Controversies in pulmonary embolism and deep venous thrombosis

The diagnosis of venous thromboembolic disease, and pulmonary embolism in p articular, remains problematic. Physicians should strongly consider empiric anticoagulation if the best available diagnostic tests are inconclusive, b ecause treatment is usually safe and successful. Twice-daily subcutaneous l ow-molecular-weight heparin, dosed without monitoring, may eventually repla ce standard heparin for most treatment of venous thromboembolism, but it is not yet labeled for the treatment of pulmonary embolism. Deep venous throm bosis and pulmonary embolism should be treated with anticoagulants rather t han inferior vena cava filters, even in oncology patients, unless anticoagu lation is contraindicated; if so, when the contraindication remits, anticoa gulation should be employed. The most effective prophylaxis of venous throm boembolism in at-risk patients should be used, with prolonged duration if e vidence from clinical trials supports efficacy and safety. Low-dose warfari n should be used to prevent venous thrombosis and indwelling central venous catheter thrombosis in patients with cancer.