Can Eliquis (apixaban) be used for acute SVT (Supraventricular Tachycardia) with a non-compressible GSV (Great Saphenous Vein)?

Management of Acute Superficial Venous Thrombosis (SVT) in the Great Saphenous Vein (GSV)

For acute superficial venous thrombosis (SVT) in a non-compressible Great Saphenous Vein (GSV), rivaroxaban 10 mg daily for 45 days is suggested as a reasonable treatment option when parenteral anticoagulation is not feasible or refused. 1

Understanding SVT in the GSV

SVT in the GSV is not a benign condition as previously thought. It carries significant risks:

• Extension of thrombus
• Progression to deep vein thrombosis (DVT)
• Potential for pulmonary embolism (PE)
• Recurrence of SVT

Treatment Algorithm for SVT in GSV

Step 1: Risk Assessment

Factors that favor anticoagulation for SVT include:

• Extensive SVT (≥5 cm in length)
• Involvement above the knee
• Proximity to saphenofemoral junction
• Severe symptoms
• Involvement of the great saphenous vein (as in this case)
• History of VTE or SVT
• Active cancer
• Recent surgery

Step 2: Anticoagulation Options

1. First-line option (if parenteral therapy acceptable):

   • Fondaparinux 2.5 mg daily for 45 days 1

2. Alternative option (if parenteral therapy refused/not feasible):

   • Rivaroxaban 10 mg daily for 45 days 1

3. Other options (less preferred):

   • Prophylactic or therapeutic LMWH 1

Step 3: Duration of Treatment

• Standard duration: 45 days 1
• This duration has been shown to effectively prevent progression of SVT, DVT, PE, or death

Evidence Supporting Anticoagulation in SVT

The 2021 CHEST guideline provides moderate-certainty evidence supporting anticoagulation for SVT of the lower limb at increased risk of clot progression 1. The evidence shows:

• Fondaparinux vs. placebo: Significantly reduces extension/recurrence of SVT (178-185 fewer events per 1,000 cases) 1
• Rivaroxaban vs. fondaparinux: Similar efficacy with 9 fewer VTE events per 1,000 cases 1

Important Clinical Considerations

1. Non-compressible GSV: This finding indicates thrombus presence and confirms the SVT diagnosis, making anticoagulation appropriate.

2. Avoid treatment confusion: This question is about SVT (Superficial Venous Thrombosis), not SVT (Supraventricular Tachycardia). The evidence regarding supraventricular tachycardia management 1, 2 is not applicable to this venous thrombosis case.

3. Monitoring: Follow-up ultrasound may be warranted to ensure resolution of the thrombus, especially if symptoms persist or worsen.

4. Common pitfalls:

   • Undertreating SVT as a benign condition
   • Confusing superficial venous thrombosis with supraventricular tachycardia
   • Using inadequate duration of anticoagulation (45 days is recommended)
   • Failing to recognize risk factors for progression to DVT/PE

Real-world Outcomes

The INSIGHTS-SVT study showed that despite anticoagulation, approximately 5.8% of patients with SVT experienced complications (primarily recurrent/extended SVT, DVT, or PE) 3. This underscores the importance of appropriate anticoagulation and follow-up.

Apixaban (Eliquis) has been well-studied for VTE treatment 4, but the specific evidence for its use in isolated SVT is more limited compared to fondaparinux and rivaroxaban, which have been specifically studied in this context 1, 5.