title: Venous thromboembolism: Predicting recurrence and the need for extended anticoagulation.
abstract: Initial treatment for venous thromboembolism (VTE) includes the acute and intermediate phases, usually lasting for 3 months. The choice to extend therapy beyond the initial 3-month window involves assessing a combination of risk factors for VTE recurrence and bleeding, along with weighing patient preferences. In some cases, such as VTE provoked by a reversible surgical risk factor, the recurrence risk is sufficiently low that most patients should not receive extended therapy. In other cases, such as VTE associated with malignancy, the recurrence risk is sufficiently high that treatment should be extended beyond the initial 3 months. However, a large number of patients fall into a grey zone where the decision on extended therapy is less clear-cut. In this review, we summarize the evidence for VTE recurrence risk and the role for extended anticoagulation given a variety of patient-specific factors and laboratory results. We also review the role of VTE risk prediction tools and provide a recommended algorithm for approaching the decision of extended anticoagulation therapy. Various agents available for extended VTE therapy, including warfarin, aspirin and the direct oral anticoagulant agents, are discussed.
authors.affiliation: University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA gbarnes@umich.edu.
authors.forename: Geoffrey D
authors.initials: GD
authors.lastname: Barnes
authors.affiliation: University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA.
authors.forename: Yogendra
authors.initials: Y
authors.lastname: Kanthi
authors.affiliation: University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA.
authors.forename: James B
authors.initials: JB
authors.lastname: Froehlich
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D006470:Hemorrhage / Q000139:chemically induced*; D006801:Humans; D009369:Neoplasms / Q000150:complications; D012008:Recurrence; D012307:Risk Factors; D013997:Time Factors; D054556:Venous Thromboembolism / Q000175:diagnosis* / Q000188:drug therapy*; D014859:Warfarin / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Anticoagulation; venous thromboembolism
references.citation: Arch Intern Med. 2000 Mar 27;160(6):761-8
references.pmid: 10737275
references.citation: N Engl J Med. 2004 Jun 17;350(25):2558-63
references.pmid: 15201412
references.citation: Ann Intern Med. 2007 Jun 5;146(11):761-7
references.pmid: 17470822
references.citation: Thromb Haemost. 2008 Jul;100(1):26-31
references.pmid: 18612534
references.citation: Thromb Res. 2008;122(5):610-7
references.pmid: 18304616
references.citation: CMAJ. 2008 Aug 26;179(5):417-26
references.pmid: 18725614
references.citation: Ann Intern Med. 2008 Oct 7;149(7):481-90, W94
references.pmid: 18838728
references.citation: Thromb Haemost. 2009 Jan;101(1):93-9
references.pmid: 19132194
references.citation: N Engl J Med. 2009 Apr 30;360(18):1851-61
references.pmid: 19329822
references.citation: J Thromb Haemost. 2009 Oct;7(10):1737-40
references.pmid: 19624461
references.citation: Blood. 2010 Jan 21;115(3):481-8
references.pmid: 19965693
references.citation: Eur J Vasc Endovasc Surg. 2010 Mar;39(3):356-65
references.pmid: 20034816
references.citation: Circulation. 2010 Apr 13;121(14):1630-6
references.pmid: 20351233
references.citation: Thromb Res. 2010 Apr;125 Suppl 2:S62-5
references.pmid: 20434008
references.citation: Ann Intern Med. 2010 May 4;152(9):578-89
references.pmid: 20439576
references.citation: Arch Intern Med. 2010 Oct 25;170(19):1710-6
references.pmid: 20975016
references.citation: Chest. 2010 Nov;138(5):1093-100
references.pmid: 20299623
references.citation: N Engl J Med. 2010 Dec 23;363(26):2499-510
references.pmid: 21128814
references.citation: Genet Med. 2011 Jan;13(1):67-76
references.pmid: 21150787
references.citation: Thromb Haemost. 2011 May;105(5):837-45
