Treatment Post-Thrombotic Syndrome (PTS)
ÎIn patients with PTS of the leg, the ACCP suggests a trial of compression stockings (2-C).
ÎIn patients with severe PTS of the leg that is not adequately relieved by compression stockings, the ACCP suggests a trial of an intermittent compression device (2-B).
ÎIn patients with PTS of the leg, the ACCP suggests that venoactive medications (eg, rutosides, defibrotide, and hidrosmin) NOT be used (2-C).
Remark: Patients who value the possibility of response over the risk of side effects may choose to undertake a therapeutic trial.
Pulmonary Embolus (PE)
ÎThe ACCP recommends initial treatment with parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or subcut UFH) over no such initial treatment (1-B).
• In patients with a high clinical suspicion of acute PE, the ACCP suggests treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests (2-C).
• In patients with an intermediate clinical suspicion of acute PE, the ACCP suggests treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h (2-C).
• In patients with a low clinical suspicion of acute PE, the ACCP suggests not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (2-C).
ÎThe ACCP suggests LMWH or fondaparinux over IV UFH (2-C for LMWH; 2-B for fondaparinux) and over subcut UFH (2-B for LMWH; 2-C for fondaparinux).
Remark: Local considerations such as cost, availability, and familiarity of use dictate the choice between fondaparinux and LMWH.
ÎIn patients treated with LMWH, the ACCP suggests once- over twice- daily administration (2-C).
Remark: This recommendation applies only when the approved once-daily regimen uses the same daily dose as the twice-daily regimen (ie, the once-daily injection contains double the dose of each bid injection). It also places value on avoiding an extra injection per day.
ÎThe ACCP recommends early initiation of VKA (eg, same day as parenteral therapy is started) over delayed initiation, and continuation of parenteral anticoagulation for a minimum of 5 days and until the INR is ≥ 2.0 for at least 24 h (1-B).
ÎIn patients with low-risk PE and whose home circumstances are adequate, the ACCP suggests early discharge over standard discharge (eg, after first 5 days of treatment) (2-B).
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Remark: Patients who prefer the security of the hospital to the convenience and comfort of home are likely to choose hospitalization over home treatment.
