Most patients with DVT and/or PE provoked by temporary risk factors will discontinue anticoagulant therapy after completion of the primary treatment. The certainty in the evidence was judged moderate for mortality, PE, and major bleeding because of imprecision, given that the CI around the absolute estimates likely crossed the thresholds that patients would consider important. Treatment of deep vein thrombosis: what factors determine appropriate treatment? Conditional recommendations include the preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications and a preference for direct oral anticoagulants over VKA for primary treatment of VTE. One Markov model272  compared an unlimited duration of conventional-intensity anticoagulation (INR range, 2.0-3.0) vs low-intensity anticoagulation (INR range, 1.5-2.0) with warfarin. The meta-analysis showed that, compared with discontinuation of anticoagulation, treating patients with indefinite antithrombotic therapy reduced the risk of PE in the study population (RR, 0.29; 95% CI, 0.15-0.56; ARR, 21 fewer per 1000 patients; 95% CI, 25 fewer to 13 fewer; high-certainty evidence), as well as for patients with recurrent provoked VTE269,324  (ARR, 18 fewer per 1000 patients; 95% CI, 21 fewer to 11 fewer; high-certainty evidence). However, they may help to select patients at low risk for complications. 3.1.2. The final document and supplemental material were revised to address pertinent inputs, but no changes were made to recommendations. The certainty in the evidence was judged moderate for mortality, major bleeding, PE, and DVT because of imprecision, given a small number of events in both treatment arms that did not meet the optimal information size and the fact that the CIs around the absolute estimates likely crossed the thresholds that patients would consider important. After completion of the primary treatment phase, anticoagulant therapy is typically discontinued for patients with VTE provoked by transient risk factors, and secondary prevention does not need to be considered (Figure 2). One economic evaluation in a Canadian setting based on a decision tree suggests home treatment as cost effective compared with hospital management.41  The other 4 reports suggest that home management leads to cost savings without compromising outcome effects and safety. was vice chair of the panel and led the panel meeting. We explored heterogeneity with the χ2 test and with the I2 statistic. Using a DOAC for the longer course of anticoagulation reduced the risk of DVT in the study population (RR, 0.21; 95% CI, 0.11-0.41; ARR, 62 fewer per 1000 patients; 95% CI, 70 fewer to 46 fewer; moderate-certainty evidence), as well as in a low-risk population268  (ARR, 18 fewer per 1000 patients; 95% CI, 21 fewer to 14 fewer; high-certainty evidence). The diagnosis, risk assessment, and management of pulmonary embolism have evolved with a better understanding of efficient use of diagnostic and therapeutic options. Introduction-GRADE evidence profiles and summary of findings tables, GRADE: an emerging consensus on rating quality of evidence and strength of recommendations, GRADE Guidelines: 16. It should be noted that patients with chronic risk factors for VTE may also have 1 (or more) transient risk factor (eg, surgery) or other nonenvironmental risk factors, such as an inherited thrombophilia, older age, or male sex.237  These additional risk factors do not change this recommendation for duration of the primary treatment phase for the thromboembolic event. The purpose of this guideline is to provide evidence-based recommendations about the treatment of DVT and PE for patients without cancer. Rather, the study assessed the effect of anticoagulation in individuals with a high D-dimer level, which is a related question but not the specific question addressed by the panel. Both tests are generally available, but ultrasonography is operator dependent and, therefore, results might vary in different settings. The guideline does not cover pregnant women. The EtD framework is shown online at: https://guidelines.gradepro.org/profile/88899593-89FA-D803-95A0-B9E113F2B50D (Recommendation 27) and https://guidelines.gradepro.org/profile/77202CC8-4CE2-DE7B-8EFF-96F7C0E80DFD (Recommendation 28). This recommendation does not apply to patients who have other conditions that would require hospitalization, have limited or no support at home, and cannot afford medications or have a history of poor adherence. Recusal was used to manage conflicts of interest. The treatment of distal (below the knee) deep vein thrombosis (DVT) is not clearly established. Ultrasound. 2020 Oct 13;4(19):4693-4738. doi: 10.1182/bloodadvances.2020001830. These patients may have ≥1 nonenvironmental risk factor for recurrent VTE, such as inherited thrombophilia, older age, and/or male sex, but these variables would not affect this recommendation concerning the duration of the primary treatment phase for the thromboembolic event. In contrast, many patients with DVT and/or PE provoked by chronic risk factors, as well as patients with unprovoked DVT and/or PE, may continue anticoagulant therapy indefinitely for secondary prevention after completion of the primary treatment (Figure 2). They may also be used by patients. These trials reported the effect of antithrombotic therapy on mortality, VTE, and major bleeding. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. In most patients with proximal DVT, the ASH guideline panel suggests anticoagulation therapy alone over thrombolytic therapy in addition to anticoagulation (conditional recommendation based on low certainty in the evidence of effects ⨁⨁○○). In Part A of the forms, individuals disclosed material interests for 2 years prior to appointment. A second set of trials included adults with objectively confirmed DVT and/or PE who had been treated with anticoagulants for 3 to 6 months without recurrence; they were randomized to receive placebo or continue with ≥6 months of additional treatment. Lastly, and most importantly, an infrastructure to provide outpatient PE treatment needs to be established to ensure that patients can be followed closely. The effect of compression stockings on PTS and DVT observed in the SOX trial was significantly different from the results of unblinded trials, as demonstrated by the tests for interaction. Additional research is necessary to identify which subsets of patients who are going to continue anticoagulant therapy indefinitely for secondary prevention can safely use a lower-dose DOAC and which patients should be maintained on a standard dose (eg, obese individuals and patients at higher risk for recurrence). 2: Clinical practice guidelines, GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. We did not identify harmful effects of stockings. Implementation of this recommendation depends on the ability to rapidly evaluate patients and initiate appropriate therapy. We considered that avoidance of PE, DVT, and major bleeding was critical for patients. The majority of individuals in this situation would want the suggested course of action, but many would not. However, new evidence may change the recommendations in the future, especially those based on low- or very-low-certainty evidence. Members of the VTE Guideline Coordination Panel reviewed the disclosures and judged which interests were conflicts and should be managed. We estimated an annualized risk for major bleeding of 2.1% assuming a risk for major bleeding close to 0 after anticoagulant discontinuation. A DVT and/or PE that occurs in the absence of any transient or chronic environmental risk factors for VTE is considered unprovoked. Remarks: Patients who present with a new VTE event during therapeutic VKA treatment should be further investigated to identify potential underlying causes. VTE, which includes DVT and PE, occurs in ∼1 to 2 individuals per 1000 each year, or ∼300 000 to 600 000 events in the United States annually.4  DVT most commonly occurs in the lower extremities but also affects the upper extremities.5,6  Approximately one third of all patients with a new diagnosis of VTE have PE, with or without DVT,7-9  and it is estimated that up to a quarter of all patients with PE present with sudden death.4, The risk for recurrent VTE varies according to whether the initial event was associated with an acquired risk factor, referred to as a provoked event, or in the absence of any provoking risk factors, referred to as an unprovoked event.10  For patients with unprovoked VTE, the risks of recurrent VTE after completing a course of anticoagulant therapy have been estimated to be 10% by 2 years and >30% by 10 years.11,12  Long-term complications include PTS, which develops in 20% to 50% of patients after DVT and is severe in up to 5% of cases,13  and chronic thromboembolic pulmonary hypertension, which may develop in up to 5% of patients with PE.14, Anticoagulant therapy is very effective at preventing recurrent VTE but is associated with an increased frequency of bleeding complications. 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