Risk Stratification of Recurrent Venous Thromboembolism.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 2981-2981
Author(s):  
Rainer B. Zotz ◽  
Andrea Gerhardt
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Risk Stratification ◽  
Conflicts Of Interest ◽  
Oral Anticoagulant Therapy ◽  
Venous Thromboembolic Event ◽  
First Episode ◽  
Recurrent Venous Thromboembolism ◽  
Yearly Incidence ◽  
Venous Thromboembolic

Abstract Abstract 2981 Poster Board II-956 Background: A better risk stratification for recurrent venous thromboembolism (VTE) in patients with a first episode of idiopathic venous thromboembolism (VTE) is urgently needed. Methods: Retrospective study covering more than 20 years after a first venous thromboembolic event in a group of 1,440 patients with VTE. Results: In the subgroup of patients (n=515) with a first spontaneous VTE, the yearly incidence of a recurrent spontaneous VTE was 8% for the time period 0-2 years and 4-6% in the following 8 years, after a first VTE, triggered by a transient risk factor (oral contraceptives, surgery or immobilization, pregnancy), the yearly incidence of a recurrent spontaneous VTE was 2% (first 2 years) and 1.3-3% (following 8 years). The hazard ratio for recurrent spontaneous VTE in patients with a first spontaneous VTE for specific predictors were as follows: prothrombin mutation heterozygous 1.2 (95% CI 0.9-1.7), FVL heterozygous 1.3 (95% CI 0.92-1.8), male sex 1.9 (95% CI 1.4-2.7), D-Dimer 2.3 (0.9-6.4), protein C (<60% activity) 2.6 (95% CI 1.2-5.7), FVL homozygous 3.0 (1.3-7.7), AT (<60% activity) 3.0 (95% CI 0.96-9.6). In Conclusion, in patients with a first spontaneous VTE the yearly recurrence rate of 5% is more than doubled in the presence of relevant thrombophilic risk factors supporting the need of long-term oral anticoagulant therapy after a first idiopathic VTE. In contrast to current ACCP recommendations, thrombophilic risk factors are of clinical relevance. Disclosures: No relevant conflicts of interest to declare.

Long-term strategies in patients with unprovoked venous thromboembolism

Phlebologie ◽  
2017 ◽  
Vol 46 (05) ◽  
pp. 288-291
Author(s):  
P. Prandoni
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Low Dose ◽  
Risk Profile ◽  
Substantial Proportion ◽  
First Episode ◽  
Vein Thrombosis ◽  
Recurrent Venous Thromboembolism ◽  
D Dimer

SummaryOnce anticoagulation is stopped, the risk of recurrent venous thromboembolism (VTE) over years approaches 40 % of all patients with a first episode of VTE. The risk is twice as high in patients with unprovoked VTE than in those with minor (either transient or persistent) risk factors of thrombosis. Although the latest international guidelines suggest indefinite anticoagulation for most patients with a first episode of unprovoked VTE, strategies that incorporate the assessment of residual vein thrombosis and D-dimer have the potential to identify a substantial proportion of subjects in whom anticoagulation can be safely discontinued. For those patients in whom anticoagulation cannot be discontinued, new opportunities are offered by the availability of low-dose anti-Xa compounds, which have been found to possess an extremely favorable benefit/risk profile.

Risk of Venous Thromboembolism Recurrence: High Negative Predictive Value of D-dimer Performed after Oral Anticoagulation Is Stopped

2002 ◽  
Vol 87 (01) ◽  
pp. 7-12 ◽  
Author(s):  
Cristina Legnani ◽  
Benilde Cosmi ◽  
Giuliana Guazzaloca ◽  
Claudia Pancani ◽  
Sergio Coccheri ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Recurrent Events ◽  
Oral Anticoagulant Therapy ◽  
Lower Limbs ◽  
First Episode ◽  
Vein Thrombosis ◽  
D Dimer

