When to Stop Anticoagulation Following a DVT or Pulmonary Embolus?
Major venous thromboembolism (VTE) requires minimum 3 to 6 months of anticoagulation, but when is it time to stop? Uncertainty remains around unprovoked VTE which accounts for approximately 50% of cases. This study by Rodger et al. (BMJ, 2017) sought to validate the use of the HERDOO2 rule which states that women with ≥ 2 HERDOO predictors [ (i) Hyperpigmentation, (ii) Edema, or Redness in either leg; (iii) D-dimer level ≥250 μg/L; (iv) Obesity with body mass index ≥30; or (v) Older age, ≥65 years] can safely discontinue anticoagulants.
Prospective Cohort Management Study
2,785 participants with a first unprovoked VTE (DVT and pulmonary embolus) at 44 centers in seven countries were enrolled. All participants completed 5-12 months of short-term anticoagulant treatment. Of 1213 women in this cohort, 51.3% were defined as low risk (0 or 1 HERDOO2 criteria) and had stopped oral anticoagulant treatment (intervention arm). Men and women at high risk (≥2 HERDOO2 criteria) remained on anticoagulant treatment at the discretion of patients and their clinicians (observation arm). In the intervention (low risk) arm, 17 women developed recurrent VTE during 564 patient years of follow-up (3.0% per patient year, 95% CI 1.8% to 4.8%). When the high risk cohort was analyzed 25 of 323 high risk women and men who stopped anticoagulants had VTE during 309 patient years of follow-up (8.1% per patient year, 95% CI 5.2% to 11.9%) and 28 of 1,802 high risk women and men who continued anticoagulant treatment experienced recurrent VTE during 1,758 patient years of follow-up (1.6% per patient year, 95% CI 1.1% to 2.3%). The ISTH suggests to stop anticoagulants in subgroups when recurrent risk for VTE at one year is < 5% and the upper bound of the 95% confidence interval is less than 8%. The data in this study fall within this guidance and suggest that for women with a first unprovoked VTE and have none or 1 HERDOO2 criteria, anticoagulants can be safetly stopped after short term treatment.
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