Long term use of anticoagulant therapy for patients with pulmonary embolism

ABSTRACT

Introduction

Anticoagulant treatment reduces recurrent venous thromboembolism (VTE) by about 90% after index pulmonary embolism. Whether anticoagulant treatment also reduces mortality in these patients remains to be defined. The main counterbalance for life long anticoagulation is the risk for anticoagulants-associated bleeding.

Areas covered

Literature search was performed in PubMed and Embase. We aimed to review the risk for recurrent VTE over time after discontinuation of anticoagulants and the risks for bleeding and for fatal bleeding over time during anticoagulant treatment. The efficacy and safety of different anticoagulant agents and regimes were reviewed.

Expert opinion

An increase in the proportion of candidates to extended anticoagulation has been claimed in the era of direct oral anticoagulants based on the safety profile and the practicality of these agents. The risk for non-major clinically relevant bleeding with direct oral anticoagulants is not negligible and is probably higher than the risk for recurrence over time in several patient categories. While awaiting further evidence on the clinical benefit of extended use of direct oral anticoagulants beyond the initial 12 months, the choice of this approach should be carefully based on the balance between the estimated risk of recurrent VTE and that of bleeding.

KEYWORDS:

• Anticoagulant
• recurrence
• long term
• venous thromboembolism
• pulmonary embolism

Article highlights box

• The need for anticoagulant therapy after initial 3 months of treatment for acute pulmonary embolism is debated.

• Risk stratification for recurrent venous thromboembolism is essential to guide patient management in terms of secondary prevention.

• The risk of fatal bleeding in patients continuing oral anticoagulants beyond 2 or 3 years is estimated to overcome the risk of fatal VTE recurrence over time in patients who discontinue treatment.

• The best strategy to prevent recurrent venous thromboembolism with an acceptable risk of bleeding among therapeutic or reduced dose of vitamin K antagonists or direct oral anticoagulants, and non-anticoagulant agents depends on patient features.

• Consistent and promising benefit to risk profile have been obtained with reduced doses of the direct oral anticoagulants apixaban and rivaroxaban mainly after venous thromboembolism not associated with identifiable risk factors.

Declaration of interest

C Becattini has presented invited lectures and has consultancies for BMS, Bayer healthcare, Daiichi Sankyo. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.