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Management of Venous Thromboembolism

A new evidence-based practice guideline from the American College of Physicians and the American Academy of Family Physicians

Based on a systematic review of the clinical evidence, the American College of Physicians and the American Academy of Family Physicians have developed a new practice guideline for the management of venous thromboembolism (VTE).

The guideline's recommendations are:

• Low-molecular-weight heparin (LMWH) should be used for inpatient treatment of deep- vein thrombosis (DVT); LMWH or unfractionated heparin may be used to treat pulmonary embolism.
  
• Outpatient treatment of VTE is appropriate for patients without prior VTE, thrombophilic conditions, or substantial comorbidity, but not in those who are pregnant or likely not to adhere to therapy.
  
• Compression stockings (over-the-counter or custom-fit) should be used starting within 1 month of proximal DVT and for at least 1 year.
  
• Although specific recommendations are not possible for VTE during pregnancy because evidence from clinical trials is lacking, warfarin should be avoided because of the risk for embryopathy and fetal bleeding.
  
• VTE caused by transient risk factors should be treated for 3 to 6 months, recurrent VTE for at least 12 months, and idiopathic VTE for up to 4 years.
  
• Long-term LMWH is effective, and may be more efficacious than warfarin, in patients with cancer or those whose INR is difficult to control.
  

Comment: Venous thromboembolism is an area in which we have the luxury of numerous clinical trials and systematic reviews; the ACP/AAFP guidelines are based on review of this evidence through mid-2006. However, many questions remain, particularly regarding duration of treatment.

— Richard Saitz MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine February 13, 2007

Citation(s):

Snow V et al. Management of venous thromboembolism: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2007 Feb 6; 146:204-10.

• Original article (Subscription may be required)
• Medline abstract (Free)

Segal JB et al. Management of venous thromboembolism: A systematic review for a practice guideline. Ann Intern Med 2007 Feb 6; 146:211-22.

• Original article (Subscription may be required)
• Medline abstract (Free)