-
Antiphospholipid syndrome Tx recommendations1,2 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended, but re-evaluate periodically
Other considerations2 - EULAR recommends considering INR 3.0-4.0 in pts w/ APS after 1st arterial thrombosis.
- If recurrent arterial or venous thrombosis in setting of VKA w/ INR 2.0-3.0, consider adding LDA, increasing INR target to 3.0-4.0, or switching to LMWH.
Footnotes 1 CHEST 2021. Stevens SM, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160(6):e545-e608. Free, full-text PDF
2 EULAR 2019. Tektonidou MG, et al. EULAR recommendations for the management of antiphospholipid syndrome in adults. Ann Rheum Dis. 2019 Oct;78(10):1296-1304. Free, full-text PDF
Other hereditary & acquired thrombophilias Tx recommendations1-4 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended, but re-evaluate periodically
Other considerations - Tx not indicated in absence of clot.1
- Consider extended tx after 1st clot in pts w/ antithrombin, protein C, or protein S deficiency; ↑basal Factor VIII activity; substantial hyperhomocysteinemia; combined heterozygosity for >1 hereditary thrombophilia (e.g., heterozygous for the factor V Leiden and prothrombin G20210A mutations, etc.); homozygosity for hereditary thrombophilia.2
- Risk of recurrence among isolated heterozygous carriers for either the factor V Leiden or prothrombin G20201A mutations is relatively low and insufficient to warrant secondary prophylaxis after 1st clot in absence of other independent predictors of recurrence. VTE FHx is not a predictor of ↑risk for VTE recurrence.2
- Offer extended anticoagulation to select pts w/ active CA (e.g., those w/ metastatic dz or receiving chemo-tx). Assess anticoagulation beyond 6mo on an intermittent basis to ensure continued favorable risk-benefit profile.5 ACCP recommends offering extended tx to pts w/ CA-assoc DVT/PE but reevaluating at least q1y or if significant change in health status.4,6 Extended anticoagulation may be discontinued when pt no longer at ↑risk of recurrent VTEs or enters last wks of life.7
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 Heit JA. Thrombophilia: common questions on laboratory assessment and management. Hematology Am Soc Hematol Educ Program. 2007:127-35. PubMed® abstract
3 ASH 2020. Ortel TL, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020 Oct 13;4(19):4693-4738. Free, full-text PDF at PubMed® Central
4 CHEST 2021. Stevens SM, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160(6):e545-e608. Free, full-text PDF
5 ASCO 2023. Key NS, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update. J Clin Oncol. 2023 Jun 1;41(16):3063-3071. Free, full-text article
6 CHEST 2016. Kearon C, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-352. Free, full-text PDF
7 ASH 2021. Lyman GH, et al. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv. 2021 Feb 23;5(4):927-974. Free, full-text PDF at PubMed® Central
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No mod-severe mitral stenosis, mechanical valve, CM, CAD, CVA/TIA, or impending cardioversion CHA2DS2-VASc = 0 in men/1 in women Tx recommendations1 - Target INR: n/a
- Range: n/a
- Duration: n/a
Footnotes 1 AHA/ACC/HRS 2019. January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Jul 9;74(1):104-132. Free, full-text article
CHA2DS2-VASc = 1 in men/2 in women Tx recommendations1 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended
Other considerations1 - Anticoagulation can be considered in pts w/ this level of risk.
- Individualize on the basis of shared decision-making.
- Re-eval of need and choice of anticoagulant, as well as stroke and bleeding risk, recommended at periodic intervals.
Footnotes 1 AHA/ACC/HRS 2019. January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Jul 9;74(1):104-132. Free, full-text article
CHA2DS2-VASc ≥2 in men/3 in women Tx recommendations1 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended
Other considerations1 - Re-eval of need and choice of anticoagulant, as well as stroke and bleeding risk, recommended at periodic intervals.
Footnotes 1 AHA/ACC/HRS 2019. January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Jul 9;74(1):104-132. Free, full-text article
w/ mitral stenosis or other valve dz Tx recommendations1-3 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended
Other considerations1-3 - Pts w/ native valvular heart dz (excluding rheumatic mitral stenosis) or who received bioprosthetic valve >3mo ago: Use shared decision-making process based on the CHA2DS2-VASc score.
- Pts w/ rheumatic MS or mechanical prosthesis should be anticoagulated.
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 AHA/ACC/HRS 2019. January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Jul 9;74(1):104-132. Free, full-text article
3 ACC/AHA 2020. Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2;143(5):e72-e227. Free, full-text article
s/p mechanical valve replacement Tx recommendations1-5 - Target INR: 3.0
- Range: 2.5-3.5
- Duration: extended
Other considerations1-5 - Plus aspirin w/ assessment for bleeding risk (75-100 mg/day, per AHA/ACC; 50-100 mg/day, per ACCP)
- ACCP recommends target INR of 2.5 (2.0-3.0) for lone aortic valves, but in the setting of risk factors, such as afib, AHA/ACC recommends target of 3.0 (2.5-3.5).
