Recurrent venous thromboembolism and bleeding with extended anticoagulation: the VTE-PREDICT risk score

Aims Deciding to stop or continue anticoagulation for venous thromboembolism (VTE) after initial treatment is challenging, as individual risks of recurrence and bleeding are heterogeneous. The present study aimed to develop and externally validate models for predicting 5-year risks of recurrence and bleeding in patients with VTE without cancer who completed at least 3 months of initial treatment, which can be used to estimate individual absolute benefits and harms of extended anticoagulation. Methods and results Competing risk-adjusted models were derived to predict recurrent VTE and clinically relevant bleeding (non-major and major) using 14 readily available patient characteristics. The models were derived from combined individual patient data from the Bleeding Risk Study, Hokusai-VTE, PREFER-VTE, RE-MEDY, and RE-SONATE (n = 15,141, 220 recurrences, 189 bleeding events). External validity was assessed in the Danish VTE cohort, EINSTEIN-CHOICE, GARFIELD-VTE, MEGA, and Tromsø studies (n = 59 257, 2283 recurrences, 3335 bleeding events). Absolute treatment effects were estimated by combining the models with hazard ratios from trials and meta-analyses. External validation in different settings showed agreement between predicted and observed risks up to 5 years, with C-statistics ranging from 0.48–0.71 (recurrence) and 0.61–0.68 (bleeding). In the Danish VTE cohort, 5-year risks ranged from 4% to 19% for recurrent VTE and 1% –19% for bleeding. Conclusion The VTE-PREDICT risk score can be applied to estimate the effect of extended anticoagulant treatment for individual patients with VTE and to support shared decision-making

Short-term versus extended anticoagulant treatment for unprovoked venous thromboembolism : A survey on guideline adherence and physicians' considerations

Background: In patients with unprovoked venous thromboembolism (VTE), anticoagulant treatment duration should be decided by weighing bleeding risk versus risk of recurrent VTE, considering patient's preference. Because both risks differ between individuals, this recommendation presumably leads to wide variation in clinical management. Objectives: To identify physician's considerations when deciding between short-term and extended anticoagulation and to assess how current guidelines are put to practice. Materials and methods: An online, 33-item survey was developed, containing questions on clinical management, considerations regarding treatment duration, risk scores, information tools and shared decision-making. It was distributed to internists, pulmonologists and residents treating patients with VTE in the Netherlands. Results: 69 internists and 73 pulmonologists including 24 residents participated in the survey. Extended treatment was preferred by 73% (104/142) of participants. Most important reasons for extended treatment were, in descending order: patient's preference, active malignancy, low estimated bleeding risk, history of VTE and hemodynamic instability during previous VTE. Most important reasons for short-term treatment were frequent falls, history of major bleeding, previous bleeding during anticoagulation, patient's preference and thrombocytopenia. Although existing risk scores are infrequently used, physicians express their need for scores combining risks of recurrence and bleeding to aid individualized decision-making. Conclusion: Our results confirm a wide variety of considerations regarding treatment duration in patients with unprovoked VTE. Although most participants followed guidelines' recommendations to prescribe indefinite treatment in absence of contraindications, rationale is not always supported by evidence. A clinical decision tool to estimate and weigh risks of recurrence and bleeding is warranted

High D-dimer levels increase the likelihood of pulmonary embolism

Objective. To determine the utility of high quantitative D-dimer levels in the diagnosis of pulmonary embolism. Methods. D-dimer testing was performed in consecutive patients with suspected pulmonary embolism. We included patients with suspected pulmonary embolism with a high risk for venous thromboembolism, i.e. hospitalized patients, patients older than 80 years, with malignancy or previous surgery. Presence of pulmonary embolism was based on a diagnostic management strategy using a clinical decision rule (CDR), D-dimer testing and computed tomography. Results. A total of 1515 patients were included with an overall pulmonary embolism prevalence of 21%. The pulmonary embolism prevalence was strongly associated with the height of the D-dimer level, and increased fourfold with D-dimer levels greater than 4000 ng mL(-1) compared to levels between 500 and 1000 ng mL(-1). Patients with D-dimer levels higher than 2000 ng mL(-1) and an unlikely CDR had a pulmonary embolism prevalence of 36%. This prevalence is comparable to the pulmonary embolism likely CDR group. When D-dimer levels were above 4000 ng mL(-1), the observed pulmonary embolism prevalence was very high, independent of CDR score. Conclusion. Strongly elevated D-dimer levels substantially increase the likelihood of pulmonary embolism. Whether this should translate into more intensive diagnostic and therapeutic measures in patients with high D-dimer levels irrespective of CDR remains to be studie