references.pmid: 21359409
references.citation: BMJ. 2011;342:d3036
references.pmid: 21610040
references.citation: J Thromb Haemost. 2011 Jun;9(6):1119-25
references.pmid: 21382171
references.citation: J Am Coll Cardiol. 2011 Jul 19;58(4):395-401
references.pmid: 21757117
references.citation: Hematology Am Soc Hematol Educ Program. 2011;2011:150-5
references.pmid: 22160027
references.citation: Chest. 2012 Feb;141(2 Suppl):53S-70S
references.pmid: 22315256
references.citation: Chest. 2012 Feb;141(2 Suppl):e419S-94S
references.pmid: 22315268
references.citation: J Thromb Thrombolysis. 2012 May;33(4):371-82
references.pmid: 22278047
references.citation: Lancet. 2012 May 12;379(9828):1835-46
references.pmid: 22494827
references.citation: N Engl J Med. 2012 May 24;366(21):1959-67
references.pmid: 22621626
references.citation: J Thromb Haemost. 2012 Jun;10(6):1019-25
references.pmid: 22489957
references.citation: Circulation. 2012 Jul 24;126(4):448-54
references.pmid: 22679142
references.citation: Thromb Res. 2012 Sep;130(3):467-71
references.pmid: 22512897
references.citation: N Engl J Med. 2013 Feb 21;368(8):699-708
references.pmid: 23216615
references.citation: N Engl J Med. 2013 Feb 21;368(8):709-18
references.pmid: 23425163
references.citation: J Thromb Haemost. 2013 Mar;11(3):435-43
references.pmid: 23279158
references.citation: Ann Rheum Dis. 2013 Jul;72(7):1182-7
references.pmid: 22930596
references.citation: J Thromb Haemost. 2013 Jun;11(6):1053-8
references.pmid: 23578305
references.citation: Blood. 2013 Aug 1;122(5):817-24
references.pmid: 23760616
references.citation: Arch Intern Med. 1991 May;151(5):933-8
references.pmid: 2025141
references.citation: Lancet. 1995 Apr 8;345(8954):882-5
references.pmid: 7707810
references.citation: Thromb Haemost. 1995 Jan;73(1):151-61
references.pmid: 7740487
references.citation: N Engl J Med. 1996 Mar 21;334(12):759-62
references.pmid: 8592549
references.citation: Ann Intern Med. 1996 Jul 1;125(1):1-7
references.pmid: 8644983
references.citation: Am J Med. 1998 Aug;105(2):91-9
references.pmid: 9727814
references.citation: Arch Intern Med. 1999 Mar 8;159(5):457-60
references.pmid: 10074953
references.citation: JAMA. 2005 May 18;293(19):2352-61
references.pmid: 15900005
references.citation: Am Heart J. 2006 Mar;151(3):713-9
references.pmid: 16504638
references.citation: Arch Intern Med. 2006 Apr 10;166(7):729-36
references.pmid: 16606808
references.citation: N Engl J Med. 2006 Oct 26;355(17):1780-9
references.pmid: 17065639
references.citation: BMJ. 2007 Mar 31;334(7595):674
references.pmid: 17289685
references.citation: J Thromb Haemost. 2007 Apr;5(4):692-9
references.pmid: 17367492
references.citation: J Am Heart Assoc. 2014;3(1):e000467
references.pmid: 24385451
references.citation: Thromb Haemost. 2014 Jan;111(1):172-9
references.pmid: 24154729
references.citation: Thromb Res. 2014 Mar;133(3):384-9
references.pmid: 24438941
references.citation: JAMA. 2014 Feb 19;311(7):717-28
references.pmid: 24549552
references.citation: J Thromb Haemost. 2014 Apr;12(4):452-8
references.pmid: 24472157
references.citation: Blood. 2014 Jul 10;124(2):196-203
references.pmid: 24879813
references.citation: Circulation. 2014 Jul 15;130(3):283-7
references.pmid: 25024124
references.citation: N Engl J Med. 2001 Jul 19;345(3):165-9
references.pmid: 11463010
references.citation: Blood. 2002 Nov 15;100(10):3484-8
references.pmid: 12393647
references.citation: N Engl J Med. 2003 Apr 10;348(15):1425-34
references.pmid: 12601075
references.citation: Circulation. 2003 Jun 17;107(23 Suppl 1):I4-8
references.pmid: 12814979
references.citation: Ann Intern Med. 2003 Jul 1;139(1):19-25
references.pmid: 12834314
references.citation: N Engl J Med. 2003 Jul 10;349(2):146-53
references.pmid: 12853587
references.citation: N Engl J Med. 2003 Aug 14;349(7):631-9
references.pmid: 12917299
references.citation: N Engl J Med. 2012 Nov 22;367(21):1979-87
references.pmid: 23121403