Abstract
The decision on treatment after a first venous thromboembolism (VTE) to prevent recurrences may be influenced by many factors. The prospective, observational, WHITE study aimed to analyze how this issue was tackled in every-day clinical practice in various countries, which have sensibly different socio-economic conditions and healthcare systems. Doctors active in 79 Internal or Vascular clinical centers in 7 countries (China, Czechia, Poland, Portugal, Russia, Slovakia, and Tunisia) enrolled VTE patients after the maintenance treatment phase. The present report analyzed information, collected in the central database, regarding the baseline characteristics, index events, type and duration of anticoagulant therapy and decision on post-maintenance treatment. From April 2018 to December 2020, 1240 patients were enrolled, 58% with an unprovoked index event. Direct oral anticoagulants (DOACs) were used in > 85% of all cases in China, Poland, Portugal, Russia and Czechia, in 52% in Slovakia and in no patient in Tunisia. The maintenance anticoagulation lasted in average approximately 6 months. Altogether, anticoagulation was stopped in 20%, extended in about 50%, regardless of whether the event was unprovoked or provoked and shifted to antithrombotics (mainly sulodexide or aspirin) in the remaining patients. In conclusion, some differences in VTE patient management were found between countries. The provoked/unprovoked nature of the index event, instead, was not the prevalent criterion to drive the decision on extension of anticoagulation, without large variations between countries. DOACs were the most widely used anticoagulant drugs, whereas > 25% of patients received antithrombotic drugs instead of anticoagulants as extended treatment.
Highlights
The guidelines [1] recommend initial treatment of deep vein thrombosis (DVT) of the lower limbs and/or pulmonary embolism (PE) with a parenteral direct-acting anticoagulant or direct oral anticoagulant (DOAC), followed by a period of anticoagulation therapy with a vitamin K antagonist (VKA) or, preferably, a direct oral anticoagulants (DOACs), or low molecular weight heparin (LMWH), in patients with cancer-associated thrombosis
The incidence of venous thromboembolism (VTE) recurrence is very low when an event is provoked by surgery or another specific strong and removable risk factor
The prevalence of hypertension was lowest in Tunisia and China, and highest in Russian patients (45.7%), who reported the highest prevalence of ischemic heart disease (16.8%) and of smokers (24%)
Summary
The guidelines [1] recommend initial treatment of deep vein thrombosis (DVT) of the lower limbs and/or pulmonary embolism (PE) with a parenteral direct-acting anticoagulant or direct oral anticoagulant (DOAC), followed by a period of anticoagulation therapy with a vitamin K antagonist (VKA) or, preferably, a DOAC, or low molecular weight heparin (LMWH), in patients with cancer-associated thrombosis. The incidence of venous thromboembolism (VTE) recurrence is very low when an event is provoked by surgery or another specific strong and removable risk factor In these cases, a three- to sixmonth treatment (defined as “maintenance” treatment period) is considered sufficient. The risk of recurrence is reported very high in subjects with permanent and strong risk factors, such as cancer, inflammatory diseases, serious acquired or inherited thrombophilic alterations, repeated VTE events, or when the first event was life-threatening. In these cases, an indefinite anticoagulant treatment is recommended. An anticoagulant treatment limited to the maintenance phase may not be sufficient and international guidelines suggest an extended (indefinite, i.e., without a predetermined stop date) anticoagulation, provided that the risk of bleeding associated with anticoagulation is not high [1]
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