Duration of anticoagulation after isolated pulmonary embolism

Abstract

In the D-dimer and ULtrasonography in Combination Italian Study (DULCIS), serial D-dimer measurement in combination with assessment of residual thrombosis (in patients with deep vein thrombosis (DVT)) identified patients who safely discontinued anticoagulation after an unprovoked venous thromboembolism (VTE).In this subgroup analysis, the value of D-dimer tests was assessed in patients with isolated pulmonary embolism (PE) compared with those with DVT, with or without PE (DVT/PE). The DULCIS database was reanalysed in relation to this target.26.8% of the DULCIS patients had isolated PE as the index event; this was more prevalent in females (34.1%) than in males (21.1%; p<0.0001). The rate of positive D-dimer was similar in isolated PE and DVT/PE. The rate of recurrences was not different in isolated PE or DVT/PE patients (4.8% ppy versus 3.8% ppy; nonsignificant) who stopped anticoagulation for negative D-dimer, but it was markedly high (11.2% ppy; p<0.0001) in those with isolated PE who remained without anticoagulation despite positive D-dimer. Recurrences were more frequently new isolated PE in patients with isolated PE than with DVT/PE (six (46.2%) out of 13 versus two (7.4%) out of 27; p=0.0085).Serial D-dimer assessment can inform on the risk of recurrent VTE and help determine the duration of anticoagulation in patients with isolated PE.

The Michigan Risk Score to predict peripherally inserted central catheter‐associated thrombosis

“…With the introduction of appropriateness criteria to guide the use of PICCs , the Michigan Risk Score adds to a growing body of knowledge that helps improve decision making related to use of this device prior to insertion. Third, as has been the case with other risk tools for venous thromboembolism , we expect that this score may prove useful in informing certain aspects of PICC care, such as the utility of diagnostic imaging when considering thrombosis (e.g. avoidance in low‐risk patients) as well as the benefit of prolonged anticoagulation following confirmed thrombosis (extended use in high‐risk categories).…”

Guided duration of anticoagulation after unprovoked venous thromboembolism using D-dimer testing

“…Therefore, the determination of the individual risk of recurrent VTE among patients with unprovoked VTE remains a major issue. In this setting, PALARETI et al [9] report, in this issue of the European Respiratory Journal, the results of a subanalysis of the "DULCIS" study, a large prospective cohort of 1010 patients with unprovoked VTE [10]; the main aim was to evaluate the accuracy of serial D-dimer assessment to predict the risk of recurrent VTE according to whether patients had unprovoked pulmonary embolism (PE) or deep vein thrombosis (DVT) [9].The first important result of this study is that the annual incidence rate of recurrent VTE was markedly higher (8-11% per year) in patients with positive D-dimer test who did not resume anticoagulation as compared to those with negative D-dimer who permanently stopped anticoagulation (3-4% per year), whether the initial episode was isolated PE or DVT (with or without PE). However, the annual incidence rate of recurrent VTE in patients with negative D-dimer was not low, particularly if VTE was isolated PE or occurred in the absence of a weak risk factor, such as minor trauma, leg injury or reduced mobility, or after 70 years.…”

“…Finally, the present subanalysis conducted by PALARETI et al [9] underlines some additional useful information: first, in patients with unprovoked VTE, the presence of negative D-dimer does not exclude a high risk of recurrent VTE, particularly in patients with isolated PE or those older than 70 years; secondly, a positive D-dimer assessment is strongly correlated with a high risk of recurrent VTE, which supports indefinite anticoagulation in most cases; thirdly, patients who had isolated PE are more likely to develop recurrence under the clinical presentation of PE as compared to patients with an initial DVT, and this observation also reinforces the need for indefinite anticoagulation in patients with unprovoked PE rather than in patients with unprovoked DVT.…”

“…Therefore, the determination of the individual risk of recurrent VTE among patients with unprovoked VTE remains a major issue. In this setting, PALARETI et al [9] report, in this issue of the European Respiratory Journal, the results of a subanalysis of the "DULCIS" study, a large prospective cohort of 1010 patients with unprovoked VTE [10]; the main aim was to evaluate the accuracy of serial D-dimer assessment to predict the risk of recurrent VTE according to whether patients had unprovoked pulmonary embolism (PE) or deep vein thrombosis (DVT) [9].…”

Prolonged anticoagulation in VTE with direct oral anticoagulants: towards an individual analysis of net clinical benefit?

“…The challenge is thus to stratify this heterogeneous population so as to identify those at high or low risk of recurrence. Several scores or clinical rules have been proposed for this end [22,23]. Among them, the "men continue and HERDOO 2" rule was recently validated in an interventional study.…”