SummaryIn some patients with previous venous thromboembolism (VTE) D-dimer levels (D-Dimer) tend to increase after oral anticoagulant therapy (OAT) is stopped. The aim of our study was to evaluate the predictive value of D-Dimer for the risk of VTE recurrence after OAT withdrawal. After a first episode of deep vein thrombosis (DVT) of the lower limbs and/or pulmonary embolism (PE), 396 patients (median age 67 years, 198 males) were followed from the day of OAT discontinuation for 21 months. D-dimer was measured on the day of OAT withdrawal (T1), 3-4 weeks (T2) and 3 months (+/− 10 days, T3) thereafter. The main outcome events of the study were: objectively documented recurrent DVT and/or PE. D-dimer was found to be increased in 15.5%, 40.3% and 46.2% of the patients at T1, T2 and T3, respectively. In 199 (50.2%) patients, D-dimer levels were elevated in at least one measurement. During a follow-up of 628.4 years, 40 recurrences were recorded (10.1% of patients; 6.4% patient-years of follow-up). D-dimer was increased in at least one measurement in 28 of these cases, but remained normal in 11 subjects (three of whom had recurrent events triggered by circumstantial factors, three with malignancyassociated factors) (in one subject D-dimer was not measured). The negative predictive value (NPV) of D-dimer was 95.6% (95% CI 91.6-98.1) at T3 and was even higher (96.7%; 95% CI 92.9-98.8) after exclusion of the six recurrences due to circumstantial factors. Only five idiopathic recurrences occurred in the 186 patients with consistently normal D-dimer. In conclusion, D-dimer has a high NPV for VTE recurrence when performed after OAT discontinuation.

scholarly journals Different Finite Durations of Anticoagulation and Outcomes following Idiopathic Venous Thromboembolism: A Meta-Analysis

Thrombosis ◽  
2010 ◽  
Vol 2010 ◽  
pp. 1-9 ◽  
Author(s):  
Aaron B. Holley ◽  
Christopher S. King ◽  
Jeffrey L. Jackson ◽  
Lisa K. Moores
Keyword(s):  
Venous Thromboembolism ◽  
Major Bleeding ◽  
Data Extraction ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Secondary Prophylaxis ◽  
First Episode ◽  
Short Course ◽  
Recurrent Venous Thromboembolism ◽  
Prospective Trials

Introduction. Controversy remains over the optimal length of anticoagulation following idiopathic venous thromboembolism. We sought to determine if a longer, finite course of anticoagulation offered additional benefit over a short course in the initial treatment of the first episode of idiopathic venous thromboembolism. Data Extraction. Rates of deep venous thrombosis, pulmonary embolism, combined venous thromboembolism, major bleeding, and mortality were extracted from prospective trials enrolling patients with first time, idiopathic venous thromboembolism. Data was pooled using random effects meta-regression. Results. Ten trials, with a total of 3225 patients, met inclusion criteria. For each additional month of initial anticoagulation, once therapy was stopped, recurrent venous thromboembolism (0.03 (95% CI: −0.28 to 0.35); ), mortality (−0.10 (95% CI: −0.24 to 0.04); ), and major bleeding (−0.01 (95% CI: −0.05 to 0.02); ) rates measured in percent per patient years, did not significantly change. Conclusions: Patients with an initial idiopathic venous thromboembolism should be treated with 3 to 6 months of secondary prophylaxis with vitamin K antagonists. At that time, a decision between continuing with indefinite therapy can be made, but there is no benefit to a longer (but finite) course of therapy.

