Clinical scores to predict recurrence risk of venous thromboembolism

Summary

Venous thromboembolism (VTE) is a common and chronic disease with a considerable risk of recurrence. Patients with unprovoked (in the absence of a transient risk factor) VTE have a recurrence risk as high as 30% within five years after cessation of anticoagulation. Depending on patient selection the case-fatality rate of recurrence ranges between 3.6%-10%. Thus, indefinite anticoagulation treatment should be considered in these patients. However, anticoagulation confers a considerable risk of bleeding (fatal bleedings 0.1%–0.5%/year). It is therefore of utmost clinical importance to identify those patients, who will not benefit from indefinite anticoagulation, i.e. patients, in whom the bleeding risk during anticoagulant treatment is higher than the risk of recurrence. Several attempts to discriminate patients with a high from those with a low risk of recurrence including screening for acquired and inherited thrombotic risk factors or measurement of coagulation activation markers have either failed (thrombophilia screening) or were of moderate success (stratification according to D-dimer only). A novel approach for assessing risk of recurrent VTE consists of linking clinical patient characteristics with laboratory testing. Several such scoring models which can be used to assess the risk of recurrent VTE have been developed and await prospective validation before they can be applied in daily routine care. The aim of this report is to describe currently available scoring systems in more detail.

Keywords

Venous thrombosis - recurrence risk - prediction model

• References

• 1 Naess IA, Christiansen SC, Romundstad P. et al. Incidence and mortality of venous thromboembolism: a population-based study. J Thromb Haemost 2007; 5: 692-699.
• 2 Carrier M, Le Gal G, Wells PS. et al. Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med 2010; 152: 578-589.
• 3 Douketis JD, Gu CS, Schulman S. et al. The risk for fatal pulmonary embolism after discontinuing anticoagulant therapy for venous thromboembolism. Ann Intern Med 2007; 147: 766-774.
• 4 Kyrle PA, Eichinger S. Deep vein thrombosis. Lancet 2005; 365: 1163-1174.
• 5 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.
• 6 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.
• 7 Ageno W, Gallus AS, Wittkowsky A. et al. Oral anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis. American College of Chest Physicians. Chest 2012; 141: e44S-e88S.
• 8 Kearon C, Akl EA, Comerota AJ. et al. American College of Chest Physicians. Antithrombotic therapy for venous thromboembolic disease. Chest 2012; 141: e419S-e494S.
• 9 Beyth RJ, Quinn L, Landefeld CS. A multicomponent intervention to prevent major bleeding complications in older patients receiving warfarin. A randomized, controlled trial. Ann Intern Med 2000; 133: 687-695.
• 10 Kyrle PA, Rosendaal FR, Eichinger S. Predicting the risk of recurrent venous thrombosis. Lancet 2010; 376: 2032-2039.
• 11 Eichinger S, Pabinger I, Stümpflen A. et al. The risk of recurrent venous thromboembolism in patients without and with factor V Leiden. Thromb Haemost 1997; 77: 624-628.
• 12 Eichinger S, Minar E, Hirschl M. et al. The risk of early recurrent venous thromboembolism after oral anticoagulant therapy in patients with the G20210A transition in the prothrombin gene. Thromb Haemost 1999; 81: 14-17.
• 13 Marchiori A, Mosena L, Prins MH. et al. The risk of recurrent venous thromboembolism among heterozygous carriers of factor V Leiden or prothrombin G20210A mutation. A systematic review of prospective studies. Haematologica 2007; 92: 1107-1114.
• 14 Segal JB, Brotman DJ, Necochea AJ. et al. Predictive value of factor V Leiden and prothrombin G20210A in adults with venous thromboembolism and in family members of those with a mutation: a systematic review. J Am Med Assoc 2009; 301: 2472-2485.
• 15 Christiansen SC, Cannegieter SC, Koster T. et al. Thrombophilia, cllinical factors, and recurrent venous thrombotic events. J Am Med Assoc 2005; 293: 2352-2361.
• 16 Baglin T, Luddington R, Brown K. et al. Incidence of recurrent venous thromboembolism in relation to clinical and thrombophilic risk factors: prospective cohort study. Lancet 2003; 362: 523-526.
• 17 Coppens M, Reijnders JH, Middeldorp S, Doggen CJ, Rosendaal FR. Testing for inherited thrombophilia does not reduce the recurrence of venous thrombosis. J Thromb Haemost 2008; 6: 1474-1477.
• 18 Kyrle PA, Weltermann A, Minar E. et al. The risk of recurrent venous thromboembolism in men and women. N Engl J Med 2004; 350: 2558-2563.
• 19 Carrier M, Rodger MA, Wells PS. et al. Residual vein obstruction to predict the risk of recurrent venous thromboembolism in patients with deep vein thrombosis: a systematic review and meta-analysis. J Thromb Haemost 2011; 9: 1119-1125.
• 20 Tan M, Mos IC, Klok FA. et al. Residual venous thrombosis as predictive factor for recurrent venous thromboembolim in patients with proximal deep vein thrombosis: a sytematic review. Br J Haematol 2011; 153: 168-178.
• 21 Palareti G, Legnani C, Cosmi B. et al. Risk of venous thromboembolism recurrence: high negative predictive value of D-dimer performed after oral anticoagulation is stopped. Thromb Haemost 2002; 87: 7-12.
• 22 Palareti G, Cosmi B, Legnani C. et al. PROLONG Investigators. D-dimer testing to determine the duration of anticoagulation therapy. N Engl J Med 2006; 355: 1780-1789.
• 23 Eichinger S, Minar E, Bialonczyk C. et al. D-dimer levels and risk of recurrent venous thromboembolism. J Am Med Assoc 2003; 290: 1071-1074.
• 24 Rodger MA, Kahn SR, Wells PS. et al. Identifying unprovoked thromboembolism patients at low risk for recurrence who can discontinue anticoagulant therapy. CMAJ 2008; 179: 417-426.
• 25 Eichinger S, Heinze G, Jandeck LM. et al. Risk assessment of recurrence in patients with unprovoked deep vein thrombosis or pulmonary embolism: the Vienna prediction model. Circulation 2010; 121: 1630-1636.
• 26 Tosetto A, Iorio A, Marcucci M. et al. Predicting disease recurrence in patients with previous unprovoked venous thromboembolism. A proposed prediction score (DASH). J Thromb Haemost 2012; 10: 1019-1025.