recent major bleeding. The influence of the site of bleeding and the time elapsed on outcome. J Thromb Haemost 2006; 4: 2367–2372.
  • 38. De Stefano V, Simioni P, Rossi E, et al. The risk of recurrent venous thromboembolism in patients with inherited deficiency of natural anticoagulants antithrombin, protein C and protein S. Haematologica 2006; 91: 695–698.
  • 39. Hoeper MM, Humbert M, Souza R, et al. A global view of pulmonary hypertension. Lancet Respir Med 2016; 4: 306–322.
  • 40. Prior DL, Adams H, Williams TJ. Update on pharmacotherapy for pulmonary hypertension. Med J Aust 2016; 205: 271–276. https://www.mja.com.au/journal/2016/205/6/update-pharmacotherapy-pulmonary-hypertension
  • 41. Jain A, Cifu AS. Prevention, diagnosis, and treatment of postthrombotic syndrome. JAMA 2016; 315: 1048–1049.
  • 42. Kahn SR, Comerota AJ, Cushman M, et al. The postthrombotic syndrome: evidence‐based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation 2014; 130: 1636–1661.
  • 43. Villalta S, Bagatella P, Piccioli A et al. Assessment of the validity and reproducibility of a clinical scale for the post‐thrombotic syndrome [abstract]. Haemostasis 1994; 24: 158a.
  • 44. Morling JR, Yeoh SE, Kolbach DN. Rutosides for treatment of post‐thrombotic syndrome. Cochrane Database Syst Rev 2015; (9): CD005625.
  • 45. Enden T, Haig Y, Klow NE, et al. Long‐term outcome after additional catheter‐directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet 2012; 379: 31–38.
  • 46. Vedantham S, Goldhaber SZ, Julian JA, et al. Pharmacomechanical catheter‐directed thrombolysis for deep‐vein thrombosis. N Engl J Med 2017; 377: 2240–2252.
  • 47. Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post‐thrombotic syndrome: a randomised placebo‐controlled trial. Lancet 2014; 383: 880–888.
  • 48. Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate‐risk pulmonary embolism. N Engl J Med 2014; 370: 1402–1411.
  • 49. Wan S, Quinlan DJ, Agnelli G, Eikelboom JW. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta‐analysis of the randomized controlled trials. Circulation 2004; 110: 744–749.
  • 50. Sharifi M, Bay C, Skrocki L, et al; “MOPETT” Investigators. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” trial). Am J Cardiol 2013; 111: 273–277.
  • 51. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep‐vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med 1998; 338: 409–415.

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