Management of Venous Thromboembolism: A Systematic Review for a Practice Guideline

6 February 2007 | Volume 146 Issue 3

Background: New treatments are available for treatment of venous thromboembolism.

Purpose: To review the evidence on the efficacy of interventions for treatment of deep venous thrombosis (DVT) and pulmonary embolism.

Data Sources: MEDLINE, MICROMEDEX, the Cochrane Controlled Trials Register, and Cochrane Database of Systematic Reviews from the 1950s through June 2006.

Study Selection: Randomized, controlled trials; systematic reviews of trials; and observational studies; all restricted to English-language articles.

Data Extraction: Paired reviewers assessed study quality and abstracted data. The authors pooled results about optimal duration of anticoagulation.

Data Synthesis: This review includes 101 articles. Low-molecular-weight heparin (LMWH) is modestly superior to unfractionated heparin at preventing recurrent DVT and is at least as effective as unfractionated heparin for treatment of pulmonary embolism. Outpatient treatment of venous thromboembolism is likely to be effective and safe in carefully chosen patients, with appropriate services available. Inpatient or outpatient use of LMWH is cost-saving or cost-effective compared with unfractionated heparin. In observational studies, catheter-directed thrombolysis safely restored vein patency in select patients. Moderately strong evidence supports early use of compression stockings to reduce postthrombotic syndrome. Limited evidence suggests that vena cava filters are only modestly efficacious for prevention of pulmonary embolism. Conventional-intensity oral anticoagulation beyond 12 months may be optimal for patients with unprovoked venous thromboembolism, although patients with transient risk factors benefit little from more than 3 months of therapy. High-quality trials support use of LMWH in place of oral anticoagulation, particularly in patients with cancer. Little evidence is available to guide treatment of venous thromboembolism during pregnancy.

Limitations: The authors could not address all management questions, and excluded non–English-language literature.

Conclusions: The strength of evidence varies across the study questions but generally is strong.

Author and Article Information

From Johns Hopkins University School of Medicine, Baltimore, Maryland, and Stanford University School of Medicine, Stanford, California.

Disclaimer: The authors are responsible for the content of this article, including any treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the U.S. Department of Health and Human Services.

Acknowledgments: The authors thank George Barnes and Renee Wilson for assistance with searches and management of the references.

Grant Support: The Johns Hopkins University Evidence-based Practice Center produced this work, portions of which were previously supported by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Rockville, Maryland, through contract 290-97-0006.

Potential Financial Conflicts of Interest: Consultancies: M.B. Streiff (Sanofi-Aventis, GlaxoSmithKline), L.V. Hoffman (Bacchus Vasular, Genentech); Honoraria: M.B. Streiff (Sanofi-Aventis, GlaxoSmithKline); Grants received: E.B. Bass (Agency for Healthcare Research and Quality); Receipt of payment for manuscript preparation: E.B. Bass (American College of Physicians).

Requests for Single Reprints: Jodi Segal, MD, MPH, Johns Hopkins University, 1830 East Monument Street, Room 8047, Baltimore, MD 21205; e-mail, jsegal{at}jhmi.edu.

Current Author Addresses: Dr. Segal: Johns Hopkins University, 1830 East Monument Street, Room 8047, Baltimore, MD 21205.

Dr. Streiff: Johns Hopkins University, 1830 East Monument Street, Suite 7300, Baltimore, MD 21205

Dr. Thornton: Johns Hopkins University, CRB 187-Oncology, 1650 Orleans Street, Baltimore, MD 21231.

Dr. Hoffman: Stanford University Medical Center, H-3646, Stanford, CA 94305.

Author Contributions: Conception and design: J.B. Segal, E.B. Bass.

Analysis and interpretation of the data: J.B. Segal, M.B. Streiff, E.B. Bass.

Drafting of the article: J.B. Segal, M.B. Streiff.

Critical revision of the article for important intellectual content: J.B. Segal, M.B. Streiff, E.B. Bass.

Final approval of the article: J.B. Segal, M.B. Streiff, E.B. Bass.

Statistical expertise: J.B. Segal.

Obtaining of funding: E.B. Bass.

Collection and assembly of data: J.B. Segal, K. Thornton.

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