A patient-level meta-analysis. Patient values and preferences in decision making for antithrombotic therapy: a systematic review: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. All-cause and disease-related health care costs associated with recurrent venous thromboembolism. The outpatient bleeding risk index: validation of a tool for predicting bleeding rates in patients treated for deep venous thrombosis and pulmonary embolism.
Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. Prospective, multicenter validation of prediction scores for major bleeding in elderly patients with venous thromboembolism. The predictive ability of bleeding risk stratification models in very old patients on vitamin K antagonist treatment for venous thromboembolism: results of the prospective collaborative EPICA study.
Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review. Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. Development of a clinical prediction rule for risk stratification of recurrent venous thromboembolism in patients with cancer-associated venous thromboembolism.
Recurrent venous thromboembolism after deep vein thrombosis: incidence and risk factors. Secondary prevention of venous thromboembolism with the oral direct thrombin inhibitor ximelagatran. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism.
Risk of recurrence after venous thromboembolism in men and women: patient level meta-analysis. Patient-level meta-analysis: effect of measurement timing, threshold, and patient age on ability of D-dimer testing to assess recurrence risk after unprovoked venous thromboembolism.
Update on the predictive value of D-dimer in patients with idiopathic venous thromboembolism. Duration of anticoagulant therapy after a first episode of an unprovoked pulmonary embolus or deep vein thrombosis: guidance from the SSC of the ISTH.
Antiphospholipid antibodies and the risk of recurrence after a first episode of venous thromboembolism: a systematic review. Predictive value of factor V Leiden and prothrombin GA in adults with venous thromboembolism and in family members of those with a mutation: a systematic review.
Influence of hereditary or acquired thrombophilias on the treatment of venous thromboembolism. Identifying unprovoked thromboembolism patients at low risk for recurrence who can discontinue anticoagulant therapy. Incidence of idiopathic deep venous thrombosis and secondary thromboembolism among ethnic groups in California.
Residual vein obstruction to predict the risk of recurrent venous thromboembolism in patients with deep vein thrombosis: a systematic review and meta-analysis. Post-thrombotic syndrome, recurrence, and death 10 years after the first episode of venous thromboembolism treated with warfarin for 6 weeks or 6 months. Risk assessment of recurrence in patients with unprovoked deep vein thrombosis or pulmonary embolism: the Vienna prediction model.
Predicting disease recurrence in patients with previous unprovoked venous thromboembolism: a proposed prediction score DASH. Methodology for the development of antithrombotic therapy and prevention of thrombosis guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Inflammatory bowel disease is a risk factor for recurrent venous thromboembolism.
International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update.
Anticoagulation for the long-term treatment of venous thromboembolism in patients with cancer. Add comment Close comment form modal. Submit a comment. Comment title. You have entered an invalid code. Submit Cancel. Thank you for submitting a comment on this article. Your comment will be reviewed and published at the journal's discretion. Please check for further notifications by email. Volume , Issue Previous Article Next Article. View Metrics.
Cited By Web Of Science Email alerts Article Activity Alert. Latest Issue Alert. Close Modal. These patients should be treated for at least 3 mo. Catheter-directed thrombolysis increases the patency of veins and reduces the incidence of postthrombotic syndrome by one-third.
Isolated subsegmental pulmonary embolism may be overdiagnosed because of breathing motion and beam-hardening artifacts. There is limited evidence to determine the effectiveness and safety of anticoagulation therapy in patients with subsegmental pulmonary embolism. The American College of Chest Physicians guideline states that anticoagulation should not be used in patients with subsegmental pulmonary embolism if they do not have proximal DVT and are at low risk of recurrence.
Patients with superficial venous thrombosis are at higher risk of developing DVT. Consider anticoagulation in extensive cases and in those associated with involvement above the knee, particularly if close to the saphenofemoral junction or the greater saphenous vein; severe symptoms; history of VTE or superficial venous thrombosis; active cancer; or recent surgery.
This is most often associated with a central venous catheter and is treated similarly to lower extremity DVT. Morbidly obese patients are usually excluded from clinical trials of anticoagulants. Data are lacking regarding direct-acting oral anticoagulants. Heparin can be used in the initial treatment of VTE. Refer to the manufacturer's directions for individual medications because some may recommend a maximum dose despite patient weight.
