Long-term Management of Venous Thromboembolism A 61-Year-Old Woman With Unprovoked Venous Thromboembolism

Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, Massachusetts, Boston, MA 02492, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 03/2011; 305(13):1336-45. DOI: 10.1001/jama.2011.361
Source: PubMed


Numerous randomized clinical trials have compared various durations of anticoagulant therapy with a vitamin K antagonist (ie, warfarin) for an initial episode of venous thromboembolism (VTE). Despite major advances in understanding the pathophysiology of thrombosis and its genetic basis, clinical risk factors at presentation have emerged as the primary determinant of recurrence risk. Following a minimum of 3 months of anticoagulant therapy, patients with VTE in association with transient risk factors (eg, major surgery, trauma, pregnancy) have a low annual recurrence risk, while patients without identifiable provocative risk factors have a recurrence risk of approximately 25% at 4 years with the highest annual rates occurring in the first 2 years. Extending warfarin therapy is highly effective in preventing recurrences but is associated with increased rates of major and minor bleeding. Clinical decision making therefore requires individualized assessment of recurrence and bleeding risk, coupled with patient preference. After 3 months of anticoagulant therapy for a first episode of unprovoked VTE, male sex, age older than 65 years, and an elevated D-dimer level 1 month after discontinuing anticoagulant therapy are useful parameters in identifying patients with an increased recurrence risk. The case of Ms W, a woman with unprovoked venous thromboembolism and hemorrhagic event while receiving anticoagulation, is used to illustrate clinical decision making to determine ongoing treatment.

2 Reads
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Superficial vein thrombosis (SVT) is an entity commonly encountered in practice. While the clinical diagnosis is reasonably straightforward, care must be taken to exclude concurrent thrombosis of the deep veins, and the possibility of the presence of occult systemic illness such as malignancy should be considered. Recent studies of the epidemiology of SVT demonstrate a high incidence of concurrent deep vein thrombosis emphasizing the need for surveying the deep veins using compression ultrasonography. Treatment decisions are may now be based upon the results of randomized clinical trials and should include a period of anticoagulation using fondaparinux or a low molecular weight heparin. The appropriate doses and duration of therapy are not fully established, and the cost-effectiveness of these drugs for the treatment of SVT needs further evaluation.
    Preview · Article · Nov 2012 · European Journal Of Haematology
  • [Show abstract] [Hide abstract]
    ABSTRACT: The US Surgeon General estimates that 100,000 to 180,000 deaths occur annually from acute pulmonary embolism (PE) in the United States. The case of Ms A, a 60-year-old woman with acute PE and right ventricular dysfunction (submassive PE), illustrates the clinical challenge of identifying this high-risk patient population and determining when more aggressive immediate therapy should be pursued in addition to standard anticoagulation. The clinical examination, electrocardiogram, cardiac biomarkers, chest computed tomography, and echocardiography can be used to risk stratify patients with acute PE. Current options for more aggressive intervention in the treatment of patients with acute PE who are at increased risk of an adverse clinical course include systemic fibrinolysis, pharmacomechanical catheter-directed therapy, surgical pulmonary embolectomy, and inferior vena cava filter insertion. Determination of the optimal duration of anticoagulation and lifestyle modification to reduce overall cardiovascular risk are critical components of the long-term therapy of patients with acute PE.
    No preview · Article · Jan 2013 · JAMA The Journal of the American Medical Association
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: To review the diagnosis and management of venous thromboembolism (VTE). Methods: Review of the literature. Results: VTE and its associated complications account for significant morbidity and mortality. Various imaging modalities can be employed to support a diagnosis of a VTE and are used based on clinical suspicion arising from the presence of signs and symptoms. Clinical decision rules have been developed that can help determine which patients warrant further testing. Anticoagulation, the mainstay of VTE treatment, increases bleeding risk, necessitating tailored treatment strategies that must incorporate etiology, risk, benefit, cost, and patient preference. Conclusion: Further study is needed to understand individual patient risks and to identify treatments that will lead to improved patient outcomes.
    No preview · Article · May 2015 · Journal of clinical outcomes management: JCOM
Show more