Treatment of DVT: how long is enough and how do you predict recurrence |
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Authors: | Giancarlo Agnelli Cecilia Becattini |
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Institution: | (1) Division of Internal and Cardiovascular Medicine, University of Perugia, Via G. Dottori 1, Perugia, 06129, Italy |
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Abstract: | Abstract Currently available anticoagulants are effective in reducing the recurrence rate of venous thromboembolism (VTE). However,
anticoagulant treatment is associated with an increased risk for bleeding complications. Thus, anticoagulation has to be discontinued
when benefit of treatment no longer clearly outweigh its risks. The duration of anticoagulant treatment is currently framed
based on the estimated individual risk for recurrent VTE. The incidence of recurrent VTE can be estimated through a two-step
decision algorithm. Firstly, the features of the patient (gender), of the initial event (proximal or distal deep vein thrombosis
or pulmonary embolism), and the associated conditions (cancer, surgery, etc) provide essential information on the risk for
recurrence after anticoagulant treatment discontinuation. Secondly, at time of anticoagulant treatment discontinuation, d-dimer levels and residual thrombosis have been indicated as predictors of recurrent VTE. Current evidence suggests that the
risk of recurrence after stopping therapy is largely determined by whether the acute episode of VTE has been effectively treated
and by the patient’s intrinsic risk of having a new episode of VTE. All patients with acute VTE should receive oral anticoagulant
treatment for three months. At the end of this treatment period, physicians should decide for withdrawal or indefinite anticoagulation.
Based on intrinsic patient’s risk for recurrent VTE and for bleeding complications and on patient preference, selected patients
could be allocated to indefinite treatment with VKA with scheduled periodic re-assessment of the benefit from extending anticoagulation.
Alternative strategies for secondary prevention of VTE to be used after conventional anticoagulation are currently under evaluation.
Cancer patients should receive low molecular-weight heparin over warfarin in the long-term treatment of VTE. These patients
should be considered for extended anticoagulation at least until resolution of underlying disease.
Abbreviated abstract The risk for recurrent venous thromboembolism can be estimated through a two-step algorithm. Firstly, the features of the
patient (gender), of the initial event (proximal or distal deep vein thrombosis or pulmonary embolism), and the associated
conditions (cancer, surgery, etc) are essential to estimate the risk for recurrence after anticoagulant treatment discontinuation.
Secondly, a correlation has been shown between d-dimer levels and residual thrombosis at time of anticoagulant treatment discontinuation and the risk of recurrence. Currently
available anticoagulants are effective in reducing the incidence of recurrent venous thromboembolism, but they are associated
with an increased risk for bleeding complications. All patients with acute venous thromboembolism should receive oral anticoagulant
treatment for three months. At the end of this treatment period physicians should decide for definitive withdrawal or indefinite
anticoagulation with scheduled periodic re-assessment of the benefit from extending anticoagulation. |
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Keywords: | Venous thromboembolism Warfarin Deep vein thrombosis Pulmonary embolism |
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