The risk of recurrent thromboembolic disorders in patients with unprovoked venous thromboembolism: new scenarios and opportunities.

The risk of recurrent thromboembolic disorders in the 10-year period following an episode of unprovoked venous thromboembolism (VTE) ranges between 30 and 50%, the rate being higher in patients with primary deep venous thrombosis (DVT) than in those with primary pulmonary embolism (PE). The clinical presentation with primary PE increases by more than three times the risk of a new PE episode over that with isolated DVT. Baseline parameters that increase this risk are the proximal location of DVT, obesity, old age and male sex, whereas the role of thrombophilia is controversial. An increasing role is played by post-baseline parameters such as the ultrasound assessment of residual vein thrombosis and the determination of D-dimer. While the latest international guidelines suggest indefinite anticoagulation for most patients with the first episode of unprovoked VTE, new scenarios are being offered by the identification of risk stratification models and by strategies that have the potential to help identify patients in whom anticoagulation can be safely discontinued, such as those that incorporate the assessment of D-dimer and residual vein thrombosis. New opportunities are being offered by low-dose aspirin, which has recently been reported to decrease by more than 30% the risk of recurrent events without increasing the bleeding risk; and especially by a few emerging anti-Xa and anti-IIa oral compounds, which are likely to induce fewer haemorrhagic complications than vitamin K antagonists while preserving at least the same effectiveness, do not require laboratory monitoring, and can be used immediately after the thrombotic episode.

Prandoni P ，Barbar S ，Milan M ，Vedovetto V ，Pesavento R ... -  《-》

The Optimal Duration of Anticoagulation in Patients with Unprovoked Venous Thromboembolism.

Prandoni P 《Advances in Experimental Medicine and Biology》

Optimal duration of anticoagulation. Provoked versus unprovoked VTE and role of adjunctive thrombophilia and imaging tests.

Prandoni P ，Barbar S ，Milan M ，Campello E ，Spiezia L ，Piovella C ，Pesavento R ... -  《-》

Residual vein thrombosis and serial D-dimer for the long-term management of patients with deep venous thrombosis.

The optimal long-term strategy for preventing recurrent venous thromboembolism (VTE) in patients with deep-vein thrombosis (DVT) is uncertain. In 620 consecutive outpatients with a first proximal DVT who had completed at least three months of anticoagulation (unprovoked in 483, associated with minor risk factors in 137), the ultrasound presence of residual vein thrombosis (RVT) was assessed and defined as an incompressibility of at least 4mm. In 517 patients without RVT and with negative D-dimer, anticoagulation was stopped and D-dimer was repeated after one and three months. Anticoagulation was resumed in 63 of the 72 patients in whom D-dimer reverted to positivity. During a mean follow-up of three years, recurrent VTE developed in 40 (7.7%) of the 517 patients, leading to an annual rate of 3.6% (95% CI, 2.6 to 4.9): 4.1% (95% CI, 2.9 to 5.7) in individuals with unprovoked DVT, and 2.2% (95% CI, 1.1 to 4.5) in those with DVT associated with minor risk factors. Of the 233 males with unprovoked DVT, 17 (7.3%) developed events in the first year of follow-up. Major bleeding complications occurred in 8 patients while on anticoagulation, leading to an annual rate of 1.2% (95% CI, 0.6 to 2.4). Discontinuing anticoagulation in patients with a first episode of proximal DVT based on the assessment of RVT and serial D-dimer leads to an overall annual rate of recurrent VTE lower than 5.0%, which is the rate deemed as acceptable by the Subcommittee on Control of Anticoagulation of the ISTH. However, in males with unprovoked DVT there is room for further improving the long-term strategy of VTE prevention. (ClinicalTrials.gov number, NCT01285661).

Prandoni P ，Vedovetto V ，Ciammaichella M ，Bucherini E ，Corradini S ，Enea I ，Cosmi B ，Mumoli N ，Visonà A ，Barillari G ，Bova C ，Quintavalla R ，Zanatta N ，Pedrini S ，Villalta S ，Camporese G ，Testa S ，Parisi R ，Becattini C ，Cuppini S ，Pengo V ，Palareti G ，Morgagni Investigators ... -  《-》

[New evidence in the secondary prevention of thromboembolic disease].

The risk of recurrent venous thromboembolism is nearly 40% of all patients after 10 years of follow up. The risk is higher in patients with permanent risk factors, who should receive indefinite anticoagulation with acenocoumarol or warfarin, except cancer patients who should receive lower doses of low molecular weight heparin The remaining patients should receive a 3-month course of treatment, after which the need to continue this treatment should be reevaluated. The decision to continue should be individually tailored and balanced against hemorrhagic risk. Determination of D-dimer values at the end of treatment and the presence of residual vein thrombosis or right ventricular dysfunction could be useful to identify patients at low risk of recurrence, who can safely discontinue anticoagulation. The emergence of new oral anticoagulants has opened up a new scenario for secondary prevention in the next few years.

Marchena Yglesias PJ 《-》