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Executive Summary
Antithrombotic Therapy and Prevention of Thrombosis,
9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines
Gordon H. Guyatt, MD, FCCP; Elie A. Akl, MD, PhD, MPH; Mark Crowther, MD;
David D. Gutterman, MD, FCCP; Holger J. Schünemann, MD, PhD, FCCP; for the American
College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel*
CHEST 2012; 141(2)(Suppl):7S–47S evidence, and some articles with quite extensive
summary tables of primary studies. In total, this
Abbreviations: ACS 5 acute coronary syndrome; AF 5 atrial represented 600 recommendations summarized in
fibrillation; AIS 5 arterial ischemic stroke; APLA 5 antiphospolipid 968 pages of text. Many readers responded that the
antibodies; ASA 5 acetylsalicylic acid; AT9 5 Antithrombotic result was too voluminous for their liking or prac-
Therapy and Prevention of Thrombosis, 9th ed: American tical use.
College of Chest Physicians Evidence-Based Clinical Practice
Cognizant of this feedback, we worked hard to
Guidelines; BMS 5 bare-metal stent; CABG 5 coronary artery
bypass graft; CAD 5 coronary artery disease; CDT 5 catheter- minimize the length of the text for the ninth iteration
directed thrombosis; CHADS2 5 congestive heart failure, hyperten- of the guidelines Antithrombotic Therapy and Pre-
sion, age 75 years, diabetes mellitus, prior stroke or transient vention of Thrombosis, 9th ed: American College of
ischemic attack; CSVT 5 cerebral sinovenous thrombosis; CTPH 5 Chest Physicians Evidence-Based Clinical Practice
chronic thromboembolic pulmonary hypertension; CUS 5 com-
Guidelines (AT9) without sacrificing key content. A
pression ultrasound; CVAD 5 central venous access device;
DES 5 drug-eluting stent; GCS 5 graduated compression stockings; number of topic editors found our shortening edits
HFS 5 hip fracture surgery; HIT 5 heparin-induced thrombocy- draconian, but we were determined to produce the
topenia; HITT 5 heparin-induced thrombocytopenia complicated leanest product possible.
by thrombosis; IA 5 intraarterial; ICH 5 intracerebral hemor- There were, however, a number of obstacles. In
rhage; IE 5 infective endocarditis; INR 5 international normalized
what we believe is a key advance in AT9, we con-
ratio; IPC 5 intermittent pneumatic compression; IPCD 5 inter-
mittent pneumatic compression device; IVC 5 inferior vena cava; ducted a systematic review of what is known about
LDUH 5 low-dose unfractionated heparin; LMWH 5 low-molecular- patients’ values and preferences regarding antithrom-
weight heparin; LV 5 left ventricular; MBTS 5 modified Blalock- botic therapy and included the results as an article
Taussig shunt; MR 5 magnetic resonance; PAD 5 peripheral artery in AT9. In another forward step, we recognized the
disease; PCI 5 percutaneous coronary intervention; PE 5 pul- problems with asymptomatic thrombosis as a surro-
monary embolism; PFO 5 patent foramen ovale; PMBV 5 percuta-
neous mitral balloon valvotomy; PTS 5 postthrombotic syndrome; gate outcome, and devised strategies to estimate
PVT 5 prosthetic valve thrombosis; r-tPA 5 recombinant tissue plas- reductions in symptomatic DVT and pulmonary
minogen activator; RVT 5 renal vein thrombosis; SC 5 subcuta- embolism with antithrombotic prophylaxis. We felt it
neous; TEE 5 transesophageal echocardiography; THA 5 total important to explain this innovation to users of AT9,
hip arthroplasty; TIA 5 transient ischemic attack; TKA 5 total knee
and this meant another article.
