CHEST Guideline for Antithrombotic Therapy in VTE
The following are 11 key points about this updated guideline document from the American College of
Chest Physicians on antithrombotic therapy for venous thromboembolism (VTE):
1. For VTE without an associated cancer diagnosis, all direct oral anticoagulants (dabigatran,
rivaroxaban, apixaban, or edoxaban) are recommended over vitamin K antagonist (VKA) therapy (all
Grade 2B) and VKA therapy is recommended over low molecular weight heparin (LMWH; Grade 2C).
2. For VTE associated with cancer, LMWH is recommended over VKA (Grade 2B) or any direct oral
anticoagulants (all Grade 2C).
3. Anticoagulants should stop after 3 months of therapy in patients with an acute, proximal deep
venous thrombosis (DVT) provoked by surgery rather than shorter or longer treatment courses
(Grade 1B).
4. Anticoagulants should also be stopped after 3 months in patients with a proximal DVT or pulmonary
embolism (PE) provoked by a nonsurgical transient risk factor over shorter or longer courses (Grade
1B for high bleeding risk patients, Grade 2B for low or moderate bleeding risk patients).
5. Anticoagulation should be given for 3 months in patients with a first unprovoked VTE and a high risk
of bleeding (Grade 1B), but should be extended without a scheduled stop date in patients with a low
or moderate risk of bleeding (Grade 2B).
6. For patients with acute VTE who are treated with anticoagulation, the guideline recommends against
the use of an inferior vena cava filter (Grade 1B).
7. For patients with an unprovoked proximal DVT or PE who are stopping anticoagulant therapy, the
guideline suggests the use of aspirin over no aspirin to prevent recurrent VTE if there are no
contraindications to aspirin therapy (Grade 2B).
8. For patients with acute DVT, the guideline recommends against the use of compression stockings
routinely to prevent the post-thrombotic syndrome (Grade 2B).
9. For patient with subsegmental PE and no DVT, the guideline suggests clinical surveillance over
anticoagulation when the risk of VTE recurrence is low (Grade 2C). The guideline recommends the
use of anticoagulation over surveillance when the risk of VTE recurrence is high (Grade 2C).
10. For patients with an acute PE and hypotension (massive PE), the guideline recommends the use of
thrombolytic therapy (Grade 2B), preferring systemic therapy over catheter-directed thrombolytic
therapy (Grade 2C).
11. For patients with recurrent VTE while treated with a non-LMWH anticoagulant, the guideline
recommends changing to LMWH therapy (Grade 2C). If patients suffer a recurrent VTE while on
LMWH treatment, the guideline recommends increasing the LMWH dose (Grade 2C).
, Cardiovascular disorders
Chapter 10, “Heart Disease” (pp. 328-446)
Chapter 11, “Systemic Hypertension” (pp. 447-478)
Chapter 12, “Blood Vessel & Lymphatic Disorders” (pp. 479-506)
Chapter 28, “Lipid Disorders” (pp. 1269-1277)
ACS protocol: low risk vs high risk mi- use of statins and ASA, ace inhibitors. High
intensity statin therapy (atorvastatin 40-80mg, rosuvastion 20 -40 mg) mod
intensity. MOST patients with vascular disease in the absence of heart failure or LV
dysfunction should be treated with an ACE
Metabolic syndrome- (three or more of the following ) abdominal obesity,
triglycerides 150mg/dl or high , HDL less than 40 for men, less than 50 for women,
fasting glucose 110 or higher and hypertension.
Contraindications to thrombolytic therapy in stroke and MIs- ST elevation in AVR
= left main or three vessel diseases. When the there is not an ST elevation,
hemorrhagic stroke
MONA, what is it an when is it used? MONA is an acronym used to help medical
professionals remember the initial treatment for acute coronary syndrome. MONA
stands for morphine, oxygen, nitroglycerin and aspirin (“MONA greet chest pain patients
at the door”).
