Our analysis showed a potential increase in mortality when using a longer course of anticoagulation compared with a shorter course of anticoagulation, without statistical significance (RR, 1.38; 95% CI, 0.85-2.23; ARR, 7 more per 1000 patients; 95% CI, 3 fewer to 22 more; moderate-certainty evidence). ASH staff supported panel appointments and coordinated meetings but had no role in choosing the guideline questions or determining the recommendations. Acquired (environmental) risk factors for DVT and/or PE that are considered chronic include cancer (discussed in a future guideline document from ASH), certain autoimmune disorders (eg, inflammatory bowel disease or antiphospholipid syndrome), and chronic immobility (Table 3).237  Some of these risk factors may fluctuate over time (eg, the autoimmune disorders), but many of these patients are considered to be at a higher risk for recurrent thromboembolism if anticoagulant therapy is discontinued. When using a DOAC for indefinite anticoagulation, the risk of DVT was reduced in the study population (RR, 0.15; 95% CI, 0.10-0.23; ARR, 49 fewer per 1000 patients; 95% CI 51 fewer to 44 fewer; high-certainty evidence), as well as for patients with recurrent provoked VTE269,324  (ARR, 26 fewer per 1000 patients; 95% CI, 28 fewer to 24 fewer; high-certainty evidence). Before appointment of the panel and during the development process, panelists disclosed financial and nonfinancial interests. These patients need to be carefully evaluated for underlying conditions and potential contraindications to individual anticoagulant agents, such as antiphospholipid syndrome, in which LMWH may be preferred over a DOAC. Remarks: Thrombolysis is reasonable to consider for submassive PE and low risk for bleeding in selected younger patients or for patients at high risk for decompensation due to concomitant cardiopulmonary disease. For patients with a recurrent unprovoked DVT or PE, the ASH guideline panel recommends indefinite antithrombotic therapy over stopping anticoagulation after completion of primary treatment (strong recommendation based on moderate certainty in the evidence of effects ⨁⨁⨁○). We considered that avoidance of PE, DVT, and major bleeding was critical for patients. This trial included adults with objectively confirmed DVT and/or PE who had been treated with a DOAC or VKA for 6 to 12 months and had not interrupted therapy for more than 7 days prior to randomization. Patients placed a high value on the benefits of risk reduction in VTE recurrence and PTS.311  However, there is important variability in how individual patients may value the risk of thrombosis vs the risk of bleeding. Lastly, and most importantly, an infrastructure to provide outpatient PE treatment needs to be established to ensure that patients can be followed closely. This recommendation applies to the patient who sustains an unprovoked VTE and who also has a history of an unprovoked VTE that was treated with a time-limited course of therapy that had been discontinued prior to the current event. For DVT, the certainty in the evidence was judged high. We considered that avoidance of PE, DVT, and major bleeding was critical for patients. Thomas L. Ortel, Ignacio Neumann, Walter Ageno, Rebecca Beyth, Nathan P. Clark, Adam Cuker, Barbara A. Hutten, Michael R. Jaff, Veena Manja, Sam Schulman, Caitlin Thurston, Suresh Vedantham, Peter Verhamme, Daniel M. Witt, Ivan D. Florez, Ariel Izcovich, Robby Nieuwlaat, Stephanie Ross, Holger J. Schünemann, Wojtek Wiercioch, Yuan Zhang, Yuqing Zhang; American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. We identified 7 systematic reviews223-229  and 2 randomized trials230,231  (n = 799). We did not identify direct evidence on a cost-effectiveness comparison for unprovoked VTE. As noted above, in the case of prognostic scores, at the time of our systematic review, we did not find any trial assessing their impact in patient-important outcomes, and the evidence regarding their discrimination ability and their validation was limited. The use of aspirin compared with a standard dose of anticoagulation increased the risk of nonfatal PE (RR, 3.10; 95% CI, 1.24-7.73; ARR, 11 more per 1000 patients; 95% CI, 1 more to 36 more; moderate-certainty evidence) or DVT (RR, 3.15; 95% CI, 1.50-6.63; ARR, 17 more per 1000 patients; 