Duration of Oral Anticoagulant Treatment in Patients with Venous Thromboembolism and a Deficiency of Antithrombin, Protein C or Protein S - A Decision Analysis

Angelique G. M. van den Belt; Barbara A. Hutten; Martin H. Prins; Patrick M. M. Bossuyt

doi:10.1055/s-0037-1614111

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2000; 84(05): 758-763
DOI: 10.1055/s-0037-1614111

Review Article

Schattauer GmbH

Duration of Oral Anticoagulant Treatment in Patients with Venous Thromboembolism and a Deficiency of Antithrombin, Protein C or Protein S - A Decision Analysis

Authors

Angelique G. M. van den Belt

¹From the Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Barbara A. Hutten

¹From the Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Martin H. Prins

¹From the Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Patrick M. M. Bossuyt

¹From the Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

Abstract

Summary

Patients with a first venous thromboembolic event and a deficiency of the coagulation inhibitors antithrombin, protein C or protein S have an increased risk of recurrent venous thromboembolism compared to patients without such a deficiency. A decision analysis was performed to assess the effect of continuing treatment with vitamin K antagonists on mortality by a reduction in fatal recurrent pulmonary embolism and an induction of fatal haemorrhages associated with their use. The treatment decision involves continuation or discontinuation of vitamin K antagonists in patients with a first spontaneous or secondary venous thromboembolism and an antithrombin, protein C or S deficiency. Although the efficiency of oral anticoagulation is high in all age groups early after the first thromboembolic event, it decreases over time. Our analysis indicates that the optimal treatment duration will vary, depending on the type of the initial event (spontaneous or secondary; deep venous thrombosis or pulmonary embolism), age, and time passed since the initial thromboembolic episode. Moreover, life-long duration of the prophylaxis seems not warranted in all patients.

Key words

Secondary prevention - duration of treatment - vitamin K antagonists - thrombophilia

Full Text

References

References
1 Becker RC, Ansell J. Antithrombotic Therapy. An abbreviated reference for clinicians. Arch Intern Med 1995; 155: 149-61 2.
2 Van den Belt AGM, Sanson B-J, Simioni P, Prandoni P, Büller HR, Girolami A, Prins MH. Recurrence of venous thromboembolism in patients with familial thrombophilia. Arch Intern Med 1997; 157: 2227-32.
3 Prandoni P, Lensing AWA, Cogo A, Cuppini S, Villalta S, Carta M, Cattelan AM, Polistena P, Bernardi E, Prins MH. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 1996; 125: 1-7.
4 Schulman S, Rhedin A-S, Lindmarker P, Carlsson A, Larfars G, Nicol P, Loogna E, Svensson E, Ljungberg B, Walter H. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. N Engl J Med 1995; 332: 1661-5.
5 Kearon C, Gent M, Hirsh J, Weitz J, Kovacs MJ, Anderson DR, Turpie AG, Green D, Ginsberg JS, Wells P, MacKinnon B, Julian JA. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. N Engl J Med 1999; 340: 901-7.
6 Van der Meer FJM, Rosendaal FR, Vandenbroucke JP, Briët E. Bleeding complications in oral anticoagulant therapy. An analysis of risk factors. Arch Intern Med 1993; 153: 1557-62.
7 Van der Meer FJM, Rosendaal FR, Vandenbroucke JP, Briët E. Assessment of a bleeding risk index in two cohorts of patients treated with oral anticoagulants. Thromb Haemost 1996; 76: 12-6.
8 McAlistar FA, Straus SE, Guyatt GH, Haynes RB. Users’ guides to the medical literature - XX. Integrating research evidence with the care of the individual patient. JAMA 2000; 283: 2829-2836.
9 Levine M, Gent M, Hirsh J, Leclerc J, Anderson D, Weitz J, Ginsberg J, Turpie AG, Demers C, Kovacs M. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med 1996; 334: 677-681.
10 The Columbus Investigators. Low-molecular-weight heparin in the treatment of patients with venous thromboembolism. N Engl J Med 1997; 337: 657-62.
11 Koopman MMW, Prandoni P, Piovella F, Ockelford PA, Brandjes DP, van der Meer J, Gallus AS, Simmonneau G, Chesterman CH, Prins MH, Bossuyt PMM, De Haes H, Van den Belt A, Sagnard L, D’Azemar P, Büller HR. for the Tasman Study Group. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. N Engl J Med 1996; 334: 682-7.
12 Research Committee of the British Thoracic Society. Optimum duration of anticoagulation for deep-vein thrombosis and pulmonary embolism. Lancet 1992; 340: 873-6.
13 Douketis JD, Kearon C, Bates S, Duku EK, Ginsberg JS. Risk of fatal pulmonary embolism in patients with treated venous thromboembolism. JAMA 1998; 279 (06) 458-62.
14 Prins MH, Hutten BA, Koopman MMW, Büller HR. Long-term treatment of venous thromboembolic disease. Thromb Haemost 1999; 82 (02) 892-8.
15 Palareti G, Leali N, Coccheri S, Poggi M, Manotti C, D’Angelo A, Pengo V, Erba N, Moia M, Ciavarella N, Devoto G, Berrettini M, Musolesi S. Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT). Lancet 1996; 348: 423-8.
16 Landefeld CS, Goldman L. Major bleeding in outpatients treated with warfarin: incidence and prediction by factors known at the start of outpatient therapy. Am J Med 1989; 87: 144-52.
17 Schulman S, Granqvist S, Holmström M, Carlsson A, Lindmarker P, Nicol P, Eklund S-G, Nordlander S, Lärfars G, Leijd B, Linder O, Loogna E. and the Duration of Anticoagulation Trial Study Group. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. N Engl J Med 1997; 336: 393-8.
18 Nordström M, Lindblad B, Bergqvist D, Kjellström T. A prospective study of the incidence of deep-vein thrombosis within a defined urban population. J Intern Med 1992; 232: 155-60.
19 Lindmarker P, Schulman S, Sten-Linder M, Wiman B, Egberg N, Johnsson H. The risk of recurrent venous thromboembolism in carriers and noncarriers of the G1691A allele in the coagulation factor V gene and the G20210A allele in the prothrombin gene. Thromb Haemost 1999; 81: 684-9.
20 Ridker PM. Long-term, low-dose warfarin among venous thrombosis patients with and without factor V Leiden mutation: rationale and design for the Prevention of Recurrent Venous Thromboembolism (PREVENT) trial. Vascular Medicine 1998; 03 (01) 67-73.