recent guidelineFinancial Disclaimer: against the drug companies
My financial interests are only as a purchaser of insurance and a taxpayer
Concern about prices
Goals of the talk
A framework for deciding on which patients might need prolonged anticoagulation
what are the guidelines for prolonged anticoagulation
what are the problems in applying those guidelines
methods for increasing the Predictive Value of the decision
Framework
Massive pulmonary embolism Other thrombotic complication
Risk of anticoagulation
Bleeding Treatment complication
Risk decay curve
with some patients requiring longer finite periods of 6 to 12 months.
Copyrights apply
IN VENOUS THROMBOEMBOLIC DISEASE
3 mo
Recurrent unprovoked DVT or PE
Indefinite
Massive PE Long-term/indefinite
DVT, deep venous thrombosis; PE, pulmonary embolism.
a For example, malignancy, antiphospholipid antibody syndrome, or natural anticoagulant deficiency.
Timing of anticoagulation initiation
Khorana score
Categorization of patients as having provoked or unprovoked venous thromboembolism: guidance from the SSC of ISTH
Journal of Thrombosis and Haemostasis, Volume: 14, Issue: 7, Pages: 1480-1483, First published: 15 April 2016, DOI: (10.1111/jth.13336)
Copyrights apply
Copyrights apply
management of anticoagulation therapy (2018)
American College of Chest Physicians (CHEST): Guideline and expert panel
report on antithrombotic therapy for VTE disease (2016)
ISTH: Guidance for the categorization of patients as having provoked or
unprovoked venous thromboembolism (2016)
IN VENOUS THROMBOEMBOLIC DISEASE
3 mo
Recurrent unprovoked DVT or PE Indefinite
DVT with ongoing risk factorsa Long-term/indefinite
Massive PE Long-term/indefinite
DVT, deep venous thrombosis; PE, pulmonary embolism.
a For example, malignancy, antiphospholipid antibody syndrome, or natural anticoagulant deficiency
Figure 1. Simplified schema of the management of venous thromboembolism. DASH indicates elevated D-dimer post anticoagulation, age <50 years at initial VTE, male sex, and hormone use in women at initial VTE; DVT, deep vein thrombosis; HERDOO-2, hyperpigmentation, edema or redness of affected leg, elevated d-dimer while on anticoagulation, obesity with body mass index >30, and age ≥65 years; PE, Pulmonary embolism; USG, ultrasonography; VTE, venous thromboembolism. *Superficial femoral and popliteal veins are proximal veins.
DOI: (10.1177/1076029616652727) An Algorithmic Approach to Management of Venous Thromboembolism
DASH score D dimer
Age
Predictor Scoring
H Hyperpigmentation 1 point total, if any one of these criteria is present
E Edema
D D-dimer ≥ 250 μg/L while anticoagulated
1 point
problems in applying the guidelines
Things that are not clear What constitutes provoked?
Airline flight
Cast immobilization
Apps
Provoked VTE with transient risk factor
VTE provoked by a nonsurgical trigger (eg, oral contraceptive pill, long flight, pregnancy), the risk of VTE recurrence is estimated to 5 percent at one year and 15 percent at five years (approximately 2.5 percent per year after the first year)
Airline Flight Risk Recent publications report the risk of venous thromboembolism (VTE) is increased 1.5 to 3 fold (Timp 2015), by approximately two fold (Cannegieter 2006; WRIGHT project 2007), or four fold (Kuipers 2007), following long-haul travel.
Kuipers and colleagues also reported that the "absolute risk of a symptomatic event within 4 weeks of flights longer than 4 h is 1/4600 flights" and "the risk of severe pulmonary embolism (PE) occurring immediately after air travel increases with duration of travel, up to 4.8 per million in flights longer than 12 h" (Kuipers 2007).
when compared with no prophylaxis or placebo.
Low-quality evidence showed no clear differences in PE between the LMWH and control groups,
less symptomatic VTE in the LMWH groups. The quality of the evidence was downgraded due to risk of bias and
imprecision.
How to decide Sum of all risks Physiologic understanding Aversions
Risk
cost
Risk aversion Ineffables
Goals of the talk
A framework for deciding on which patients might need prolonged anticoagulation
what are the guidelines for prolonged anticoagulation
what are the problems in applying those guidelines
methods for increasing the Predictive Value of the decision
Low molecular weight heparin for prevention of venous thromboembolism in patients with lower- limb immobilization.
rationale for extending anticoagulation indefinitely
based upon long-term epidemiologic studies of recurrence risk after cessation of a conventional course of anticoagulation
as well as randomized trials and meta-analyses that suggest that anticoagulation for prolonged periods successfully reduces the rate of VTE recurrence
Airline flight: UpToDate PATIENTS UNLIKELY TO BENEFIT
We and others agree that indefinite anticoagulation is unlikely to benefit the populations described below, provided that
persistent risk factors, which would elevate the risk of recurrence, are absent [3-5]. (See 'Assess additional risk factors'
below.)
