Recent advances in the number of available anticoagulants, in-diagnostic algorithms, and in-risk stratification and prognostication tools have rapidly transformed the care of venous thromboembolism (VTE) patients over the past several years. New developments include easier and safer treatment options, cost-effective diagnostic strategies and tools that help triage pulmonary embolism (PE) patients with “large clots” toward thrombolysis and “small clots” toward outpatient management without the need for prolonged hospitalization. Additionally, effective strategies for the prevention of long-term consequences of VTE, including recurrence and post-thrombotic syndrome, have become clearer. This Guide provides a quick overview of VTE to support clinicians in delivering high-value care to their patients.
In 1960, Barritt and Jordan performed the first randomized trial of anticoagulation in pulmonary embolism. Their dramatic results, which were extrapolated to patients with deep vein thrombosis, ushered in the era of anticoagulation treatment for acute VTE. For decades, inpatient care with unfractionated heparin infusion followed by a vitamin K antagonist (warfarin in the United States) was the standard of care. In the 1990s, low-molecular-weight heparin became available and back-to-back trials published in The New England Journal of Medicine in 1996 showed that acute VTE could be treated in the outpatient arena. Within the past several years, four direct oral anticoagulants have been approved for acute treatment of VTE — two of these can be given without the need for initial parenteral anticoagulation, allowing for oral-only treatment.
In concert with advances in anticoagulation treatment, the diagnosis of acute VTE has also advanced while the use of venography and pulmonary angiography has virtually disappeared from clinical practice. More recent advancements in diagnostic pathways recommend using a Bayesian approach and utilizing D-dimer testing in patients with low pretest probability, where VTE is ruled out with a negative D-dimer; thus forgoing the expense, radiation exposure (for PE) and unintended consequence of detecting trivial clots.
The validation of risk stratification tools and the use of biomarkers now allow more precise triage algorithms for patients with PE, assuring that care is performed in the correct environment, such as the intensive care unit, a general inpatient unit or at home. Thrombolysis has been shown to decrease mortality in high-risk patients with PE and its use in patients with DVT is being investigated to prevent post-thrombotic syndrome.
The recurrence rate of VTE is 5 to 10 percent per year in patients with unprovoked VTE. Although the decision to extend treatment of VTE past the initial three months usually falls to outpatient care providers, hospitalists are positioned to begin the discussion for indefinite anticoagulation in appropriate patients. The utility of clinical prediction rules, D-dimer testing and thrombophilia testing is important when transitioning patients out of the hospital.
This Implementation Guide varies from previous Society of Hospital Medicine (SHM) Guides because it does not specifically address quality improvement processes. Wonderful examples of how to build a process improvement team, perform a gap analysis, gain hospital leadership support, use quality improvement tools, develop care maps and measure process improvement can be found in other SHM Guides and at the SHM “Quality 101” project site (http://www.hospitalmedicine.org/Web/Quality_Innovation/Quality_101/Web/Quality___Innovation/Quality_101/Landing_Page.aspx?hkey=da9afa38-dedd-4250-bee9-dba1a4f6aea2).
This Implementation Guide is intended to be a quick-read resource for the busy hospitalist and the sections are relativelyshort by design, with key references to guide further reading if needed. The aim is to complement and not replacecomprehensive guidelines like the 10th edition update on Antithrombotic Therapy for VTE Disease https://www.ncbi.nlm.nih.gov/pubmed/?term=kearon+c+and+chest+and+2016 and expert guidance documents such as those published by the acforum.org.
This Implementation Guide is supported in part by an unrestricted grant from Janssen Pharmaceuticals, Inc.
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