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| ==2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)<ref name="pmid22315276">{{cite journal| author=Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO et al.| title=VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e691S-736S | pmid=22315276 | doi=10.1378/chest.11-2300 | pmc=PMC3278054 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315276 }} </ref>==
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| ===Maternal Complications of Anticoagulant Therapy===
| | 6.0 Long-term Treatment of Patients With PE |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For pregnant patients, we recommend LMWH for the prevention and treatment of VTE, instead of UFH. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
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| |}
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| ===Fetal Complications of Antithrombotic Therapy During Pregnancy===
| | 6.4. In patients with PE and active cancer, if there is a low or moderate bleeding risk, we recommend extended anticoagulant therapy over 3 months of therapy (Grade 1B), and if there is a high bleeding risk, we suggest extended anticoagulant therapy (Grade 2B). |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women receiving anticoagulation for the treatment of VTE who become pregnant, we recommend LMWH over vitamin K antagonists during the first trimester ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: A]]), in the second and third trimesters ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]]), and during late pregnancy when delivery is imminent ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]]). ''''<nowiki>"</nowiki>
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For pregnant patients, we recommend LMWH for the prevention and treatment of VTE, instead of UFH. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' For pregnant women, we recommend avoiding the use of oral direct thrombin (eg, dabigatran) and anti-Xa (eg, rivaroxaban, apixaban) inhibitors. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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|
| {|class="wikitable"
| | Remarks: In all patients who receive extended anticoagulant therapy, the continuing use of treatment should be reassessed at periodic intervals (eg, annually). |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For women requiring long-term vitamin K antagonists who are attempting pregnancy and are candidates for LMWH substitution, we suggest performing frequent pregnancy tests and substituting LMWH for vitamin K antagonists when pregnancy is achieved rather than switching to LMWH while attempting pregnancy. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For pregnant women, we suggest limiting the use of fondaparinux and parenteral direct thrombin inhibitors to those with severe allergic reactions to heparin (eg, HIT) who cannot receive danaparoid. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
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| |}
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|
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| ===Use of Anticoagulants in Breast-feeding Women===
| | 6.5. In patients with PE who are treated with VKA, we recommend a therapeutic INR range of 2.0 to 3.0 (target INR of 2.5) over a lower (INR < 2) or higher (INR 3.0-5.0) range for all treatment durations (Grade 1B). |
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| {|class="wikitable"
| | 6.6. In patients with PE and no cancer, we suggest VKA therapy over LMWH for long-term therapy (Grade 2C). For patients with PE and no cancer who are not treated with VKA therapy, we suggest LMWH over dabigatran or rivaroxaban for long-term therapy (Grade 2C). |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For lactating women using warfarin, acenocoumarol, or UFH who wish to breast-feed, we recommend continuing the use of warfarin, acenocoumarol, or UFH. ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: A]]) ''''<nowiki>"</nowiki>
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For lactating women using LMWH, danaparoid, or r-hirudin who wish to breast-feed, we recommend continuing the use of LMWH, danaparoid, or r-hirudin. ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]]) ''''<nowiki>"</nowiki>
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| |-
| |
|
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|
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' For breast-feeding women, we recommend alternative anticoagulants rather than oral direct thrombin (eg, dabigatran) and factor Xa inhibitors (eg, rivaroxaban, apixaban). ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]]) ''''<nowiki>"</nowiki>
| | 6.7. In patients with PE and cancer, we suggest LMWH over VKA therapy (Grade 2B). In patients with PE and cancer who are not treated with LMWH, we suggest VKA over dabigatran or rivaroxaban for long-term therapy (Grade 2C). |
| |-
| |
| |}
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|
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For breast-feeding women, we suggest alternative anticoagulants rather than fondaparinux. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For lactating women using low-dose aspirin for vascular indications who wish to breast-feed, we suggest continuing this medication. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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|
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| ===VTE in Patients Using Assisted Reproductive Technology===
| |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women undergoing assisted reproduction, we recommend against the use of routine thrombosis prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
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| |}
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|
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|
| {|class="wikitable"
| | 3.6 Patients Undergoing General, GI, Urological, Gynecologic, Bariatric, Vascular, Plastic, or Reconstructive Surgery |
| |-