arthroplasty; UAC 5 umbilical arterial catheter; UEDVT 5 upper-
extremity DVT; UFH 5 unfractionated heparin; US 5 ultrasound; We included, for the first time, an article on diag-
UVC 5 umbilical venous catheter; VAD 5 ventricular assist device; nosis addressing patients with symptoms and signs
VKA 5 vitamin K antagonist suggesting DVT. We increased the range of interven-
tions we have covered, resulting in additional recom-
mendations. Finally, we produced many summary
8S Executive Summary
For further details, see Kahn et al.2 3.4.3. For critically ill patients, we suggest using
LMWH or LDUH thromboprophylaxis over no
2.0 Hospitalized Acutely Ill Medical Patients prophylaxis (Grade 2C).
2.3. For acutely ill hospitalized medical patients 3.4.4. For critically ill patients who are bleeding,
at increased risk of thrombosis, we recommend or are at high risk for major bleeding, we
anticoagulant thromboprophylaxis with low- suggest mechanical thromboprophylaxis with
molecular-weight heparin [LMWH], low-dose GCS (Grade 2C) or IPC (Grade 2C) until the
3.6.6. For high-VTE-risk patients undergoing 5.4.1. For thoracic surgery patients at mod-
abdominal or pelvic surgery for cancer who are erate risk for VTE who are not at high risk for
not otherwise at high risk for major bleeding perioperative bleeding, we suggest LDUH
complications, we recommend extended-duration (Grade 2B), LMWH (Grade 2B), or mechanical
pharmacologic prophylaxis (4 weeks) with LMWH prophylaxis with optimally applied IPC (Grade 2C)
over limited-duration prophylaxis (Grade 1B). over no prophylaxis.
Remarks: Patients who place a high value on mini- Remarks: Three of the seven authors favored a strong
mizing out-of-pocket health-care costs might prefer (Grade 1B) recommendation in favor of LMWH or
limited-duration over extended-duration prophylaxis LDUH over no prophylaxis in this group.
in settings where the cost of extended-duration pro-
phylaxis is borne by the patient. 5.4.2. For thoracic surgery patients at high risk
for VTE who are not at high risk for periopera-
3.6.7. For high-VTE-risk general and abdominal- tive bleeding, we suggest LDUH (Grade 1B) or
pelvic surgery patients who are at high risk for LMWH (Grade 1B) over no prophylaxis. In addi-
major bleeding complications or those in whom the tion, we suggest that mechanical prophylaxis
consequences of bleeding are thought to be with elastic stockings or IPC should be added to
particularly severe, we suggest use of mechan- pharmacologic prophylaxis (Grade 2C).
ical prophylaxis, preferably with IPC, over no
prophylaxis until the risk of bleeding diminishes 5.4.3. For thoracic surgery patients who are at
and pharmacologic prophylaxis may be initiated high risk for major bleeding, we suggest use of
(Grade 2C). mechanical prophylaxis, preferably with opti-
mally applied IPC, over no prophylaxis until the
3.6.8. For general and abdominal-pelvic sur- risk of bleeding diminishes and pharmacologic
gery patients at high risk for VTE (6%; Caprini prophylaxis may be initiated (Grade 2C).
score, 5) in whom both LMWH and unfrac-
tionated heparin are contraindicated or unavail- 6.0 Patients Undergoing Craniotomy
able and who are not at high risk for major 6.4.1. For craniotomy patients, we suggest that
bleeding complications, we suggest low-dose mechanical prophylaxis, preferably with IPC,
aspirin (Grade 2C), fondaparinux (Grade 2C), or be used over no prophylaxis (Grade 2C) or phar-
mechanical prophylaxis, preferably with IPC macologic prophylaxis (Grade 2C).
(Grade 2C), over no prophylaxis.
