Treatment Decision-Making of Secondary Prevention After Venous Thromboembolism: Data From the Real-Life START2-POST-VTE Register

Abstract

Patients with venous thromboembolism (VTE) should receive a decision on the duration of anticoagulant treatment (AT) that is often not easy to make. Sixteen Italian clinical centers included patients with recent VTE in the START2-POST-VTE register and reported the decisions taken on duration of AT in each patient and the reasons for them. At the moment of this report, 472 (66.9%) of the 705 patients included in the registry were told to stop AT in 59.3% and to extend it in 40.7% of patients. Anticoagulant treatment lasted ≥3 months in >90% of patients and was extended in patients with proximal deep vein thrombosis because considered at high risk of recurrence or had thrombophilic abnormalities. d-dimer testing, assessment of residual thrombus, and patient preference were also indicated among the criteria influencing the decision. In conclusion, Italian doctors stuck to the minimum 3 months AT after VTE, while the secondary or unprovoked nature of the event was not seen as the prevalent factor influencing AT duration which instead was the result of a complex and multifactorial evaluation of each patient.

Unprovoked or provoked venous thromboembolism: not the prevalent criterion to decide on anticoagulation extension in clinical practice of various countries—the prospective, international, observational WHITE study

“…This appears to be in contrast with what suggested by experts [ 2 ] and international guidelines [ 1 ] which have recommended at least 3 months of anticoagulation for all VTE patients and to consider extension of treatment in those with unprovoked events who have a non-high risk of bleeding. However, this result, fully consistent with what Italian vascular doctors decided in a cohort of VTE patients [ 12 ], indicates that many physicians in the everyday clinical practice of different countries prefer not to comply with a pretended obligation dictated by the classification as unprovoked/provoked event, but rather to try and assess the multifactorial individual recurrence risk. Indeed, at the multivariable analysis, the provoked/unprovoked nature of the event along with its site (PE or not), the presence of PTS signs and the presence of concomitant diseases, significantly affected the probability to continue with anticoagulation or antithrombotic treatment, rather than stopping.…”

“…Not many studies have assessed the treatment of VTE patients in real-world populations. Among Italian VTE patients, prevalently managed by vascular doctors, an anticoagulation for < 3 months was recorded in more patients (9%) than found in the present study; conversely, quite similar (36.8%) was the prevalence of patients who were treated for > 180 days [12]. Completely different results were reported in a Canadian study [13], in which only 73% of patients with proven VTE were treated with anticoagulation (with VKAs) and for a much shorter period (median 61 days).…”

Current Trends in the Duration of Anticoagulant Therapy for Venous Thromboembolism: A Systematic Review

“…The introduction of DOACs, like rivaroxaban, have provided some promising results for a non-inferior, more convenient alternative anticoagulant regimen to prevent recurrent VTE. In a multicenter prospective registry study done by Antonucci et al in 2020, the most frequently prescribed treatment for extended treatment (anticoagulation therapy greater than six months up to a year) were apixaban 33.8% (5mg BID), rivaroxaban 29.3% (20mg OID), apixaban 13.1% (2.5mg BID), edoxaban 12.6% (60mg OID), LMWH/fondaparinux 6.5%, VKA 3.0%, dabigatran 1.5% (150mg BID); this study also suggests that physicians are aware of and are more comfortable with DOACs and administer them in extended anticoagulant treatment to reduce recurrent VTEs [ 38 ]. Rivaroxaban is the most studied of the DOAC drugs.…”

“…The common factors physicians used for corroborating a 12 month or indefinite anticoagulant treatment decision were age (older than 65 years), an unprovoked causal factor, proximal VTE over distal and recurrent VTE or residual thrombus [ 10 , 38 ]. Few studies included the use of D-dimer level monitoring in conjunction, and results were similar to those who did not, suggesting D-dimer may not provide pertinent evidence in the decision-making process [ 11 ].…”

Long‐term follow‐up of patients with venous thromboembolism and COVID‐19: Analysis of risk factors for death and major bleeding

“…12,13,18 The frequency of PE in our study (64%) was markedly higher than the previously reported in real-world VTE studies, where it ranges from 25% to 38%. 19,20 In the previously mentioned RIETE Registry study, 83% of COVID-19 patients with VTE had acute PE, while only 17% had isolated DVT. 17 A meta-analysis that included COVID-19…”