Venous thromboembolism

About VTE

Venous thromboembolism (VTE) includes pulmonary embolism (PE) and deep vein thrombosis (DVT), as well as thrombosis in other parts of the venous system, such as the superficial veins¹. Thrombosis development is thought to be triggered by a combination of blood stasis, plasma hypercoagulability and endothelial dysfunction, most often initiated in the valve pockets of large veins².

What is the burden of VTE?

Globally, VTE is the third most common type of cardiovascular disease, after myocardial infarction and stroke³. VTE is a leading cause of disability, preventable hospital death and mortality worldwide, incurring a high patient and socioeconomic burden of disease^1,4,5.

What are the risk factors for VTE?

Risk factors that can predispose individuals to VTE include surgery, hospitalisation, history of cardiovascular disease, trauma/injury, and some types of medications and medical conditions^3,6. For example, people with cancer are at an increased risk of VTE (cancer-associated thrombosis, CAT)^7,8. The risk of CAT is higher for those with active, metastatic cancer, who are hospitalised and/or undergoing systemic chemotherapy⁹. Considering the unique pathophysiology of thrombosis in patients with cancer, as well as additional considerations for treatment, specific guideline recommendations are available to inform management of CAT^1,3,9–11.

How is venous thromboembolism diagnosed?

The most common symptoms of DVT include pain, swelling and tenderness in the affected part of the body^1,3,12. Symptoms of PE include dyspnoea/shortness of breath, haemoptysis, presyncope or syncope, tachycardia, hypotension and chest pain^1,3,12. A diagnosis of VTE is not always straightforward because other conditions have similar symptoms^12,13. For DVT, the diagnostic approach is informed by the suspected location of the DVT and clinical probability of DVT. For PE without haemodynamic instability, diagnosis is also informed by clinical probability, whereas PE with haemodynamic instability requires an emergency diagnosis and immediate referral for reperfusion treatment³.

What do current guidelines recommend for management of venous thromboembolism?

According to 2020/2021 guidelines^1,3,10,14. VTE management includes VTE prophylaxis in high-risk patients, risk assessment (bleeding and thrombosis), treatment selection, guidance on which patients with VTE may be managed at home and monitoring/follow-up. Treatment options for VTE include pharmacological anticoagulant therapies such as vitamin K antagonists (VKAs), low molecular weight heparin (LMWH), direct acting oral anticoagulants (DOACs), and thrombolytic therapies^1,3,10,12,14. Phases of VTE treatment include initial and primary treatment (3–6 months), after which a decision should be made about whether to continue anticoagulation for secondary prevention of VTE recurrence^3,12,14.

References

1. Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. European Journal of Vascular and Endovascular Surgery. 2021;61(1):9–82.
2. Wolberg AS, Rosendaal FR, Weitz JI, Jaffer IH, Agnelli G, Baglin T, et al. Venous thrombosis. Nature Reviews Disease Primers. 2015;1.
3. Konstantinides S v., Meyer G, Bueno H, Galié N, Gibbs JSR, Ageno W, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS). European Heart Journal. 2020;41(4):543–603.
4. Heit JA. Predicting the risk of venous thromboembolism recurrence. American Journal of Hematology. 2012;87(Suppl 1):S63–S67.
5. Badescu M, Ciocoiu M, Badulescu O, Vladeanu M-C, Bojan I, Vlad C, et al. Prediction of bleeding events using the VTE‑BLEED risk score in patients with venous thromboembolism receiving anticoagulant therapy (Review). Experimental and Therapeutic Medicine. 2021;22(5).
6. Phillippe H. Overview of venous thromboembolism. American Journal of Managed Care. 2017;23:S376–S382.
7. Fernandes CJ, Morinaga LTK, Alves JL, Castro MA, Calderaro D, Jardim CVP, et al. Cancer-associated thrombosis: The when, how and why. European Respiratory Review. 2019;28(151).
8. Khorana AA, Kuderer NM, Culakova E, Lyman GH, Francis CW. Development and validation of a predictive model for chemotherapy-associated thrombosis. Blood. 2008;111(10):4902–4907.
9. Lyman GH, Carrier M, Ay C, Nisio M di, Hicks LK, Khorana AA, et al. American Society of Hematology 2021 guidelines for management of venous thromboembolism: Prevention and treatment in patients with cancer. Blood Advances. 2021;5(4):927–974.
10. National Comprehensive Cancer Network. NCCN Guidelines: Cancer-associated venous thromboembolic disease (version 3). 2021. Dated November 15, 2021.
11. Key NS, Chb MB, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update. Journal of Clinical Oncology. 2019;38:496–520.
12. National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing: NICE Guideline. 2020.
13. Lim W, le Gal G, Bates SM, Righini M, Haramati LB, Lang E, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: Diagnosis of venous thromboembolism. Blood Advances. 2018;2(22):3226–3256.

14. Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Cuker A, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: Treatment of deep vein thrombosis and pulmonary embolism. Blood Advances. 2020;4(19):4693–4738.