title: Timing of recurrent venous thromboembolism early after the index event: a meta-analysis of randomized controlled trials.
abstract: BACKGROUND
  Studies suggest a decreasing risk of recurrent venous thromboembolism (rVTE) in relation to time since the index event. We sought to conduct a meta-analysis examining the time course of rVTE over the first 3-months of anticoagulation.
  
  
  METHODS
  A literature search of MEDLINE, EMBASE and CENTRAL (through 4/2013) was conducted to identify randomized trials of acute pharmacologic treatment and prevention of rVTE, enrolling ≥200 subjects/treatment arm, requiring anticoagulation for ≥3-months and reporting time-to-objectively-confirmed rVTE. Trials assessing extended-duration treatment, randomizing only cancer patients or not in English were excluded. Treatment arms were divided into monthly and weekly time periods for comparison (months 1-3 and weeks 1-12 after the index event). Treatment arm rVTE rates (per person-year) were pooled using a random-effects approach.
  
  
  RESULTS
  Fifteen trials (31 treatment arms; n=27,237) were included. Higher rVTE rates were observed during the first month after the index event (0.19, 95% CI=0.16-0.23) compared to the second (0.05, 95% CI 0.04-0.06; p<0.001 vs. first month) and third months (0.02, 95% CI=0.02-0.03; p<0.001 vs. first month). While the highest rate of rVTE was in week 1 (0.29, 95% CI=0.21-0.37; p<0.01 vs. week 2), rates remained high through the fourth week (between 0.15 and 0.10 events/person-year) before decreasing and stabilizing at week 5 (≤0.05 events/person-year; p<0.01 vs. week 4).
  
  
  CONCLUSIONS
  Our findings demonstrate a significant interaction between rVTE rates and time after the index event. High rVTE rates during the 3-4 weeks following the index event emphasize the importance of frequent surveillance during this time and the early optimization of pharmacologic therapy.
authors.affiliation: University of Connecticut School of Pharmacy, Storrs, CT; Evidence-Based Practice Center, Hartford Hospital, Hartford, CT.
authors.forename: Brendan L
authors.initials: BL
authors.lastname: Limone
authors.forename: Adrian V
authors.initials: AV
authors.lastname: Hernandez
authors.forename: Daniel
authors.initials: D
authors.lastname: Michalak
authors.forename: Brahim K
authors.initials: BK
authors.lastname: Bookhart
authors.forename: Craig I
authors.initials: CI
authors.lastname: Coleman
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage*; D018450:Disease Progression; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012307:Risk Factors; D013997:Time Factors; D054556:Venous Thromboembolism / Q000188:drug therapy / Q000473:pathology* / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants
keywords: Anticoagulants; Deep vein thrombosis; Meta-analysis; Pulmonary embolism; Venous thromboembolism