Duke criteria for infective endocarditis, presentation and treatment-
Diagnostic : 2 Major Criteria and 0 Minor Criteria
Diagnostic : 1 Major Criteria and 3 Minor Criteria
Diagnostic : 0 Major Criteria and 5 Minor Criteria
Major Diagnostic Criteria
Positive blood culture for typical Infective Endocarditis organisms (strep
viridins or bovis, HACEK, staph aureous without other primary site,
enterococcus), from 2 separate blood cultures or 2 positive cultures from
samples drawn > 12 hours apart, or 3 or a majority of 4 separate cultures of
blood (first and last sample drawn 1 hour apart)
Echocardiogram with oscillating intracardiac mass on valve or supporting
structures, in the path of regurgitant jets, or on implanted material in the
absence of an alternative anatomic explanation, or abscess, or new partial
dehiscence of prosthetic valve or new valvular regurgitation
, Minor Diagnostic Criteria
Predisposing heart condition or intravenous drug use
Temp > 38.0° C (100.4° F)
Vascular phenomena: arterial emboli, pulmonary infarcts, mycotic aneurysms,
intracranial bleed, conjunctival hemorrhages, Janeway lesions
Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots,
rheumatoid factor
Microbiological evidence: positive blood culture but does not meet a major
criterion as noted above or serological evidence of active infection with
organism consistent with endocarditis (excluding coag neg staph, and other
common contaminants)
Echocardiographic findings: consistent with endocarditis but do not meet a
major criterion as noted above
Heart murmurs: physical exams, grades of murmurs-
Murmurs are sounds created by turbulent blood flow. They can occur at any time during the
cardiac cycle. When you detect a murmur, you need to listen for a minute or more to determine
its characteristics—the timing, pitch, quality, intensity, and pattern. You'll also want to identify
where you hear it the loudest and if the sound radiates to other areas.
To establish timing, focus on whether you hear the murmur continuously, during systole (after
S and before S ) or during diastole (after S and before S ). When the murmur is confined to
1 2 2 1
either systole or diastole, determine whether you hear it at the beginning (early), middle (mid),
or end (late).
Systolic murmurs typically fall into two categories: mid-systolic and holosystolic (or pansystolic).
A mid-systolic murmur begins after S and concludes before S . You should notice a distinct gap
1 2
between the two heart sounds and the murmur. Pay particular attention to the gap before S . It 2
will help you to distinguish a mid-systolic murmur from a holosystolic murmur, which is heard
immediately after S and right up to S without any pauses.
1 2
Once you've established its timing, shift your focus to the murmur's actual sound. Is it high-
pitched, low-pitched, or somewhere in between? How would you describe its quality? Is it harsh
or musical? Rumbling or blowing? What is its intensity? Do you have to really concentrate to
hear a faint sound? Or do you notice the sound as soon as you put your stethoscope on the
chest?
Murmurs are graded on a six-point scale. In a grade I murmur, the sound is barely audible,
whatever the patient's position. A grade II murmur is faint; a grade III is moderately loud, and a
The following are 11 key points about this updated guideline document from the American College of
Chest Physicians on antithrombotic therapy for venous thromboembolism (VTE):
1. For VTE without an associated cancer diagnosis, all direct oral anticoagulants (dabigatran,
rivaroxaban, apixaban, or edoxaban) are recommended over vitamin K antagonist (VKA) therapy (all
Grade 2B) and VKA therapy is recommended over low molecular weight heparin (LMWH; Grade 2C).
2. For VTE associated with cancer, LMWH is recommended over VKA (Grade 2B) or any direct oral
anticoagulants (all Grade 2C).
3. Anticoagulants should stop after 3 months of therapy in patients with an acute, proximal deep
venous thrombosis (DVT) provoked by surgery rather than shorter or longer treatment courses
(Grade 1B).
4. Anticoagulants should also be stopped after 3 months in patients with a proximal DVT or pulmonary
embolism (PE) provoked by a nonsurgical transient risk factor over shorter or longer courses (Grade
1B for high bleeding risk patients, Grade 2B for low or moderate bleeding risk patients).
5. Anticoagulation should be given for 3 months in patients with a first unprovoked VTE and a high risk
of bleeding (Grade 1B), but should be extended without a scheduled stop date in patients with a low
or moderate risk of bleeding (Grade 2B).
6. For patients with acute VTE who are treated with anticoagulation, the guideline recommends against
the use of an inferior vena cava filter (Grade 1B).
7. For patients with an unprovoked proximal DVT or PE who are stopping anticoagulant therapy, the
guideline suggests the use of aspirin over no aspirin to prevent recurrent VTE if there are no
contraindications to aspirin therapy (Grade 2B).
8. For patients with acute DVT, the guideline recommends against the use of compression stockings
routinely to prevent the post-thrombotic syndrome (Grade 2B).
9. For patient with subsegmental PE and no DVT, the guideline suggests clinical surveillance over
anticoagulation when the risk of VTE recurrence is low (Grade 2C). The guideline recommends the
use of anticoagulation over surveillance when the risk of VTE recurrence is high (Grade 2C).
10. For patients with an acute PE and hypotension (massive PE), the guideline recommends the use of
thrombolytic therapy (Grade 2B), preferring systemic therapy over catheter-directed thrombolytic
therapy (Grade 2C).
