The secondary prevention of venous thromboembolism: Towards an individual therapeutic strategy

Vascular ◽  
2018 ◽  
Vol 26 (6) ◽  
pp. 670-682 ◽  
Author(s):  
Giovanna Elmi ◽  
Attilia M Pizzini ◽  
Mauro Silingardi
Keyword(s):  
Venous Thromboembolism ◽  
Secondary Prevention ◽  
Recurrent Events ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
External Validation ◽  
Bleeding Risk ◽  
Individual Risk ◽  
Risk Of Recurrence ◽  
The Individual

After the anticoagulant withdrawal, a substantial proportion of patients with venous thromboembolism will develop recurrent events. Whether to consider an extended treatment depends on the risk of recurrence and bleeding risk. The assessment of the individual risk profile remains a difficult task. Several basal and post-basal factors modulate the risk of recurrence and may help clinicians to select patients who can benefit from the extended therapy. During the year 2017, new evidence regarding the post-basal factors was provided by the Morgagni and Scope studies. Another interesting novelty was the VTE-BLEED score, the first bleeding risk score that obtained the external validation in venous thromboembolism setting. In secondary prevention, the use of direct oral anticoagulants is growing instead of vitamin K antagonist. Even at lower doses, direct oral anticoagulants showed to be effective and safe, to reduce all-cause mortality and seemed to be superior to placebo for the composite outcome of fatal bleeding and fatal recurrence. After the recently published Einstein-Choice trial, the role of aspirin has become truly marginal as rivaroxaban 10 mg showed a bleeding risk similar to aspirin 100 mg but a greater effectiveness reducing the relative risk of recurrence by about 70%. Another option for secondary prevention could be sulodexide, with a lower protective effect than direct oral anticoagulants but an interesting safety profile. In conclusion, in our opinion, an individual strategy taking into account the risk of recurrence, bleeding risk, therapeutic options and patient preferences is the most appropriate approach to secondary prevention of venous thromboembolism.

scholarly journals Breadth of complications of long-term oral anticoagulant care

Hematology ◽  
2018 ◽  
Vol 2018 (1) ◽  
pp. 432-438 ◽  
Author(s):  
Walter Ageno ◽  
Marco Donadini
Keyword(s):  
Oral Anticoagulants ◽  
Case Fatality ◽  
Bleeding Risk ◽  
Medical Intervention ◽  
Individual Risk ◽  
Anticoagulant Treatment ◽  
Risk Of Recurrence ◽  
Recurrent Vte ◽  
The Individual

Abstract The majority of patients with venous thromboembolism (VTE) have a considerable long-term risk of recurrence and may require extended duration of anticoagulant treatment after the initial 3 to 6 months. The decision to extend treatment is based not only on the individual risk of recurrence, but should also consider the potential complications associated with anticoagulation, taking into account that anticoagulant drugs are among the drugs most frequently associated with hospital admission due to adverse drug reactions. The most feared complication of oral anticoagulants is bleeding, which in some cases may be fatal or may affect critical organs. Case-fatality rates of bleeding have been reported to be ∼3 times higher than case-fatality rates of recurrent VTE. Even when nonserious, bleeding may require medical intervention and/or may impact on patient quality of life or working activity. Factors associated with bleeding during anticoagulant treatment include, among others, advanced age, cancer, renal or liver insufficiency, or concomitant antithrombotic drugs, but no bleeding risk score is sufficiently accurate for use in clinical practice. Not uncommonly, bleeding occurs as a complication of trauma or medically invasive procedures. Nonbleeding complications associated with oral anticoagulants are unusual, and their relevance is extremely uncertain, and include vascular calcification, anticoagulation-related nephropathy, and osteoporosis. Finally, because VTE not uncommonly affects young individuals and the mean age of the population is ∼60 years, the costs associated with extended anticoagulation should not be forgotten. The costs of the drugs need to be balanced against health outcome costs associated with both recurrent VTE and bleeding.

scholarly journals Recurrent Venous Thromboembolism: What Is the Risk and How to Prevent It

Scientifica ◽  
2012 ◽  
Vol 2012 ◽  
pp. 1-17 ◽  
Author(s):  
Gualtiero Palareti
Keyword(s):  
Venous Thromboembolism ◽  
Recurrent Events ◽  
Thrombotic Event ◽  
Chronic Thromboembolic Pulmonary Hypertension ◽  
Individual Risk ◽  
First Episode ◽  
Postthrombotic Syndrome ◽  
Risk Of Recurrence ◽  
Vein Thrombosis ◽  
The Individual

Venous thromboembolism (VTE) that includes deep vein thrombosis and/or pulmonary embolism is a frequent, severe, and potentially lethal disease. After a first episode, VTE has a strong tendency to recur. While VTE is an acute disease, it may have variable outcomes in early and late phases after initial presentation. Furthermore, the incidence of late, clinically important consequences (postthrombotic syndrome and/or chronic thromboembolic pulmonary hypertension) increases in case of recurrent events. The aims of the present review are (i) to analyze the incidence and risk factors for recurrence of VTE (either those related to the type of first thrombotic event or to the patients), the risks associated with occurrence of recurrent events, and the problems linked to the diagnosis, not always easy, of recurrent events; (ii) to discuss whether or not it is possible to predict the individual risk of recurrence after a first event, by stratifying patients at high or low risk of recurrence, and how this can influence their treatment; (iii) to comment what the current guidelines and guidance suggest/recommend about anticoagulant treatment after a first VTE event and, finally, to propose practical indications on how to manage individual patients affected by VTE.

