Major bleeding appeared reduced with mechanical vs pharmacological prophylaxis, with a RR of 0.87 (95% CI, 0.25-3.08) and an ARR of 4 fewer per 1000 (95% CI, 21 fewer to 58 more per 1000) (very low certainty in the evidence). Question. This guideline covers diagnosing and managing venous thromboembolic diseases in adults. There were no published cost-effectiveness analyses, and no cost differences between fondaparinux and LMWH were assumed. The 3 RCTs reported the effects of DOAC vs LMWH on mortality, VTE-related mortality, PE, symptomatic DVT, and major bleeding. For patient with subsegmental PE and no DVT, the guideline suggests clinical surveillance over anticoagulation when the risk of VTE recurrence is low (Grade 2C). A relevant trial was published after the guideline panel finalized this recommendation and during revision of this manuscript.146  The study did not find that rivaroxaban was superior to placebo when given to medical patients at increased predicted VTE risk for 45 days after hospital discharge.146  This finding is consistent with the conclusions of the systematic review conducted for this recommendation. No quantitative estimates were available on the risk of falls, ischemia, and limb ulceration. If symptomatic DVT develops, the potential impact is high. Major bleeding is probably not increased with UFH or LMWH (RR, 1.01; 95% CI, 0.40-2.54), and absolute risk increase (ARI) was 7 more per 1000 (95% CI, 30 fewer to 76 more per 1000). Among these anticoagulants, the panel suggests using LMWH (low certainty in the evidence of effects ⊕⊕◯◯) or fondaparinux (very low certainty in the evidence of effects ⊕⊕◯◯) rather than UFH (conditional recommendation). The panel also suggested that pneumatic compression devices might reduce mobility and cause falls in patients who ambulate, although the panel did not review specific evidence for these outcomes, and some evidence suggests no increased risk of falls with pneumatic compression devices.139. None of the studies reported whether the symptomatic DVTs were proximal or distal; therefore, we estimated the absolute effect on proximal and distal DVT by applying results to a representative baseline risk. treatment with anticoagulation for at least 3 months over treatment of a shorter duration (Grade 1B), and we recommend treatment with anticoagulation for 3 months over treatment of a longer time-limited period (eg, 6, 12, or 24 months) (Grade 1B). 0000070774 00000 n 0000019023 00000 n In addition to synthesizing evidence systematically, the McMaster GRADE Centre supported the guideline-development process, including determining methods, preparing agendas and meeting materials, and facilitating panel discussions. The EtD framework is shown at https://dbep.gradepro.org/profile/01137182-5DA7-ADF7-B58C-BBAF33FD4DCD. Framing the question and deciding on important outcomes, Nadroparin for the prevention of venous thromboembolism in nonsurgical patients: a systematic review and meta-analysis, Heparin for the prevention of venous thromboembolism in acutely ill medical patients (excluding stroke and myocardial infarction), Prevention of deep venous thrombosis and pulmonary embolism following stroke: a systematic review of published articles, How complete is the evidence for thromboembolism prophylaxis in general medicine patients? In absolute and relative terms, LMWH compared with UFH appeared to have a moderate impact on mortality and VTE. The resulting ARR for symptomatic proximal DVT was 0 fewer per 1000 (95% CI, 0-1 fewer per 1000) for a baseline risk of 0.2%, and the ARR for symptomatic distal DVT was 2 fewer per 1000 (95% CI, 0-4 fewer per 1000) for a baseline risk of 0.6%. 0000057707 00000 n Remark: If a patient’s status changes to acute, other recommendations would apply. The certainty in these estimated effects was moderate owing to imprecision of the estimates when the small possible benefits are balanced against the harms. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. Preventing hospital-associated venous thromboembolism: a guide for effective quality improvement. Major bleeding did not appear to differ between LMWH and UFH (RR, 0.98; 95% CI, 0.76-1.27; RR, 1 fewer per 1000; 95% CI, 13 fewer to 14 more per 1000). Please note that the guidelines listed are Acrobat PDF files. This affected the degree of certainty that panel members had in making recommendations, so they made explicit assumptions about the meaning of the outcomes to patients through the use of marker states, rather than leaving them implicit. 0000046019 00000 n 0000006088 00000 n Other researchers participated to fulfill requirements of an academic degree or program. VTE prophylaxis was administered by provider choice from among several medications and with or without concomitant compression stockings.36, Overall VTE hazard ratio (HR), 32 (95% CI, 4.1-251), VTE HR with prophylaxis, 0.13 (95% CI, 0.04-0.4), Incidence of major or clinically relevant nonmajor bleeding with prophylaxis = 1.6% (95% CI, 0.5-4.6). National Institute for Health and Care Excellence. 