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The newer oral anticoagulants (NOACs) are now recommended over vitamin K antagonists such as warfarin for initial and long-term treatment of venous thromboembolism (VTE) in updated CHEST guidelines.

"For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran [Pradaxa] (Grade 2B), rivaroxaban [Xarelto] (Grade 2B), apixaban [Eliquis] (Grade 2B) or edoxaban [Savaysa] (Grade 2B) over vitamin K antagonist therapy, and suggest vitamin K antagonist therapy over low molecular weight heparin (Grade 2C)," , of the American University of Beirut, Lebanon, and colleagues recommended.

For patients with cancer, "we suggest low molecular weight heparin over vitamin K antagonists (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C) or edoxaban (Grade 2C)," they wrote .

The update also reversed course on compression stockings to prevent postthrombotic syndrome in acute deep vein thrombosis (DVT), now recommending these are not routinely needed.

ACCP's new recommendations aren't particularly strong, noted , of Brigham and Women's Hospital in Boston, who has been involved with the American Heart Association (AHA)'s Get With the Guidelines program. Grade 2 under the CHEST criteria is "weak," while levels of evidence B and C are moderate and low quality, respectively.

Nevertheless, NOACs have already been fairly broadly accepted in specialty practice for VTE, so it's a matter of the guidelines catching up to practice rather than driving it, Bhatt said. For primary practice, however, he predicted more of an impact in driving up NOAC use.

The last AHA/American College of Cardiology scientific statement on VTE came out in 2011, before the first NOAC approvals in this indication.

Another notable CHEST recommendation was a grade 1B recommendation against inferior vena cava (IVC) filters in acute deep vein thrombosis or pulmonary embolism patients treated with anticoagulants.

This stance "is a viewpoint the data support" but clinical use has been variable because of "a lot of uncertainty in general around who are the optimal patients for filters," Bhatt told 番茄社区app.

A more controversial recommendation in the update was that thrombolytic treatment for acute pulmonary embolism should go through a peripheral vein rather than catheter-directed thrombolysis (Grade 2C).

Bhatt called this recommendation surprising. "It's important to realize these are experts assessing the data, but that doesn't make it absolutely gospel that that's the right thing to do," he said. "For example, if I had a patient who was hypotensive, I might at least consider taking them to cath lab and doing catheter-directed lysis."

The CHEST guidelines acknowledged that higher bleeding-risk patients with access to the expertise and resources required to do catheter-directed thrombolysis are likely to choose that over systemic thrombolytic therapy.

"In patients with acute pulmonary embolism associated with hypotension and who have (i) a high bleeding risk, (ii) failed systemic thrombolysis, or (iii) shock that is likely to cause death before systemic thrombolysis can take effect (e.g., within hours), if appropriate expertise and resources are available, we suggest catheter assisted thrombus removal over no such intervention (Grade 2C)," the authors added.

Another change was addition of guidance suggesting no absolute need to switch anticoagulants after the first 3 months for patients who will receive extended therapy, although reasonable to change in response to changing patient circumstances or preferences. Periodic reassessment of continued use is also advised in the guideline.

Other groups endorsing the CHEST guideline included the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the International Society for Thrombosis and Haemostasis, and the American Society of Health-System Pharmacists.

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