6.4.2. For craniotomy patients at very high risk
3.6.9. For general and abdominal-pelvic sur-
for VTE (eg, those undergoing craniotomy for
gery patients, we suggest that an inferior vena
malignant disease), we suggest adding pharma-
cava (IVC) filter should not be used for primary
cologic prophylaxis to mechanical prophylaxis
VTE prevention (Grade 2C).
once adequate hemostasis is established and the
3.6.10. For general and abdominal-pelvic surgery risk of bleeding decreases (Grade 2C).
patients, we suggest that periodic surveillance
with venous compression ultrasound should 7.0 Patients Undergoing Spinal Surgery
not be performed (Grade 2C). 7.4.1. For patients undergoing spinal surgery,
we suggest mechanical prophylaxis, prefer-
4.0 Patients Undergoing Cardiac Surgery
ably with IPC, over no prophylaxis (Grade 2C),
4.4.1. For cardiac surgery patients with an unfractionated heparin (Grade 2C), or LMWH
uncomplicated postoperative course, we sug- (Grade 2C).
8.4.4. For major trauma patients, we suggest 2.3.1. In patients undergoing THA or TKA,
that an IVC filter should not be used for pri- irrespective of the concomitant use of an IPCD
mary VTE prevention (Grade 2C). or length of treatment, we suggest the use
of LMWH in preference to the other agents
8.4.5. For major trauma patients, we suggest that we have recommended as alternatives: fonda-
periodic surveillance with venous compression parinux, apixaban, dabigatran, rivaroxaban,
ultrasound should not be performed (Grade 2C). LDUH (all Grade 2B), adjusted-dose VKA, or
aspirin (all Grade 2C).
Prevention of VTE in Orthopedic Remarks: If started preoperatively, we suggest admin-
Surgery Patients istering LMWH 12 h before surgery. Patients
who place a high value on avoiding the inconvenience
For further details, see Falck-Ytter et al.4
of daily injections with LMWH and a low value on
2.0 Patients Undergoing Major Orthopedic Surgery: the limitations of alternative agents are likely to
Total Hip Arthroplasty (THA), Total Knee Arthroplasty choose an alternative agent. Limitations of alter-
(TKA), Hip Fracture Surgery (HFS) native agents include the possibility of increased
bleeding (which may occur with fondaparinux, rivar-
2.1.1. In patients undergoing THA or TKA, we oxaban, and VKA), possible decreased efficacy (LDUH,
recommend use of one of the following for a VKA, aspirin, and IPCD alone), and lack of long-term
minimum of 10 to 14 days rather than no anti- safety data (apixaban, dabigatran, and rivaroxaban).
thrombotic prophylaxis: low-molecular-weight Furthermore, patients who place a high value on
heparin (LMWH), fondaparinux, apixaban, dab- avoiding bleeding complications and a low value on
Remarks: Patients with abnormal isolated distal US We recommend that in patients with high pre-
findings on whole-leg US who place a high value on test probability, moderately or highly sensitive
avoiding the inconvenience of repeat testing and a D-dimer assays should not be used as stand-
low value on avoiding treatment of false-positive alone tests to rule out DVT (Grade 1B).
results are likely to choose treatment over repeat US.
Patients with severe symptoms and risk factors for 3.5. If risk stratification is not performed in
extension as outlined in Perioperative Management patients with suspected first lower extremity
of Antithrombotic Therapy. Antithrombotic Therapy DVT, we recommend one of the following
and Prevention of Thrombosis, 9th ed: American initial tests: (i) proximal CUS or (ii) whole-
College of Chest Physicians Evidence-Based Clinical leg US rather than (i) no testing (Grade 1B),
Practice Guidelines are more likely to benefit from (ii) venography (Grade 1B), or D-dimer testing
treatment over repeat US. (Grade 2B).
2.2.1. In patients with a high clinical suspicion of 2.4. In patients with acute DVT of the leg, we
acute VTE, we suggest treatment with parenteral recommend early initiation of VKA (eg, same
anticoagulants compared with no treatment while day as parenteral therapy is started) over
awaiting the results of diagnostic tests (Grade 2C). delayed initiation, and continuation of paren-
teral anticoagulation for a minimum of 5 days
2.2.2. In patients with an intermediate clinical and until the international normalized ratio
suspicion of acute VTE, we suggest treatment (INR) is 2.0 or above for at least 24 h (Grade 1B).
with parenteral anticoagulants compared with
no treatment if the results of diagnostic tests 2.5 Choice of Initial Anticoagulant Regimen in
are expected to be delayed for more than 4 h Patients With Proximal DVT
(Grade 2C).
