Abstract

Conclusion: Oral anticoagulation therapy can be safely discontinued after 6 months in woman who have zero or one potential predictor of recurrent venous thromboembolism (VTE). Summary: Optimal duration of anticoagulation after unprovoked VTE is controversial. In this study the authors sought to identify clinical predictors to identify patients at low risk of VTE recurrence after discontinuation of oral anticoagulants. This was a multicenter prospective cohort study involving 646 patients with a first unprovoked major VTE. Patients were enrolled during a 4-year period, and 600 completed a mean 18-month follow-up. Data were collected for 16 potential predictors of recurrent VTE during the time patients were taking oral anticoagulation therapy (5 to 7 months after initiation). After discontinuation of oral anticoagulation therapy, patients were monitored for recurrent VTE. During follow-up, 91 confirmed episodes of recurrent VTE were identified (annual risk, 9.3%; 95% confidence interval [CI], 7.1%-11.3%). The annual risk for men was 13.7% (95% CI, 10.8%-17.0%). No combination of clinical predictors could identify a low-risk subgroup of men. Zero or one of the following characteristics were present in 52% of women: D-dimer level >250 mg/L while taking warfarin; body mass index >30 kg/m2; hyperpigmentation, edema, or redness of either leg; or age >65 years. Women with zero or one of these predictors had an annual risk of VTE recurrence of 1.6% (95% CI, 0.3%-4.6%). Women with two or more of these predictors had an annual risk of VTE recurrence of 14.1% (95% CI, 10.9%-17.3%). Comment: This study is consistent with the previously determined adverse effect of male sex on the recurrence of VTE (Lancet 2006;368:371-8). There are three major points here. First, identification of risk factors after 5 to 7 months of oral anticoagulation therapy is a strong predictor of recurrent VTE. Second, D-dimer levels after stopping oral anticoagulation may not be sufficient to identify patients at low risk of recurrence, whereas D-dimer levels while taking oral anticoagulation may be a strong predictor of recurrent VTE. The point is particularly interesting in that it allows more efficient care of patients. Stopping anticoagulation and testing D-dimer levels 1 month later and subsequently restarting anticoagulation therapy if necessary is impractical and exposes potentially high-risk patients to a period without anticoagulation. Finally, the authors identified a clinical decision rule that identifies women at low risk of VTE.

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