Venous thromboembolism ( VTE ), comprising deep vein thrombosis ( DVT ) and pulmonary embolism ( PE ), is a common, potentially lethal condition with acute morbidity.
Researchers have reviewed the etiology of venous thromboembolism and the 3 phases of venous thromboembolism treatment: acute ( first 5-10 days ), long-term ( from end of acute treatment to 3-6 months ), and extended ( beyond 3-6 months ).
Cochrane reviews, meta-analyses, and randomized controlled trials, as well as other clinical trials for topics not covered by the former, were reviewed. Literature searches using broad terms were used to find meta-analyses published in the last 15 years.
Low-molecular-weight Heparin ( LMWH ) along with vitamin K antagonists and the benefits and proven safety of ambulation have allowed for outpatient management of most cases of deep vein thrombosis in the acute phase.
Development of new oral anticoagulants further simplifies acute-phase treatment and 2 oral agents can be used as monotherapy, avoiding the need for LMWH.
Patients with pulmonary embolism can also be treated in the acute phase as outpatients, a decision dependent on prognosis and severity of pulmonary embolism.
Thrombolysis is best reserved for severe venous thromboembolism; inferior vena cava filters, ideally the retrievable variety, should be used when anticoagulation is contraindicated.
In general, DVT and PE patients require 3 months of treatment with anticoagulants, with options including LMWH, vitamin K antagonists, or direct factor Xa or direct factor IIa inhibitors.
After this time, decisions for further treatment are based on balancing the risk of VTE recurrence, determined by etiology of the venous thromboembolism ( transient risk factors, unprovoked or malignancy associated ), against the risk of major hemorrhage from treatment.
Better prediction tools for major hemorrhage are needed.
Experience with new oral anticoagulants as acute, long-term, and extended therapy options is limited as yet, but as a class they appear to be safe and effective for all phases of treatment.
The mainstay of venous thromboembolism treatment is anticoagulation, while interventions such as thrombolysis and inferior vena cava filters are reserved for limited circumstances.
Multiple therapeutic modes and options exist for venous thromboembolism treatment with small but nonetheless important differential effects to consider.
Anticoagulants will probably always increase bleeding risk, necessitating tailored treatment strategies that must incorporate etiology, risk, benefit, cost, and patient preference. ( Xagena )
Wells PS et al, JAMA 2014;311:717-728