The risk of recurrent venous thromboembolic disease — implications for treatment
- 85 Downloads
Patients with venous thromboembolism are at risk of recurrent thrombosis. Since this risk is particularly high within the first weeks and months after the acute event, intensive heparin treatment followed by oral anticoagulants for at least 3 to 6 months is generally recommended. After discontinuation of secondary thromboprophylaxis, the cumulative incidence of recurrence still remains high (approximately 20 % after 5 years).
Patients at risk of recurrence may be identified by evaluation of clinical and/or laboratory findings. Patients with cancer, the antiphospholipid antibody (APLA) syndrome, patients with antithrombin-, protein C- or protein S-deficiency, or patients with hyperhomocysteinemia are at an especially high risk of recurrent thrombosis. In patients with the factor V Leiden mutation or the G20210A variant in the prothrombin gene, data on the recurrence rate are currently controversial or unknown.
While a massive activation of coagulation and fibrinolysis is observed during and after an acute venous thromboembolic event, monitoring of coagulation activation markers, such as prothrombin fragment F1 + 2, has not proven helpful for prediction of recurrence.
Since the risks of secondary thromboprophylaxis (mainly bleeding) have to be weighed against the benefit in terms of prevention of recurrence, it is common practice to discontinue oral anticoagulants after 6 months. However, some patients have an increased risk of recurrence, and prolonged secondary thromboprophylaxis should be considered. Although randomized trials to compare different treatment modalities in patients at high risk of recurrence are currently lacking, we suggest that after a first or second venous thromboembolic event patients with cancer, with an APLA-syndrome, patients with type I antithrombin deficiency, patients with combined deficiencies and probably patients with hyperhomocysteinemia are candidates for secondary thromboprophylaxis beyond 6 months. The presence of factor V Leiden alone does not justify secondary thromboprophylaxis longer than 6 months.
Key wordsVenous thromboembolism recurrence treatment
Unable to display preview. Download preview PDF.
- 2.d’Angelo A, Selhub J (1997) Homocysteine and thrombotic disease. Blood 90:1–11Google Scholar
- 5.Eichinger S, Stümpflen A, Hirschl M, Bialonczyk C, Pabinger I, Herkner K, Schneider B, Lechner K, Kyrie PA (1997) Hyperhomocysteinemia is a risk factor of recurrent venous thromboembolism in male patients. Thromb Haemost (Suppl): 184Google Scholar
- 7.Kyrie PA, Eichinger S, Pabinger I, Stümpflen A, Hirschl M, Bialonczyk C, Schneider B, Mannhalter C, Melichart M, Traxler G, Weltermann A, Speiser W, Lechner K (1997) Prothrombin fragment F1 + 2 is not predictive for recurrent venous thromboembolism. Thromb Haemost 77:829–833Google Scholar
- 9.Levine MN, Hirsh J, Landefeld S, Raskob G (1992) Hemorrhagic complications of anticoagulant treatment. Chest 102 (Suppl): 352–363Google Scholar
- 10.Pabinger I, Brücker S, Kyrie PA, Schneider B, Korninger HC, Niessner H, Lechner K (1992) Hereditary deficiency of antithrombin III, protein C and protein S: Prevalence in patients with a history of venous thrombosis and criteria for rational patient screening. Blood Coagul Fibrinolysis 3: 547–553PubMedCrossRefGoogle Scholar
- 16.Schulman S, Rhedin AS, Lindmarker P, Carlsson A, Lärfars G, Nicol P, Loogna E, Svensson E, Ljungberg B, Walter H, Viering S, Nordlander S, Leijd B, Kjell-Ake J, Hjorth M, Linder O, Boberg J, and the Duration of Anticoagulation Trial Study Group (1995) A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. N Engl J Med 332:1661–1665PubMedCrossRefGoogle Scholar