AHA statement describes prevention, treatment of the postthrombotic syndrome

A new scientific statement from the American Heart Association on the postthrombotic syndrome offers evidence-based prevention, diagnosis, and treatment strategies for inpatient and outpatient care.

The statement, which was published online Sept. 22 and will appear in the Oct. 28 Circulation, begins with an overview of the postthrombotic syndrome (PTS) (including epidemiology, diagnosis, and risk factors), followed by practical recommendations for clinicians caring for patients with deep venous thrombosis (DVT).

Recommendations for primary and secondary prevention of DVT to prevent PTS include using thromboprophylaxis in patients at significant risk for DVT (class I recommendation; C evidence) and providing anticoagulation of appropriate intensity and duration to treat the initial DVT (class I recommendation; B evidence). To optimize anticoagulation, the statement recommends frequent, regular internal normalized ratio monitoring in patients treated with a vitamin K antagonist, especially for the first few months (class I recommendation; B evidence). The effectiveness of new oral anticoagulants compared with vitamin K antagonists is unknown, the statement said (class IIb recommendation; C evidence). Also unknown is the effectiveness of low-molecular-weight heparin (LMWH) alone compared to LMWH followed by a vitamin K antagonist (class IIb recommendation; B evidence).

Effectiveness of elastic compression stockings (ECS) for preventing PTS is also uncertain, but the stockings are reasonable to use in reducing symptomatic swelling in patients with proximal DVT (class IIb recommendation; A evidence). The statement also includes recommendations on thrombolysis and endovascular treatment approaches for acute DVT to prevent PTS.

To treat PTS, a trial of ECS may be considered (class IIb recommendation; C evidence), and for those with a moderate or severe case and significant edema, a trial of intermittent compression is reasonable (class IIb recommendation; C evidence), the statement says. Effectiveness and safety of rutoside, hidrosmin, and defibrotide is uncertain (class IIb recommendation; B evidence), but supervised exercise training is reasonable. For venous ulcer management, the statement says compression should be used (class I recommendation; A evidence), multi-component compression systems are more effective than single-component ones (class I recommendation; B evidence), pentoxifylline can be useful alone or with compression (class IIa recommendation; A evidence), and neovalve reconstruction may be considered in refractory cases (class IIb recommendation; C evidence).

The statement also addresses the special populations of upper-extremity PTS and pediatric PTS and lists research needs in the field.