The optimal duration of anticoagulant therapy after unprovoked venous thromboembolism – still a challenging issue

VASA ◽  
2017 ◽  
Vol 46 (2) ◽  
pp. 87-95 ◽  
Author(s):  
Giovanna Elmi ◽  
Giuseppe Di Pasquale ◽  
Raffaele Pesavento
Keyword(s):  
Venous Thromboembolism ◽  
Safety Profile ◽  
Vitamin K Antagonists ◽  
Dabigatran Etexilate ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Bleeding Risk ◽  
Risk Of Recurrence ◽  
Extended Treatment

Abstract. As about 50 % of patients with unprovoked venous thromboembolism (VTE) will develop new episodes after discontinuing therapy, indefinite treatment is suggested in patients with low or moderate bleeding risk. Baseline and post-baseline factors can help clinicians to identify patients at high risk of recurrence, who require extended treatment. Residual vein obstruction and D-dimer assay have been shown to be suitable methods for assessing the risk of VTE recurrences after a first unprovoked VTE. In treatment for VTE the use of direct oral anticoagulants (DOAC) is growing instead of the standard adjusted dose of vitamin K antagonists. The DOAC safety profile has recently been strengthened with systematic reviews and meta-analyses. Idarucizumab is only approved for the reversal of dabigatran etexilate; intravenous antidotes for factor Xa inhibitors are under development. Their advent is of great interest. In the extended treatment of VTE sulodexide has been demonstrated to significantly decrease the risk of recurrences with an excellent safety profile. Aspirin is substantially less effective than oral anticoagulants in preventing recurrences but could play a role among patients who decided to stop anticoagulants. In conclusion, for the secondary prevention of VTE several options are available, without a recognised best choice regarding the treatment duration and the choice of drugs. An individual strategy taking into account risk of recurrence, bleeding risk, therapeutic options, and patient preferences is appropriate.

Effect of Antithrombotic Therapy on Secondary Bleeding After Proctological Surgery

2020 ◽  
Author(s):  
Ryo Maemoto ◽  
Shingo Tsujinaka ◽  
Yasuyuki Miyakura ◽  
Erika Machida ◽  
Nao Kakizawa ◽  
...  
Keyword(s):  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Individual Risk ◽  
Bleeding Rate ◽  
Secondary Bleeding ◽  
Number Of Patients ◽  
Anticoagulant Drugs ◽  
The Individual ◽  
Median Interval

Abstract Background: The purpose of this study was to identify the incidence and severity of secondary bleeding after proctological surgery for patients with or without antithrombotic therapy.Methods: We retrospectively identified 113 patients who underwent proctological surgery in our hospital from March 2009 to February 2019. In general, antiplatelet drugs were continued and anticoagulant drugs were either substituted or withdrawn prior to the surgery. The severity of secondary bleeding was classified as mild, moderate, severe.Results: Eighteen patients underwent antiplatelet therapy (A group) and 95 patients did not undergo antithrombotic therapy (N group). Secondary bleeding was observed in nine patients (8.0%) and patients in the A group exhibited significantly higher rate of secondary bleeding rate than patients in the N group (39% vs. 2.4%, P < 0.01). The median interval from surgery to the onset of secondary bleeding was 5 (range: 0-11days). The severity of bleeding was the highest in patients administered direct oral anticoagulants (DOAC) and was the lowest in those administered aspirin. There was no mortality or cardiovascular event.Conclusions: Antithrombotic therapy is associated with high risk of secondary bleeding after proctological surgery, particularly in patients who undergo anticoagulant therapy. Delaying of postoperative resumption of anticoagulants may be considered in balancing the individual risk of postoperative thromboembolic complications against the risk of secondary bleeding. Future prospective studies with larger number of patients are needed to determine the appropriate timing of resuming antithrombotic therapy.

scholarly journals Current Recommendations for the Management of Cancer-Associated Venous Thromboembolism

2021 ◽  
Vol 7 (2) ◽  
pp. 27-38
Author(s):  
Katalin Makó
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Cancer Patients ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Term Treatment ◽  
Long Term Treatment ◽  
High Bleeding Risk ◽  
Cancer Associated Thrombosis

