Kearon et al. Chest. 2016. doi:10.1016/j.chest.2015.11.026
"Background
We update recommendations on 12 topics that were in the 9th edition of these guidelines, and address 3 new topics.
Methods
We generate strong (Grade 1) and weak (Grade 2) recommendations based on high (Grade A), moderate (Grade B) and low (Grade C) quality evidence
Results
For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B) or edoxaban (Grade 2B) over VKA therapy, and suggest VKA therapy over LMWH (Grade 2C). For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C) or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an IVC filter (Grade 1B). For DVT, we suggest not using compression stockings routinely to prevent PTS (Grade 2B). For subsegmental PE and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C), and anticoagulation over clinical surveillance with a high risk (Grade 2C). We suggest thrombolytic therapy for PE with hypotension (Grade 2B), and systemic therapy over catheter directed thrombolysis (Grade 2C). For recurrent VTE on a non-LMWH anticoagulant, we suggest LMWH (Grade 2C), and for recurrent VTE on LMWH we suggest increasing the LMWH dose (Grade 2C).
Conclusion
Of 54 recommendations included in the 30 statements, 20 were strong and none was based on high quality evidence highlighting the need for further research."
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Emergency Medicine Literature of Note - January 13, 2016 - Posted by Ryan Radecki
"This new guideline states patients with subsegmental PE, without another identifiable VTE source, and at low risk for recurrent VTE, have the option of watchful waiting. They cite no new groundbreaking evidence, but generally recognize the low rates of recurrent VTE in retrospective and observational studies. They also recognize a diagnosis of subsegmental PE is quite likely to be a false-positive, as covered in my last ACEPNow column, unless the following conditions are met:
We suggest that a diagnosis of subsegmental PE is more likely to be correct (i.e. a true-positive) if: (1) the CT pulmonary angiogram (CTPA) is of high quality with good opacification of the distal pulmonary arteries; (2) there are multiple intraluminal defects; (3) defects involve more proximal sub-segmental arteries (i.e. are larger); (4) defects are seen on more than one image; (5) defects are surrounded by contrast rather than appearing to be adherent to the pulmonary artery; (6) defects are seen on more than one projection; (7) patients are symptomatic, as opposed to PE being an incidental finding; (8) there is a high clinical pre-test probability for PE; and D-Dimer level is elevated, particularly if the increase is marked and otherwise unexplained.
Patients discharged without anticoagulation should be provided prospective guidance on seeking care for new or progressive symptoms. These recommendations are appropriately GRADE category 2C, reflecting moderate/weak certainty and a low level of evidence – but, it at least provides a framework to have a reasonable conversation and shared decision-making with a patient."