0000004216 00000 n Two available studies assessed the risk of VTE in total joint arthroplasty patients, finding no association between preoperative or postoperative air travel and VTE risk.154,156  However, findings might be biased if travelers took precautions to reduce their risk of VTE, and studies might have been underpowered to detect associations. sion of DVT on serial imaging for two weeks.8,10,11 Evidence supports outpatient treatment of PE if the risk of nonadherence is low and the patient is clinically 0000063517 00000 n These patients may be referred to the KPWA Anticoagulation/Anemia Management Service (AMS). With regard to future research, the panel suggests: Studies of risk assessment tools for guidance on defining high-risk status for VTE and bleeding at discharge; Trials of pharmacological or nonpharmacological interventions in selected high-risk medical patients for VTE at discharge143 ; and. People without known VTE risk factors who place a high value on prevention of VTE may choose to use graduated compression stockings. 0000071057 00000 n These associations were no longer evident by 12 weeks after travel. We did not find any systematic reviews addressing the questions and, thus, conducted a new systematic review. The panel assumed no impact on health equity and that the use of fondaparinux was acceptable and probably feasible. ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. Mechanical vs pharmacological prophylaxis, 8. Catheter-related DVT. In 2014, in response to long-standing member interest, ASH initiated an effort to develop evidence-based clinical practice guidelines for hematology that meet the highest standards of development, rigor and trustworthiness. Congenital or acquired thrombophilic condition (eg, factor V Leiden, lupus anticoagulant, protein C, or protein S deficiency). Graduated compression stockings were considered to not be cost-effective, to be acceptable to some but not to other stakeholders, and probably feasible. We identified 1 systematic review that provided evidence to address this question.145  Our update of the systematic review identified 1 additional study.42  All studies included acutely and critically ill medical patients. Overall, the certainty in these estimated effects is very low owing to very serious indirectness and serious risk of bias for the estimates (see evidence profile in the online EtD framework). VTE in hospitalized and nonhospitalized medical patients and long-distance travelers confers an important disease burden and can be fatal. For each guideline question, the McMaster GRADE Centre prepared a GRADE Evidence-to-Decision (EtD) framework, using the GRADEpro Guideline Development Tool (https://gradepro.org).12,13,18  The EtD table summarized the results of systematic reviews of the literature that were updated or performed for these guidelines. For patients with acute DVT, the guideline recommends against the use of compression stockings routinely to prevent the post-thrombotic syndrome (Grade 2B). The panel assumed that avoidance of death, PE, and DVT was critical or important for decision making to patients. They recommended against the use of aspirin or anticoagulants. The guideline panel determined that there is very low certainty in the evidence that there are net desirable consequences from pharmacological prophylaxis compared with mechanical prophylaxis in acutely or critically ill medical patients. Formal decision aids are not likely to be needed to help individual patients make decisions consistent with their values and preferences. dvt treatment guidelines 2018 pdfhow to dvt treatment guidelines 2018 pdf for This organization has completed the National Health Council’s Standards of Excellence Certification Program and meets the highest standards of accountability, ethical practice, organizational effectiveness, and … The ACCP guidelines were most similar to the ASH guideline in scope and methods. With a baseline risk of 0.5% for proximal DVT, this translated to an ARR of 1 fewer per 1000 (95% CI, 1 fewer to 2 more per 1000). The same RR was used for distal DVT, resulting in an ARR of 0 fewer per 1000 (95% CI, 1 fewer to 20 more per 1000) for a low-risk population and 0 fewer per 1000 (95% CI, 4 fewer to 61 more per 1000) for a high-risk population. On occasion, a strong recommendation is based on low or very low certainty in the evidence. A case-control study did not show a higher risk for VTE with air travel or long-duration travel by car, bus, or train among patients with prior VTE compared with those without prior VTE.160  This lack of increased risk was not explained by preventive measures taken during travel, because these were equally distributed between cases and controls. DVT AND PE ANTICOAGULATION MANAGEMENT thromboembolism (VTE) in patients with acute deep vein thrombosis (DVT) and/or CHEST guidelines support the use of the PE severity index (PESI) to identify These guidelines were issued in 2013 and will be reviewed in 2017 or sooner if new evidence To provide guidance in preventing venous thromboembolism. 1: Introduction, Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches The GRADE Working Group, GRADE guidelines: 1. 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