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Rationale and indications for indefinite anticoagulation in patients with venous thromboembolism

Authors
Gregory YH Lip, MD, FRCPE, FESC, FACC
Russell D Hull, MBBS, MSc
Section Editors
Jess Mandel, MD
Lawrence LK Leung, MD
Deputy Editor
Geraldine Finlay, MD

INTRODUCTION

Deep vein thrombosis (DVT) and acute pulmonary embolism (PE) are two manifestations of venous thromboembolism (VTE). Anticoagulation is the mainstay of therapy for patients with VTE. Most patients with VTE are anticoagulated for a finite period (3 to 12 months) following a first episode of VTE. Select patients at increased risk of recurrent thrombosis beyond the conventional period may benefit from indefinite anticoagulation. Anticoagulation is administered in this setting to reduce the lifetime risk of recurrent thrombosis and VTE-associated death.

This topic will discuss therapeutic indefinite anticoagulation as opposed to prophylactic anticoagulation following an episode of VTE. Populations that are likely or unlikely to benefit from indefinite anticoagulation will be discussed along with the factors that contribute to making this decision. The indications for the initial and long term treatment of lower extremity DVT, as well as alternate therapies for patients with DVT and PE are discussed in detail separately. (See "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Overview of the treatment, prognosis, and follow-up of acute pulmonary embolism in adults" and "Venous thromboembolism: Initiation of anticoagulation (first 10 days)" and "Venous thromboembolism: Anticoagulation after initial management".)  

TERMINOLOGY

For the purposes of discussion in this topic, the following terms apply:

The term unprovoked deep vein thrombosis (DVT) implies that no identifiable provoking environmental event for DVT is evident [1]. In contrast, a provoked DVT is one that is usually caused by a known event (eg, surgery, hospital admission). VTE events can be provoked by transient major risk factors (ie, major surgery >30 minutes, hospitalization or immobility ≥3 days, cesarian section), transient minor risk factors (minor surgery <30 minutes, hospitalization <3 days, pregnancy, estrogen therapy, reduced mobility ≥3 days) or persistent risk factors. Persistent risk factors include reversible conditions (eg, curable malignancy, inflammatory bowel disease that resolves) and irreversible conditions such as inheritable thrombophilias, chronic heart failure, and metastatic end-stage malignancy. (See "Overview of the causes of venous thrombosis".)

Proximal deep venous thrombosis (DVT) is one that is located in the popliteal, femoral, or iliac veins. Isolated distal DVT has no proximal component, is located below the knee, and is confined to the calf veins (peroneal, posterior, anterior tibial, and muscular veins) (table 1). Pulmonary embolism (PE) can be located in the main, segmental, or subsegmental branches of the pulmonary artery.

                                    

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Literature review current through: Nov 2016. | This topic last updated: Fri Jul 22 00:00:00 GMT 2016.
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