Recurrent Venous Thromboembolism

 

Venous thromboembolism (VTE) recurrence rates are three times higher in patients with chronic or no risk factors compared with those who have transient risk factors after stopping anticoagulation therapy. In patients with unprovoked VTE, age-appropriate screening is sufficient evaluation for occult malignancy. Thrombophilia evaluation should be considered only in selected patients because routine evaluation has not been shown to improve outcomes. Patients with VTE should receive three months of anticoagulation therapy. The context of the initial VTE, risk of bleeding and recurrence, and patient preference should be considered when determining whether to continue treatment beyond the initial three months. There is growing evidence regarding the use of risk assessment models to determine risk of recurrence, but this has not been incorporated into guidelines. All pregnant patients with a prior VTE should receive postpartum prophylaxis for six weeks. Antepartum prophylaxis should be used in pregnant people with a history of unprovoked or hormonally induced VTE. High-risk patients undergoing surgery may require extended VTE prophylaxis postoperatively.

Venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep venous thrombosis (DVT), occurs in 300,000 to 600,000 people (1 to 2 per 1,000) and accounts for up to 100,000 deaths annually in the United States.1 Literature has traditionally categorized VTE as provoked (i.e., at least one identifiable risk factor) or unprovoked (i.e., no identifiable risk factors), but newer literature distinguishes patients with VTE as having transient (i.e., reversible) or chronic risk factors.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Perform only age-appropriate cancer screening to detect occult malignancy in patients with VTE.10,22,23

A

NICE guidelines, one randomized controlled trial, one meta-analysis

Do not routinely test for thrombophilia in patients with provoked VTE. Routine testing in patients with unprovoked VTE is discouraged.10,26,27

A

NICE guidelines, one randomized controlled trial, one meta-analysis

Patients with VTE due to a transient risk factor (provoked) can stop anticoagulation after three months of treatment.30

C

CHEST guidelines

Patients with VTE due to chronic risk factors or with no identifiable risk factors (unprovoked) should continue anticoagulation indefinitely unless they are at high risk of bleeding.10,30

C

NICE and CHEST guidelines


CHEST = American College of Chest Physicians; NICE = National Institute for Health and Care Excellence; VTE = venous thromboembolism.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Perform only age-appropriate cancer screening to detect occult malignancy in patients with VTE.10,22,23

A

NICE guidelines, one randomized controlled trial, one meta-analysis

Do not routinely test for thrombophilia in patients with provoked VTE. Routine testing in patients with unprovoked VTE is discouraged.10,26,27

A

NICE guidelines, one randomized controlled trial, one meta-analysis

Patients with VTE due to a transient risk factor (provoked) can stop anticoagulation after three months of treatment.30

C

CHEST guidelines

Patients with VTE due to chronic risk factors or with no identifiable risk factors (unprovoked) should continue anticoagulation indefinitely unless they are at high risk of bleeding.10,30

C

NICE and CHEST guidelines


CHEST = American College of Chest Physicians; NICE = National Institute for Health and Care Excellence; VTE = venous thromboembolism.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST PRACTICES IN HEMATOLOGY

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not test for protein C, protein S, or antithrombin III levels during an active clotting event to diagnose a hereditary deficiency. These tests are not analytically accurate during an active clotting event.

American Society for Clinical Pathology

Do not do workup for clotting disorder (order hypercoagulable testing) for patients who develop a first episode of deep venous thrombosis from a known cause.

Society for Vascular Medicine

Do not test for thrombophilia in adult patients with venous thromboembolism caused by major

The Authors

show all author info

HILLARY R. MOUNT, MD, is division chief of family medicine, inpatient director of family medicine hospitalists, and an associate professor in the Department of Family and Community Medicine at the University of Cincinnati (Ohio) College of Medicine....

MEGAN RICH, MD, MEd, is director of the Family Medicine Residency Program and an associate professor in the Department of Family and Community Medicine at the University of Cincinnati College of Medicine.

MICHAEL S. PUTNAM, MD, is an assistant professor in the Department of Family and Community Medicine at the University of Cincinnati College of Medicine.

Address correspondence to Hillary R. Mount, MD, University of Cincinnati College of Medicine, 2123 Auburn Ave., Ste. 340, Cincinnati, OH 45219 (email: mounthr@uc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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