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Review
October 16, 2018

Venous ThromboembolismAdvances in Diagnosis and Treatment

Author Affiliations
  • 1Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
  • 2Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
  • 3Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
  • 4Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
JAMA. 2018;320(15):1583-1594. doi:10.1001/jama.2018.14346
Key Points

Question  What advances in diagnosis and treatment of venous thromboembolism have occurred in the past 5 years?

Findings  Alternative approaches have been developed for improvement and simplification of currently recommended diagnostic algorithms and for assessment of specific subgroups. The introduction of direct oral anticoagulants has resulted in simplified treatment of venous thromboembolism with a lower risk of bleeding. Decisions on initiation and duration of therapy can now be more carefully implemented.

Meaning  Advances in diagnosis and treatment enabled more patient-specific management of venous thromboembolism.

Abstract

Importance  Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common and potentially fatal disease.

Objective  To summarize the advances in diagnosis and treatment of VTE of the past 5 years.

Evidence Review  A systematic search was conducted in EMBASE Classic, EMBASE, Ovid MEDLINE, and other nonindexed citations using broad terms for diagnosis and treatment of VTE to find systematic reviews and meta-analyses, randomized trials, and prospective cohort studies published between January 1, 2013, and July 31, 2018. The 10th edition of the American College of Chest Physicians Antithrombotic Therapy Guidelines was screened to identify additional studies. Screening of titles, abstracts, and, subsequently, full-text articles was performed in duplicate, as well as data extraction and risk-of-bias assessment of the included articles.

Findings  Thirty-two articles were included in this review. The application of an age-adjusted D-dimer threshold in patients with suspected PE has increased the number of patients in whom imaging can be withheld. The Pulmonary Embolism Rule-Out Criteria safely exclude PE when the pretest probability is low. The introduction of direct oral anticoagulants has allowed for a simplified treatment of VTE with a lower risk of bleeding regardless of etiology or extent of the VTE (except for massive PE) and has made extended secondary prevention more acceptable. Thrombolysis is best reserved for patients with massive PE or those with DVT and threatened limb loss. Insertion of inferior vena cava filters should be avoided unless anticoagulation is absolutely contraindicated in patients with recent acute VTE. Graduated compression stockings are no longer recommended to treat DVT but may be used when acute or chronic symptoms are present. Anticoagulation may no longer be indicated for patients with isolated distal DVT at low risk of recurrence.

Conclusions and Relevance  Over the past 5 years, substantial progress has been made in VTE management, allowing for diagnostic and therapeutic strategies tailored to individual patient characteristics, preferences, and values.

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