Anticoagulation in venous thromboembolism for the general physician

Venous thromboembolism (VTE) is frequently encountered across various specialties. The management of VTE has become more nuanced, requiring consideration of several factors when deciding on the choice and duration of anticoagulation. This evidence-based review article summarises the current practice and evidence behind anticoagulation in VTE, incorporating national and international guidelines. Factors influencing decision-making around the choice and duration of anticoagulation, along with special circumstances such as cancer and antiphospholipid syndrome, are discussed. The clinical utility of thrombophilia screening is also addressed.

Incidence of bleeding and recurrence in isolated distal deep vein thrombosis: findings from the Venous Thrombosis Registry in Østfold Hospital

BACKGROUND

Isolated distal deep vein thrombosis (IDDVT) is a common presentation of deep vein thrombosis. There are limited data on the long-term risk of recurrence after IDDVT.

OBJECTIVES

We aimed to determine the short- and long-term incidence of venous thrombosis (VTE) recurrence after cessation of anticoagulation and the 3-month incidence of bleeding during anticoagulant treatment in patients with IDDVT.

METHODS

Between January 2005 and May 2020, 475 patients with IDDVT and without active cancer were identified from the Venous Thrombosis Registry in Østfold Hospital, which is an ongoing registry of consecutive patients with VTE at Østfold Hospital, Norway. Major and clinically relevant, nonmajor bleeding as well as recurrent VTE were registered, and the cumulative incidences of these events were assessed.

RESULTS

The median age of the patients was 59 years (IQR, 48-72 years), 243 (51%) patients were women, and 175 events (36.8%) were classified as unprovoked. The 1-, 5-, and 10-year cumulative incidences of recurrent VTE were 5.6% (95% CI, 3.7-8.4), 14.7% (95% CI, 11.1-19.4), and 27.2% (95% CI, 21.1-34.5), respectively. The recurrence rates were higher for unprovoked IDDVT than for provoked IDDVT. Among the recurrent events, 18 (29%) were pulmonary embolisms and 21 (33%) were proximal deep vein thromboses. The 3-month cumulative incidence of major bleeding was 1.5% (95% CI, 0.7-3.1) overall and 0.8% (95% CI, 0.2-3.1) when restricted to patients treated with direct oral anticoagulants.

CONCLUSION

Despite initial treatment, the long-term risk of VTE recurrence after first-time IDDVT is high. The bleeding rates during anticoagulation, particularly with direct oral anticoagulants, were acceptably low.

Revisiting an ancient legend: Influence of the lunar cycle on occurrence of first-ever unprovoked seizures

BACKGROUND

The mythical effect of the lunar cycle on seizures has been debated over time. Previously healthy individuals presenting with first-ever seizures in whom investigations are negative often invoke questions about potential reasons including a full moon.

AIMS

To determine whether there is a temporal relationship between the occurrence of the first-ever unprovoked seizure and the lunar cycle.

METHODS

We studied adults who presented with a first-ever unprovoked seizure to two tertiary centres in Australia. Seizure onset time was obtained from the emergency department and ambulance documentations. We used Poisson regression modelling and incidence rate ratios (IRR) to determine whether seizures have a preponderance for a particular lunar phase. We performed further analysis on "first seizure epilepsy" and "first seizure not epilepsy" subgroups based on the International League Against Epilepsy criteria for a diagnosis of epilepsy after a single unprovoked seizure.

RESULTS

We analysed 1710 patients (38% females; median 39 yr), of whom 18% had epileptiform abnormalities on EEG and potentially epileptogenic lesions were detected on neuroimaging in 28%. Based on the EEG and imaging findings, 684 (40%) patients were categorized as "first seizure epilepsy" and 1026 (60%) "first seizure not epilepsy". The whole cohort and subgroup analysis demonstrated no significant difference in the seizure occurrence among the four lunar quarters.