11. For patients with recurrent VTE while treated with a non-LMWH anticoagulant, the guideline
recommends changing to LMWH therapy (Grade 2C). If patients suffer a recurrent VTE while on
LMWH treatment, the guideline recommends increasing the LMWH dose (Grade 2C).
, Cardiovascular disorders
Chapter 10, “Heart Disease” (pp. 328-446)
Chapter 11, “Systemic Hypertension” (pp. 447-478)
Chapter 12, “Blood Vessel & Lymphatic Disorders” (pp. 479-506)
Chapter 28, “Lipid Disorders” (pp. 1269-1277)
ACS protocol: low risk vs high risk mi- use of statins and ASA, ace inhibitors. High
intensity statin therapy (atorvastatin 40-80mg, rosuvastion 20 -40 mg) mod
intensity. MOST patients with vascular disease in the absence of heart failure or LV
dysfunction should be treated with an ACE
Metabolic syndrome- (three or more of the following ) abdominal obesity,
triglycerides 150mg/dl or high , HDL less than 40 for men, less than 50 for women,
fasting glucose 110 or higher and hypertension.
Contraindications to thrombolytic therapy in stroke and MIs- ST elevation in AVR
= left main or three vessel diseases. When the there is not an ST elevation,
hemorrhagic stroke
MONA, what is it an when is it used? MONA is an acronym used to help medical
professionals remember the initial treatment for acute coronary syndrome. MONA
stands for morphine, oxygen, nitroglycerin and aspirin (“MONA greet chest pain patients
at the door”).
Duke criteria for infective endocarditis, presentation and treatment-
Diagnostic : 2 Major Criteria and 0 Minor Criteria
Diagnostic : 1 Major Criteria and 3 Minor Criteria
Diagnostic : 0 Major Criteria and 5 Minor Criteria
Major Diagnostic Criteria
Positive blood culture for typical Infective Endocarditis organisms (strep
viridins or bovis, HACEK, staph aureous without other primary site,
enterococcus), from 2 separate blood cultures or 2 positive cultures from
samples drawn > 12 hours apart, or 3 or a majority of 4 separate cultures of
blood (first and last sample drawn 1 hour apart)
Echocardiogram with oscillating intracardiac mass on valve or supporting
structures, in the path of regurgitant jets, or on implanted material in the
absence of an alternative anatomic explanation, or abscess, or new partial
dehiscence of prosthetic valve or new valvular regurgitation
, Minor Diagnostic Criteria
Predisposing heart condition or intravenous drug use
Temp > 38.0° C (100.4° F)
Vascular phenomena: arterial emboli, pulmonary infarcts, mycotic aneurysms,
intracranial bleed, conjunctival hemorrhages, Janeway lesions
Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots,
rheumatoid factor
Microbiological evidence: positive blood culture but does not meet a major
criterion as noted above or serological evidence of active infection with
organism consistent with endocarditis (excluding coag neg staph, and other
common contaminants)
Echocardiographic findings: consistent with endocarditis but do not meet a
major criterion as noted above
Heart murmurs: physical exams, grades of murmurs-
Murmurs are sounds created by turbulent blood flow. They can occur at any time during the
cardiac cycle. When you detect a murmur, you need to listen for a minute or more to determine
its characteristics—the timing, pitch, quality, intensity, and pattern. You'll also want to identify
where you hear it the loudest and if the sound radiates to other areas.
To establish timing, focus on whether you hear the murmur continuously, during systole (after
S and before S ) or during diastole (after S and before S ). When the murmur is confined to
1 2 2 1
either systole or diastole, determine whether you hear it at the beginning (early), middle (mid),
or end (late).
Systolic murmurs typically fall into two categories: mid-systolic and holosystolic (or pansystolic).
A mid-systolic murmur begins after S and concludes before S . You should notice a distinct gap
1 2
between the two heart sounds and the murmur. Pay particular attention to the gap before S . It 2
will help you to distinguish a mid-systolic murmur from a holosystolic murmur, which is heard
immediately after S and right up to S without any pauses.
1 2
Once you've established its timing, shift your focus to the murmur's actual sound. Is it high-
pitched, low-pitched, or somewhere in between? How would you describe its quality? Is it harsh
or musical? Rumbling or blowing? What is its intensity? Do you have to really concentrate to
hear a faint sound? Or do you notice the sound as soon as you put your stethoscope on the
chest?
Murmurs are graded on a six-point scale. In a grade I murmur, the sound is barely audible,
whatever the patient's position. A grade II murmur is faint; a grade III is moderately loud, and a
