Executive Summary : Antithrombotic Therapy and …

1 Executive Summary : Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice guidelines Gordon H. Guyatt, Elie A. Akl, Mark Crowther, David D. Gutterman, Holger J. Schu nemann and for the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel Chest 2012;141;7S-47S. DOI The online version of this article, along with updated information and services can be found online on the World Wide Web at: Supplemental material related to this article is available at: Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright2012by the American College of Chest Physicians, 3300. Dundee Road, Northbrook, IL 60062.

2 All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. ( ). ISSN:0012-3692. Downloaded from by guest on February 23, 2012. 2012 American College of Chest Physicians CHEST Supplement Antithrombotic Therapy AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP guidelines . Executive Summary Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice guidelines Gordon H. Guyatt, MD, FCCP; Elie A. Akl, MD, PhD, MPH; Mark Crowther, MD;. David D. Gutterman, MD, FCCP; Holger J. Sch nemann, MD, PhD, FCCP; for the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel*. CHEST 2012; 141(2)(Suppl):7S 47S evidence, and some articles with quite extensive Summary tables of primary studies.

3 In total, this Abbreviations: ACS 5 acute coronary syndrome; AF 5 atrial represented 600 recommendations summarized in fibrillation; AIS 5 arterial ischemic stroke; APLA 5 antiphospolipid 968 pages of text. Many readers responded that the antibodies; ASA 5 acetylsalicylic acid; AT9 5 Antithrombotic result was too voluminous for their liking or prac- Therapy and Prevention of Thrombosis, 9th ed: American tical use. College of Chest Physicians Evidence-Based Clinical Practice Cognizant of this feedback, we worked hard to guidelines ; BMS 5 bare-metal stent; CABG 5 coronary artery bypass graft; CAD 5 coronary artery disease; CDT 5 catheter- minimize the length of the text for the ninth iteration directed thrombosis; CHADS2 5 congestive heart failure, hyperten- of the guidelines Antithrombotic Therapy and Pre- sion, age 75 years, diabetes mellitus, prior stroke or transient vention of Thrombosis, 9th ed: American College of ischemic attack; CSVT 5 cerebral sinovenous thrombosis; CTPH 5 Chest Physicians Evidence-Based Clinical Practice chronic thromboembolic pulmonary hypertension; CUS 5 com- guidelines (AT9) without sacrificing key content.

4 A. pression ultrasound; CVAD 5 central venous access device;. DES 5 drug-eluting stent; GCS 5 graduated compression stockings; number of topic editors found our shortening edits HFS 5 hip fracture surgery; HIT 5 heparin-induced thrombocy- draconian, but we were determined to produce the topenia; HITT 5 heparin-induced thrombocytopenia complicated leanest product possible. by thrombosis; IA 5 intraarterial; ICH 5 intracerebral hemor- There were, however, a number of obstacles. In rhage; IE 5 infective endocarditis; INR 5 international normalized what we believe is a key advance in AT9, we con- ratio; IPC 5 intermittent pneumatic compression; IPCD 5 inter- mittent pneumatic compression device; IVC 5 inferior vena cava; ducted a systematic review of what is known about LDUH 5 low-dose unfractionated heparin; LMWH 5 low-molecular- patients' values and preferences regarding antithrom- weight heparin; LV 5 left ventricular; MBTS 5 modified Blalock- botic Therapy and included the results as an article Taussig shunt; MR 5 magnetic resonance; PAD 5 peripheral artery in AT9.

5 In another forward step, we recognized the disease; PCI 5 percutaneous coronary intervention; PE 5 pul- problems with asymptomatic thrombosis as a surro- monary embolism; PFO 5 patent foramen ovale; PMBV 5 percuta- neous mitral balloon valvotomy; PTS 5 postthrombotic syndrome; gate outcome, and devised strategies to estimate PVT 5 prosthetic valve thrombosis; r-tPA 5 recombinant tissue plas- reductions in symptomatic DVT and pulmonary minogen activator; RVT 5 renal vein thrombosis; SC 5 subcuta- embolism with Antithrombotic prophylaxis. We felt it neous; TEE 5 transesophageal echocardiography; THA 5 total important to explain this innovation to users of AT9, hip arthroplasty; TIA 5 transient ischemic attack; TKA 5 total knee and this meant another article. arthroplasty; UAC 5 umbilical arterial catheter; UEDVT 5 upper- extremity DVT; UFH 5 unfractionated heparin; US 5 ultrasound; We included, for the first time, an article on diag- UVC 5 umbilical venous catheter; VAD 5 ventricular assist device; nosis addressing patients with symptoms and signs VKA 5 vitamin K antagonist suggesting DVT.