95% CI, 4 more to 46 more; moderate-certainty evidence). We did not identify direct evidence on a cost-effectiveness comparison for VTE provoked by a chronic risk factor. We did find studies evaluating the prognostic performance of the different tools: an individual patient meta-analysis of observational studies and 1 RCT (n = 2527)300  showed an independent association of residual vein thrombosis and recurrent VTE (HR, 1.32; 95% CI, 1.06-1.65). These patients are considered to be at a higher risk for recurrent thromboembolism if anticoagulant therapy is discontinued. therapy followed by anticoagulation is recommended. As documented above, although thrombolytic therapy may reduce mortality for patients with PE and hemodynamic compromise, it is also associated with an increased risk for major bleeding and intracranial bleeding. Clinical study of venous filter implantation combined with catheterization thrombolytic therapy for deep vein thrombosis [in Chinese]. To estimate the absolute effect of the intervention, we calculated the risk difference by multiplying the pooled risk ratio and the baseline risk of each outcome. For the baseline risk of major bleeding, we used data from 2 randomized trials on people with VTE; the risk of major bleeding with placebo during an 18-month or 24-month treatment with anticoagulants was as low as 0.5%306  and as high as 1.5% in 18 months.259  The EtD framework is shown online at: https://guidelines.gradepro.org/profile/C151C2DC-8A88-9E05-9D73-2FEB6B917C00. The certainty in the evidence was judged high for PE, DVT, and major bleeding but moderate for mortality because of imprecision, given that the CI around the absolute estimates crossed thresholds that patients would likely consider important. The panel did recognize the potential safety advantage of using a catheter-directed approach, but the imprecision of the data limited any conclusions that would favor this approach. PE recurrence and DVT were not reported in any of the identified studies. Primary treatment continues anticoagulant therapy for 3 to 6 months total and represents the minimal duration of treatment for the VTE. Participants were randomized to directed therapy or systemic thrombolytic therapy. Aspirin reduced the risk of DVT in the study population (RR, 0.55; 95% CI, 0.31-0.98; ARR, 64 fewer per 1000 patients; 95% CI, 98 fewer to 3 fewer), as well as for patients with chronic risk factors269,274  (ARR, 24 fewer per 1000 patients; 95% CI, 37 fewer to 1 fewer; moderate-certainty evidence). One set of trials included adults with objectively confirmed DVT and/or PE at the time of diagnosis, who were randomized to a shorter course (3-6 months) or a longer course (6-12 months) of anticoagulant therapy. Results from an individual-level meta-analysis, Predicting disease recurrence in patients with previous unprovoked venous thromboembolism: the DASH prediction score, Predicting disease recurrence in patients with previous unprovoked venous thromboembolism: a proposed prediction score (DASH), Clinical prediction guide to predict thrombosis recurrence after a first unprovoked venous thromboembolism. Other variables that may be important for the individual patient include whether the medication must be taken with food, preference for once-daily vs twice-daily dosing, the need to use a pill box, or the need to crush tablets prior to administration. In 1 trial, participants were randomized to home or hospital management; regardless of the treatment arm, all participants received subcutaneous enoxaparin, 1 mg/kg twice daily, followed by VKA.56  In another trial,57  patients were randomized to early discharge on 15 mg of oral rivaroxaban twice daily, followed by 20 mg of oral rivaroxaban once daily for 90 days, whereas the inpatient group received local standard of care, which included any US Food and Drug Administration–approved anticoagulant strategy. Therefore, it was not possible to completely rule out a small difference between the alternatives on mortality. We considered that avoidance of PE, DVT, and major bleeding was critical for patients. Observational studies also demonstrated a potential increase in major bleeding risk (RR, 2.68; 95% CI, 0.11-63.45; ARR could not be calculated; very-low-certainty evidence). 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