- AHA/ACC/HRS recommends that target INR (2.0-3.0 or 2.5-3.5) be based on type and location of prosthesis.
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 AHA/ACC/HRS 2014. January CT, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130(23):e199-267. Free, full-text PDF at PubMed® Central
3 AHA/ACC 2014. Nishimura RA, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10;129(23):2440-92. Free, full-text article
4 AHA/ACC 2017. Nishimura RA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11;70(2):252-289. Free, full-text article
5 ACC/AHA 2020. Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2;143(5):e72-e227. Free, full-text article
w/ hypertrophic or dilated CM Tx recommendations1,2 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended
Other clinical considerations Footnotes 1 AHA/ACC/HRS 2014. January CT, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130(23):e199-267. Free, full-text PDF at PubMed® Central
2 Koniaris LS and Goldhaber SZ. Anticoagulation in dilated cardiomyopathy. J Am Coll Cardiol. 1998 Mar 15;31(4):745-8. Free, full-text article
Tx recommendations1 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended
Other considerations1,2 - In pts who have undergone PCI w/ stenting: Double tx w/ warfarin + P2Y12 inhibitor is preferred to ↓ bleed risk assoc w/ triple tx (aspirin + P2Y12 inhibitor + warfarin).
- If triple tx used: Consider transition to double tx after 4wk.
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 AHA/ACC/HRS 2019. January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Jul 9;74(1):104-132. Free, full-text article
Tx recommendations1 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended
Other considerations1 - stable = no ACS in past yr
- warfarin alone recommended above warfarin + aspirin
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
Tx recommendations1,2 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended
Other considerations2 - Treat pts w/ aspirin until anticoagulation reaches therapeutic level.
- Initiate oral anticoagulation 1-2wk after stroke onset.
- Consider earlier anticoagulation for pts at ↓risk of bleeding complications (e.g., those w/ small infarct burden and no evidence of hemorrhage on imaging).
- Consider delaying anticoagulation for pts at ↑risk of hemorrhagic complications.
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 CHEST 2012. Lansberg MG, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e601S-e636S. Free, full-text PDF at PubMed® Central
Peri-cardioversion to NSR Tx recommendations1,2 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: Start at least 3wk prior to cardioversion, continue at least 4wk after
Other considerations1,2 - In pts w/ atrial fib/flutter >48h or of unknown duration who require immediate cardioversion due to hemodynamic instability: Start anticoag ASAP.
- Base decision to continue tx beyond 4wk on thromboembolic risk vs. bleeding risk profile.2
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 AHA/ACC/HRS 2019. January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Jul 9;74(1):104-132. Free, full-text article
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Tx recommendations1,2 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended
Other considerations1,2 - Anticoagulate pts w/ rheumatic MS plus any of: afib, previous VTE, LA diameter >55 mm, LA thrombus.
- Pts w/ valvular heart dz (excluding those w/ rheumatic MS or a mechanical prosthesis) and afib: Use shared decision-making process based on the CHA2DS2-VASc score.
Footnotes 1 CHEST 2012. Whitlock RP, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e576S-e600S. Free, full-text PDF at PubMed® Central
2 ACC/AHA 2020. Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2;143(5):e72-e227. Free, full-text article
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s/p heart valve replacement/repair
Tx recommendations1-4
- Target INR: 2.5 (3.0 w/ risk factors or early-gen valve)
- Range: 2.0-3.0 (2.5-3.5 w/ risk factors or early-gen valve)
- Duration: extended
Other considerations1-4 - Plus aspirin w/ assessment for bleeding risk (75-100 mg/day, per AHA/ACC; 50-100 mg/day, per ACCP)
- Thrombosis risk factors include: afib, previous thromboembolism, LV systolic dysfunction, hypercoag state.
- Older-gen valves: Starr-Edwards (caged-ball) and tilting disc (not including Medtronic-Hall).
- In pts w/ On-X valve, target range may be ↓ to 1.5-2.0 at 3mo post-op.
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 AHA/ACC 2014. Nishimura RA, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10;129(23):2440-92. Free, full-text article
3 AHA/ACC 2017. Nishimura RA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11;70(2):252-289. Free, full-text article
4 ACC/AHA 2020. Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2;143(5):e72-e227. Free, full-text article
Mitral, tricuspid, or double Tx recommendations1-4 - Target INR: 3.0
- Range: 2.5-3.5
- Duration: extended
Other considerations1-4 - Plus aspirin w/ assessment for bleeding risk (75-100 mg/day, per AHA/ACC; 50-100 mg/day, per ACCP)
- Pts being considered for percutaneous mitral balloon valvotomy (PMBV) w/ LA thrombus on TEE: Delay procedure and anticoagulate until LA thrombus resolved.
