Updates in ACCP antithrombotic guidelines

What is new in the updated American College of Chest Physicians (ACCP) antithrombotic guidelines? In your opinion, what are the most important changes?

James Douketis: The ACCP guidelines are considered the foundation for evidence-based practices for the prevention and treatment of venous thromboembolic disease. Just this year [video was recorded in 2016], a  new, 10th edition of these guidelines was published. It covered a broad spectrum of areas ranging from treatment of small, calf deep vein thrombosis (DVT) to treatment of extensive, life-threatening, massive DVT and pulmonary embolism.

[I think there are] 3 key areas that are different. The first is that now, with the availability of novel oral anticoagulants (NOACs), the guidelines have provided a suggestion that [NOACs] should be first-line treatment for acute venous thromboembolism over the conventional treatment of low-molecular-weight heparin and vitamin K antagonists. But this is not a strong recommendation, so we can continue to use the current treatment.

The second area that is different is in the prevention of the postthrombotic syndrome, with the SOX trial, which showed that using compression socks in all patients after lower extremity DVT does not appear to be a benefit to reduce the risk of postthrombotic syndrome. So that is a new recommendation. Having said that, we can still use compression stockings in patients who have symptoms of the postthrombotic syndrome, such as swelling or pain.

The third area is patients with cancer-associated thrombosis. The 10th edition of ACCP guidelines reaffirmed that low-molecular-weight heparins remain the first-line treatment for cancer-associated thrombosis, but now there is a  mention of using a NOAC as an alternative to a vitamin K antagonist.