LIFEBLOODTHE

ThrombosisCHARITY

Venous thromboembolism –Treatment and secondary prevention

Ulcus cruris Chronic PE

PE

DVT

Post-thromboticsyndrome

Death

Deep vein

insufficiency

Pulmonaryhypertension

LIFEBLOODTHE

ThrombosisCHARITY Deep vein thrombosis

Common femoral vein

Thrombus

KneeProximal

Distal

LIFEBLOODTHE

ThrombosisCHARITY

VTE event

Acute Continue

Treatment and secondary prevention of VTE

Heparin or LMWHtogether with a VKA (e.g. warfarin) until an INR of 2.0-3.0 is achieved

VKA (e.g. warfarin)INR 2.0-3.0

LIFEBLOODTHE

ThrombosisCHARITY

VTE - treatment options

Acute Acute Long-term Long-term

Anticoagulation - UFH/LMWH

Thrombolysis

Thrombectomy

Inferior vena cava filters (IVCF)

Anticoagulation- VKAs (e.g. warfarin)- LMWH

Stockings

LIFEBLOODTHE

ThrombosisCHARITY 7th ACCP recommendations

- Initial treatment for acute DVT or PE

Confirmed DVT or non-massive PE

– Initial treatment with sc LMWH or iv UFH (or sc if DVT) [Grade 1A] for at least 5 days [Grade 1C]

– Start VKA with LMWH or UFH on day 1 [Grade 1A]

– Stop LMWH or UFH when INR stable >2.0 [Grade 1A]

High clinical suspicion of VTE

– Anticoagulation until outcome of diagnostic tests [Grade 1C+]

Büller H et al. Chest 2004;126:401S–428S

LIFEBLOODTHE

ThrombosisCHARITY

VTE event

Acute Continue

Heparin or LMWHtogether with a VKA (e.g. warfarin) untill an INR of 2.0-3.0is achieved

VKA (e.g. warfarin)INR 2.0-3.0

3-6-12 months or lifelong

Decision point

Risk of VTE (5-7%/year)vs. Risk of bleeding (3-4%/year)

How long?

Treatment and secondary prevention of VTE

LIFEBLOODTHE

ThrombosisCHARITY

• First episode with a transient risk factor– 3 months after distal or proximal DVT [Grade 1A]– At least 3 months after PE [Grade 1A]

• First episode of idiopathic DVT/PE– VKA for at least 6–12 months [Grade 1A] but

consider indefinite duration [Grade 2A]

• Two or more episodes of DVT/PE– Suggest indefinite treatment [Grade 2A]

• Target INR 2.5 (range 2.0–3.0) [Grade 1A]

Büller H et al. Chest 2004;126:401S–428S

7th ACCP recommendations- Long-term treatment for DVT or PE

LIFEBLOODTHE

ThrombosisCHARITY

Long-term treatment of DVT

• Recurrence rate of VTE in patients with DVT dependent on – Underlying risk factors for DVT – Duration of treatment

• Decision regarding duration of treatmentdependent on – Underlying risk factors for DVT – Risk of haemorrhage from oral anticoagulation– Patient preference

• Numerous regimens studied to improve benefit of long-term treatment while reducing the dose

LIFEBLOODTHE

ThrombosisCHARITY

Recurrence of VTE after stopping oral anticoagulation

0

5

10

15

Event rate (%)

0 3 6 12 24

Months

3 months treatment

LIFEBLOODTHE

ThrombosisCHARITY

0

5

10

15

Event rate(%)

3 months treatment

0 3 6 12 24

Months

6 months treatment

Recurrence of VTE after stopping oral anticoagulation

LIFEBLOODTHE

ThrombosisCHARITY

0

5

10

15

Event rate(%)

0 3 6 12 24

Months

3 months treatment

6 months treatment

1 year treatment

Recurrence of VTE after stopping oral anticoagulation

LIFEBLOODTHE

ThrombosisCHARITY

Optimal duration of anticoagulation after VTE

DURAC I 897 6 1.5 24 9.5% 18.1% 1.1% 0.2%

LAFIT 162 27 3 10 1.3% 27.4% 3.8% 0.0%

WODIT-DVT 267 12 3 12 3.0% 8.3% 3.0% 0.8%

WODIT-PE 326 6-12 3 32.7 4.1% 9.1% 1.8% 0.0%

DOTAVK 539 6 3 15 8.7% 8.1% 2.6% 1.9%

DURAC II 227 Indefinite 6 43 2.6% 20.7% 8.6% 2.7%

months months months LongOAC

OAC, oral anticoagulation

ShortOAC

LongOAC

ShortOAC

Reference No. ofpatients

LongOAC

ShortOAC

Followup

RecurrentVTE

Major bleeding

LIFEBLOODTHE

ThrombosisCHARITY

Intensity of anticoagulant therapyRecurrent VTECumulative event rate (%)

0.25

0.20

0.15

0.10

0.05

0.00

0 1 2 3 4Years of follow-up

Low INR – PREVENT

Conventional INR - ELATE

Placebo - PREVENT

Low INR – ELATE

Ridker PM et al. N Engl J Med 2003; 348:1425-34Kearon C et al. N Engl J Med 2003;349:631-9