2.5.1. In patients with acute DVT of the leg, we
2.2.3. In patients with a low clinical suspicion of suggest LMWH or fondaparinux over IV UFH
acute VTE, we suggest not treating with paren- (Grade 2C) and over SC UFH (Grade 2B for
teral anticoagulants while awaiting the results LMWH; Grade 2C for fondaparinux).
of diagnostic tests, provided test results are
Remarks: Local considerations such as cost, avail-
expected within 24 h (Grade 2C).
ability, and familiarity of use dictate the choice
2.3 Anticoagulation in Patients With Isolated Distal between fondaparinux and LMWH. LMWH and
DVT fondaparinux are retained in patients with renal
impairment, whereas this is not a concern with UFH.
2.3.1. In patients with acute isolated distal DVT
of the leg and without severe symptoms or risk 2.5.2. In patients with acute DVT of the leg
factors for extension, we suggest serial imaging treated with LMWH, we suggest once- over
of the deep veins for 2 weeks over initial antico- twice-daily administration (Grade 2C).
agulation (Grade 2C).
Remarks: This recommendation only applies when
2.3.2. In patients with acute isolated distal DVT the approved once-daily regimen uses the same
of the leg and severe symptoms or risk factors daily dose as the twice-daily regimen (ie, the once-
for extension (see text), we suggest initial antico- daily injection contains double the dose of each
agulation over serial imaging of the deep veins twice-daily injection). It also places value on avoiding
(Grade 2C). an extra injection per day.
4.1. In patients with acute symptomatic DVT of 5.3 Timing of Initiation of VKA and Associated
the leg, we suggest the use of compression stock- Duration of Parenteral Anticoagulant Therapy
ings (Grade 2B). 5.3. In patients with acute PE, we recommend
early initiation of VKA (eg, same day as paren-
Remarks: Compression stockings should be worn for teral therapy is started) over delayed initiation,
2 years, and we suggest beyond that if patients have and continuation of parenteral anticoagulation
developed PTS and find the stockings helpful. for a minimum of 5 days and until the INR is 2.0
Patients who place a low value on preventing PTS or or above for at least 24 h (Grade 1B).
a high value on avoiding the inconvenience and dis-
comfort of stockings are likely to decline stockings. 5.4 Choice of Initial Parenteral Anticoagulant Regimen
in Patients With PE
4.2 Physical Treatment of Patients With PTS
5.4.1. In patients with acute PE, we suggest
4.2.1. In patients with PTS of the leg, we sug- LMWH or fondaparinux over IV UFH (Grade 2C
gest a trial of compression stockings (Grade 2C). for LMWH; Grade 2B for fondaparinux) and over
SC UFH (Grade 2B for LMWH; Grade 2C for
4.2.2. In patients with severe PTS of the leg that
fondaparinux).
is not adequately relieved by compression stock-
ings, we suggest a trial of an intermittent com- Remarks: Local considerations such as cost, availability,
pression device (Grade 2B). and familiarity of use dictate the choice between
fondaparinux and LMWH. LMWH and fondaparinux
4.3 Pharmacologic Treatment of Patients With PTS are retained in patients with renal impairment,
4.3. In patients with PTS of the leg, we suggest that whereas this is not a concern with UFH. In patients
venoactive medications (eg, rutosides, defibrot- with PE where there is concern about the adequacy
ide, and hidrosmin) not be used (Grade 2C). of SC absorption or in patients in whom thrombolytic
therapy is being considered or planned, initial treat-
Remarks: Patients who value the possibility of response ment with IV UFH is preferred to use of SC therapies.
over the risk of side effects may choose to undertake a
therapeutic trial. 5.4.2. In patients with acute PE treated with
LMWH, we suggest once- over twice-daily admin-
5.1 Initial Anticoagulation for Patients With Acute istration (Grade 2C).
Pulmonary Embolism (PE)
Remarks: This recommendation only applies when
5.1. In patients with acute PE, we recommend the approved once-daily regimen uses the same
initial treatment with parenteral anticoagula- daily dose as the twice-daily regimen (ie, the once-
tion (LMWH, fondaparinux, IV UFH, or SC daily injection contains double the dose of each
UFH) over no such initial treatment (Grade 1B). twice-daily injection). It also places value on avoiding
an extra injection per day.
