The American Society of Hematology (ASH) in 2020 has given recommendations for the management of DVT/PE as per the time frame of diagnosis. Dr. Monish Raut covers initial management of venous thromboembolism in the first part of this series.

Incidence of venous thromboembolism including deep vein thrombosis (DVT) and pulmonary embolism (PE) is 1 to 2 individuals per 1000 each year. Proper, timely management of the condition can prevent dreadful complications.

Time frame of decisions

The first 5 to 21 days after the diagnosis of a new VTE determines the initial management. Primary treatment is the minimal duration of anticoagulant treatment for the VTE for 3 to 6 months. The next phase is decided based on whether anticoagulation should be stopped or continued for secondary prevention of recurrent VTE.

Practical management of venous thromboembolism- Initial management

1. The American Society of Hematology (ASH) guideline panel recommends providing home care over hospital treatment for patients with uncomplicated deep vein thrombosis and with low risk of complications. Primary care in the hospital can help patients with limb threatening DVT or high risk of bleeding, having sub-massive/massive pulmonary embolism and those needing IV painkillers. Clinical prediction scores such as The Pulmonary Embolism Severity Index (PESI) and simplified PESI can help in identifying patients at low risk of complications.
2. The advisory panel recommends the use of direct oral anticoagulants (DOACs) over antagonists of vitamin K (VKAs) in patients with DVT and/or PE except in renal dysfunction (CrCL <30 mL/min), moderate to severe liver dysfunction, or antiphospholipid syndrome.
3. The guideline does not give preference to any particular DOAC over another in patients with DVT and/or PE. Many factors can significantly affect the choice of specific DOACs such as cost, need for parenteral anticoagulation, daily dosing, renal function, presence of cancer, concomitant drugs.
4. The recommendation panel recommends anticoagulation treatment alone over thrombolytic therapy with anticoagulation in most patients with proximal DVT. Thrombolysis can be considered for patients with limb threatening DVT (phlegmasia cerulea dolens) and for selected, younger patients with symptomatic DVT involving the iliac and common femoral veins but having less chances of bleeding.
5. The guideline panel strongly prefers thrombolytic therapy followed by anticoagulation to anticoagulation alone in patients with pulmonary embolism with haemodynamic instability.
6. ASH recommends anticoagulation alone over the routine use of thrombolysis in addition to anticoagulation in patients with pulmonary embolism on echocardiography and RV dysfunction without haemodynamic instability. Selected younger patients with sub-massive PE having low risk for bleeding and patients with concomitant cardiopulmonary disease prone to decompensation can be considered for thrombolysis.
7. Catheter-directed thrombolysis over systemic thrombolysis can be suggested in patients with extensive DVT in whom thrombolysis is considered appropriate. This method can potentially outweigh the bleeding risks related to systemic thrombolysis especially in centres with appropriate infrastructure, clinical staff, and procedural experience.
8. Anticoagulation alone can be suggested rather than anticoagulation plus insertion of an inferior vena cava (IVC) filter in patients with proximal DVT and significant pre-existing cardiopulmonary disease, and also for patients with PE and haemodynamic compromise. IVC filter may be indicated in patients with contraindication to anticoagulation.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Monish S Raut is a Consultant in Cardiothoracic Vascular Anaesthesiology. His area of expertise is perioperative management and echocardiography with numerous publications in various national and international indexed journals.