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Optimal Duration of Anticoagulation After Venous Thromboembolism: Fixed and Evidence-Based, or Flexible and Personalized?

Samuel Z. Goldhaber, MD
[+] Article and Author Information

From Brigham and Women's Hospital, Boston, MA 02115.


Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Samuel Z. Goldhaber, MD, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115; e-mail, sgoldhaber@partners.org.


Ann Intern Med. 2009;150(9):644-646. doi:10.7326/0003-4819-150-9-200905050-00012
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Optimal management of acute venous thromboembolism (VTE) requires institution of rapidly effective and safe anticoagulation. Much clinical investigation has focused on developing convenient and reliable anticoagulation regimens that use parenteral low-molecular-weight heparin or fondaparinux as a “bridge” to oral anticoagulant therapy with warfarin. Many novel oral anticoagulant therapies, administered in fixed doses without routine coagulation monitoring, are in advanced development and have the potential for eventual approval as monotherapy for pulmonary embolism or deep venous thrombosis (DVT).

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Duration of anticoagulation
Posted on May 5, 2009
ferdinando cortese
Alliance Community Hospital
Conflict of Interest: None Declared

TO THE EDITOR. Dr.Goldhaber states that based on the results of the PREVENT trial indefinite anticoagulation with warfarin should be the standard of practice in unprovoked DVT. But this conclusion could be challenged for several reasons (1). The PREVENT trial showed a significant decrease in recurrent DVT but not in overall mortality. Of the 8 deaths in the placebo group only 2 were due to pulmonary embolism. Furthermore 9 patients in the placebo group but only 4 in the warfarin group developed cancer indicating that the slight increase in mortality in the placebo group may be due to the development of neoplasia It seems therefore that the the risk of death from stopping anticoagulation is less than 1% over the ~2 year period of median follow up in the trial, probably not different frm the risk of hemorragic death from anticoagulation. Lifelong anticoagulation is risky and associated with significant morbidity and mortality and may not be appropriate for all patients with unprovoked DVT.

Reference.

1. Paul M.Ridker,M.D., Samuel Z.Goldhaber,M.D., Ellie danelson, M.I.A., Yves Rosenberg, M.D., Charles S. Eby, M.D., Steven R.Deitcher, M.D., Mary Cushman, M.D., et al. Nes England Journal of Medicine 2003;348:1425-1434

Conflict of Interest:

None declared

PREVENT Trial: Current Standard for Optimal Duration and Intensity of Anticoagulation after VTE
Posted on June 20, 2009
Samuel Z. Goldhaber
Brigham and Women's Hospital and Harvard Medical School
Conflict of Interest: None Declared

The PREVENT Trial studied the optimal management of patients who had suffered an initial idiopathic and unprovoked venous thromboembolism (VTE). Although PREVENT was not powered for mortality, the Data Monitoring and Safety Board terminated the study early because of the marked reduction in recurrent VTE in the low intensity warfarin group (target INR between 1.5 and 2.0) compared with the placebo group. I am not aware of any cancer risk with warfarin, which has been available in the United States since 1954. The long-term risk of recurrent VTE after an initial deep vein thrombosis or pulmonary embolism is high, about 30% after 10 years following the discontinuation of anticoagulation. Therefore, patients managed without anticoagulation after unprovoked VTE face a substantial long-term risk of suffering a recurrent event. The take home message from PREVENT is to consider long-term anticoagulation with low intensity warfarin after an initial 3-6 months of standard anticoagulation in patients with idiopathic VTE.

Conflict of Interest:

None declared

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