Inconsistencies in the planning of the duration of anticoagulation among outpatients with acute deep-vein thrombosis

David Spirk; Marc Husmann; Torsten Willenberg; Martin Banyai; Ulrich Frank; Thomas Baldi; Beatrice Amann-Vesti; Iris Baumgartner; Nils Kucher

doi:10.1160/TH10-08-0506

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2011; 105(02): 239-244
DOI: 10.1160/TH10-08-0506

Blood Coagulation, Fibrinolysis and Cellular Haemostasis

Schattauer GmbH

Inconsistencies in the planning of the duration of anticoagulation among outpatients with acute deep-vein thrombosis

Results from the OTIS-DVT Registry

David Spirk^*

¹Medical Department, sanofi-aventis (suisse) sa, Meyrin, Switzerland

,

Marc Husmann^*

²Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland

,

Torsten Willenberg

³Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland

,

Martin Banyai

⁴Department of Internal Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland

,

Ulrich Frank

⁵Department of Internal Medicine, Cantonal Hospital Chur, Chur, Switzerland

,

Thomas Baldi

⁶Department of Internal Medicine, University Hospital Basel, Basel, Switzerland

,

Beatrice Amann-Vesti

²Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland

,

Iris Baumgartner

³Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland

,

Nils Kucher

³Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland

› Author Affiliations

Abstract

Summary

Three-month anticoagulation is recommended to treat provoked or first distal deep-vein thrombosis (DVT), and indefinite-duration anticoagulation should be considered for patients with unprovoked proximal, un-provoked recurrent, or cancer-associated DVT. In the prospective Out-patient Treatment of Deep Vein Thrombosis in Switzerland (OTIS-DVT) Registry of 502 patients with acute objectively confirmed lower extremity DVT (59% provoked or first distal DVT; 41% unprovoked proximal, unprovoked recurrent, or cancer-associated DVT) from 53 private practices and 11 hospitals, we investigated the planned duration of anticoagulation at the time of treatment initiation. The decision to administer limited-duration anticoagulation therapy was made in 343 (68%) patients with a median duration of 107 (interquartile range 91–182) days for provoked or first distal DVT, and 182 (interquartile range 111–184) days for unprovoked proximal, unprovoked recurrent, or cancer-associated DVT. Among patients with provoked or first distal DVT, anticoagulation was recommended for <3 months in 11%, ≥3 months in 63%, and for an indefinite period in 26%. Among patients with unprovoked proximal, unprovoked recurrent, or cancer-associated DVT, anticoagulation was recommended for <6 months in 22%, 6–12 months in 38%, and for an indefinite period in 40%. Overall, there was more frequent planning of indefinite-duration therapy from hospital physicians as compared with private practice physicians (39% vs. 28%; p=0.019). Considerable inconsistency in planning the duration of anticoagulation therapy mandates an improvement in risk stratification of outpatients with acute DVT.

Keywords

Deep-vein thrombosis - anticoagulants - outpatient treatment

Full Text

References

References
1 Beckman MG, Hooper WC, Critchley SE. et al. Venous Thromboembolism: A Public Health Concern. Am J Prev Med 2010; 38: S495-S501.
2 White RH. The epidemiology of venous thromboembolism. Circulation 2003; 107: I4-I8.
3 Cohen AT, Agnelli G, Anderson FA. et al. Venous Thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007; 98: 756-774.
4 Oger E. Incidence of venous thromboembolism: a community-based study in Western France. EPIGETBO Study Group. Groupe d’Etude de la Thrombose de Bretagne Occidentale. Thromb Haemost 2000; 83: 657-660.
5 Kearon C, Ginsberg JS, Anderson DR. et al. Comparison of 1 month with 3 months of anticoagulation for a first episode of venous thromboembolism associated with a transient risk factor. J Thromb Haemost 2004; 2: 743-749.
6 White RH, Murin S, Wun T. et al. Recurrent venous thromboembolism after surgery-provoked versus unprovoked thromboembolism. J Thromb Haemost 2010; 8: 987-997.
7 Prandoni P, Lensing AW, Cogo A. et al. The Long-Term Clinical Course of Acute Deep Venous Thrombosis. Ann Intern Med 1996; 125: 1-7.
8 Pini M, Aiello S, Manotti C. et al. Low molecular weight heparin versus warfarin the prevention of recurrence after deep vein thrombosis. Thromb Haemost 1994; 72: 191-197.
9 Levine MN, Hirsh J, Gent M. et al. Optimal duration of oral anticoagulant therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis. Thromb Haemost 1995; 74: 606-611.
10 Schulman S, Rhedin AS, Lindmarker P. et al. 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: 1661-1665.
11 Pinede L, Ninet J, Duhaut P. et al. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation 2001; 103: 2453-2460.
12 Ridker PM, Goldhaber SZ, Danielson E. et al. Long-term, low-intensity warfarin therapy for prevention of recurrent venous thromboembolism. N Engl J Med 2003; 348: 1425-1434.
13 Murin S, Romano PS, White RH. Comparison of outcomes after hospitalization for deep vein thrombosis or pulmonary embolism. Thromb Haemost 2002; 88: 407-414.
14 Kearon C, Gent M, Hirsh J. et al. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. N Engl J Med 1999; 340: 901-907.
15 Kearon C, Kahn SR, Agnelli G. et al. Antithrombotic Therapy for Venous Thromboembolic Disease. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8^thEdition). CHEST 2008; 133: 454S-545S.
16 Ost D, Tepper J, Mihara H. et al. Duration of anticoagulation following venous thromboembolism: a meta-analysis. J Am Med Assoc 2005; 294: 706-715.
17 Korte W, Mazzolai L, Bounameaux H. 8. ACCP Guidelines on Antithrombotic Therapy Neuigkeiten, kommentiert von Schweizer Experten. Schweiz Med Forum 2009; 9: 454-455.
18 Galanaud JP, Sevestre-Pietri MA, Bosson JL. et al. Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: Results from the OPTIMEV study. Thromb Haemost 2009; 102: 493-500.
19 Kucher N, Spirk D, Kalka C. et al. Clinical predictors of prophylaxis use prior to the onset of acute venous thromboembolism in hospitalized patients. SWIss Venous ThromboEmbolism Registry (SWIVTER). J Thromb Haemost 2008; 6: 2082-2087.
20 Galanaud JP, Quenet S, Rivron-Guillot K. et al. Comparison of the clinical history of symptomatic isolated distal deep-vein thrombosis vs. proximal deep vein thrombosis in 11 086 patients. J Thromb Haemost 2009; 7: 2028-2034.
21 Prandoni P, Noventa F, Ghirarduzzi A. et al. The risk of recurrent venous thromboembolism after discontinuing anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism. A prospective cohort study in 1,626 patients. Haematologica 2007; 92: 199-205.