What you need to know about antithrombotic guidelines

The lack of evidence supporting the “economy class syndrome” myth in air travel made major news headlines recently. While certainly interesting and accurate, that topic was just one among many topics addressed in the larger framework of the new evidence-based guidelines.

The American College of Chest Physicians (ACCP) released the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in its February issue of CHEST, the peer-reviewed journal of the ACCP.  This ninth edition of the guidelines represents important innovations in terms of methodology and recommendations.

As the Guidelines Panel Chair, I’d like to share insight into some of the advances that had an impact on the more than 600 recommendations for the prevention, diagnosis, and treatment of thrombosis (blood clots), a serious condition that affects between 350,000 and 600,000 Americans each year.

First and foremost, these guidelines are based on patient-centered care. Explicit consideration was given to increased focus on patient values and preferences, restricting the outcomes only to those deemed important for the patient.

For instance, there has been a drive to give every patient deep vein thrombosis (DVT) prevention therapy, regardless of his or her risk factors. As a result, many patients receive unnecessary therapies that provide little benefit and could have adverse effects.

Instead, these new guidelines recommend that health-care practitioners focus on the individual patient, suggesting that clinicians consider a patient’s risk for DVT/venous thromboembolism and risk for bleeding before administering or prescribing preventive therapy. To take it one step further, the guidelines provide comprehensive risk recommendations for clinical areas that include medical patients, nonorthopedic surgery, orthopedic surgery, pregnancy, cardiovascular disease, atrial fibrillation, stroke, pediatrics, and long-distance travel.

Antithrombotic guideline authors took a critical look at the overall development process, scrutinizing the methodology. This led to the resulting evidence that the risk of DVT in most long-distance travel is extremely low, and for most people, not worth any other intervention other than moving around periodically.

The guidelines do note groups of people at sufficient risk for the development of DVT that it might be an issue during long-distance travel on flights longer than 6 hours. These include:

  • Previous DVT/pulmonary embolism or known thrombophilic disorder
  • Malignancy
  • Recent surgery or trauma
  • Immobility
  • Advanced age
  • Estrogen use, including oral contraceptives
  • Pregnancy
  • Severe obesity

The guideline offers recommendations for travelers at increased risk who are on flights of 6 hours or more. These include frequent movement; calf muscle stretching; sitting in an aisle seat, if possible; and considering the use of below-knee compression stockings.

The guidelines are endorsed by the following medical associations: the American Association for Clinical Chemistry, American College of Clinical Pharmacy, American Society of Health-System Pharmacists, American Society of Hematology, International Society of Thrombosis and Hemostasis, and the American College of Obstetrics and Gynecology (pregnancy article only).

I am proud of the depth of knowledge, thought, and detail that went into the development of these guidelines. I believe that it will lead to a significant improvement in diagnosing, treating, and preventing DVT.

For more information about the guidelines and accompanying clinician resources, visit the ACCP Antithrombotic Guidelines. Patient resources can be found at OneBreath.

Gordon Guyatt is Guidelines Panel Chair, American College of Chest Physicians.

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