5.2 Parenteral Anticoagulation Prior to Receipt of the
Results of Diagnostic Work-up for PE 5.5 Early vs Standard Discharge of Patients With
Acute PE
5.2.1. In patients with a high clinical suspicion
of acute PE, we suggest treatment with paren- 5.5. In patients with low-risk PE and whose
teral anticoagulants compared with no treat- home circumstances are adequate, we suggest
ment while awaiting the results of diagnostic early discharge over standard discharge (eg,
tests (Grade 2C). after first 5 days of treatment) (Grade 2B).
6.6. In patients with PE and no cancer, we sug- 8.1.1. In patients with superficial vein thrombo-
gest VKA therapy over LMWH for long-term sis of the lower limb of at least 5 cm in length,
therapy (Grade 2C). For patients with PE and no we suggest the use of a prophylactic dose of
cancer who are not treated with VKA therapy, fondaparinux or LMWH for 45 days over no
we suggest LMWH over dabigatran or rivaroxa- anticoagulation (Grade 2B).
ban for long-term therapy (Grade 2C).
Remarks: Patients who place a high value on avoiding
6.7. In patients with PE and cancer, we suggest the inconvenience or cost of anticoagulation and a
LMWH over VKA therapy (Grade 2B). In patients low value on avoiding infrequent symptomatic VTE
with PE and cancer who are not treated with are likely to decline anticoagulation.
LMWH, we suggest VKA over dabigatran or
8.1.2. In patients with superficial vein throm-
rivaroxaban for long-term therapy (Grade 2C).
bosis who are treated with anticoagulation, we
Remarks (6.6-6.7): Choice of treatment in patients suggest fondaparinux 2.5 mg daily over a pro-
with and without cancer is sensitive to the individual phylactic dose of LMWH (Grade 2C).
patient’s tolerance for daily injections, need for labo- 9.1 Acute Anticoagulation for Patients With UEDVT
ratory monitoring, and treatment costs. Treatment of
VTE with dabigatran or rivaroxaban, in addition to 9.1.1. In patients with UEDVT that involves
being less burdensome to patients, may prove to be the axillary or more proximal veins, we recom-
associated with better clinical outcomes than VKA mend acute treatment with parenteral anti-
and LMWH therapy. When these guidelines were coagulation (LMWH, fondaparinux, IV UFH,
being prepared (October 2011), postmarketing studies or SC UFH) over no such acute treatment
of safety were not available. Given the paucity of cur- (Grade 1B).
rently available data and that new data are rapidly
emerging, we give a weak recommendation in favor 9.1.2. In patients with acute UEDVT that
of VKA and LMWH therapy over dabigatran and involves the axillary or more proximal veins, we
rivaroxaban, and we have not made any recommen- suggest LMWH or fondaparinux over IV UFH
dation in favor of one of the new agents over the other. (Grade 2C) and over SC UFH (Grade 2B).
9.2.2. In patients with UEDVT who undergo 10.0 Patients With Splanchnic Vein Thrombosis
thrombolysis, we recommend the same inten- 10.1. In patients with symptomatic splanchnic
sity and duration of anticoagulant therapy as in vein thrombosis (portal, mesenteric, and/or
similar patients who do not undergo thromboly- splenic vein thromboses), we recommend anti-
sis (Grade 1B). coagulation over no anticoagulation (Grade 1B).
