Duration of Anticoagulation: Applying the Guidelines and Beyond

Abstract

Despite an improved understanding of the risk factors underlying venous thromboembolism (VTE), extensive clinical investigation, and detailed clinical guidelines, the decision to extend anticoagulation indefinitely for an individual patient with VTE is often problematic. Patients with VTE in association with major surgery, trauma, immobilization, or pregnancy are at relatively low risk of recurrence and generally do not require more than 3 to 6 months of anticoagulant therapy. For patients with a first unprovoked, or idiopathic, episode of VTE, an individualized approach should be taken in deciding on the duration of anticoagulation based on the patient's recurrence and bleeding risk, as well as their personal preference. Although the presence of genetic thrombophilic disorders (factor V Leiden and prothrombin G20210A gene mutations; deficiencies of antithrombin, protein C, and protein S) predispose patients to a first episode of VTE, there is inconsistent data on whether testing for these defects changes patient outcomes or should alter their management. In patients with a single unprovoked VTE, measurement of D-dimer several weeks following the completion of anticoagulant therapy appears useful in stratifying patients with a first unprovoked episode of VTE with regard to recurrence risk. Through a series of clinical vignettes, the utility of the laboratory in risk-stratifying patients with respect to recurrence risk will be discussed, along with decision making regarding the duration of anticoagulation. The potential impact of having a nonremovable inferior vena caval filter will also be addressed.

Educational protocol for patients on oral anticoagulant therapy: construction and validation

“…Determining the period for assessing the expected results, i.e., the performance of the patient when participating in an educational intervention focused on self-care with the OAT will be linked to the reality of each health service. [28][29][30] As regards our reality, it was suggested that this review was conducted two months after the participant's discharge.…”

Editor's Choice – Management of the Diseases of Mesenteric Arteries and Veins

“…persisting risk factors and previous venous thromboembolism); and (iii) the consequences of recurrence or progression (extensive bowel involvement and short bowel syndrome). 274 Patients with the new risk factors for MVT, such as JAK2 mutation with or without myeloproliferative disorders, should be considered for indefinite treatment, given the persistent nature of their risk factors. The advantage of prolonged anticoagulation should be balanced with the risk of major bleeding, including recent major haemorrhage, uncontrolled hypertension, serum creatinine >1.2 mg/dL, anaemia, or age >75.…”

“…The advantage of prolonged anticoagulation should be balanced with the risk of major bleeding, including recent major haemorrhage, uncontrolled hypertension, serum creatinine >1.2 mg/dL, anaemia, or age >75. 274 Other studies have suggested that the optimal duration of anticoagulant treatment should also take into consideration the recanalisation rate of the mesenteric veins, as this may greatly affect mesenteric venous haemodynamics and, consequently, the risk of recurrence. DUS at 1 and 3 and 6 months after an endovascular procedure may allow examination of the portal system and shunting function after TIPS.…”

Management of inherited thrombophilia: guide for genetics professionals

“…Despite these associations, measurement of clotting factor levels is not routinely included in a thrombophilia evaluation (9). Clotting factor assays are not standardized for thrombophilia testing and threshold values for identifying high-risk individuals vary considerably among the different populations studied (9).…”