Thrombosis and the Antiphospholipid Syndrome

Hematology ◽  
2005 ◽  
Vol 2005 (1) ◽  
pp. 462-468 ◽  
Author(s):  
Thomas L. Ortel
Keyword(s):  
Risk Factors ◽  
Antiphospholipid Syndrome ◽  
Antiphospholipid Antibodies ◽  
Thromboembolic Event ◽  
Randomized Clinical Trials ◽  
Venous Thromboembolic Event ◽  
Thromboembolic Events ◽  
Additional Risk ◽  
Initial Event ◽  
Venous Thromboembolic

Abstract The antiphospholipid syndrome is an antibody-mediated hypercoagulable state characterized by recurrent venous and arterial thromboembolic events. Several studies have determined that the frequency of antiphospholipid syndrome in patients presenting with a venous thromboembolic event is between 4% and 14%. Because of the high risk for recurrent thromboembolism in these patients, current recommendations suggest a longer, potentially lifelong, course of antithrombotic therapy following an initial event. Although most authorities agree on an extended course of therapy, considerable controversy surrounds the optimal target therapeutic INR for patients with antiphospholipid syndrome. For an initial venous thromboembolic event, a target INR of 2.0 to 3.0 is supported by two prospective, randomized clinical trials. In contrast, relatively limited data exist for an initial arterial thromboembolic event in patients who have the antiphospholipid syndrome, and therapeutic recommendations range from aspirin to warfarin with a high target INR. Recurrent thromboembolic events can be extremely difficult to treat, and some patients may benefit from the addition of immunosuppressive therapies. Importantly, as many as 50% of the initial thromboembolic events sustained by patients with antiphospholipid antibodies occur in the setting of additional, coincident prothrombotic risk factors, indicating the importance of addressing any additional risk factors, such as hypercholesterolemia, in these patients. Prospective studies are needed to address the role of thromboprophylactic strategies in asymptomatic individuals with antiphospholipid antibodies in the absence of additional risk factors.

Venous Thromboembolic Diseases

2014 ◽  
pp. 346-355
Author(s):  
Gregory Piazza ◽  
Samuel Z. Goldhaber
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Risk Stratification ◽  
Laboratory Testing ◽  
Clinical Findings ◽  
Venous Thromboembolic ◽  
Long Term Consequences ◽  
Practical Recommendations

This chapter reviews the pathophysiology of VTE, including its risk factors and long-term consequences. Diagnostic algorithms that integrate clinical findings, laboratory testing, and imaging are described. The role of risk stratification for identification of high-risk PE patients is highlighted. Options for the management of VTE are reviewed. Finally, practical recommendations for the prevention of VTE are provided.

scholarly journals Risk and Risk Factors Associated With Recurrent Venous Thromboembolism Following Surgery in Patients With History of Venous Thromboembolism

2019 ◽  
Vol 2 (5) ◽  
pp. e193690 ◽  
Author(s):  
Banne Nemeth ◽  
Willem M. Lijfering ◽  
Rob G. H. H. Nelissen ◽  
Inger B. Schipper ◽  
Frits R. Rosendaal ◽  
...  
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Factors Associated ◽  
Recurrent Venous Thromboembolism ◽  
History Of

P3850Impact of sex and risk factors for venous thromboembolism on the clinical course of first acute venous thromboembolism. Insights from the PREFER in VTE

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Giustozzi ◽  
S Barco ◽  
L Valerio ◽  
F A Klok ◽  
M C Vedovati ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Venous Thromboembolism ◽  
Baseline Risk ◽  
Major Surgery ◽  
First Episode ◽  
Risk Of Recurrence ◽  
Recurrent Vte ◽  
The Impact

