Acute Management of VTE – CHEST Guideline (2016, with 2021 updates)
Recommendations (Abbreviated):
1. Proximal DVT/PE – long term (3 months) anticoagulation therapy > no therapy
a. No cancer-associated thrombus– dabigatran, rivaroxaban, apixaban, edoxaban (NOAC) > VKA
therapy > LMWH
b. With cancer-associated thrombus – LMWH > VKA therapy > NOAC
2. Proximal DVT/PE provoked/unprovoked by surgery (regardless of bleeding risk) – long term (3 months)
anticoagulation therapy > other treatment duration(s)
3. Isolated DVT provoked/unprovoked by surgery – long term (3 months) anticoagulation therapy > other
4. First VTE, unprovoked proximal DVT/PE, with
a. Low/moderate bleeding risk – extended anticoagulation therapy (no stop) > other
b. High bleeding risk – 3 months anticoagulation therapy
5. Second unprovoked VTE, with
a. Low/moderate bleeding risk – extended anticoagulation therapy (no stop) > other
b. High bleeding risk – 3 months anticoagulation therapy
6. DVT/PE and active cancer-associated thrombus (regardless of bleeding risk) – extended anticoagulation
therapy (no stop) > other
7. Unprovoked proximal DVT/PE who stopped anticoagulation therapy and no CI to aspirin – use aspirin > no
aspirin
8. Acute isolated distal DVT,
a. Without severe symptoms/RFs for extension – serial imaging of deep veins > anticoagulation
b. With severe symptoms/RFs for extension – anticoagulation > serial imaging of deep veins
9. Acute isolated distal DVT and managed with anticoagulation – use same anticoagulation as patients with
acute proximal DVT
10. Acute isolated distal DVT and managed with serial imaging,
a. Thrombus does not extend – no anticoagulation therapy
b. Thrombus does extend – use anticoagulation therapy
11. Acute proximal DVT – use anticoagulation therapy > CDT
12. Acute DVT/PE and treated with anticoagulants – not recommended to use IVC filter
13. Acute DVT – not recommended to use compression stockings routinely to prevent PTS
14. Subsegmental PE and no proximal DVT, with
a. Low risk for recurrent VTE – clinical surveillance > anticoagulation
b. High risk for recurrent VTE – anticoagulation > clinical surveillance
15. Low risk PE and adequate home circumstances – early discharge/treatment at home ok > standard
discharge (after first 5 days of treatment)
16. Acute PE associated with hypotension (SBP < 90 mmHg) and do not have a high bleeding risk –
systemically administered thrombolytic therapy > none
17. Acute PE not associated with hypotension – systemically administered thrombolytic therapy is not
recommended
a. Who deteriorate after starting anticoagulation therapy and low bleeding risk – systemically
administered thrombolytic therapy
18. Acute PE associated with hypotension (SBP < 90 mmHg) and have a high bleeding risk, failed systemic
thrombolysis, or shock that’s likely to cause death within a few hours (before thrombolysis can begin
working) – catheter-assisted thrombus removal* > none
19. CTEPH* - pulmonary thromboendartectomy > none
20. UEDVT (axillary or more proximal veins) – anticoagulant therapy alone > thrombolysis
a. If undergo thrombolysis – use same intensity/duration as patients who don’t undergo thrombolysis
21. Recurrent VTE on VKA therapy/NOAC and compliant* - switch treatment to LMWH (at least temporarily)
a. If on LMWH – increase dose of LMWH by ¼ - 1/3
