Minimizing recurrent venous thromboembolismBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4686 (Published 25 July 2019) Cite this as: BMJ 2019;366:l4686
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In patients with venous thromboembolic disease (VTE), the risk of recurrence is high. Secondary prophylaxis with anticoagulant therapy reduces thrombotic risk, but at the expense of an increased risk of bleeding. Some factors, such as male sex or an increase in D-dimer concentration after anticoagulation ends, are associated with an increased risk of recurrence; others, such as venosaresidual thrombosis, have a more controversial, even contradictory relationship. Some models for predicting the risk of thrombotic recurrence after anticoagulation in unprovoked VTE have been proposed, but need external validation to know their real usefulness in clinical practice. This article analyzes the risk factors for thrombotic recurrence and the existing prediction models.
The recurrence of Deep Venous Thrombosis (DVT) after a symptomatic episode is high, especially in patients who have a diagnosis of cancer, short-term anticoagulation or previous thromboembolic events. The identification of these factors will allow us to take into account the cases that could benefit from a longer treatment in various risk situations.
The association between cancer and thrombosis known as Trousseau syndrome is a frequent, potentially lethal complication, and it is associated with reduced survival for all stages of cancer compared to cancer patients who do not develop VTE. The most common form of clinical presentation is VTE, which includes DVT and pulmonary thromboembolism (PET).
The higher recurrence rate of VTE in cancer patients led to the development of randomized clinical trials to evaluate other treatment strategies for these patients. To date we have data from five studies designed to compare prolonged treatment (for 3-6 months) with LMWH versus standard therapy with anticoagulant drugs.
In case of recurrence despite anticoagulant treatment, it is recommended to verify that the patient receives doses of anticoagulant treatment in the therapeutic range and with adequate adherence to the treatment. They also recommend confirming with objective evidence that it is a recurrence of VTE and confirming that the patient's symptoms are not due to the oncological process or other intercurrent complications. Once the above points have been ruled out, in patients who present VTE recurrence during treatment with oral anticoagulants, it is suggested to change to treatment with Low Molecular Weight Heparins (LMWH) at least temporarily, this temporality is defined for at least one month. In those patients who present VTE recurrence during treatment with LMWH at therapeutic doses, it is suggested to increase the LMWH dose from 25% to 33%.
The management of VTE in cancer patients is usually more complex than in the general population without cancer.
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Competing interests: No competing interests