Provoked VTE with transient risk factor — For most patients who have a provoked VTE with transient medical or surgical
risk factors, we recommend anticoagulation for three to six months rather than periods of longer or shorter duration. For
those with a VTE provoked by a transient surgical risk factor, the risk of VTE recurrence is estimated to be 1 percent at one
year and 3 percent at five years (approximately 0.5 percent per year after the first year) [3-5,7,8]. For those with a VTE
provoked by a nonsurgical trigger (eg, oral contraceptive pill, long flight, pregnancy), the risk of VTE recurrence is
estimated to 5 percent at one year and 15 percent at five years (approximately 2.5 percent per year after the first year) [3-
Which anticoagulant
Incidence and mortality of venous thrombosis: a population-based study
Journal of Thrombosis and Haemostasis, Volume: 5, Issue: 4, Pages: 692-699, First published: 02 April 2007, DOI: (10.1111/j.1538-7836.2007.02450.x)
rationale for extending anticoagulation indefinitely
long-term epidemiologic studies of recurrence risk after cessation of a conventional course of anticoagulation
randomized trials and meta-analyses suggest that anticoagulation for prolonged periods reduces the rate of VTE recurrence
DASH score Application
previously diagnosed with VTE completed a 3-6 month course of anticoagulation DASH Scores ≤1 are associated with 3.1% annual recurrence
may be low enough to consider discontinuing anticoagulation.
DASH Scores ≥2 are at high risk for recurrent VTE
may require long-term anticoagulation.
Copyrights apply
0–0.49 years
0.50–2.99 years
Idiopathic† 373 2.57 (2.17– 3.04)
4.36 (3.12– 6.08)
1.83 (1.44– 2.32)
1.24 (0.87– 1.75)
4.85 (3.07– 7.66)
1.05 (0.68– 1.63)
1.09 (0.68– 1.75)
33.78 (26.41– 43.21)
7.29 (5.25– 10.13)
2.48 (1.24– 4.95)
VTE PROVOKED BY A TRANSIENT RISK FACTOR*
Major transient risk factor during the 3 months before diagnosis ofVTE
A risk factor is considered ‘major’ if it has been shown to beassociated with:
(1)half the risk of recurrent VTE after stopping anticoagulant ther-apy (compared with if there was no transient risk factor), whenthe risk factor occurred up to 3 months before the VTE†;or
(2)a greater than10-fold increase in the risk of having a first VTE.
Examples:
•Surgery with general anesthesia for greater than 30 min.
•Confined to bed in hospital (only ‘bathroom privileges’) for atleast 3 days with an acute illness.
•Cesarean section
Minor (yet important) transient risk factor during the 2 months before diagnosis of VTE A risk factor is considered ‘minor’ if it has been shown to be associated with:
(1)half the risk of recurrent VTE after stopping anticoagulant therapy (compared with if there was no transient risk factor), when the risk factor occurred up to 2 months before the VTE †;or
(2)a 3 to 10-fold increase in the risk of having a first VTE.
Examples:•Surgery with general anesthesia for less than 30 min.
•Admission to hospital for less than 3 days with an acute illness.
•Estrogen therapy.
•Pregnancy or puerperium.
•Confined to bed out of hospital for at least 3 days with an acuteillness.
•Leg injury associated with reduced mobility for at least 3 days
VTE PROVOKED BY A PERSISTENT RISK FACTOR
Active cancer
Cancer is considered active if any of the following apply:(1)has not received potentially curative treatment; or
(2)there is evidence that treatment has not been curative (e.g. recurrent or progressive disease)‡;or
(3)treatment is ongoing.
On-going non-malignant condition associated with at least a 2-fold riskof recurrent VTE after stopping anticoagulant therapy
Example:Inflammatory bowel disease.
Compression stockings for preventing deep vein thrombosis in airline passengers
Eleven randomised trials (n = 2906) were included in this review
Sixteen of 1804 people developed superficial vein thrombosis
There were no symptomless DVTs
No deaths, pulmonary emboli or symptomatic DVTs were reported.
Copyrights apply
• Age ≤50 years
DASH score
HERDOO2
Women ≥18 years old with unprovoked VTE. Patients diagnosed 5–7 months before enrollment. On heparin or low molecular weight heparin (LMWH) for ≥5 days and oral
anticoagulation for 5–7 months after the event. Without recurrent VTE during the treatment period. Noncompressible segment on compression ultrasound of popliteal (or more
proximal) leg vein, high-probability V/Q scan, or segmental (or larger) artery filling defect on spiral CT.
Exclusion criteria: Leg fracture. Lower-extremity plaster cast. Immobilization for >3 days.
Gl thti <3 th bf id t
Who should get long term anticoagulation for PE/DVT
Financial Disclaimer: against the drug companies
Goals of the talk
Slide Number 26
Airline flight: UpToDate
Airline Flight Risk
Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-limb immobilization.
Predictive Value
Slide Number 33
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Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-limb immobilization.
rationale for extending anticoagulation indefinitely
Airline flight: UpToDate
DASH score Application
Slide Number 47
Categorization of patients as having provoked or unprovoked venous thromboembolism: guidance from the SSC of ISTH
Minor (yet important) transient risk factor during the 2 months before diagnosis of VTE
VTE PROVOKED BY A PERSISTENT RISK FACTOR
Cochrane Systematic Review - Intervention Version published: 14 September 2016
Slide Number 54