Short-term versus extended anticoagulant treatment for unprovoked venous thromboembolism: A survey on guideline adherence and physicians' considerations

Abstract

Background: In patients with unprovoked venous thromboembolism (VTE), anticoagulant treatment duration should be decided by weighing bleeding risk versus risk of recurrent VTE, considering patient's preference. Because both risks differ between individuals, this recommendation presumably leads to wide variation in clinical management. Objectives: To identify physician's considerations when deciding between short-term and extended anticoagulation and to assess how current guidelines are put to practice. Materials and methods: An online, 33-item survey was developed, containing questions on clinical management, considerations regarding treatment duration, risk scores, information tools and shared decision-making. It was distributed to internists, pulmonologists and residents treating patients with VTE in the Netherlands. Results: 69 internists and 73 pulmonologists including 24 residents participated in the survey. Extended treatment was preferred by 73% (104/142) of participants. Most important reasons for extended treatment were, in descending order: patient's preference, active malignancy, low estimated bleeding risk, history of VTE and hemodynamic instability during previous VTE. Most important reasons for short-term treatment were frequent falls, history of major bleeding, previous bleeding during anticoagulation, patient's preference and thrombocytopenia. Although existing risk scores are infrequently used, physicians express their need for scores combining risks of recurrence and bleeding to aid individualized decision-making. Conclusion: Our results confirm a wide variety of considerations regarding treatment duration in patients with unprovoked VTE. Although most participants followed guidelines' recommendations to prescribe indefinite treatment in absence of contraindications, rationale is not always supported by evidence. A clinical decision tool to estimate and weigh risks of recurrence and bleeding is warranted.

Treatment Decision-Making of Secondary Prevention After Venous Thromboembolism: Data From the Real-Life START2-POST-VTE Register

“…Two recent, survey-based studies, performed in different geographic context (Australia and Northern Europe), have investigated the physician’s attitude to adhere to the guideline indications. 8,9 Although in both studies most physicians said they followed the guideline indications on the issue (very likely, even our Italian physicians would have given the same answer if asked), both studies showed a considerable variability in VTE management practices, in a way similar to what we found in our study. In particular, the difficulty in assessing the individual patient risk of developing a major bleeding complication during AT was underlined in the study by de Winter et al 9 as well as in the present study.…”

“…Recent reports, with data coming from different countries, confirm a wide variability in the practice of physicians as regards AT duration in management of patients with VTE. 8,9 Although it is relevant to assess to what extent physicians follow the guidelines on this issue, it is also very important to understand how the treating physicians tackle the issue in daily clinical practice; many factors may influence their decision, such as personal experience, confidence in guideline recommendations, and patient characteristics and preferences.…”

Deciding on Treatment Duration for Unprovoked Venous Thromboembolism: What is Important to Patients?

“…23 Interestingly, this is also what physicians focus most on. 24 In line with previous studies, patients were less concerned with risk of bleeding. 13,23 A possible explanation could be that patients are familiar with VTE, as opposed to bleeding.…”

Characteristics of patients receiving extended treatment after incident venous thromboembolism

“…Most important reasons for short-term treatment were frequent falls, history of major bleeding, previous bleeding during anticoagulation, the patient's preference and thrombocytopenia. 25 In another international survey from 2020 of clinicians regarding their management of VTE following the initial 3-6 months of anticoagulation, a consensus on long-term management for patients with unprovoked VTE was found. For the remainder, there was a lack of consensus regarding the need for indefinite anticoagulation.…”

“…An online survey investigating physicians' considerations when deciding between short‐term and extended anticoagulation after VTE showed that the most important reasons for extended treatment were, in descending order, the patient's preference, active malignancy, low estimated bleeding risk, history of VTE and haemodynamic instability during previous VTE. Most important reasons for short‐term treatment were frequent falls, history of major bleeding, previous bleeding during anticoagulation, the patient's preference and thrombocytopenia 25 . In another international survey from 2020 of clinicians regarding their management of VTE following the initial 3–6 months of anticoagulation, a consensus on long‐term management for patients with unprovoked VTE was found.…”