CONCLUSIONS

First unprovoked seizures are not influenced by the lunar cycle. Patients pondering the cause of their first-ever unprovoked seizure can be reassured that the full moon was not responsible. This article is protected by copyright. All rights reserved.

Extended anticoagulation after venous thromboembolism: should it be done?

Most physicians understand venous thromboembolism (VTE) to be an acute and time-limited disease. However, pathophysiological and epidemiological data suggest that in most patients VTE recurrence risk is not resolved after the first 6 months of anticoagulation. Recurrence rates are high and potentially life-threatening. In these cases, it would make sense to prolong anticoagulation for an undetermined length of time. However, what about the bleeding rates, induced by prolonged anticoagulation? Would they not outweigh the benefit of reducing the VTE recurrent risk? How long should anticoagulation be continued, and should all patients suffering from VTE be provided with extended anticoagulation? This review will address the most recent data concerning extended anticoagulation in VTE secondary prophylaxis.

The reviews of this paper are available via the supplementary material section.

Optimal long-term pharmacological treatment of patients with venous thromboembolism that was unprovoked or associated with weak risk factors

INTRODUCTION

Unprovoked venous thromboembolism (VTE) tend to recur. Many factors, patient- or event-related, influence the individual risk of recurrence. After initial and long-term (usually for 3-6 months) anticoagulant therapy, extended anticoagulation has been recommended in patients at high risk of recurrence, provided they do not have a high risk of bleeding. Areas covered: The effect of different risk factors on the risk of recurrence is discussed, as well as risk factors for bleeding. The estimation of individual balance between these two risks is crucial to decide which can be the best treatment duration in single patients. The use of direct oral anticoagulants, with likely less risk of bleeding, may influence the balance. D-dimer assessment during and after anticoagulation is stopped is also commented for its role to help identifying the individual risk of recurrence. Expert commentary: All patients with a first VTE should be reconsidered after the initial 3-6 months of treatment. Anticoagulation can then be stopped or continued in relation to low or very high risk of recurrence, respectively. Serial D-dimer assessment during the first 2 or 3 months after anticoagulation is stopped is useful in patients with uncertain risk evaluation (especially after unprovoked events).

[Anticonvulsive Therapy after the First Unprovoked Seizure – Pros and Cons]

A first seizure is a critical life time event with severe consequences. A very thorough work-up is needed to find out the cause of the seizure and to number the risk of recurrence. Reasons for an anticonvulsive therapy are a pathologic EEG, a pathologic neurologic examination, the proof of a structural lesion, focal seizure onset or seizure onset while sleeping or classification as an epilepsy syndrome with high recurrence risk like juvenile myoclonic epilepsy or juvenile absence epilepsy. Psychological and social aspects like the patients or relatives fear of a further seizure, the risk of injury and occupational and recreational aspects must be considered as well. Reasons against an anticonvulsive therapy are mainly related to adverse effects like gain of weight and osteoporosis.

Management of patients with unprovoked venous thromboembolism: an evidence-based and practical approach

OPINION STATEMENT

The management of patients with unprovoked venous thromboembolism is a common and challenging clinical problem. Although the initial antithrombotic management is well-established, there is uncertainty about the optimal long-term anticoagulant management, specifically whether patients should receive a short (i.e., 3- to 6-month) duration of anticoagulant therapy or indefinite anticoagulation. Factors that may be considered to estimate patients' risk for recurrent thromboembolism include the mode of initial clinical presentation, as deep vein thrombosis or pulmonary embolism, patient sex, antecedent hormonal therapy use, thrombophilia, D-dimer levels, and residual vein occlusion in patients with deep vein thrombosis. Many of these factors have been integrated into clinical prediction guides which stratify patients with unprovoked venous thromboembolism according to their risk for disease recurrence and, thereby, can assist clinicians in decisions about the duration of anticoagulation. The objective of this review is to consider the evidence relating to the clinical significance of purported risk factors and provide a practical case-based approach to guide decisions on duration of anticoagulation for patients with unprovoked venous thromboembolism.