Inconsistencies in the planning of the duration of anticoagulation among outpatients with acute deep-vein thrombosis

 

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Summary

Three-month anticoagulation is recommended to treat provoked or first distal deep-vein thrombosis (DVT), and indefinite-duration anticoagulation should be considered for patients with unprovoked proximal, un-provoked recurrent, or cancer-associated DVT. In the prospective Out-patient Treatment of Deep Vein Thrombosis in Switzerland (OTIS-DVT) Registry of 502 patients with acute objectively confirmed lower extremity DVT (59% provoked or first distal DVT; 41% unprovoked proximal, unprovoked recurrent, or cancer-associated DVT) from 53 private practices and 11 hospitals, we investigated the planned duration of anticoagulation at the time of treatment initiation. The decision to administer limited-duration anticoagulation therapy was made in 343 (68%) patients with a median duration of 107 (interquartile range 91–182) days for provoked or first distal DVT, and 182 (interquartile range 111–184) days for unprovoked proximal, unprovoked recurrent, or cancer-associated DVT. Among patients with provoked or first distal DVT, anticoagulation was recommended for <3 months in 11%, ≥3 months in 63%, and for an indefinite period in 26%. Among patients with unprovoked proximal, unprovoked recurrent, or cancer-associated DVT, anticoagulation was recommended for <6 months in 22%, 6–12 months in 38%, and for an indefinite period in 40%. Overall, there was more frequent planning of indefinite-duration therapy from hospital physicians as compared with private practice physicians (39% vs. 28%; p=0.019). Considerable inconsistency in planning the duration of anticoagulation therapy mandates an improvement in risk stratification of outpatients with acute DVT.

^* Both authors contributed equally.

• References

• 1 Beckman MG, Hooper WC, Critchley SE. et al. Venous Thromboembolism: A Public Health Concern. Am J Prev Med 2010; 38: S495-S501.
  CrossrefPubMedGoogle Scholar
• 2 White RH. The epidemiology of venous thromboembolism. Circulation 2003; 107: I4-I8.
  PubMedGoogle Scholar
• 3 Cohen AT, Agnelli G, Anderson FA. et al. Venous Thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007; 98: 756-774.
  Article in Thieme ConnectPubMedGoogle Scholar
• 4 Oger E. Incidence of venous thromboembolism: a community-based study in Western France. EPIGETBO Study Group. Groupe d’Etude de la Thrombose de Bretagne Occidentale. Thromb Haemost 2000; 83: 657-660.
  Article in Thieme ConnectPubMedGoogle Scholar
• 5 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.
  CrossrefPubMedGoogle Scholar
• 6 White RH, Murin S, Wun T. et al. Recurrent venous thromboembolism after surgery-provoked versus unprovoked thromboembolism. J Thromb Haemost 2010; 8: 987-997.
  PubMedGoogle Scholar
• 7 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.
  CrossrefPubMedGoogle Scholar
• 8 Pini M, Aiello S, Manotti C. et al. Low molecular weight heparin versus warfarin the prevention of recurrence after deep vein thrombosis. Thromb Haemost 1994; 72: 191-197.
  Article in Thieme ConnectPubMedGoogle Scholar
• 9 Levine MN, Hirsh J, Gent M. et al. Optimal duration of oral anticoagulant 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.
  Article in Thieme ConnectPubMedGoogle Scholar
• 10 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. N Engl J Med 1995; 332: 1661-1665.
  CrossrefPubMedGoogle Scholar
• 11 Pinede L, Ninet J, Duhaut P. et al. Comparison of 3 and 6 months of oral anticoagulant 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.
  CrossrefPubMedGoogle Scholar
• 12 Ridker PM, Goldhaber SZ, Danielson E. et al. Long-term, low-intensity warfarin therapy for prevention of recurrent venous thromboembolism. N Engl J Med 2003; 348: 1425-1434.
  CrossrefPubMedGoogle Scholar
• 13 Murin S, Romano PS, White RH. Comparison of outcomes after hospitalization for deep vein thrombosis or pulmonary embolism. Thromb Haemost 2002; 88: 407-414.
  Article in Thieme ConnectPubMedGoogle Scholar
• 14 Kearon C, Gent M, Hirsh 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.
  CrossrefPubMedGoogle Scholar
• 15 Kearon C, Kahn SR, Agnelli G. et al. Antithrombotic Therapy for Venous Thromboembolic Disease. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8^thEdition). CHEST 2008; 133: 454S-545S.
  CrossrefPubMedGoogle Scholar
• 16 Ost D, Tepper J, Mihara H. et al. Duration of anticoagulation following venous thromboembolism: a meta-analysis. J Am Med Assoc 2005; 294: 706-715.
  CrossrefPubMedGoogle Scholar
• 17 Korte W, Mazzolai L, Bounameaux H. 8. ACCP Guidelines on Antithrombotic Therapy Neuigkeiten, kommentiert von Schweizer Experten. Schweiz Med Forum 2009; 9: 454-455.
  PubMedGoogle Scholar
• 18 Galanaud JP, Sevestre-Pietri MA, Bosson JL. et al. Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: Results from the OPTIMEV study. Thromb Haemost 2009; 102: 493-500.
  Article in Thieme ConnectPubMedGoogle Scholar
• 19 Kucher N, Spirk D, Kalka C. et al. Clinical predictors of prophylaxis use prior to the onset of acute venous thromboembolism in hospitalized patients. SWIss Venous ThromboEmbolism Registry (SWIVTER). J Thromb Haemost 2008; 6: 2082-2087.
  CrossrefPubMedGoogle Scholar
• 20 Galanaud JP, Quenet S, Rivron-Guillot K. et al. Comparison of the clinical history of symptomatic isolated distal deep-vein thrombosis vs. proximal deep vein thrombosis in 11 086 patients. J Thromb Haemost 2009; 7: 2028-2034.
  CrossrefPubMedGoogle Scholar
• 21 Prandoni P, Noventa F, Ghirarduzzi A. et al. The risk of recurrent venous thromboembolism after discontinuing anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism. A prospective cohort study in 1,626 patients. Haematologica 2007; 92: 199-205.
  CrossrefPubMedGoogle Scholar