The optimum length of anticoagulation therapy after venous thromboembolism - universal or individualised approach?

Česká verzia

Authors: J. Hirmerová
Authors place of work: II. interní klinika Lékařské fakulty UK a FN Plzeň, přednosta doc. MUDr. Jan Filipovský, CSc.
Published in the journal: Vnitř Lék 2007; 53(6): 662-668
Category: Reviews

Summary

Long-term peroral anticoagulation treatment is indicated after a thromboembolic event. The length of treatment should be based on balancing the risk of recurrence against the risk of bleeding complications. The minimum period of treatment is 3 months and can be reduced in certain cases; however, for many patients, a longer period of treatment may be recommendable. The presence or absence of a provoking factor and the nature of such a factor are of primary relevance when deciding on the length of treatment. Patients after a thromboembolic event provoked by a transitory (reversible) risk factor (surgery, accident, estrogen treatment etc.) have a very low risk of recurrence and a three-month treatment period is sufficient for them. In the remaining cases, extended treatment is recommendable, spanning from 6 to 12 months minimally. The type and scope of the event and the number of possible previous events should also be considered. Patients with a malignancy have a higher risk of recurrence and benefit most from long-term therapy with low-molecular weight heparin. Male sex, some thrombophilias and, according to some studies, the presence of residual thrombus in the vein, all increase the risk of recurrence. D-dimer detection results may also be useful in determining treatment length. They should be measured both before discontinuation of treatment and, more importantly, one month after treatment termination. A negative result in the D-dimer detection test means that there is a very low recurrence risk whilst a positive result indicates high risk of recurrence, in which case renewal of anticoagulation therapy should be considered. Deciding on the length of therapy is a complex process and should involve interdisciplinary cooperation.

Key words:
thromboembolic disease – deep venous thrombosis – pulmonary embolism – anticoagulant treatment – recurrence – risk factor

Zdroje

1. Büller HR, Agnelli G, Hull RD et al. Antithrombotic therapy for venous thromboembolic disease. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 401S-428S.

2. Kearon C Long-term management of patients after venous thromboembolism. Circulation 2004; 110 [Suppl I): I-10-I-18.

3. Prandoni P, Lensing AW, Cogo A et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 1996; 125: 1-7.

4. Research Comittee of the British Thoracic Society. Optimum duration of anticoagulation for deep vein thrombosis and pulmonary embolism. Lancet 1992; 340: 873-876.

5. Schulman S, Rhedin AS, Lindmarker P et al. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism: Duration of Anticoagulation Trial Study Group. N Engl J Med 1995; 332: 1661-1665.

6. Levine MN, Hirsch J, Gent M et al. Optimal duration of oral anticoagulation therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis. Thromb Haemost 1995; 74: 606-611.

7. Pinede L, Ninet J, Duhaut P et al. Comparison of 3 and 6 months of oral anticoagulation therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation 2001; 103: 2453-2460.

8. Kearon C, Ginsberg JS, Anderson DR et al. Comparison of 1 month with 3 months of anticoagulation for a first episode of venous thromboembolism associated with a transient risk factor. J Thromb Haemost 2004; 2: 743-749.

9. Kearon C, Gent M, Hirsch J et al. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. N Engl J Med 1999; 340: 901-907.

10. Agnelli G, Prandoni P, Santamaria MG et al. Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. N Engl J Med 2001; 345: 165-169.

11. Agnelli G, Prandoni P, Becattini C et al. Extended oral anticoagulant therapy after a first episode of pulmonary embolism. Ann Intern Med 2003; 139: 19-25.

12. Schulman S, Granqvist S, Holstrom M et al. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. N Engl J Med 1997; 336: 393-398.

13. Ridker PM, Goldhaber SZ, Danielson E et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N Engl J Med 2003; 348: 1425-1434.

14. Kearon C, Ginsberg JS, Kovacs MJ et al. Extended Low-Intensity Anticoagulation for Thrombo-Embolism Investigators. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. N Engl J Med 2003; 349: 631-639.

15. van Dongen CJJ, Vink RV, Hutten BA et al. The incidence of recurrent venous thromboembolism after treatment with vitamin K antagonists in relation to time since first event. Arch Int Med 2003; 163: 1285-1293.

16. Ost D, Tepper J, Mihara H et al. Duration of anticoagulation following venous thromboembolism. A meta-analysis. JAMA 2005; 294: 706-715.

