Updated recommendations are highlighted in this guideline for the treatment of patients with venous thromboembolism (VTE). Among the updated recommendations are:

• For VTE in patients who do not have cancer, as long-term anticoagulant therapy, dabigatran, rivaroxaban, apixaban, or edoxaban is suggested over VKA (vitamin K antagonist i.e., warfarin) therapy, and VKA therapy is suggested over LMWH.

• For patients with isolated distal DVT who do not have severe symptoms or risk factors for extension serial imaging of the deep veins for 2 weeks is recommended over anticoagulation.

• For DVT, the guidelines suggest not using compression stockings routinely to prevent PTS.

• For subsegmental PE and no proximal DVT, clinical surveillance is suggested over anticoagulation in patients with a low risk of recurrent VTE.

• Thrombolytic therapy is indicated only for pulmonary embolus with hypotension. Systemic therapy is recommended over catheter directed thrombolysis.

• In patients who do not continue extended anticoagulation after VTE, aspirin may be used to decrease recurrence by about one-third, compared to the 80% decrease with full anticoagulation.

• Recommendations for who should stop anticoagulation at 3 months or receive extended therapy have not changed.

Citation: Kearon O, Aki EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline. Chest. 2016. doi:10.1016/j.chest.2015.11.026.

Commentary: The most common questions regarding VTE that we face in primary care is which anticoagulant to use in the treatment of VTE, and how long we should treat for. The first decision we make after the diagnosis of VTE is whether to treat with heparin bridging to warfarin therapy vs using a non-vitamin K oral anticoagulant (NOAC). Evidence shows that the risk reduction for recurrent VTE with NOACs is similar to the risk reduction with VKA. The risk of bleeding, particularly intra-cranial bleeding, is lower with NOACs than with warfarin. Based on the lower risk of bleeding and the greater convenience of NOACs, the ACCP in this guideline recommend NOACs as the preferred agents. The next important decision is the duration of therapy. There is a 30%, 5-year recurrence rate after a single unprovoked DVT or PE. An isolated distal DVT has the rate of recurrence that is about half as much as after a proximal DVT or PE. The risk of recurrence after a second unprovoked episode is approximately 50% higher than after a single episode. This high recurrence risk is why ACCP has consistently recommended long-term anticoagulant therapy after unprovoked DVT or PE for patients who are not at excessive risk of bleeding. —Neil Skolnik, MD