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| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For women undergoing assisted reproduction who develop severe ovarian hyperstimulation syndrome, we suggest thrombosis prophylaxis (prophylactic LMWH) for 3 months postresolution of clinical ovarian hyperstimulation syndrome rather than no prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
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| |}
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|
| |
|
| ===VTE Following Cesarean Section===
| | 3.6.6. For high-VTE-risk patients undergoing abdominal or pelvic surgery for cancer who are not otherwise at high risk for major bleeding complications, we recommend extended-duration pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women undergoing cesarean section without additional thrombosis risk factors, we recommend against the use of thrombosis prophylaxis other than early mobilization. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
| |
| |}
| |
|
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|
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For women at increased risk of VTE after cesarean section because of the presence of one major or at least two minor risk factors, we suggest pharmacologic thromboprophylaxis (prophylactic LMWH) or mechanical prophylaxis (elastic stockings or intermittent pneumatic compression) in those with contraindications to anticoagulants while in hospital following delivery rather than no prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For women undergoing cesarean section who are considered to be at very high risk for VTE and who have multiple additional risk factors for thromboembolism that persist in the puerperium, we suggest that prophylactic LMWH be combined with elastic stockings and/or intermittent pneumatic compression over LMWH alone. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' For selected high-risk patients in whom significant risk factors persist following delivery, we suggest extended prophylaxis (up to 6 weeks after delivery) following discharge from the hospital. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
| |
| |}
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|
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|
| ===Treatment of Proven Acute VTE During Pregnancy===
| |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For pregnant women with acute VTE, we recommend therapy with adjusted-dose subcutaneous LMWH over adjusted-dose UFH. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For pregnant women with acute VTE, we recommend LMWH over vitamin K antagonist treatment antenatally. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' For pregnant women receiving adjusted-dose LMWH therapy and where delivery is planned, we recommend discontinuation of LMWH at least 24 h prior to induction of labor or cesarean section (or expected time of neuraxial anesthesia) rather than continuing LMWH up until the time of delivery. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
| |
| |}
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|
| {|class="wikitable"
| | 4.0 Patients With Cancer in the Outpatient Setting |
| |-
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| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For pregnant women with acute VTE, we suggest that anticoagulants should be continued for at least 6 weeks postpartum (for a minimum total duration of therapy of 3 months) in comparison with shorter durations of treatment. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
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| |}
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|
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|
| ===Prevention of VTE in Pregnant Women With Prior DVT or PE===
| | 4.2.1. In outpatients with cancer who have no additional risk factors for VTE, we suggest against routine prophylaxis with LMWH or LDUH (Grade 2B) and recommend against the prophylactic use of VKAs (Grade 1B). |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For all pregnant women with prior VTE, we suggest postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than no prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For pregnant women at low risk of recurrent VTE (single episode of VTE associated with a transient risk factor not related to pregnancy or use of estrogen), we suggest clinical vigilance antepartum rather than antepartum prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' For pregnant women at moderate to high risk of recurrent VTE (single unprovoked VTE, pregnancy- or estrogen-related VTE, or multiple prior unprovoked VTE not receiving long-term anticoagulation), we suggest antepartum prophylaxis with prophylactic- or intermediate-dose LMWH rather than clinical vigilance or routine care. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' For pregnant women receiving long-term vitamin K antagonists, we suggest adjusted-dose LMWH or 75% of a therapeutic dose of LMWH throughout pregnancy followed by resumption of long-term anticoagulants postpartum, rather than prophylactic-dose LMWH. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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|
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| ===Prevention of VTE in Pregnant Women With Thrombophilia and No Prior VTE===
| | Remarks: Additional risk factors for venous thrombosis in cancer outpatients include previous venous thrombosis, immobilization, hormonal therapy, angiogenesis inhibitors, thalidomide, and lenalidomide. |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and have a positive family history for VTE, we suggest antepartum prophylaxis with prophylactic- or intermediate-dose LMWH and postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than no prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For pregnant women with all other thrombophilias and no prior VTE who have a positive family history for VTE, we suggest antepartum clinical vigilance and postpartum prophylaxis with prophylactic- or intermediate-dose LMWH or, in women who are not protein C or S deficient, vitamin K antagonists targeted at INR 2.0 to 3.0 rather than routine care. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and who do not have a positive family history for VTE, we suggest antepartum clinical vigilance and postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than routine care. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' For pregnant women with all other thrombophilias and no prior VTE who do not have a positive family history for VTE, we suggest antepartum and postpartum clinical vigilance rather than pharmacologic prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |}
