The HERDOO2 Score Predicts Recurrent VTE in Women

April 20, 2017

The HERDOO2 Score Predicts Recurrent VTE in Women

  1. Paul S. Mueller, MD, MPH, FACP

After unprovoked venous thromboembolism, long-term anticoagulation probably is unnecessary in women with zero or one HERDOO2 criterion.

  1. Paul S. Mueller, MD, MPH, FACP

As many as 10% of patients with unprovoked venous thromboembolism (VTE) develop recurrent VTE within 1 year after stopping anticoagulation therapy. To identify a subgroup of patients with unprovoked VTE who were at low risk for recurrence, researchers previously derived the HERDOO2 rule (Hyperpigmentation, Edema, or Redness in either leg; d-dimer level ≥250 µg/L; Obesity [body-mass index ≥30 kg/m2]; and Older [age, ≥65]). In the original derivation study, women with ≤1 HERDOO2 criterion had a low recurrence rate (1.6% annually), but the rule was unable to identify a low-risk male group (NEJM JW Gen Med Oct 1 2008 and CMAJ 2008; 179:417).

Now, the researchers have validated this rule prospectively in 2785 patients with unprovoked VTE who had completed 5 to 12 months of anticoagulation. During additional average follow-up of 1 year, results were as follows:

  • Women at low risk (those with ≤1 HERDOO2 criterion) stopped anticoagulation; their recurrence rate was 3%.

  • Management of high-risk women (≥2 HERDOO2 criteria) was left to clinician discretion; recurrence rates were 7.4% in those who stopped anticoagulation and 2.5% in those who continued it.

  • Management of men (all considered to be at high risk) also was left to clinician discretion; recurrence rates were 8.4% in men who stopped anticoagulation and 1.2% in those who continued it.

Comment

In this study, 3% of women with unprovoked VTE and zero or one HERDOO2 criterion developed recurrent VTE by 1 year. The authors conclude that this rate is low enough to justify stopping anticoagulation therapy after a standard course. Given that about half of women with unprovoked VTEs met low-risk criteria, this recommendation would apply to a substantial number of patients. Notably, the HERDOO2 decision rule should not be used in men.

Editor Disclosures at Time of Publication

  • Disclosures for Paul S. Mueller, MD, MPH, FACP at time of publication Consultant / advisory board Boston Scientific (Patient Safety Advisory Board) Editorial boards Medical Knowledge Self-Assessment Program (MKSAP 17 General Internal Medicine Committee); MKSAP 17 General Internal Medicine (author/contributor) Leadership positions in professional societies American Osler Society (Vice President)

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