Consider extended anticoagulation if the bleeding risk is low. LMWH is the preferred agent. Warfarin Coumadin is teratogenic; avoid in pregnancy. Direct-acting oral anticoagulants are not tested in pregnant patients; therefore, their safety is unknown; avoid in pregnancy. Anticoagulation should be continued for at least 3 months and at least 6 weeks postpartum. Information from references 6 , 8 , 9 , and 31 through This article updates a previous article on this topic by Ramzi and Leeper.
Search dates: September to February , and December 10, Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Reprints are not available from the authors. Nielsen JD. The incidence of pulmonary embolism during deep vein thrombosis. Centers for Disease Control and Prevention.
Venous thromboembolism blood clots. Data and statistics. June 22, Accessed November 29, Wilbur J, Shian B. Diagnosis of deep venous thrombosis and pulmonary embolism. Am Fam Physician. Treatment of venous thromboembolism [published correction appears in JAMA. Updated guidelines on outpatient anticoagulation. Oral anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians [published correction appears in Ann Fam Med. Ann Fam Med. Low-molecular-weight heparin in outpatient treatment of DVT. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial.
Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane Database Syst Rev. Physicians' Desk Reference.
Accessed December 16, December 16, Lexicomp online. Accessed July 1, Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of pulmonary embolism. Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of deep vein thrombosis. Idarucizumab for dabigatran reversal.
N Engl J Med. Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors [published correction appears in Am J Hematol. Am J Hematol. Fibrinolysis for patients with intermediate-risk pulmonary embolism. Vena caval filters for the prevention of pulmonary embolism. Inferior vena cava filters: indications and management. Curr Opin Cardiol. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial.
Cardiovasc Intervent Radiol. Recurrent venous thromboembolism after deep vein thrombosis: incidence and risk factors. Arch Intern Med. Kearon C, Akl EA. Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism. D-dimer testing to determine the duration of anticoagulation therapy [published correction appears in N Engl J Med. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines [published correction appears in Chest.
Compression stockings to prevent post-thrombotic syndrome. Thrombolysis for acute deep vein thrombosis. None of the clinical prediction models for recurrent VTE are able to actually drive duration of anticoagulation. If the favorable safety profile of direct oral anticoagulants from clinical trials would be confirmed in real-life, extension of anticoagulation could be reconsidered in large proportions of patients after an unprovoked PE.
Although these symptoms can be related to underlying comorbidities, patients should be assessed for the presence of new onset pulmonary vascular disease and chronic thromboembolic pulmonary hypertension because these disease processes not only increase the risk for recurrent VTE but can also be more effectively managed if identified early on.
Current guidelines indicate that the choice of anticoagulant in the early phase of treatment can be continued for extended therapy. However, there are alternate medication and dosing options available to patients who require indefinite anticoagulation. In appropriate patient populations, such as those without active cancer or renal insufficiency, direct-acting oral anticoagulants can be considered for extended therapy given the relative reduction in bleeding risk over vitamin K antagonists.
For many patients, the decision to stop anticoagulation after the initial treatment course is dictated by concerns regarding anticoagulation and its interference in their daily lives. If a patient with an unprovoked PE and thus higher risk for recurrence elects to discontinue anticoagulation, routine follow-up and serial D-dimer testing at weeks and then again at months after stopping treatment are recommended.
Those patients with elevated D-dimer on follow-up testing should be advised of the ongoing risk of VTE recurrence off anticoagulation. Among patients with elevated D-dimer levels after initial anticoagulation, those who discontinue anticoagulation have an increased hazard ratio for VTE recurrence of 2. Key Points Patients diagnosed with PE who are deemed appropriate candidates for therapeutic anticoagulation should be treated for an initial period of 3 months.
In general, those patients with unprovoked PE or those with persistent risk factors should be considered for indefinite anticoagulation with routine follow-up to assess ongoing benefit. Validated tools exist to quantify risk of recurrent VTE and may be helpful in patients with unprovoked PE who have an intermediate bleeding risk or in those who choose to discontinue anticoagulation.
Serial D-dimer testing is a useful tool to detect recurrence and inform the decision to restart anticoagulation after the initial 3-month period in patients with unprovoked PE.
Patients with unexplained persistent dyspnea or exercise intolerance merit ongoing anticoagulation while undergoing workup for new onset pulmonary vascular disease such as chronic thromboembolic pulmonary hypertension.
Identifying Provoked vs. Unprovoked PE Identifying patients who may benefit from extended anticoagulation requires a careful history that permits clinicians to classify a PE as either provoked or unprovoked. Special Patient Populations Consistent with therapeutic anticoagulation for other disease processes, the benefit of treatment must be weighed against the risk of bleeding.
0コメント