17. Hirsch J, Fuster V, Ansell J et al. American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy. Circulation 2003; 107: 1692-1711.

18. Kuijer P, Hutten BA, Prins M et al. Prediction of the risk of bleeding during anticoagulant treatment for venous throboembolism. Arch Intern Med 1999; 159: 457-460.

19. Gumulec J, Kessler P, Penka M et al. Krvácivé komplikace při léčbě warfarinem. Vnitř Lék 2006; 52 (Suppl 1): 79-91.

20. Eichinger S, Weltermann A, Minar E et al. Symptomatic pulmonary embolism and the risk of recurrent venous thromboembolism. Arch Intern Med 2004; 164: 92-96.

21. Jiménez D, Díaz G, Marín E et al. The risk of recurrent venous thromboembolism in patients with unprovoked symptomatic deep vein thrombosis and asymptomatic pulmonary embolism. Thromb Haemost 2006; 95: 562-566.

22. Schulman S, Ögren M. New concepts in optimal management of anticoagulant therapy for extended treatment of venous thromboembolism. Thromb Haemost 2006; 96: 258-266.

23. Baglin T, Luddington K, Brown K et al. Incidence of recurrent venous thromboembolism in relation to clinical and thrombophilic risk factors: prospective cohort study. Lancet 2003; 362: 523-526.

24. Malý J, Dulíček P, Penka M et al. Prevence žilní tromboembolické nemoci ve vnitřním lékařství a v neurologii. Vnitř Lék 2006; 52 (Suppl 1): 63-67.

25. Kyrle PA, Minar E, Bialonczyk C et al. The risk of recurrent venous thromboembolism in men and women. N Engl J Med 2004; 350: 2558-2563.

26. Baglin T, Luddington K, Brown K et al. High risk of recurrent venous thromboembolism in men. J Thromb Haemost 2004; 2: 2152-2155.

27. McRae S, Tran H, Schulman S et al. Effect of patient’s sex on risk of recurrent venous thromboembolism: a meta-analysis. Lancet 2006; 368: 371-378.

28. Ridker PM, Miletich JP, Stampfer MJ et al. Factor V Leiden and risk of recurrent idiopathic venous thromboembolism. Circulation 1995; 92: 2800-2802.

29. Simioni P, Prandoni P, Lensing AW et al. The risk of recurrent venous thromboembolism in patients with Arg506Gln mutation in the gene for factor V (factor V Leiden). N Engl J Med 1997; 336: 399-403.

30. Simioni P, Prandoni P, Lensing AW et al. Risk for subsequent venous thromboembolic complications in carriers of the prothrombin or the factor V gene mutation with a first episode of deep-vein thrombosis. Blood 2000; 96: 3329-3333.

31. Miles JS, Miletich JP, Goldhaber SZ et al. G20210A mutation in the prothrombin gene and the risk of recurrent venous thromboembolism. J Am Coll Cardiol 2001; 37: 215-218.

32. De Stefano V, Martinelli I, Manucci PM et al. The risk of recurrent deep venous thrombosis among heterozygous carriers of both factor V Leiden and the G20210A prothrombin mutation. N Engl J Med 1999; 341: 801-806.

33. Eichinger S, Pabinger I, Stumflen A et al. The risk of recurrent venous thromboembolism in patients with and without factor V Leiden. Thromb Haemost 1997; 77: 624-628.

34. Eichinger S, Minar E, Hirschl M et al. The risk of early recurrent venous thromboembolism after oral anticoagulant therapy in patients with the G20210A transition in the prothrombin gene. Thromb Haemost 1999; 81: 14-17.

35. Lindmarker P, Schulman S, Sten-Linder M et al. The risk of recurrent venous thromboembolism in carriers and non-carriers of the G1691A allele in the coagulant factor V gene and the G20210A allele in the prothrombin gene. Thromb Haemost 1999; 81: 684-689.

36. Margaglione M, D’Andrea G, Colaiazzo D et al. Coexistence of factor V Leiden and factor II A20210 mutations and recurrent venous thromboembolism. Thromb Haemost 1999; 82: 1583-1587.

37. De Stefano V, Martinelli I, Manucci PM et al. The risk of recurrent venous thromboembolism among heterozygous carriers of the G20210A prothrombin gene mutation. Br J Haematol 2001; 113: 630-635.

38. Simioni P. Risk of recurrent venous thromboembolism and thrombophilia: does discrepancy make complexity or vice versa? J Thromb Haemost 2003; 1: 16-18.