Footnotes 1 CHEST 2012. Whitlock RP, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e576S-e600S. Free, full-text PDF at PubMed® Central
2 ACC/AHA 2020. Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2;143(5):e72-e227. Free, full-text article
3 AHA/ACC 2014. Nishimura RA, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10;129(23):2440-92. Free, full-text article
4 AHA/ACC 2017. Nishimura RA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11;70(2):252-289. Free, full-text article
Bioprosthetic replacement Tx recommendations1-4 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: 3-6mo post-op
Other considerations1-4 - Plus aspirin (75-100 mg/day). ACCP favors aspirin alone (50-100 mg/day) in pts in NSR who’ve had surgical aortic bioprosthesis placed, but recommendation pre-dates studies showing benefit of early anticoagulation.
- Initial anticoagulation for ≥3mo after TAVR reasonable, per existing AHA/ACC guidelines, but evidence is evolving.
- ACCP and ESC suggest dual antiplatelet tx over VKA.
Footnotes 1 CHEST 2012. Whitlock RP, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e576S-e600S. Free, full-text PDF at PubMed® Central
2 AHA/ACC 2017. Nishimura RA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11;70(2):252-289. Free, full-text article
3 AHA/ACC 2014. Nishimura RA, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10;129(23):2440-92. Free, full-text article
4 Baumgartner H, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017 Sep 21;38(36):2739-2791. Free, full-text PDF
Tx recommendations1-4 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: 3-6mo post-op
Other considerations1-3 - Plus aspirin (75-100 mg/day)
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 AHA/ACC 2014. Nishimura RA, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10;129(23):2440-92. Free, full-text article
3 AHA/ACC 2017. Nishimura RA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11;70(2):252-289. Free, full-text article
4 Baumgartner H, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017 Sep 21;38(36):2739-2791. Free, full-text PDF
Tx recommendations1-4
- Target INR: 2.5 if mitral
- Range: 2.0-3.0 if mitral
- Duration: 3mo post-op
Other considerations1 - In pts undergoing mitral repair w/ prosthetic band and NSR, follow w/ aspirin alone after initial 3mo.
- Aspirin alone (50-100 mg/day) sufficient for aortic repairs.
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 AHA/ACC 2014. Nishimura RA, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10;129(23):2440-92. Free, full-text article
3 AHA/ACC 2017. Nishimura RA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11;70(2):252-289. Free, full-text article
4 Baumgartner H, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017 Sep 21;38(36):2739-2791. Free, full-text PDF
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Tx recommendations1-5 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: at least 3mo2-4
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 CHEST 2016. Kearon C, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-352. Free, full-text PDF
Tx x3mo recommended over shorter or longer duration in pts w/ 1st DVT/PE attributed to surgery or other transient risk factor. For those w/ 1st DVT/PE, no transient risk, and low to mod bleeding risk, extended tx recommended; if high bleeding risk, 3mo recommended over longer tx. Extended tx recommended in pts w/ CA-assoc DVT/PE.
3 ASH 2021. Lyman GH, et al. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv. 2021 Feb 23;5(4):927-974. Free, full-text PDF at PubMed® Central
Extended anticoagulation may be discontinued when pt no longer at high risk of recurrent VTEs or if pt enters last wks of life.
4 ASCO 2023. Key NS, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update. J Clin Oncol. 2023 Jun 1;41(16):3063-3071. Free, full-text article
Offer extended anticoagulation to select pts w/ active CA (e.g., those w/ metastatic dz or those receiving chemo-tx). Anticoagulation beyond 6mo needs to be assessed on an intermittent basis to ensure continued favorable risk-benefit profile.
5 CHEST 2021. Stevens SM, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160(6):e545-e608. Free, full-text PDF
Major transient risk factors (present w/in 3mo before dx):
• Surgery w/ general anesthesia for >30min
• Confinement to hospital bed (only “bathroom privileges”) for ≥3 days, w/ acute illness
• C-section
• Major trauma
Minor transient risk factors (present w/in 2mo before dx):
• Surgery w/ general anesthesia for <30min
• Admission to hospital for <3 days, w/ acute illness
• Estrogen tx
• Pregnancy
• Puerperium
• Confinement to out-of-hospital bed for ≥3 days, w/ acute illness
• Leg injury assoc w/ ↓mobility for ≥3 days
• Prolonged car/air travel
The following factors may favor choosing anticoagulation:
1. Positive D-dimer (esp. when markedly so, w/o an alternative reason)
2. Extensive thrombosis (e.g., >5 cm in length, involves multiple veins, >7 mm in max diameter)
3. Thrombosis close to proximal veins
4. No reversible provoking factor for DVT
5. Active CA
6. VTE hx
7. Inpatient
8. COVID-19
9. Highly symptomatic
10. Pt prefers to avoid repeat imaging
The following factors may favor choosing serial imaging:
1. Thrombosis confined to muscular veins of the calf (i.e., soleus, gastrocnemius)
2. High or moderate bleeding risk
3. Pt prefers to avoid anticoagulation
Tx recommendations1-4 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended,3,4 unless ↑bleeding risk and clot not CA assoc
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 CHEST 2016. Kearon C, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-352. Free, full-text PDF
3 ASH 2021. Lyman GH, et al. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv. 2021 Feb 23;5(4):927-974. Free, full-text PDF at PubMed® Central
Extended anticoagulation may be discontinued when pt no longer at high risk of recurrent VTEs or if pt enters last wks of life.
