Episode 6 – ACCP Antithrombotics and VTE Guidelines - a podcast by Scott D. Weingart, MD FCCM

From American College of Chest Physicians

Antithrombotic Therapy and Prevention of Thrombosis, 9th ed Guidelines



Chest 2012;141:7S-47S (Executive Summary)



For outpatient treatment, start 10 mg daily for the first 2 days followed by INR measurements



Give 1 day of LMWH or UFH before initiation, if treating VTE



If the patient is on VKAs, avoid NSAIDs and certain ABX (table 8 from full guidelines)







Avoid anti-plt agents unless clinical condition warrants



Normal goal is 2-3, including antiphospholipid



No need to taper when d/cing



Heparin – 80/18 for VTE, 70/15 for cardiac or stroke patients



For outpatients with VTE treated with SC UFH, they suggest weight-adjusted dosing (first dose 333 units/kg, then 250 units/kg) without monitoring rather than fixed or weight-adjusted dosing with monitoring

High INRs

4.5-10, no bleeding: no vitamin K necessary



> 10, no bleeding: Oral Vitamin K



If anticoagulant related major bleeding: 4-factor PCC and Vitamin K Slow IV Injection



See Michelle Lin’s Paucis Verbis on the same

Critically Ill Patients

Recommend against routine screening



Use LMWH or LDUH in all patients unless contra-indicated



For travelers at risk of VTE, use graded compression stockings; do not prescribe aspirin or anticoagulants

Diagnosis of DVT

Low Risk

moderate sens d-dimer, high sens d-dimer, or CUS of proximal veins only. D-dimers are preferred



If d-dimer is positive, get Compression Ultrasound (CUS) of proximal veins

Moderate Risk

Use High sens d-dimer, CUS of prox, or CUS of whole leg



Can stop if high-sens D-dimer is negative



If no d-dimer or d-dimer postive, need a second CUS 1 week later if only prox CUS done



If whole leg CUS is negative, you are done

High Risk

Prox CUS or Whole Leg CUS



If prox CUS and d-dimer negative as well, done



If d-dimer positive or only prox CUS, get 1 week f/u CUS



If whole leg CUS is negative, you are done

Recurrent

In patients with past DVT, recommend high-sens d-dimer, if positive get Prox CUS and 1 week Prox CUS



If negative, get just one Prox CUS



If the old CUS is not available, confirm with venography if positive CUS

Upper Ext

Go right to Doppler CUS for upper extremity dvt suspicion

Treatment of DVT

Start with IV or SQ UFH, LMWH, or fondaparinux (Latter two preferred)



If high pretest, start heparin immediately; If moderate, start heparin only if diagnostic tests are expected to be > 4 hours delayed



Isolated distal DVT-serial CUS rather than treatment unless severe symptoms or risk factors for extension (see full text)



Ambulate DVTs, no bed rest



In patients with hypotension (SBP) < 90 and PE, give systemic thrombolytics (through peripheral, rather than PA cath)

Atrial Fib

Chads 0 – nothing



Chads 1/2 – VKA/oral anti-coag; Dabi is preferred



If a-fib > 48 hours; give 3 weeks of VKA/dabi before cardioversion. Or get TEE with LMWH. Follow with 1 month of Vka/oral anti-coag



If a-fib < 48 hours; Start LMWH and then VKA for 4 weeks



If hemodynamically unstable, treat with anticoagulation ASAP preferably before cardioversion and then continue for 4 weeks



Treat a-flutter like a-fib for all of the above

Stroke

If hemorrhagic,

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