9.3 Long-term Anticoagulation for Patients With
UEDVT 10.2. In patients with incidentally detected
splanchnic vein thrombosis (portal, mesen-
9.3.1. In most patients with UEDVT that is asso- teric, and/or splenic vein thromboses), we sug-
ciated with a central venous catheter, we sug- gest no anticoagulation over anticoagulation
gest that the catheter not be removed if it is (Grade 2C).
functional and there is an ongoing need for the
catheter (Grade 2C). 11.0 Patients With Hepatic Vein Thrombosis
9.3.2. In patients with UEDVT that involves 11.1. In patients with symptomatic hepatic vein
the axillary or more proximal veins, we suggest thrombosis, we suggest anticoagulation over no
a minimum duration of anticoagulation of anticoagulation (Grade 2C).
3 months over a shorter period (Grade 2B).
11.2. In patients with incidentally detected
Remarks: This recommendation also applies if the hepatic vein thrombosis, we suggest no antico-
UEDVT was associated with a central venous cath- agulation over anticoagulation (Grade 2C).
eter that was removed shortly after diagnosis.
9.3.3. In patients who have UEDVT that is asso-
ciated with a central venous catheter that is Treatment and Prevention of
removed, we recommend 3 months of antico- Heparin-Induced Thrombocytopenia
agulation over a longer duration of therapy in For further details, see Linkins et al.8
patients with no cancer (Grade 1B), and we sug-
gest this in patients with cancer (Grade 2C). 2.1 Platelet Count Monitoring Combined With the
4Ts Score for Patients Receiving Heparin/LMWH
9.3.4. In patients who have UEDVT that is asso-
ciated with a central venous catheter that is not 2.1.1. For patients receiving heparin in whom
removed, we recommend that anticoagulation clinicians consider the risk of heparin-induced
is continued as long as the central venous cath- thrombocytopenia (HIT) to be . 1%, we suggest
eter remains over stopping after 3 months of that platelet count monitoring be performed
treatment in patients with cancer (Grade 1C), every 2 or 3 days from day 4 to day 14 (or until
and we suggest this in patients with no cancer heparin is stopped, whichever occurs first)
(Grade 2C). (Grade 2C).
9.3.5. In patients who have UEDVT that is not 2.1.2. For patients receiving heparin in whom
associated with a central venous catheter or with clinicians consider the risk of HIT to be , 1%,
cancer, we recommend 3 months of anticoagula- we suggest that platelet counts not be moni-
tion over a longer duration of therapy (Grade 1B). tored (Grade 2C).
5.3 Patients Who Require Renal Replacement Therapy 6.3. In patients with a past history of HIT who
have acute thrombosis (not related to HIT) and
5.3.1. In patients with acute or subacute HIT normal renal function, we suggest the use of
who require renal replacement therapy, we fondaparinux at full therapeutic doses until
suggest the use of argatroban or danaparoid transition to a VKA can be achieved (Grade 2C).
over other nonheparin anticoagulants (Grade 2C).
5.3.2. In patients with a past history of HIT who 2.1.8. For patients with AF, including those with
require ongoing renal replacement therapy paroxysmal AF, who are at low risk of stroke
or catheter locking, we suggest the use of (eg, CHADS2 [congestive heart failure, hyper-
regional citrate over the use of heparin or tension, age 75 years, diabetes mellitus, prior
LMWH (Grade 2C). stroke or transient ischemic attack] score 5 0),
we suggest no therapy rather than antithrom-
5.4 Pregnant Patients botic therapy (Grade 2B). For patients who do
choose antithrombotic therapy, we suggest aspi-
5.4. In pregnant patients with acute or subacute rin (75 mg to 325 mg once daily) rather than
HIT, we suggest danaparoid over other non- oral anticoagulation (Grade 2B) or combination
heparin anticoagulants (Grade 2C). We suggest therapy with aspirin and clopidogrel (Grade 2B).
the use of lepirudin or fondaparinux only if
danaparoid is not available (Grade 2C). Remarks: Patients who place an exceptionally high
value on stroke reduction and a low value on avoiding
Remarks: Other factors, such as drug availability,
bleeding and the burden associated with antithrom-
cost, and ability to monitor the anticoagulant effect,
botic therapy are likely to choose antithrombotic
may influence the choice of agent.
