Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guideline
David D. Gutterman , MD, FCCP ; Holger J. Schü 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
Full Text
The
eighth iteration of the American College of Chest Physicians
Antithrombotic Guidelines presented, in a paper version, a narrative
evidence summary and rationale for the recommendations, a small number
of evidence profiles summarizing bodies of evidence, and some articles
with quite extensive summary tables of primary studies. In total, this
represented 600 recommendations summarized in 968 pages of text. Many
readers responded that the result was too voluminous for their liking or
practical use.
Cognizant of this feedback, we worked
hard to minimize the length of the text for the ninth iteration of the
guidelines Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (AT9) without sacrificing key content. A number of topic
editors found our shortening edits draconian, but we were determined to
produce the leanest product possible.
There were,
however, a number of obstacles. In what we believe is a key advance in
AT9, we conducted a systematic review of what is known about patients’
values and preferences regarding antithrombotic therapy and included the
results as an article in AT9. In another forward step, we recognized
the problems with asymptomatic thrombosis as a surrogate outcome, and
devised strategies to estimate reductions in symptomatic DVT and
pulmonary embolism with antithrombotic prophylaxis. We felt it important
to explain this innovation to users of AT9, and this meant another
article.
We included, for the first time, an article on
diagnosis addressing patients with symptoms and signs suggesting DVT. We
increased the range of interventions we have covered, resulting in
additional recommendations. Finally, we produced many summary of
findings tables, which offer extremely succinct and informative
presentations of best estimates of effect and the confidence associated
with those estimates.
If published in the same
fashion as the Antithrombotic and Thrombolytic Therapy, 8th ed: American
College of Chest Physicians Antithrombotic Guidelines, this would have
resulted in a document with > 850 pages of paper text, an
unacceptable length. Given this and with the advice of the journal, we
decided to adopt a highly focused print version that includes only this
executive summary and the following articles:
- An introduction describing the major innovations in AT9
- A methods article explaining how we developed the guidelines (a potential model for other guideline groups interested in optimal rigor)
- Recommendations and grading from each article embedded in the table of contents of each article
Those
seeking the rationale for the recommendations, including the supporting
evidence, should access the online version of the guideline (http://http://chestjournal.chestpubs.org/content/141/2_suppl)
that includes a narrative summaries and supporting summary of findings
tables. The numbering indicated beside the recommendations in this
summary is aligned with the sections and tables found in the full
articles. Those interested in a deeper understanding of the evidence can
turn to online data supplements for each of the articles that include
recommendations. There, they will find evidence profiles (expanded
versions of the summary of findings tables) and some tables summarizing
the methods and results, and the risk of bias, associated with the
individual studies that contributed to the evidence profiles and summary
of findings tables.
The world of medical information
is rapidly becoming a world of electronic storage and presentation of
primary studies, recommendations, and a wide variety of other
information of interest to health care practitioners. Although our
abbreviated paper copy presentation represents a necessary response to a
challenging situation, it is also a harbinger of the increasingly
electronic world of medical information into which future editions of
guidelines are destined to move.
Summary of Recommendations
Note
on Shaded Text: Throughout this guideline, shading is used within the
summary of recommendations sections to indicate recommendations that are
newly added or have been changed since the publication of
Antithrombotic and Thrombolytic Therapy: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).
Recommendations that remain unchanged are not shaded.