39. Ho WK, Hankey GJ, Quinlan DJ et al. Risk of recurrent veous thromboembolism in patients with common thrombophilia. Arch Intern Med 2006; 166: 729-736.

40. Hron G, Eichinger S, Weltermann A et al. Family history for venous thromboembolism and the risk for recurrence. Am J Med 2006; 119: 50-53.

41. Palareti G, Legnani C, Cosmi B et al. Predictive value of D-dimer test for recurrent venous thromboembolism after anticoagulation withdrawal in subjects with a previous idiopathic event and carriers of congenital thrombophilia. Circulation 2003; 108: 313-318.

42. Christiansen SC, Cannegieter SC, Koster T et al. Thrombophilia, clinical factors and recurrent venous thrombotic events. JAMA 2005; 293: 2352-2361.

43. Auerbach AD, Sanders GD, Hambleton J. Cost-effectiveness of testing for hypercoagulability and effects on treatment strategies in patients with deep vein thrombosis. Am J Med 2004; 116: 816-828.

44. Kyrle P, Minar E, Hirschl M et al. High plasma levels of factor VIII and the risk of recurrent venous thromboembolism. N Engl J Med 2000; 343: 457-462.

45. van Hylckama Vlieg A, van der Linden I, Bertina RM et al. High levels of factor IX increase the risk of venous thrombosis. Blood 2000; 95: 3678-3682.

46. Meijers JCM, Tekelenburg WLH, Bouma BN et al. High levels of coagulation factor XI as a risk factor of venous thrombosis. N Engl J Med 2003; 42: 696-701.

47. Cushman M. Inherited risk factors for venous thrombosis. Hematology 2005; 44: 452-457.

48. Weltermann A, Eichinger S, Bialonczyk C et al. The risk of recurrent venous thromboembolism among patients with high factor IX levels. J Thromb Haemost 2003; 1: 28-32.

49. Schulman S, Svenungsson E, Granqvist S. Anticardiolipin antibodies predict early recurrence of thromboembolism and death among patients with venous thromboembolism following anticoagulant therapy. Am J Med 1998; 104: 332-338.

50. Eichinger S, Stumpflen A, Hirschl M et al. Hyperhomocysteinemia is a risk factor of recurrent venous thromboembolism. Thromb Haemost 1998; 80: 566-569.

51. Lee AYY. Venous thromboembolism and cancer: prevention and therapy. Vnitř Lék 2006; 52 (Suppl 1): 127-131.

52. Galli M, Ageno W, Squizatto A et al. Residual vein obstruction in patients with a single episode of deep vein thrombosis and in patients with recurrent deep vein thrombosis. Thromb Haemost 2005; 94: 93-95.

53. Prandoni P, Lensing AWA, Prins M et al. Residual Venous Thrombosis as a predictive factor of recurrent venous thromboembolism. Ann Intern Med 2002; 137: 966-960.

54. Piovella F, Crippa L, Barone M et al. Normalization rates of compression ultrasonography in patients with a first episode of deep vein thrombosis of the lower limbs: association with DVT recurrence and new thrombosis. Haematologica 2002; 87: 515-522.

55. Cosmi B, Legnani C, Cini M et al. D-dimer levels in combination with residual venous obstruction and the risk of recurrence after anticoagulation withdrawal for a first idiopathic deep vein thrombosis. Thromb Haemost 2005; 94: 969-974.

56. Palareti G, Legnani C, Cosmi B et al. Risk of venous thromboembolism recurrence: high negative predictive value of D-dimer performed after oral anticoagulation is stopped. Thromb Haemost 2002; 87: 7-12.

57. Eichinger S, Minar E, Bialonczyk C et al. D-dimer levels and risk of recurrent venous thromboembolism. JAMA 2003; 290: 1071-1074.

58. Palareti G, Cosmi B, Legnani C et al. D-dimer testing to determine the duration of anticoagulation therapy. N Engl J Med 2006; 355: 1780-1789.

59. Hoeper MM, Mayer E, Simonneau G et al. Chronic thromboembolic pulmonary hypertension. Circulation 2006; 113: 2011-2020.

60. Decousus H, Leizorovics A, Parent F et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep vein thrombosis. N Engl J Med 1998; 338: 409-415.

61. Kessler P. Antikoagulační léčba warfarinem v roce 2006. Kardiofórum 2006; 4: 43-51.