What are the treatments for arterial and venous thromboses (blood clots)?

From the Guidelines

Treatments for arterial and venous thromboses differ based on their distinct pathophysiology, with anticoagulation being the cornerstone of treatment for venous thrombosis, as recommended by the most recent guidelines 1. For arterial thrombosis, immediate management includes antiplatelet therapy with aspirin (162-325mg initially, then 81mg daily) and often clopidogrel (300-600mg loading dose, then 75mg daily) 1. Urgent revascularization through thrombolysis (using agents like alteplase), percutaneous intervention, or surgery may be necessary to restore blood flow. For venous thrombosis, anticoagulation typically starts with parenteral anticoagulants like low molecular weight heparin (enoxaparin 1mg/kg twice daily) or unfractionated heparin, followed by oral anticoagulants. Direct oral anticoagulants (DOACs) such as apixaban (10mg twice daily for 7 days, then 5mg twice daily) or rivaroxaban (15mg twice daily for 21 days, then 20mg daily) are now preferred over warfarin for most patients due to fewer monitoring requirements 1. Some key points to consider in the treatment of venous thrombosis include:

• The optimum duration of oral anticoagulant therapy is influenced by the competing risks of bleeding and recurrent venous thromboembolism, as noted in earlier guidelines 1.
• Treatment duration varies from 3 months for provoked events to indefinite therapy for unprovoked or recurrent thromboses, with considerations for the use of reduced-dose anticoagulation for extended treatment 1.
• Compression stockings may help manage symptoms of venous thrombosis, particularly in preventing postthrombotic syndrome (PTS) 1. The different approaches reflect that arterial clots are primarily platelet-rich and form in high-flow conditions, while venous clots are fibrin and red cell-rich, forming in low-flow states, thus requiring different pharmacological strategies. Given the most recent evidence, the use of DOACs is recommended for the treatment of venous thrombosis due to their efficacy and safety profile compared to traditional anticoagulants 1.

From the FDA Drug Label

Heparin Sodium Injection is indicated for: • Prophylaxis and treatment of venous thrombosis and pulmonary embolism; • Prevention of postoperative deep venous thrombosis and pulmonary embolism in patients undergoing major abdominothoracic surgery or who, for other reasons, are at risk of developing thromboembolic disease; • Atrial fibrillation with embolization; • Treatment of acute and chronic consumptive coagulopathies (disseminated intravascular coagulation); • Prevention of clotting in arterial and cardiac surgery; • Prophylaxis and treatment of peripheral arterial embolism. XARELTO is a factor Xa inhibitor indicated: to reduce risk of stroke and systemic embolism in nonvalvular atrial fibrillation for treatment of deep vein thrombosis (DVT) for treatment of pulmonary embolism (PE) for reduction in the risk of recurrence of DVT or PE for the prophylaxis of DVT, which may lead to PE in patients undergoing knee or hip replacement surgery for prophylaxis of venous thromboembolism (VTE) in acutely ill medical patients to reduce the risk of major cardiovascular events in patients with coronary artery disease (CAD) to reduce the risk of major thrombotic vascular events in patients with peripheral artery disease (PAD), including patients after recent lower extremity revascularization due to symptomatic PAD

The treatments for arterial and venous thromboses include:

• Heparin for prophylaxis and treatment of venous thrombosis and pulmonary embolism, prevention of postoperative deep venous thrombosis and pulmonary embolism, and prophylaxis and treatment of peripheral arterial embolism 2
• Rivaroxaban (XARELTO) for treatment of deep vein thrombosis (DVT), treatment of pulmonary embolism (PE), reduction in the risk of recurrence of DVT or PE, and prophylaxis of DVT 3
• Warfarin for prevention of thromboembolic complications, although the label does not explicitly mention arterial and venous thromboses, it does mention anticoagulation and prevention of thromboembolic disease 4

From the Research

Treatments for Arterial and Venous Thromboses

• The treatment for arterial and venous thromboses typically involves anticoagulation and antiplatelet therapy, depending on the specific condition and patient risk factors 5.
• Anticoagulants are used to prevent the formation of new blood clots and to stop existing clots from getting bigger, while antiplatelet agents inhibit platelet activation and aggregation 6.
• For venous thromboembolism (VTE), anticoagulation therapy is the primary treatment, with the goal of preventing recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE) 7.
• The duration of anticoagulation therapy for VTE can vary, with shorter courses (3-6 months) being more beneficial for primary treatment, and indefinite antithrombotic treatment being more beneficial for secondary prevention of unprovoked VTE or VTE provoked by chronic risk factors 7.
• Thrombolytic strategies, such as thrombolysis with or without additional endovascular techniques, can be used to treat acute DVT, with the goal of reducing long-term complications such as post-thrombotic syndrome (PTS) 8.
• Antiplatelet therapy, such as aspirin, can be used to prevent arterial thrombosis, with newer agents being developed to target specific sites in the sequence of platelet activation 9.

Anticoagulation and Antiplatelet Therapy

• Anticoagulation therapy can be used to treat both arterial and venous thromboses, with different types of anticoagulants being used depending on the specific condition and patient risk factors 5, 7.
• Antiplatelet therapy can be used to prevent arterial thrombosis, with agents such as aspirin, ticlopidine, and clopidogrel being commonly used 6, 9.
• The combination of anticoagulation and antiplatelet therapy can be used in certain situations, such as in patients with a history of both arterial and venous thromboembolic events 5.

Thrombolytic Strategies

• Thrombolytic strategies, such as thrombolysis with or without additional endovascular techniques, can be used to treat acute DVT, with the goal of reducing long-term complications such as PTS 8.
• Systemic thrombolysis and catheter-directed thrombolysis (CDT) have similar effectiveness in treating DVT, with complete clot lysis occurring more frequently after thrombolysis and PTS incidence being slightly reduced 8.
• However, thrombolytic strategies are associated with an increased risk of bleeding complications, which can be reduced with the use of stricter exclusion criteria and newer thrombolytic agents 8.