VTE RECURRENCE

Risk of VTE Recurrence

The risk of recurrent VTE after stopping anticoagulants appears to be similar whether anticoagulant therapy is stopped after 3 months vs. after 6 to 24 months of treatment.

This suggests that 3 months of treatment is sufficient to treat the acute episode of VTE if the decision is to not continue anticoagulation long-term.

But continuing After 3 months, decision will depend on balancing the risk of recurrence

(which depends mainly on whether the VTE was provoked by a transient risk factor, unprovoked, or related to a major persistent risk factor )

and the risk of bleeding .

• VTE provoked by TRANSIENT risk factor

Transient Major risk factor

(risk of recurrence 1% in one year)

• Surgery with general anesthetic for >30 minutes

• Admission to hospital for an acute illness with confinement to bed for at least 3 days

Transient Minor risk factor

( risk of recurrence is 5% in one year )

• Surgery with general anesthetic for <30 minutes

• Admission to hospital with an acute illness for less than 3 days

• Confined to bed out of hospital for at least 3 days with an acute illness

• Hormonal therapy

• Pregnancy or the puerperium

• Travel more than 8h

• VTE provoked by PERSISTENT Risk Factors:

• 1) Persistent risk factors that usually prompt continuation of anticoagulation:

[ ] Active cancer

[ ] Antiphospholipid antibody positivity

[ ] High risk hereditary thrombophilia:

[antithrombin, protein C or protein S deficiency]

[homozygous or compound heterozygous for

factor VLeiden or prothrombin G20210A with

history of VTE] .

• 2) Persistent risk factors that do not usually influence duration of anticoagulation:

[ ] Low risk hereditary thrombophilia and/or family history of VTE:

(heterozygosity for factor V Leiden ,prothrombin

G20210A)

does not appear to be a clinically important risk for

recurrence during or after anticoagulant therapy.

[ ] A positive family history alone does not increase the risk of recurrent VTE.

[ ] Presence of an inferior vena cava filter: should not influence the duration of anticoagulant therapy.

[ ] Residual abnormalities on ultrasound: These are detected in approximately one third of patients.

Notice

[ ] the risk of recurrence is lower for VTE provoked by a surgical ( major) risk factor than for Those associated with non-surgical (minor) risk factors.

[ ] the risk of recurrence is higher with unprovoked event or Persistent strong risk factor.

[ ] Patients with a first unprovoked episode of proximal DVT or PE, have a risk of recurrence of about 10% in the first year, 25% in the first 5 years

So Long-term anticoagulation should be considered..

The risk of recurrence after a first unprovoked proximal DVT or PE can be further stratified according to the patient's sex and D-dimer results measured 1month post stopping anticoagulants treatment

male and D-dimer negative: 8% in the first year

male and D-dimer positive 16% in the first year

female and D-dimer negative: 5% in the first year;

female and D-dimer positive: 10% in the first year.

[ ] Prognostic models to support decision of prolonged anticoagulation course in unprovoked thrombosis

three models to predict the risk of recurrent VTE after anticoagulation discontinuation following a first unprovoked DVT or PE have undergone external

Validation However each have significant limitations ..

HERDOO2_DASH_VIENNA PREDICTION MODULE ...

References:

venous thromboembolism: guidance from the SSC of ISTH.