In this episode, I’ll discuss the consolidated CHEST guidelines on antithrombotic therapy for venous thromboembolism disease.
The CHEST guidelines on venous thromboembolism disease are an invaluable resource, but one flaw that has persisted since 2016 has made referencing the guidelines awkward and inconvenient. When the 1st updated to the 9th edition of the guidelines was published in 2016 the authors chose to only carry forward guidance statements that were new or changed. This meant that any unchanged guidance statements from the 2012 9th edition were still considered to be part of the guidelines, but were not reprinted in the 2016 document. When the 2nd update of the guidelines happened in 2021, the practice continued, leaving important information and guidance statements spread across 3 documents.
For example, if a clinician wanted to review the latest guideline information on risk factors for bleeding, they would need to review table 11 in the 2016 1st update to the guidelines. If they wanted to know what the guideline authors recommended for resuming IV heparin after surgery was, they would need to review the 2012 guideline document on perioperative management of antithrombotic therapy. In addition, there was a nomenclature change between the 2016 and 2021 update where the term NOAC was abandoned for the term DOAC to refer to the direct-acting oral anticoagulants.
This drawback reduced the utility of the guidelines and introduced the possibility for confusion about what the current recommendations from the panel were.
Thankfully a new document has been published to address these issues in the journal CHEST titled Antithrombotic Therapy for VTE Disease: Compendium and Review of CHEST Guidelines 2012-2021.
This new document now contains a definitive list of all guidance statements using the most recent version from the previous publications. Below each statement, the panel of experts added remarks to give additional context to the guidance statements. In addition, the recommendations are now color coded with green representing a recommendation in favor, red representing a recommendation against, and the intensity of the color in terms of dark or light representing strong or weak recommendations.
Finally, the panel identified 5 statements that are no longer considered relevant to practice. These 5 statements and their rationale for deletion are as follows:
From 2012:
Statement 2.5.2 read: In patients with acute DVT of the leg treated with LMWH, we suggest once- over twice-daily administration, and statement 5.4.2. read: in patients with acute PE treated with LMWH, we suggest once- over twice-daily administration. These were removed because they were confusing and could lead to incorrect dosing.
Statement 9.4 read: In patients with acute symptomatic UEDVT, we suggest against the use of compression sleeves or venoactive medications. This was removed due to lack of evidence supporting any guideline statement on the issue.
Statment 11.2 read: In patients with incidentally detected hepatic vein thrombosis, we suggest no anticoagulation over anticoagulation. This was removed because it is in conflict with newer versions of the guidelines and the panel no longer supports it.
From 2016:
Statement 4 read: In patients with DVT of the leg or PE who receive extended therapy, we suggest that there is no need to change the choice of anticoagulant after the first 3 months. This was removed because it could be confusing and contradictory to statements in the new compendium.
Statement 26 read: In selected patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are identified by an experienced thromboendarterectomy team, we suggest pulmonary thromboendarterectomy over no pulmonary thromboendarterectomy. This was removed because it was considered out of scope for the guidelines, but not because the panel disagreed with the content of the statement.
Overall, this updated document should make referencing the CHEST guidelines clearer and easier for clinicians.
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