Q: How long should a patient be anticoagulated after a VTE?
To answer this question, you need to ask yourself: Was this a provoked or unprovoked VTE? Was this the first time or is this a recurrent VTE? What is the patient’s bleeding risk? What are the risk factors for recurrence of VTE?
“If there are no contraindications, current guidelines recommend anticoagulation for a minimum of three months for PE and proximal DVT. If a reversible provoking factor is identified as the cause of VTE, anticoagulation beyond three months is not recommended. Extended anticoagulation is recommended for patients with an unprovoked VTE and low risk of bleeding. Indefinite anticoagulation is recommended for patients with a second VTE and low or moderate risk of bleeding.” AAFP 2017
“-Most patients with the first episode of VTE (proximal DVT and/or PE) are anticoagulated for a finite period of 3 to 12 months.
-Indefinite anticoagulation must be individualized and should be based on: 1) an estimate of the risk of recurrence of the VTE, 2) Risk of bleeding from the anticoagulation, 3) What the patient wants (his values and preferences).
-Indefinite anticoagulation should be used for most patients with the first episode of unprovoked proximal DVT, unprovoked symptomatic PE, or active cancer in whom the risk of bleeding is low to moderate. Indefinite anticoagulation should also be used in patients with a recurrent episode of unprovoked VTE.
Don’t use routinely indefinite anticoagulation for patients with a provoked episode of VTE with major transient risk factors (eg, surgery, cessation of hormonal therapy). Also, avoid indefinite anticoagulation in patients with a high bleeding risk; however, if the risk for bleeding resolves, indefinite anticoagulation may be reconsidered.
For most patients with recurrent provoked VTE or a first episode of provoked VTE with irreversible, multiple, or minor risk factors, a first episode of unprovoked isolated distal DVT or an unprovoked episode of incidental PE, therapy must be individualized based upon a careful assessment of patient-specific risks of bleeding and thrombosis. There are wide variations in both the recurrence risk and benefit in these populations.”
“For indefinite anticoagulation, it’s better to continue the current anticoagulant rather than switch to a new agent unless there is a compelling reason to do so.
For most patients, use full intensity anticoagulation (eg, warfarin with INR target 2 to 3).
If a patient doesn’t want anticoagulation, use aspirin if there is no contraindication.
F/u Yearly. Patients receiving indefinite anticoagulation are seen at least annually. During f/u assess for recurrence, adequacy of therapeutic control, the development of contraindications to anticoagulation, altered bleeding risk, and chronic hemorrhage, as well as for changes in agent preference.”
https://www.uptodate.com/contents/rationale-and-indications-for-indefinite-anticoagulation-in-patients-with-venous-thromboembolism
https://www.uptodate.com/contents/overview-of-the-treatment-prognosis-and-follow-up-of-acute-pulmonary-embolism-in-adults