therapy rather than no antithrombotic therapy. Other
6.1 Patients With a History of HIT Who Require factors that may influence the choices above are a
Cardiac Surgery consideration of patient-specific bleeding risk and
the presence of additional risk factors for stroke,
6.1.1. In patients with a history of HIT in whom including age 65 to 74 years and female gender, which
heparin antibodies have been shown to be have been more consistently validated, and vascular
absent who require cardiac surgery, we suggest disease, which has been less well validated (see sec-
the use of heparin (short-term use only) over tion 2.1.12). The presence of multiple non-CHADS2
nonheparin anticoagulants (Grade 2C). risk factors for stroke may favor oral anticoagulation
therapy.
6.1.2. In patients with a history of HIT in whom
heparin antibodies are still present who require 2.1.9. For patients with AF, including those with
cardiac surgery, we suggest the use of nonhepa- paroxysmal AF, who are at intermediate risk of
rin anticoagulants (see 5.1.1) over heparin or stroke (eg, CHADS2 score 5 1), we recommend
LMWH (Grade 2C). oral anticoagulation rather than no therapy
(Grade 1B). We suggest oral anticoagulation
6.2 Patients Who Require PCI
rather than aspirin (75 mg to 325 mg once
6.2. In patients with a history of HIT in whom daily) (Grade 2B) or combination therapy with
heparin antibodies have been shown to be aspirin and clopidogrel (Grade 2B). For patients
2.0.3. For patients with rheumatic mitral valve 7.1.1. In patients with infective endocarditis
disease complicated by the presence of left (IE), we recommend against routine anticoagu-
atrial thrombus, we recommend VKA therapy lant therapy, unless a separate indication exists
(target INR, 2.5; range, 2.0-3.0) over no VKA (Grade 1C).
therapy (Grade 1A). 7.1.2. In patients with IE, we recommend
2.0.4. For patients with rheumatic mitral valve against routine antiplatelet therapy, unless a
disease complicated singly or in combination by separate indication exists (Grade 1B).
the presence of atrial fibrillation or previous 7.2 Role of Anticoagulants in Patients With Prosthetic
systemic embolism, we recommend VKA therapy Valve Endocarditis
(target INR, 2.5; range, 2.0-3.0) over no VKA
therapy (Grade 1A). 7.2. In patients on VKA for a prosthetic valve
who develop IE, we suggest VKA be discontin-
2.1 Patients With Rheumatic Mitral Valve Disease ued at the time of initial presentation until it
Undergoing Percutaneous Mitral Balloon Valvotomy is clear that invasive procedures will not be
(PMBV) required and the patient has stabilized without
2.1.1. For patients being considered for PMBV signs of CNS involvement. When the patient is
with preprocedural TEE showing left atrial deemed stable without contraindications or neu-
thrombus, we recommend postponement of rologic complications, we suggest reinstitution
PMBV and that VKA therapy (target INR, 3.0; of VKA therapy (Grade 2C).
range, 2.5-3.5) be administered until thrombus 7.3 Patients With Nonbacterial Thrombotic Endocarditis
resolution is documented by repeat TEE over
no VKA therapy (Grade 1A). 7.3. In patients with nonbacterial thrombotic
endocarditis and systemic or pulmonary emboli,
2.1.2. For patients being considered for PMBV we suggest treatment with full-dose IV UFH or
with preprocedural TEE showing left atrial SC LMWH over no anticoagulation (Grade 2C).
2.1.3. In patients with acute ischemic stroke in 3.1.2. In patients with acute ischemic stroke and
whom treatment cannot be initiated within 4.5 h restricted mobility, we suggest prophylactic-dose
of symptom onset, we recommend against IV LMWH over prophylactic-dose UFH (Grade 2B).
r-tPA (Grade 1B). 3.1.3. In patients with acute stroke and restricted
2.2 Intraarterial Thrombolysis in Patients With mobility, we suggest against elastic compression
Acute Ischemic Stroke stockings (Grade 2B).
