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Long-Term Management of Venous Thromboembolism (VTE): Options and Considerations

This guide provides an overview of the long-term management strategies for venous thromboembolism (VTE), focusing on the use of low molecular weight heparin (LMWH), oral anticoagulation (with INR of 2.0-3.0), and their implications for treatment duration (3 months to indefinite). It discusses considerations for patients, including those at high risk of bleeding, such as those with uncontrolled adenocarcinoma or thrombophilias. Additionally, it covers the predictors for recurrent VTE, including elevated D-dimer levels, and emphasizes the importance of periodic reassessment and patient preferences in ongoing treatment.

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Long-Term Management of Venous Thromboembolism (VTE): Options and Considerations

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  1. Chapter Seven Venous Disease Coalition Long-Term Management of VTE VTE Toolkit

  2. LMWH S/C 1 Oral Anticoagulation (INR 2.0 - 3.0) Long-Term Treatment of DVT/PE:2 options 3 mos.-indefinite 5-7 d VTE Toolkit

  3. LMWH S/C 1 Oral Anticoagulation (INR 2.0 - 3.0) Long-Term Treatment of DVT/PE:2 options 3 mos.-indefinite 5-7 d 2 ? LMWH S/C pregnancy, uncontrolled adenocarcinoma, high bleeding risk, patient preference VTE Toolkit

  4. Anticoagulation Treatment of VTE Recurrent VTE With anticoagulation, the risk of recurrent VTE is very low. 0 VTE Toolkit Time VTE

  5. Anticoagulation Treatment of VTE If the VTE was provoked (surgery, trauma, pregnancy, acute illness, etc.), the risks of recurrent VTE after a period of anticoagulation is low. Recurrent VTE 0 VTE Toolkit Time VTE

  6. Anticoagulation If the VTE was unprovoked, associated with cancer or some thrombophilias, the risks of recurrent VTE after a period of anticoagulation is higher. Treatment of VTE Recurrent VTE 0 VTE Toolkit Time VTE

  7. D-Dimer to Predict VTE Recurrence Patients with abnormal D-Dimer one month after discontinuation of anticoagulation have a significantly greater incidence of recurrent VTE than patients with a normal D-dimer. Palareti - D-Dimer testing to determine the duration of anticoagulation therapy. N Engl J Med 2006;355:1780 VTE Toolkit

  8. Ongoing risk factors – cancer, immobility, high risk thrombophilia (APLA, AT deficiency) • Unprovoked initial VTE • Older age • Male gender • Obesity • Residual DVT • Elevated D-dimer 1 month after stopping anticoagulants Predictors of Recurrent VTE VTE Toolkit

  9. 1st Episode: • Transient, reversed risk 3 - 6 mos. • Unprovoked12 mos indefinite* • Ongoing risk (unresolved • cancer, AT deficiency, APLA) indefinite* • Recurrent Episodes: indefinite* Duration of Treatment for VTE • * Periodic reassessment to discuss: • Patient risk factors for bleeding and thrombosis • New knowledge about risk of recurrence • Patient preference VTE Toolkit

  10. Venous Disease Coalition www.vasculardisease.org/venousdiseasecoalition/ VTE Toolkit

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