A SURVEY OF THROMBOSIS SPECIALISTS ON THE PRACTICAL MANAGEMENT OF EXTENSIVE DEEP VEIN THROMBOSIS AND A PROTOCOL FOR A RANDOMIZED TRIAL

Abstract

BACKGROUND: Though direct oral anticoagulants (DOACs) have become a standard of care in the treatment of acute deep vein thrombosis (DVT), it is our observation that physicians tend to initiate heparin or low-molecular-weight heparin, hereafter called “heparin”, for the treatment of extensive DVT or phlegmasia cerulea dolens (PCD). This might be due to a perception that heparin might relieve DVT-related symptoms more quickly than DOACs. Whether these assumptions are true has not been evaluated. METHODS: We conducted a survey of thrombosis specialists in North America to explore the practical management of anticoagulant therapy in patients with extensive DVT, and the underlying reasons for the selection of heparin over DOACs. A cross-sectional, web-based survey was distributed to thrombosis specialists who are members of four thrombosis societies. RESULTS: Eighty-nine respondents provided consent. Most respondents selected DOACs over heparin in a case scenario representing mild DVT-related symptoms and limited thrombus involvement (81% vs. 19%). Most respondents selected heparin over DOACs in a case scenario representing early stage PCD (84% vs.16.3%) or a patient with high bodyweight (72% vs. 28%). In a case scenario representing extensive DVT, 57.4% of the respondents selected heparin, whereas, 42.6% selected DOACs. In the respondents who selected heparin over DOACs, the major reason was that heparin might relieve DVT-related symptoms more quickly because of its anti-inflammatory effects. DISCUSSION: Severity of DVT-related symptoms, thrombus extent, and bodyweight play a role in the selection of anticoagulant therapy. Despite a lack of evidence to support the hypothesis with respect to which anticoagulant is superior, most thrombosis specialists selected heparin over DOACs in patients with severe DVT-related symptoms and extensive thrombus involvement. Observation of variations in the selection of anticoagulant therapy for the treatment of extensive DVT also indicates that clinical trials in this patient population are needed.