Venous thromboembolism: Initiation of anticoagulation (first 10 days)
- Gregory YH Lip, MD, FRCPE, FESC, FACC
Gregory YH Lip, MD, FRCPE, FESC, FACC
- Professor of Cardiovascular Medicine
- The University of Birmingham, UK
- Russell D Hull, MBBS, MSc
Russell D Hull, MBBS, MSc
- Professor of Medicine
- University of Calgary, Canada
- Section Editors
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
- Jess Mandel, MD
Jess Mandel, MD
- Section Editor — Pulmonary Vascular Disease
- Professor of Medicine
- University of California, San Diego
Venous thromboembolism (VTE) is comprised of two entities, deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE has significant morbidity and mortality for both the inpatient and outpatient population. The risk of recurrent thrombosis and embolization is highest in the first few days and weeks following diagnosis. Thus, initial anticoagulation during the first few days (ie, 0 to 10 days) is critical in the prevention of recurrence and VTE-related death.
The agents used, timing, duration, and dosing of initial anticoagulation for the treatment of VTE are discussed in this topic. The indications and overview of VTE treatment, as well as long-term (3 to 12 months) and extended (indefinite) anticoagulation for patients with VTE are discussed separately. (See "Overview of the treatment of lower extremity deep vein thrombosis (DVT)", section on 'Patients with contraindications to anticoagulation' and "Venous thromboembolism: Anticoagulation after initial management" and "Rationale and indications for indefinite anticoagulation in patients with venous thromboembolism".)
For the purposes of discussion in this topic, the following terms apply:
●Initial anticoagulation refers to anticoagulant therapy that is administered immediately following diagnosis of acute venous thromboembolism (VTE); it is often given over the first few days (typically from 0 to 10 days) while planning for long term anticoagulation. Long-term anticoagulant therapy is typically administered for a finite period beyond the initial period, usually three to six months and occasionally up to 12 months. Extended anticoagulation usually refers to therapy that is administered indefinitely. (See "Venous thromboembolism: Anticoagulation after initial management" and "Rationale and indications for indefinite anticoagulation in patients with venous thromboembolism".)
●Factor Xa and direct thrombin inhibitors have a variety of names including newer/novel oral anticoagulants, non-vitamin K antagonist oral anticoagulants (NOAs, NOACs), direct oral anticoagulants (DOACs), and target-specific oral anticoagulants (TOACs, TSOACs) . Throughout this topic we refer to these agents by their pharmacologic class, factor Xa and direct thrombin inhibitors. (See "Direct oral anticoagulants: Dosing and adverse effects".)
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- BLEEDING RISK
- SELECTION OF AGENT
- General population
- Special populations
- - Renal failure
- - Hemodynamic instability
- - Extensive clot burden
- - Anticipated need for discontinuation or reversal
- - Obesity or poor subcutaneous absorption
- - Malignancy
- - Pregnancy
- - Heparin-induced thrombocytopenia
- OUTPATIENT ANTICOAGULATION
- ANTICOAGULANT AGENTS
- Low molecular weight heparin
- - Dosing
- - Efficacy
- - Dosing
- - Efficacy
- Unfractionated heparin
- - Dosing
- - Efficacy
- Direct factor Xa and thrombin inhibitors
- - Dosing
- - Efficacy
- Duration of therapy for heparin
- EMPIRIC ANTICOAGULATION
- TRANSITIONING TO MAINTENANCE THERAPY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS