Long‐term Risk of Recurrent Venous Thromboembolism Among Patients Receiving Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism

2021 ◽  
Author(s):  
Faizan Khan ◽  
Tobias Tritschler ◽  
Miriam Kimpton ◽  
Philip S. Wells ◽  
Clive Kearon ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Recurrent Venous Thromboembolism

TREATMENT OF DEEP VENOUS THROMBOSIS AND ECONOMIC ASPECTS

1987 ◽  
Author(s):  
Russell D Hull ◽  
Gary E Raskob
Keyword(s):  
Venous Thromboembolism ◽  
Venous Thrombosis ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant Therapy ◽  
Term Therapy ◽  
Vein Thrombosis ◽  
Warfarin Sodium ◽  
Intravenous Heparin ◽  
Recurrent Venous Thromboembolism

Initial therapy with intravenous heparin, followed by long-term anticoagulant therapy for three months or more, is the treatment of choice for most patients with acute venous thrombosis. Inferior vena caval interruption, using a transvenously inserted filter, is the management of choice for preventing pulmonary embolism in patients in whom anticoagulant therapy is contraindicated, and in the very rare patient in whom anticoagulant therapy is ineffective. The role of thrombolytic therapy has not been completely resolved. It was hoped that thrombolytic therapy would minimize or prevent the post-phlebitic syndrome; unfortunately, this may not be the case because the critical factor in the development of the post-phlebitic syndrome appears to be venous valve damage, which occurs early in the formation of venous thrombosis. Thrombolytic therapy should be considered in selected patients with acute massive venous thrombosis (eg. the patient with phlegmasia cerulea dolens).Intravenous heparin administered in doses which prolong the activated partial thromboplastin time (APTT) to 1.5 to 2 times control is highly effective and is associated with a low frequency (2%) of recurrent venous thromboembolism. A recent randomized trial (1) in patients with proximal-vein thrombosis indicates that failure to achieve an adequate anticoagulant response (APTT > 1.5 times control) is associated with a high risk (20%) of recurrent venous thromboembolism. Therefore, sufficient heparin should be administered to maintain the APTT above 1.5 times the control value.Intravenous heparin is continued for 7 to 10 days, overlapped with oral anticoagulant therapy for 4 to 5 days before heparin is stopped. Multiple randomized clinical trials in patients with proximal-vein thrombosis indicate that when heparin is administered for 7 to 10 days, followed by adequate long-term anticoagulant therapy, the frequency of recurrent venous thromboembolism is very low (2%). An alternative approach is to commence heparin and oral anticoagulants together at the time of diagnosis, and to discontinue heparin on the fourth or fifth day. If this latter approach is effective, it would avoid 4 to 5 days of unnecessary hospitalization in many patients, and would markedly reduce the cost of initial heparin therapy. A recent randomized trial (2) in patients with submassive venous thromboembolism suggests that 4 to 5 days of initial heparin therapy is effective and safe, but this approach must be evaluated by further randomized clinical trials before it is routinely recommended.Recent clinical trials indicate that inadequate long-term therapy in patients with proximal-vein thrombosis results in a high frequency (40-50%) of recurrent venous thromboembolism and is cost-ineffective because of the diagnostic and treatment costs of recurrent venous thromboembolism (3). The risk of recurrence is markedly reduced to 2% by adequate long-term anticoagulant therapy with warfarin sodium or adjusted subcutaneous heparin; both of these approaches are markedly more cost-effective than inadequate long-term therapy (3). Oral anticoagulant therapy with warfarin sodium for three months (or longer in selected patients), is less expensive than adjusted subcutaneous heparin and is preferred in most patients with acute proximal-vein thrombosis. The risk of bleeding associated with oral anticoagulant therapy can be reduced to less than 5%, without loss of effectiveness for preventing recurrent venous thromboembolism, by adjusting the dose of warfarin sodium to achieve a less intense anticoagulant effect (PT 1.25 to 1.5 times control using a rabbit brain thromboplastin such as Simplastin or Dade-C, corresponding to an INR of 2.0 to 3.0). Less intense warfarin sodium therapy is the most cost-effective of the alternative long-term anticoagulant regimens (3). Adjusted dose subcutaneous heparin is an effective and safe alternative to warfarin sodium; although slightly more expensive, it is the long-term regimen of choice in pregnant patients, and in patients returning to geographically remote areas lacking the facilities for anticoagulant monitoring (in whom the dose is adjusted during the first few days of long-term therapy and then fixed). REFERENCES: (1) Hull R, Raskob G, Hirsh J et al. N Engl J Med 1986;315:1109-1114. (2) Gallus A, Jackaman J, Tillett J et al.Lancet 1986;2:1293-1296. (3) Hull R, Raskob G, Hirsh J, Sackett DL. JAMA 1984;252:235-239.