6 We increased the range of interven- tions we have covered, resulting in additional recom- mendations. Finally, we produced many Summary TheChesteighth iteration of the American College of Physicians Antithrombotic guidelines pre- of findings tables, which offer extremely succinct and informative presentations of best estimates of effect sented, in a paper version, a narrative evidence sum- and the confidence associated with those estimates. mary and rationale for the recommendations, a small If published in the same fashion as the Antithrom- number of evidence profiles summarizing bodies of botic and Thrombolytic Therapy , 8th ed: American CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 7S. Downloaded from by guest on February 23, 2012. 2012 American College of Chest Physicians College of Chest Physicians Antithrombotic Guide- tables) and some tables summarizing the methods lines, this would have resulted in a document and results, and the risk of bias, associated with the with.

7 850 pages of paper text, an unacceptable individual studies that contributed to the evidence length. Given this and with the advice of the journal, profiles and Summary of findings tables. we decided to adopt a highly focused print version The world of medical information is rapidly becom- that includes only this Executive Summary and the ing a world of electronic storage and presentation following articles: of primary studies, recommendations, and a wide variety of other information of interest to health care An introduction describing the major innovations practitioners. Although our abbreviated paper copy in AT9 presentation represents a necessary response to a A methods article explaining how we devel- challenging situation, it is also a harbinger of the oped the guidelines (a potential model for other increasingly electronic world of medical information guideline groups interested in optimal rigor) into which future editions of guidelines are destined Recommendations and grading from each arti- to move.

8 Cle embedded in the table of contents of each article Summary of Recommendations Those seeking the rationale for the recommenda- Note on Shaded Text: Throughout this guideline, tions, including the supporting evidence, should shading is used within the Summary of recommenda- access the online version of the guideline (http:// tions sections to indicate recommendations that are ) newly added or have been changed since the publica- that includes a narrative summaries and support- tion of Antithrombotic and Thrombolytic Therapy : ing Summary of findings tables. The numbering indi- American College of Chest Physicians Evidence- cated beside the recommendations in this Summary Based Clinical Practice guidelines (8th Edition). Rec- is aligned with the sections and tables found in the ommendations that remain unchanged are not shaded.

9 Full articles. Those interested in a deeper under- standing of the evidence can turn to online data supplements for each of the articles that include rec- Evidence-Based Management of ommendations. There, they will find evidence pro- Anticoagulant Therapy files (expanded versions of the Summary of findings For further details, see Holbrook et Revision accepted August 31, 2011. Loading Dose for Initiation of Vitamin K Antagonist Affiliations: From the Department of Clinical Epidemiology (VKA) Therapy and Biostatistics (Drs Guyatt, Akl, and Sch nemann) and Depart- ment of Medicine (Drs Guyatt, Crowther, and Sch nemann), For patients sufficiently healthy to be McMaster University Faculty of Health Sciences, Hamilton, treated as outpatients, we suggest initiating VKA. ON, Canada; Departments of Medicine and Family Medicine (Dr Akl), State University of New York, Buffalo, NY; Cardiovascular Therapy with warfarin 10 mg daily for the first Research Center (Dr Gutterman), Medical College of Wisconsin, 2 days followed by dosing based on international Milwaukee, WI.)

10 Normalized ratio (INR) measurements rather than *For complete panel list, see: content/141/2_suppl/2S starting with the estimated maintenance dose Funding/Support: The Antithrombotic Therapy and Prevention (Grade 2C). of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice guidelines received support from Initial Dose Selection and Pharmacogenetic the National Heart, Lung, and Blood Institute [R13 HL104758] Testing and Bayer Schering Pharma AG. Support in the form of educa- tional grants were also provided by Bristol-Myers Squibb; Pfizer, For patients initiating VKA Therapy , we Inc; Canyon Pharmaceuticals; and sanofi-aventis US. recommend against the routine use of pharma- Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, cogenetic testing for guiding doses of VKA.