Stopping Anticoagulant Therapy in Patients with First Unprovoked Venous Thromboembolism

January 15, 2015

Stopping Anticoagulant Therapy in Patients with First Unprovoked Venous Thromboembolism

  1. Jamaluddin Moloo, MD, MPH

Don't rely on negative D-dimer results to help select patients for discontinuing anticoagulation.

  1. Jamaluddin Moloo, MD, MPH

Do all patients with first unprovoked venous thromboembolism (VTE) require long-term anticoagulation? In this study, researchers evaluated whether a negative d-dimer test result safely identifies patients in whom anticoagulation can be stopped. d-dimer testing was done in 410 patients with first episodes of unprovoked VTE (i.e., proximal deep venous thrombosis of the legs or pulmonary embolism) who had been receiving anticoagulation therapy for 3 to 7 months. Patients with positive results during coagulation continued anticoagulation; those with negative results stopped anticoagulation and had second d-dimer tests 1 month later. If second tests were positive, anticoagulation was reinitiated; if they were negative, therapy was stopped indefinitely. Patients were followed for an average of 2.2 years.

Of 392 patients who had negative d-dimer results and discontinued anticoagulation, 2 had recurrent VTE before repeat d-dimer testing at 1 month. Among those who underwent repeat d-dimer testing, 15% tested positive and were restarted on anticoagulant therapy. Among those who tested negative and remained off anticoagulant therapy, rates of recurrent VTE were 6.7% per patient-year overall, 9.7% per patient-year in men, 5.4% per patient-year in women who were not taking estrogen when the initial VTE occurred, and 0.0% per patient-year in women who were taking estrogen when the initial VTE occurred and who subsequently stopped estrogen.

Comment

These results support the American College of Chest Physicians guideline suggesting that patients with first unprovoked VTE receive indefinite anticoagulation unless their bleeding risk is high (Chest 2012; 141:e419S); for most patients, negative d-dimer tests will not confer low enough risk to support stopping anticoagulation. However, women who were taking estrogen at the time of initial VTE had no recurrences after stopping estrogen; further d-dimer testing or anticoagulation in such women does not appear to be indicated. For patients who are reluctant to continue indefinite anticoagulation, the authors present several scenarios in which repeat d-dimer testing might guide decision-making.

Editor Disclosures at Time of Publication

  • Disclosures for Jamaluddin Moloo, MD, MPH at time of publication Grant / Research support Colorado Health Foundation

Citation(s):

Reader Comments (2)

SUSAN MARSHALL Physician, Nephrology

again very interesting

Wilbur Howard MD Physician, Obstetrics/Gynecology

"Taking estrogen" is very nonspecific. That could include OCP's. which are known to increase the risk for DVT., but it would be important to know of those using non-oral ET which does not.

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