Extended Anticoagulation in VTE Geoffrey Barnes, MD Cardiovascular and Vascular Medicine University...
-
Upload
samuel-burke -
Category
Documents
-
view
221 -
download
2
Transcript of Extended Anticoagulation in VTE Geoffrey Barnes, MD Cardiovascular and Vascular Medicine University...
Extended Anticoagulation in VTE
Geoffrey Barnes, MDCardiovascular and Vascular Medicine
University of Michigan, USA
1st Qatar Conference on Safe Anticoagulation Management
February 27, 2015
Outline
• VTE Recurrence Risk• Patient Selection for Extended Therapy• Medication Selection for Extended Therapy• My Approach
Definitions
• Venous Thromboembolism (VTE)– Deep Venous Thrombosis (DVT)– Pulmonary Embolism (PE)
• Treatment Phases– Acute/Initial – first few days– Intermediate/Long-term – up to 3-6 months– Chronic/Extended – beyond first 3-6 months
• Provoked– Transient surgical procedure– Immobilization– Pregnancy or Hormone-related (e.g estrogen
contraceptives)
Lancet. 2012; 379: 1835-1846
Clinical Case
• 65 year old man with CAD and a first unprovoked femoral-popliteal DVT
• Completed 3 months of warfarin therapy
• What is his recurrence risk?• Does he need further therapy?• If so, what is the best medication to use?
Outline
• VTE Recurrence Risk• Patient Selection for Extended Therapy• Medication Selection for Extended Therapy• My Approach
Provoked vs Unprovoked
Surgically Provoked
Non-surgically Provoked
Unprovoked Cancer-related0
5
10
15
20
25
0.7
4.2
7.4
20.7
Recu
rren
ce R
isk (%
)
Arch Int Med 2010;170:1710-1716Blood 2002; 100:3484-8
D-Dimer
Blood 2010; 115: 481–488CMAJ 2008; 179: 417–426
On Anticoagulation
Negative D-Dimer
Positive D-Dimer
28%
4 weeks without Anticoagulation
Hypercoagulable States
• Factor V Leiden• Protein C/S Deficiency• Antithrombin Deficiency• Elevated Homocysteine• Dysfibrinogenemia• Antiphospholipid Antibodies
Hypercoagulable States
• Considerations– How significant is the increased VTE recurrence
risk?– How frequently is the hypercoagulable state
found?– Can testing be done on anticoagulation?– Are there treatment implications?
Blood 2013;122:817-824Circulation 2014;130:283-287
Hypercoagulable States
• Factor V Leiden• Protein C/S Deficiency• Antithrombin Deficiency• Elevated Homocysteine• Dysfibrinogenemia• Antiphospholipid Antibodies– VTE Recurrence Risk (RR ~2)– Favor use of Warfarin over DOACs currently
Blood 2013;122:817-824Circulation 2014;130:283-287
Outline
• VTE Recurrence Risk• Patient Selection for Extended Therapy• Medication Selection for Extended Therapy• My Approach
VTE Recurrence Predictors
• Provoked vs Unprovoked• PE and Proximal DVT vs Distal DVT• Age• Obesity• Gender• D-dimer• Hypercoagulable States
Risk Prediction Models
CMAJ 2008;179:417-426Circulation 2010; 121:1630-1636J Thromb Haemost 2012; 10: 1019–1025
Men and HERDOO
Vienna Risk Model
DASH
Gender X X XD-Dimer X X X
Signs of Post-Thrombotic Syndrome
X
Obesity XAge X
Location of DVT/PE XProvoked? X
Men and HERDOO-2
High Risk:• All Men• Women with 2+ of• Post-thrombotic
Syndrome• Elevated D-dimer• Obesity
75% of patients are High Risk
Freedom from Recurrent VTE
CMAJ 2008;179:417-426
Outline
• VTE Recurrence Risk• Patient Selection for Extended Therapy• Medication Selection for Extended Therapy• My Approach
VTE Recurrence Risk
NEJM 2003;348:1425-1434. NEJM 2003;349:631-639. NEJM 2013;368:709-718. NEJM 2010;363:2499-2510 NEJM 2012;368:699-708. NEJM 2012;368:699-708. Circulation 2014;130:1062-1071
Outline
• VTE Recurrence Risk• Markers of Recurrence Risk• Patient Selection for Extended Therapy• Medication Selection for Extended Therapy• My Approach
My Approach
Barnes GD Vascular Medicine 2015 (in press)
Predictive Factors:• Provoked• D-Dimer• Gender
My Approach
• Drug Selection– Another indication?• Example: Aspirin for CAD
– Prefer to continue current medication?– Balance efficacy and risk• Usually use apixaban or rivaroxaban
Clinical Case
• 65 year old man with CAD and a first unprovoked femoral-popliteal DVT
• Completed 3 months of warfarin therapy
• What is his recurrence risk?– High: >7-10% per year
• Does he need further therapy?– Yes
• If so, what is the best medication to use?– Apixaban or Rivaroxaban if CAD stable– Aspirin if recent PCI or MI requiring clopidogrel