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Watch the video below for a discussion by Dr Ander Cohen on the evaluation of the risk of VTE recurrence.
The risk of VTE recurrence after cessation of anticoagulant varies according to the features of the index DVT or PE.1-3 Other risk factors (e.g. proximal vs. distal location and male vs. female sex) contribute to the risk.2,3
Of note, VTE recurrence is higher in those with unprovoked (i.e., idiopathic) VTE than those with provoked VTE (i.e., VTE associated with a transient major clinical risk factor).4,5 A UK study including 35,373 first VTE events revealed 28.4% of those with unprovoked VTE had a risk of a recurrent event within 10 years, compared with 20.5% of those with provoked VTE.4
Patients with VTE (without cancer) who are receiving an anticoagulant should have a review within 3 months to discuss the risks and benefits of continuing anticoagulation therapy.7 Patients may have had their treatment initiated while in hospital but may be discharged from secondary care before their treatment is complete. GPs therefore play an important role in the long-term management of patients with VTE.
The key primary estimator of recurrence in patients with VTE who stop anticoagulation is unprovoked VTE. Such patients have approximately 10% and 30% risk of experiencing a recurrent VTE event at 1 and 5 years, respectively.8
Recent research shows that recurrence rates in patients with VTE provoked by minor persistent or minor transient risk factors are equivalent to those with unprovoked VTE. Therefore, such patients may also benefit from extended anticoagulation therapy.9
Watch the video below for a discussion by Dr Ander Cohen on the updated 2020 NICE guideline recommendations for the use of DOACs for the long-term treatment of appropriate patients with confirmed DVT or PE.
NICE NG158 recommends considering stopping anticoagulation 3 months‡ after a provoked DVT / PE, if the provoking factor is no longer present and the clinical course has been uncomplicated. Provoked DVT or PE is defined as:5
NICE NG158 recommends considering continuing anticoagulation beyond 3 months§ after an unprovoked DVT / PE, basing the decision on the balance between the person’s risk of venous thromboembolism (VTE) recurrence and their risk of bleeding. Unprovoked is defined as:5
For people who do not have renal impairment, active cancer, established triple positive antiphospholipid syndrome or extreme body weight (less than 50 kg or more than 120 kg), NICE NG158 recommends the following:5
For people with renal impairment, active cancer, established triple positive antiphospholipid syndrome or extreme body weight (less than 50 kg or more than 120 kg), consider carrying on with the current treatment if it is well tolerated.5
-NICE NG158, 20205
A short duration of treatment (at least 3 months) should be based on transient risk factors (e.g., recent surgery, trauma, or immobilisation).1,2 The duration of overall therapy should be individualised after careful assessment of the treatment benefit against the risk for bleeding.5
It is important not to rely solely on predictive risk tools to assess the need for long-term anticoagulation treatment.
Please note that the BMS / Pfizer Alliance are not responsible for the accuracy of these assessment tools.
The decision to stop or continue anticoagulation should always include patient involvement.5 As described by NICE quality standards for patient experience, patients should be supported by healthcare professionals to understand relevant treatment options, including benefits, risks, potential consequences and be actively involved in shared decision-making.10
In Preventing VTE recurrence: Preventing recurrence | Which patients may benefit from extended anticoagulation? | Evidence in long-term prevention of VTE recurrence |
BMI=Body Mass Index CPRD=Clinical Practice Research Datalink DOAC=Direct-acting Oral Anticoagulant DVT=Deep Vein Thrombosis HRT=Hormone Replacement Therapy MHRA=Medicines and Healthcare products and Regulatory Agency NICE=National Institute for Health and Care Excellence OAC=Oral Anticoagulant PE=Pulmonary Embolism VTE=Venous Thromboembolism