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Friday, January 15, 2016

New ACCP guidelines on VTE-stockings out, NOACs solidly in -outpatient treatment of pulmonary emboli for some patients

The American College of Chest Physicians (ACCP) has issued its tenth set of recommendations regarding venous thrombo embolic disease (VTE) .See full  free text.

Noteworthy is the solid recommendation for the New (or novel) oral anticoagulants (NOACs) over the old favorite Warfarin which was the oral anticoagulant of choice (the only one in the U.S.)) for over fifty years.NOACs were first approved by the FDA for treatment of non-valvular atrial fibrillation and more recently for DVTs and PEs.

Recommendation wise the four NOACs currently approved are not created equal. Rivaroxaban and Apixaban can be used without pre treatment with a parenteral anticoagulant,typically low molecular weight heparin,  while dabigaran and endoxaban cannot.

The ACCP panel lead by Clive Kearon of McMaster University rescinded their earlier recommendation for the use of compression stocking to prevent the post thrombotic syndrome.

The outpatient treatment of some patients with PE is a game changer or sea change  or whatever the current cliche of choice is  for major changes in medical practice.Prior to the NOACs the standard of care was several days in the hospital overlapping  with heparin until the patient was safely anticoagulated with a reasonably stable INR . Now  patients who are hemodynamically stable with a suitable home environment can be either discharged after a brief time in the hospital or sent home from  the ER on either rivaroxaban or apicaban with a double dose for the first week.

The distinction between provoked and  unproved continues to be emphasized. With provoked DVT or PE three months seems to be the standard of care , while for unprovoked- reassessment at the end of three months is recommended at which time  the nebulous balancing of bleeding and clots risk is somehow determined.

The problem of  pulmonary emboli in the subsegmental pulmonary arteries is addressed without a clear cut definite recommendation being made .Watch and wait with follow up testing or treat-for patients with a subsegmental embolus and a negative leg vein study.

Subsegmental emboli are often asymptomatic and also are CT angiogram are more likely to be false positive and subject to varying readings when the study is interpreted by more than one radiologist

The argument of 3 months versus six months of anticoagulation has morphed into three months versus extended anticoagulation.

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