Long-Term Outcomes in Patients Undergoing Coronary Stenting on Dual Oral Antiplatelet Treatment Requiring Oral Anticoagulant Therapy

2008 ◽  
Vol 102 (12) ◽  
pp. 1618-1623 ◽  
Author(s):  
Roberta Rossini ◽  
Giuseppe Musumeci ◽  
Corrado Lettieri ◽  
Maria Molfese ◽  
Laurian Mihalcsik ◽  
...  
Keyword(s):  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Coronary Stenting ◽  
Long Term Outcomes ◽  
Antiplatelet Treatment

scholarly journals Compliance with and awareness about long-term oral anticoagulant therapy among Saudi patients in a University Hospital, Riyadh, Saudi Arabia

2016 ◽  
Vol 7 (1) ◽  
pp. 10 ◽  
Author(s):  
NervanaM. K Bayoumy ◽  
ShehanahFahad Al-Omair ◽  
NorahAhmed Musallam ◽  
NoraYazid Al-Deghaither ◽  
NoufAbdulwahab Al-Sadoun
Keyword(s):  
Saudi Arabia ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
University Hospital ◽  
Saudi Patients

Bleeding complications to long-term oral anticoagulant therapy

1994 ◽  
Vol 1 (1) ◽  
pp. 17-25 ◽  
Author(s):  
Annette Lemche Gull�v ◽  
Birgitte Gade Koefoed ◽  
Palle Petersen
Keyword(s):  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Bleeding Complications

Efficacy and Safety of Intravenous Phytonadione (Vitamin K1) in Patients on Long-term Oral Anticoagulant Therapy

2001 ◽  
Vol 76 (3) ◽  
pp. 260-266 ◽  
Author(s):  
Raymond C. Shields ◽  
Robert D. McBane ◽  
James D. Kuiper ◽  
Hongzhe Li ◽  
John A. Heit
Keyword(s):  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Vitamin K1 ◽  
Efficacy And Safety

scholarly journals How I treat recurrent venous thromboembolism in patients receiving anticoagulant therapy

Blood ◽  
2017 ◽  
Vol 129 (25) ◽  
pp. 3285-3293 ◽  
Author(s):  
Sam Schulman
Keyword(s):  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Drug Regimen ◽  
Underlying Disease ◽  
Drug Levels ◽  
Recurrent Venous Thromboembolism ◽  
Clinical Trial Evidence ◽  
Trial Evidence

Oral anticoagulant therapy for venous thromboembolism is very effective. When oral anticoagulants are managed well, the risk of recurrence is approximately 2 per 100 patient-years. The main reasons for a breakthrough event are underlying disease and subtherapeutic drug levels. The most common underlying disease that results in recurrence on treatment is cancer. Subtherapeutic drug levels can be caused by poor adherence to the drug regimen, interactions with other drugs or food, or inappropriate dosing. It is important to investigate and understand the cause whenever such an event occurs and to improve management of anticoagulants thereby avoiding further recurrences. Here we present 4 illustrative cases together with a discussion of the underlying pathology. Whereas the mechanisms are usually quite well understood, the management of further anticoagulation after a breakthrough event is based on minimal or no clinical trial evidence.

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