Abstract Cancer-associated thrombosis (CAT) is a major cause of death in oncological patients. The mechanisms of thrombogenesis in cancer patients are not fully established, and it seems to be multifactorial in origin. Also, several risk factors for venous thromboembolism (VTE) are present in these patients such as tumor site, stage, histology of cancer, chemotherapy, surgery, and immobilization. Anticoagulant treatment in CAT is challenging because of high bleeding risk during treatment and recurrence of VTE. Current major guidelines recommend low molecular weight heparins (LMWHs) for early and long-term treatment of VTE in cancer patients. In the past years, direct oral anticoagulants (DOACs) are recommended as potential treatment option for VTE and have recently been proposed as a new option for treating CAT. This manuscript will give a short overview of risk factors involved in the development of CAT and a summary on the recent recommendations and guidelines for treatment of VTE in patients with malignancies, discussing also some special clinical situations (e.g. renal impairment, catheter-related thrombosis, and thrombocytopenia).

scholarly journals Optimal duration of anticoagulant therapy in patients with venous thromboembolism

2018 ◽  
Vol 12 (4) ◽  
pp. 235-244
Author(s):  
Gualtiero Palareti
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Anticoagulant Therapy ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Severe Disease ◽  
Direct Oral Anticoagulants ◽  
Late Complications ◽  
Risk Of Recurrence ◽  
Risk Of Bleeding

Venous thromboembolism, a frequent and severe disease, has clinically important early and late complications and a strong tendency to recur. Anticoagulant therapy is the mainstay of treatment, performed by immediate administration of: i) parenteral anticoagulants followed by vitamin K antagonists, either dabigatran or edoxaban, two direct oral anticoagulants (DOACs); or ii) direct rivaroxaban or apixaban, two DOACs that can be used as single-drug approach. Treatment should last no less than 3 months in all patients though how long it should last thereafter is a more complex issue. The risk of recurrence results from several event- or patient-associated factors. Some patients have low risk and may be treated for 3 to 6 months only. Others (the majority) have a high risk of recurrence (approximately 50% in 10 years). Unfortunately, the protective effect of anticoagulation against recurrence is present only during treatment and is lost when therapy is stopped. For this reason, international guidelines recommend that there is no pre-definite period of anticoagulation (e.g. 1 or 2 years, and so on) in patients at high risk and suggest instead indefinite (extended) anticoagulation, provided there is no high risk of bleeding. When the decision is difficult, adjunctive criteria may be adopted, such as male sex and abnormal D-dimer assessed after anticoagulation is stopped, to identify patients at high risk who need indefinite therapy. The use of DOACs, especially at lower doses with a lower risk of bleeding, may make indefinite anticoagulation for patients easier.

scholarly journals Contrasts in Glioblastoma—Venous Thromboembolism versus Bleeding Risk

Cells ◽  
2021 ◽  
Vol 10 (6) ◽  
pp. 1414
Author(s):  
Viktoria Muster ◽  
Thomas Gary
Keyword(s):  
Venous Thromboembolism ◽  
Patient Group ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Bleeding Events ◽  
Therapeutic Anticoagulation ◽  
Vulnerable Patient ◽  
Risk Treatment ◽  
Thrombogenic Potential

Glioblastoma is among the tumor entities with an extreme thrombogenic potential and patients are at very high risk of developing a venous thromboembolism (VTE) over the course of the disease, with an incidence of up to 30% per year. Major efforts are currently being made to understand and gain novel insights into the underlying pathomechanisms of the development of VTE in patients with glioblastoma and to find appropriate biomarkers. Yet, patients with glioblastoma not only face a high thromboembolic risk but are also at risk of bleeding events. In the case of VTE, a therapeutic anticoagulation with low molecular weight heparin or, in the case of low bleeding risk, treatment with a direct oral anticoagulant, is recommended, according to recently published guidelines. With respect to an elevated bleeding risk in glioblastoma patients, therapeutic anticoagulation remains challenging in this patient group and prospective data for this vulnerable patient group are scarce, particularly with regard to direct oral anticoagulants.

Venous thromboembolism in the elderly

Phlebologie ◽  
2016 ◽  
Vol 45 (04) ◽  
pp. 215-218
Author(s):  
C. Ploenes
Keyword(s):  
Venous Thromboembolism ◽  
Old Age ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
The Elderly ◽  
Clinical Findings ◽  
Self Medication ◽  
Initial Symptoms

SummaryOld age is an independent risk factor of venous thromboembolism. Nevertheless initial symptoms are often attributed to existing cardiac or pulmonary comorbidity. Once deep thromboembolism (DTE) is in focus, the synopsis of clinical findings and anamnestic clues help to take further steps to establish or rule out the diagnosis (e.g. Wells score). Treatment consists in oral anticoagulation, either by vitamin-k-antagonists or by direct oral anticoagulants (“DOACs”). Strict compliance of patients or main caregivers is essential in both cases. Simultaneous medication of platelet-inhibitingor nonsteroidal anti-inflammatory drugs – often unknown self medication – results in a raised bleeding risk and should be avoided. If longterm anticoagulation is mandatory, a strategy of sequential dose-reduced anticoagulation can be considered, especially in the case of increased bleeding-risk. Systemic fibrinolysis of pulmonary embolism goes along with a very high bleeding risk in old age and should be performed only in case of vital circulatory depression or failure.

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