Abstract Introduction The interaction between sex and specific provoking risk factors for venous thromboembolism (VTE) may influence initial presentation and prognosis. Purpose We investigated the impact of sex on the risk of recurrence across subgroups of patients with first VTE classified according to baseline risk factors. Methods PREFER in VTE was an international, non-interventional registry (2013–2015) including patients with a first episode of acute symptomatic objectively diagnosed VTE. We studied the risk of recurrence in patients classified according to baseline provoking risk factors for VTE consisted of i) major transient (major surgery/trauma, >5 days in bed), ii) minor transient (pregnancy or puerperium, estroprogestinic therapy, prolonged immobilization, current infection or bone fracture/soft tissue trauma); iii) unprovoked events, iv) active cancer-associated VTE. Results A total of 3,455 patients diagnosed with first acute VTE were identified, of whom 1,623 (47%) were women. The percentage of patients with a major transient risk factor was 22.2% among women and 19.7% among men. Minor transient risk factors were present in 21.3% and 12.4%, unprovoked VTE in 51.6% and 61.6%, cancer-associated VTE in 4.9% of women and 6.3% of men, respectively. The proportions of cases treated with Vitamin-K antagonists (VKAs) and direct oral anticoagulants (DOACs) were similar between sexes. Median length of treatment of VKAs was 181.5 and 182.0 days and of DOACs was 113.0 and 155.0 days in women and men, respectively. At 12-months of follow-up, VTE recurrence was reported in 74 (4.8%) women and 80 (4.5%) men. Table 1 shows the sex-specific proportion of recurrences by VTE risk factor categories. Table 1 Major Transient (n=722) Minor transient (n=573) Cancer-associated (n=195) Unprovoked (1965) Women (361) Men (361) OR (95% CI) Women (346) Men (227) OR (95% CI) Women (79) Men (116) OR (95% CI) Women (837) Men (1128) OR (95% CI) One-year follow-up, n (N%)   Recurrent VTE, 21 (6.2) 10 (2.9) 0.46 (0.2; 0.9) 9 (2.7) 12 (5.4) 2.09 (0.9; 5.0) 6 (8.0) 5 (4.5) 0.54 (0.2; 1.9) 38 (4.7) 53 (4.7) 1.03 (0.7; 1.6)   Major bleeding, 6 (1.8) 5 (1.5) 0.83 (0.3; 2.7) 5 (1.5) 1 (0.5) 0.30 (0.1; 2.6) 1 (1.3) 3 (2.7) 2.07 (0.2; 20) 10 (1.2) 15 (1.4) 1.11 (0.6; 2.4)   All-cause death, 37 (10.2) 31 (8.5) 0.82 (0.5; 1.4) 10 (2.9) 14 (6.2) 2.21 (0.9; 5.1) 26 (32.9) 49 (42.2) 1.49 (0.8; 2.7) 33 (3.9) 30 (2.7) 0.66 (0.4; 1.1) Conclusions The proportion of patients with recurrent VTE events after first acute symptomatic VTE provoked by transient risk factors was not negligible during the first year of follow-up during in both women and men. These results may have implications on the decision whether to consider extended anticoagulant therapy in selected patients with provoked events. Acknowledgement/Funding This study was funded by Daiichi Sankyo.

scholarly journals How I treat recurrent venous thromboembolism in patients receiving anticoagulant therapy

Blood ◽  
2017 ◽  
Vol 129 (25) ◽  
pp. 3285-3293 ◽  
Author(s):  
Sam Schulman
Keyword(s):  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Drug Regimen ◽  
Underlying Disease ◽  
Drug Levels ◽  
Recurrent Venous Thromboembolism ◽  
Clinical Trial Evidence ◽  
Trial Evidence

Oral anticoagulant therapy for venous thromboembolism is very effective. When oral anticoagulants are managed well, the risk of recurrence is approximately 2 per 100 patient-years. The main reasons for a breakthrough event are underlying disease and subtherapeutic drug levels. The most common underlying disease that results in recurrence on treatment is cancer. Subtherapeutic drug levels can be caused by poor adherence to the drug regimen, interactions with other drugs or food, or inappropriate dosing. It is important to investigate and understand the cause whenever such an event occurs and to improve management of anticoagulants thereby avoiding further recurrences. Here we present 4 illustrative cases together with a discussion of the underlying pathology. Whereas the mechanisms are usually quite well understood, the management of further anticoagulation after a breakthrough event is based on minimal or no clinical trial evidence.

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