2.2.1. In patients with acute ischemic stroke due Remarks: Pharmacologic and mechanical prophy-
to proximal cerebral artery occlusions who do laxis should be initiated as early as possible and should
not meet eligibility criteria for treatment with be continued throughout the hospital stay or until
IV r-tPA, we suggest intraarterial (IA) r-tPA the patient has regained mobility. Mechanical devices
initiated within 6 h of symptom onset over no should be temporarily removed as often as needed
IA r-tPA (Grade 2C). to allow for early mobilization and screening for
skin complications.
2.2.2. In patients with acute ischemic stroke we
suggest IV r-tPA over the combination IV/IA Combining pharmacologic therapy with intermittent
r-tPA (Grade 2C). pneumatic compression devices may yield additional
benefit in prevention of VTEs compared with either
Remarks: Carefully selected patients who value the method used alone.
uncertain benefits of combination IV/IA throm-
bolysis higher than the associated risks may choose 3.2 VTE Prevention in Patients With Hemorrhagic
this intervention. Patients who prefer to avoid risk in Stroke
the setting of uncertain benefits are more likely to 3.2.1. In patients with acute primary intracere-
choose IV r-tPA alone. bral hemorrhage and restricted mobility, we
suggest prophylactic-dose SC heparin (UFH or
2.3 Mechanical Thrombectomy in Patients With
LMWH) started between days 2 and 4 or inter-
Acute Ischemic Stroke
mittent pneumatic compression devices over
2.3. In patients with acute ischemic stroke, we no prophylaxis (Grade 2C).
suggest against the use of mechanical throm-
3.2.2. In patients with acute primary intrac-
bectomy (Grade 2C).
erebral hemorrhage and restricted mobility,
Remarks: Carefully selected patients who value we suggest prophylactic-dose LMWH over
the uncertain benefit of mechanical thrombectomy prophylactic-dose UFH (Grade 2B).
4.2.2. In patients with a history of ischemic Remarks: Patients with a history of ICH who might
stroke or TIA and atrial fibrillation, including benefit from antithrombotic therapy are those at rel-
paroxysmal AF, we suggest oral anticoagulation atively low risk of recurrent ICH (eg, with deep hem-
with dabigatran 150 mg bid over adjusted-dose orrhages) and relatively high risk (. 7% per year) of
VKA therapy (target range, 2.0-3.0) (Grade 2B). cardiac thromboembolic events (eg, with mechanical
heart valves or CHADS2 score . 4 points).
4.2.3. In patients with a history of ischemic
stroke or TIA and atrial fibrillation, including
paroxysmal AF, who are unsuitable for or choose The Primary and Secondary Prevention
not to take an oral anticoagulant (for reasons of Cardiovascular Disease
other than concerns about major bleeding), we For further details, see Vandvik et al.12
3.0.2. For women requiring long-term VKAs who 5.1.2. For women undergoing assisted repro-
are attempting pregnancy and are candidates duction who develop severe ovarian hyperstim-
for LMWH substitution, we suggest perform- ulation syndrome, we suggest thrombosis
ing frequent pregnancy tests and substituting prophylaxis (prophylactic LMWH) for 3 months
LMWH for VKAs when pregnancy is achieved postresolution of clinical ovarian hyperstimu-
rather than switching to LMWH while attempt- lation syndrome rather than no prophylaxis
ing pregnancy (Grade 2C). (Grade 2C).
Remarks: Women who place little value on avoid- Remarks: Women who are averse to taking medica-
ing the risks, inconvenience, and costs of LMWH tion for very small benefit and those who consider
therapy of uncertain duration while awaiting preg- self-injecting a considerable burden will be disin-
nancy and a high value on minimizing the risks of clined to use LMWH for extended thrombosis pro-
early miscarriage associated with VKA therapy are phylaxis. Given that the absolute benefit decreases as
likely to choose LMWH while attempting pregnancy. time from the hyperstimulation event increases, such