Long-term Anticoagulant Therapy for Idiopathic Pulmonary Embolism in the Elderly A Decision Analysis

Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
Chest (Impact Factor: 7.48). 12/2008; 135(5):1243-51. DOI: 10.1378/chest.08-1164
Source: PubMed


Elderly patients with idiopathic pulmonary embolism (PE) are at high risk for recurrent venous thromboembolic disease and might benefit from long-term anticoagulant therapy. But they are also at higher risk for bleeding complications. Because there have been no clinical trials addressing PE treatment in elderly patients, the balance of therapeutic benefits and risks is unclear.
We constructed a decision-analytic model to forecast the effects of long-term warfarin therapy for idiopathic PE. We focused on 65- and 80-year-old outpatients, with or without a propensity for falls, who previously had completed 6 to 12 months of anticoagulant therapy without experiencing a major bleed. The model incorporated age-appropriate thromboembolic recurrence rates after PE, major bleeding risks of warfarin use, and the contribution of falls to major bleeding episodes in anticoagulated elderly patients. We used probabilistic sensitivity analysis to model outcomes over ranges of potential thromboembolic and bleeding risks.
In our baseline analysis, long-term warfarin was superior to conventional duration therapy. Depending on the patient subgroup (stratified by age and fall risk), it increased life expectancy by 0.16 to 0.56 years and event-free life expectancy by 0.32 to 0.51 years. Probabilistic sensitivity analysis demonstrated that long-term warfarin therapy was likely to increase life expectancy when compared with conventional-duration therapy (76 to 93% likelihood across all groups).
Extended anticoagulant therapy for idiopathic PE may be beneficial in a subgroup of elderly patients who tolerate the initial 6 to 12 months of therapy without bleeding complications. In this population, advanced age and fall risk were not contraindications to long-term anticoagulation.

10 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Bij ongeveer 50% van de patiënten met een longembolie vindt men geen uitlokkende gebeurtenis. Van deze idiopathische longembolie is bekend dat de kans op een recidief twee tot drie keer groter is dan bij de longembolie waarvoor wel een verklaring kon worden gegeven, zoals een periode van immobilisatie. De gebruikelijke behandeling bestaat uit 3 tot 6 maanden orale anticoagulantia. Die behandeling is niet zonder problemen. Enerzijds kan tijdens de antistolling een bloeding optreden,wat vooral bij ouderen vaker optreedt, anderzijds kan na staken een recidief optreden. Sommigen zijn er voorstander van om wegens de kans op recidieven na het staken van de antistolling langer te ontstollen. Ofschoon tegenstanders van dit beleid vooral het verhoogde bloedingsrisico noemen, is wel gebleken dat de kans op bloedingen vooral groot is in de eerste maanden na aanvang van de antistollingstherapie.
    No preview · Article · Aug 2009
  • [Show abstract] [Hide abstract]
    ABSTRACT: There is high incidence of venous thromboembolism, comprising of deep vein thrombosis and pulmonary embolism, in hospitalized patients. The need for systemic thromboprophylaxis is essential, especially in patients with inherited or acquired patient-specific risk factors or in patients undergoing surgeries associated with high incidence of postoperative deep vein thrombosis and pulmonary embolism. These patients, on prophylactic or therapeutic doses of anticoagulants, may present for surgery. General or regional anaesthesia may be considered depending on the type and urgency of surgery and degree of anticoagulation as judged by investigations. The dilemma regarding the type of anaesthesia can be solved if the anaesthesiologist is aware of the pharmacokinetics of drugs affecting haemostasis. The anaesthesiologist must keep abreast with the latest developments of methods and drugs used in the prevention and management of venous thromboembolism and their implications in the conduct of anaesthesia.
    No preview · Article · Mar 2010 · Indian journal of anaesthesia
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: There is some uncertainty about the management of pulmonary embolism in nonagenarians. Immobility plays an important role in the pathogenesis of venous thromboembolism in the elderly. Of 858 nonagenarians with acute venous thromboembolism enrolled in Registro Informatizado de la Enfermedad TromboEmbolica venosa registry, 41% had recent immobility and only 7.7% had recent surgery. Comorbidity is common: 19% of patients had chronic heart failure, 9.8% chronic lung disease, 14% cancer, and 63% had abnormal creatinine levels. Most (92%) of the patients were initially treated with low-molecular-weight heparin and then 46% switched to antivitamin K drugs. During follow-up, the proportion of patients who developed recurrent venous thromboembolism (4.9%) or major bleeding complications (6.2%) was similar, but the 5.9% of fatal pulmonary embolisms by far exceeded the 2.2% of fatal bleeding events. The most common clinical symptoms are isolated dyspnea and syncope, and presentation as pulmonary infarction (with hemoptysis and pleuritic chest pain) is rare. In patients aged at least 90 years presenting with acute pulmonary embolism, the incidence of fatal pulmonary embolism by far outweighs the incidence of fatal bleeding, and pulmonary embolism is the most common cause of death. Thus, there seems to be more reason to be concerned about fatal pulmonary embolism than about bleeding in elderly patients presenting with pulmonary embolism.
    Full-text · Article · Sep 2010 · Current opinion in pulmonary medicine
Show more