4 ASCO 2023. Key NS, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update. J Clin Oncol. 2023 Jun 1;41(16):3063-3071. Free, full-text article
Anticoagulation beyond 6mo needs to be assessed on an intermittent basis to ensure continued favorable risk-benefit profile.
Cardioembolic ischemic stroke Tx recommendations1 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended
Other considerations1,2 - Treat w/ aspirin until anticoagulation has reached a therapeutic level.
- Oral anticoagulation should generally be initiated w/in 1-2wk after stroke onset.
- Earlier anticoagulation can be considered for pts at low risk of bleeding complications (e.g., those w/ small infarct burden and no evidence of hemorrhage on imaging).
- Consider delaying anticoagulation for pts at high risk of hemorrhagic complications.
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 CHEST 2012. Lansberg MG, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e601S-e636S. Free, full-text PDF at PubMed® Central
Cerebral venous thrombosis Tx recommendations1-5 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: at least 3mo
Other considerations1,2,4,5 - Initiate anticoag w/ UFH or LMWH; transition to oral anticoagulant when stable.
- If provoked by transient5 risk factor, treat x3-6mo.
- If unprovoked, treat x6-12mo.
- Extended anticoag may be considered if recurrent CVT, VTE after CVT, or 1st CVT w/ severe thrombophilia (homozygous prothrombin G20210A mutation, homozygous factor V Leiden mutation, protein C or S deficiencies, antithrombin deficiency, antiphospholipid syndrome, or combined thrombophilia defects).
Footnotes 1 CHEST 2012. Guyatt GH, et al. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):7S-47S. Free, full-text PDF at PubMed® Central
2 CHEST 2012. Lansberg MG, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e601S-e636S. Free, full-text PDF at PubMed® Central
3 AHA/ASA 2021. Kleindorfer DO, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52(7)e364-e467. Free, full-text article
4 AHA/ASA 2011. Saposnik G, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Apr;42(4):1158-92. Free, full-text article
5 CHEST 2021. Stevens SM, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160(6):e545-e608. Free, full-text PDF
Major transient risk factors (present w/in 3mo before dx):
• Surgery w/ general anesthesia for >30min
• Confinement to hospital bed (only “bathroom privileges”) for ≥3 days, w/ acute illness
• C-section
• Major trauma
Minor transient risk factors (present w/in 2mo before dx):
• Surgery w/ general anesthesia for <30min
• Admission to hospital for <3 days, w/ acute illness
• Estrogen tx
• Pregnancy
• Puerperium
• Confinement to out-of-hospital bed for ≥3 days, w/ acute illness
• Leg injury assoc w/ ↓mobility for ≥3 days
• Prolonged car/air travel
LV thrombus after STEMI or w/ ↓LVEF Tx recommendations1,2 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: at least 3mo
Other considerations1,2 - Can use w/ aspirin or DAPT (aspirin + P2Y12 inhibitor) as indicated for ACS or if stent placed.
- Extend VKA x3-6mo w/ drug-eluting stent.
- When triple tx (VKA + aspirin + P2Y12 inhibitor) is used, an INR of 2.0-2.5 might be reasonable, although prospective data are lacking.
Footnotes 1 ACCF/AHA 2013. O’Gara PT, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61(4):e78-e140. Free, full-text PDF
2 CHEST 2012. Vandvik PO, et al. Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e637S-e668S. Free, full-text PDF at PubMed® Central
-
Tx recommendations1 - Target INR: 2.5
- Range: 2.0-3.0
- Duration: extended
Other considerations1 - Use w/ antiplatelet tx according to manufacturer’s instructions.
- If major cerebral or GI bleed, hold temporarily, but no established guidelines re: duration of cessation or timing of reinitiation of anticoag following resolution of bleeding event.
Footnotes 1 AATS/ISHLT 2020. Kirklin JK, et al. American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support. J Heart Lung Transplant. 2020 Mar;39(3):187-219. Free, full-text article
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