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| ===Thrombophilia and Pregnancy Complications===
| | 4.2.2. In outpatients with solid tumors who have additional risk factors for VTE and who are at low risk of bleeding, we suggest prophylactic-dose LMWH or LDUH over no prophylaxis (Grade 2B). |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women with recurrent early pregnancy loss (three or more miscarriages before 10 weeks of gestation), we recommend screening for APLAs. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For women who fulfill the laboratory criteria for APLA syndrome and meet the clinical APLA criteria based on a history of three or more pregnancy losses, we recommend antepartum administration of prophylactic- or intermediate-dose UFH or prophylactic LMWH combined with low-dose aspirin, 75 to 100 mg/d, over no treatment. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |}
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|
| |
|
| {|class="wikitable"
| | Remarks: Additional risk factors for venous thrombosis in cancer outpatients include previous venous thrombosis, immobilization, hormonal therapy, angiogenesis inhibitors, thalidomide, and lenalidomide. |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
| |
| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For women with a history of pregnancy complications, we suggest not to screen for inherited thrombophilia. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For women with inherited thrombophilia and a history of pregnancy complications, we suggest not to use antithrombotic prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
| |
| |}
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| ===Management of Women With a History of Preeclampsia or Recurrent Fetal Loss and No Thrombophilia===
| | 4.4. In outpatients with cancer and indwelling central venous catheters, we suggest against routine prophylaxis with LMWH or LDUH (Grade 2B) and suggest against the prophylactic use of VKAs (Grade 2C). |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women considered at risk for preeclampsia, we recommend low-dose aspirin throughout pregnancy, starting from the second trimester, over no treatment. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women with two or more miscarriages but without APLA or thrombophilia, we recommend against antithrombotic prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
| |
| |}
| |
| | |
| ===Maternal and Fetal Risks Related to Anticoagulation During Pregnancy for Mechanical Prosthetic Valves===
| |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For pregnant women with mechanical heart valves, we recommend one of the following anticoagulant regimens in preference to no anticoagulation ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: A]])'':
| |
| | |
| (a) Adjusted-dose bid LMWH throughout pregnancy. We suggest that doses be adjusted to achieve the manufacturer’s peak anti-Xa LMWH 4 h postsubcutaneous-injection or
| |
| | |
| (b) Adjusted-dose UFH throughout pregnancy administered subcutaneously every 12 h in doses adjusted to keep the mid-interval aPTT at least twice control or attain an anti-Xa heparin level of 0.35 to 0.70 units/mL or | |
| | |
| (c) UFH or LMWH (as above) until the 13th week, with substitution by vitamin K antagonists until close to delivery when UFH or LMWH is resumed.<nowiki>"</nowiki> | |
| |-
| |
| |}
| |
6.0 Long-term Treatment of Patients With PE
6.4. In patients with PE and active cancer, if there is a low or moderate bleeding risk, we recommend extended anticoagulant therapy over 3 months of therapy (Grade 1B), and if there is a high bleeding risk, we suggest extended anticoagulant therapy (Grade 2B).
Remarks: In all patients who receive extended anticoagulant therapy, the continuing use of treatment should be reassessed at periodic intervals (eg, annually).
6.5. In patients with PE who are treated with VKA, we recommend a therapeutic INR range of 2.0 to 3.0 (target INR of 2.5) over a lower (INR < 2) or higher (INR 3.0-5.0) range for all treatment durations (Grade 1B).
6.6. In patients with PE and no cancer, we suggest VKA therapy over LMWH for long-term therapy (Grade 2C). For patients with PE and no cancer who are not treated with VKA therapy, we suggest LMWH over dabigatran or rivaroxaban for long-term therapy (Grade 2C).
6.7. In patients with PE and cancer, we suggest LMWH over VKA therapy (Grade 2B). In patients with PE and cancer who are not treated with LMWH, we suggest VKA over dabigatran or rivaroxaban for long-term therapy (Grade 2C).
3.6 Patients Undergoing General, GI, Urological, Gynecologic, Bariatric, Vascular, Plastic, or Reconstructive Surgery
3.6.6. For high-VTE-risk patients undergoing abdominal or pelvic surgery for cancer who are not otherwise at high risk for major bleeding complications, we recommend extended-duration pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B).
4.0 Patients With Cancer in the Outpatient Setting
4.2.1. In outpatients with cancer who have no additional risk factors for VTE, we suggest against routine prophylaxis with LMWH or LDUH (Grade 2B) and recommend against the prophylactic use of VKAs (Grade 1B).
Remarks: Additional risk factors for venous thrombosis in cancer outpatients include previous venous thrombosis, immobilization, hormonal therapy, angiogenesis inhibitors, thalidomide, and lenalidomide.
4.2.2. In outpatients with solid tumors who have additional risk factors for VTE and who are at low risk of bleeding, we suggest prophylactic-dose LMWH or LDUH over no prophylaxis (Grade 2B).
Remarks: Additional risk factors for venous thrombosis in cancer outpatients include previous venous thrombosis, immobilization, hormonal therapy, angiogenesis inhibitors, thalidomide, and lenalidomide.
4.4. In outpatients with cancer and indwelling central venous catheters, we suggest against routine prophylaxis with LMWH or LDUH (Grade 2B) and suggest against the prophylactic use of VKAs (Grade 2C).