LIFEBLOOD THE Thrombosis CHARITY Venous thromboembolism – Treatment and secondary prevention Ulcus cruris Chronic PE PE DVT Post-thrombotic syndrome Death Deep vein insufficiency Pulmonary hypertension

LIFEBLOOD THE Thrombosis CHARITY Deep vein thrombosis Common femoral vein Thrombus Knee Proximal Distal

LIFEBLOOD THE Thrombosis CHARITY VTE event AcuteContinue Treatment and secondary prevention of VTE Heparin or LMWH together with a VKA (e.g. warfarin) until an INR of is achieved VKA (e.g. warfarin) INR

LIFEBLOOD THE Thrombosis CHARITY VTE - treatment options Acute Long-term  Anticoagulation - UFH/LMWH  Thrombolysis  Thrombectomy  Inferior vena cava filters (IVCF)  Anticoagulation - VKAs (e.g. warfarin) - LMWH  Stockings

LIFEBLOOD THE Thrombosis CHARITY 7 th ACCP recommendations - Initial treatment for acute DVT or PE  Confirmed DVT or non-massive PE – Initial treatment with sc LMWH or iv UFH (or sc if DVT) [Grade 1A] for at least 5 days [Grade 1C] – Start VKA with LMWH or UFH on day 1 [Grade 1A] – Stop LMWH or UFH when INR stable >2.0 [Grade 1A]  High clinical suspicion of VTE – Anticoagulation until outcome of diagnostic tests [Grade 1C+] Büller H et al. Chest 2004;126:401S–428S

LIFEBLOOD THE Thrombosis CHARITY VTE event AcuteContinue Heparin or LMWH together with a VKA (e.g. warfarin) untill an INR of is achieved VKA (e.g. warfarin) INR months or lifelong Decision point Risk of VTE (5-7%/year) vs. Risk of bleeding (3-4%/year) How long? Treatment and secondary prevention of VTE

LIFEBLOOD THE Thrombosis CHARITY First episode with a transient risk factor –3 months after distal or proximal DVT [Grade 1A] –At least 3 months after PE [Grade 1A] First episode of idiopathic DVT/PE –VKA for at least 6–12 months [Grade 1A] but consider indefinite duration [Grade 2A] Two or more episodes of DVT/PE –Suggest indefinite treatment [Grade 2A] Target INR 2.5 (range 2.0–3.0) [Grade 1A] Büller H et al. Chest 2004;126:401S–428S 7 th ACCP recommendations - Long-term treatment for DVT or PE

LIFEBLOOD THE Thrombosis CHARITY Long-term treatment of DVT Recurrence rate of VTE in patients with DVT dependent on – Underlying risk factors for DVT – Duration of treatment Decision regarding duration of treatment dependent on – Underlying risk factors for DVT – Risk of haemorrhage from oral anticoagulation – Patient preference Numerous regimens studied to improve benefit of long-term treatment while reducing the dose

LIFEBLOOD THE Thrombosis CHARITY Recurrence of VTE after stopping oral anticoagulation Event rate (%) Months 3 months treatment

LIFEBLOOD THE Thrombosis CHARITY Event rate (%) 3 months treatment Months 6 months treatment Recurrence of VTE after stopping oral anticoagulation

LIFEBLOOD THE Thrombosis CHARITY Event rate (%) Months 3 months treatment 6 months treatment 1 year treatment Recurrence of VTE after stopping oral anticoagulation

LIFEBLOOD THE Thrombosis CHARITY Optimal duration of anticoagulation after VTE DURAC I %18.1%1.1%0.2% LAFIT %27.4%3.8%0.0% WODIT-DVT %8.3%3.0%0.8% WODIT-PE %9.1%1.8%0.0% DOTAVK %8.1%2.6%1.9% DURAC II227Indefinite6432.6%20.7%8.6%2.7% months Long OAC OAC, oral anticoagulation Short OAC Long OAC Short OAC Reference No. of patients Long OAC Short OAC Follow up Recurrent VTE Major bleeding

LIFEBLOOD THE Thrombosis CHARITY Intensity of anticoagulant therapy Recurrent VTE Cumulative event rate (%) Years of follow-up Low INR – PREVENT Conventional INR - ELATE Placebo - PREVENT Low INR – ELATE Ridker PM et al. N Engl J Med 2003; 348: Kearon C et al. N Engl J Med 2003;349:631-9