Pulmonary Embolism Severity Index may be used to help stratify risk Suggest care at home or early discharge for patients with low-risk PE who have adequate home support (grade 2B)Ĭriteria: clinically stable no recent bleeding, no advanced renal disease, no advanced hepatic disease, no thrombocytopenia (< 70 × 10 3 per μL ) adequate support at home and ability to adhere to regimen patient feels comfortable with home care no evidence of right ventricular dysfunction normal cardiac biomarkers Two studies have demonstrated a reduction in recurrence of VTE in patients with cancer treated with a direct oral anticoagulant (e.g., rivaroxaban, edoxaban ) compared with LMWH (e.g., dalteparin ) however, the studies also demonstrated an increased risk of bleeding, specifically in patients with esophageal or gastroesophageal cancer 4, 5ĬHEST guidelines have not been updated in response to these studies * Recommended for outpatient treatment of cancer-associated provoked or unprovoked VTE over direct oral anticoagulants (grade 2C) and vitamin K antagonists (grade 2B) Simplification of anticoagulation management: no need for frequent dosage adjustments or international normalized ratio monitoringĪndexanet alfa (Andexxa) is available to reverse apixaban (Eliquis) and rivaroxaban (Xarelto), and idarucizumab (Praxbind) is available to reverse dabigatran (Pradaxa) Recommended for outpatient treatment of non–cancer-associated provoked or unprovoked VTE over vitamin K antagonists (grade 2B) and LMWH (grade 2C) Suggest initiating aspirin to prevent future VTE in patients with an unprovoked DVT or PE who decide to stop anticoagulation (grade 2B)Īspirin should not be considered a substitute for anticoagulation but is suggested for patients who wish to stop therapy and not pursue lifelong anticoagulation following an unprovoked DVT or PE Low-molecular-weight heparin is recommended as the anticoagulant of choice in patients with cancer and venous thromboembolism however, direct oral anticoagulants may be appropriate in select situations. 20, 21Ĭonsensus guidelines and a two-dose validation study Vitamin K antagonists should be used for the prevention of stroke in patients with atrial fibrillation with moderate-to-severe mitral stenosis and a CHA 2DS 2-VASc score of 2 or higher in men and 3 or higher in women. 20Ĭonsensus guideline on the management of venous thromboembolism and atrial fibrillationīleeding risk assessment should be performed and any modifiable risk factors addressed during each visit. Idarucizumab has been effective for reversing the anticoagulant effects of dabigatran, and andexanet alfa has been effective for reversing the effects of rivaroxaban and apixaban.ĭirect oral anticoagulants should be used as first-line agents for the treatment of venous thromboembolism and the prevention of stroke in patients with nonvalvular atrial fibrillation and a CHA 2DS 2-VASc score of 2 or higher in men and 3 or higher in women. Major bleeding should be treated with vitamin K and 4-factor prothrombin complex concentrate for patients already being treated with a vitamin K antagonist. Validated bleeding risk assessments such as HAS-BLED should be performed at each visit and modifiable factors should be addressed. Low-molecular-weight heparin continues to be recommended as a first-line treatment for patients with venous thromboembolism and active cancer, although there is growing evidence of effectiveness for the use of direct oral anticoagulants in this patient population. The immediate effect of direct oral anticoagulants permits select patients at low risk to initiate treatment in the outpatient setting for venous thromboembolism, including pulmonary embolism. Vitamin K antagonists inhibit the production of vitamin K-related factors and require a minimum of five days overlap with parenteral anticoagulants, whereas direct oral anticoagulants directly inhibit factor II or factor Xa, providing more immediate anticoagulation. Vitamin K antagonists are recommended for patients with mechanical valves and valvular atrial fibrillation. Direct oral anticoagulants are first-line agents for eligible patients for treating venous thromboembolism and preventing stroke in those with nonvalvular atrial fibrillation. Anticoagulation therapy is recommended for preventing, treating, and reducing the recurrence of venous thromboembolism, and preventing stroke in persons with atrial fibrillation.
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