Journal Article Walking the tightrope: a balanced discussion of the benefits and harms of extended duration anticoagulation for venous thrombo-embolism Get access Gregory Piazza Gregory Piazza Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA Corresponding author. Tel: +1 617 732 6984, Fax: +1 617 738 7652, Email: gpiazza@bwh.harvard.edu https://orcid.org/0000-0003-1407-5276 Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal, Volume 44, Issue 14, 7 April 2023, Pages 1245–1247, https://doi.org/10.1093/eurheartj/ehac731 Published: 19 January 2023 

Walking the tightrope: a balanced discussion of the benefits and harms of extended duration anticoagulation for venous thrombo-embolism.

A decision to stop or continue anticoagulation after 3 months of anticoagulation for venous thromboembolism (VTE) should be made by weighing individual risks of recurrence and bleeding.To determine the optimal ratio of recurrence risk reduction to increase the risk of bleeding in terms of maximizing quality-adjusted life years (QALYs) gained.Using a microsimulation model, outcomes within 5 years were simulated after assigning extended treatment if absolute recurrence risk reduction outweighed absolute increase in clinically relevant bleeding risk (International Society on Thrombosis and Haemostasis definition), weighted by a certain ratio. Data were simulated based on the Bleeding Risk Study, a prospective cohort including patients after ≥3 months of anticoagulation for unprovoked VTE or provoked VTE with history of VTE. The VTE-PREDICT risk score was used to estimate 5-year risks of recurrent VTE and clinically relevant bleeding.Among 10,000 individuals (mean age, 60.2 years, 36% female), the ratio of 0.90 (95% CI, 0.51-3.40; ie, bleeding is considered 0.90 the severity of recurrent VTE), with 99% of patients assigned extended anticoagulation, was considered optimal and resulted in 93 (95% CI, -23 to 203) additional QALYs compared with the least favorable ratio (5.10, 0% extended anticoagulation). At the optimal ratio, treatment based on VTE-PREDICT yielded 44 (95% CI, -69 to 157) additional QALYs versus standard of care.With the current evidence, the optimal ratio between relevant bleeding risk and absolute recurrence risk reduction remains uncertain. Our results confirm that clinical equipoise exists regarding the decision to stop or continue anticoagulation after initial VTE treatment, emphasizing the importance of shared decision-making. 

Balancing risks of recurrent venous thromboembolism and bleeding with extended anticoagulation: a decision analysis

Residual thrombosis: still relevant in the DOAC era?

Anticoagulation is the cornerstone of treatment for venous thromboembolism (VTE; deep vein thrombosis and pulmonary embolism). After an initial treatment of at least 3 months, a decision must be made to stop treatment or to continue indefinitely to prevent VTE recurrence. Although highly effective, anticoagulation carries a risk of major ... read more bleeding. Therefore, guidelines recommend basing the decision on a careful weighing of risks of recurrent VTE and bleeding, taking into account patient’s preference. However, deciding on treatment for individual patients is challenging as risks of recurrence and bleeding are heterogeneous. The first part of this thesis focuses on risk prediction. Previously published risk scores for recurrent VTE and bleeding were found not to be suitable for clinical practice because of methodological shortcomings, lack of independent external validation and insufficient predictive performance. Hence, new models for the prediction of recurrent VTE and clinically relevant bleeding within 5 years after the initial treatment for VTE were developed. These models will be made available as online calculator, which can also be used to estimate the effect of extended treatment with different anticoagulants for individual patients. Furthermore, different methods of estimating risk of bleeding in patients with cancer-associated thrombosis were compared. The second part of this thesis describes different perspectives on the decision to stop or continue anticoagulation using the results of a survey of physicians and interviews with patients. Furthermore, a randomized trial was conducted to study the effect of an educational app on VTE and anticoagulation on patient satisfaction. show less 

https://dspace.library.uu.nl/bitstream/handle/1874/416880/mariadewinterthesis%20-%2062791a7e700af.pdf?sequence=1&isAllowed=y

Individualizing treatment decisions for patients with venous thromboembolism

Objective: Recently, some pregnant women in Türkiye are hesitant to undergo gestational diabetes mellitus (GDM) screening tests and this trend is more common. The objective of the study is to assess the pregnant women's knowledges, decisions, reasons for hesitations about having the GDM screening tests and test rejection rates. Material and Methods: This cross-sectional study included 647 pregnant women who applied for an antenatal outpatient clinic and who had not yet been diagnosed with GDM and a survey was conducted using questionnaire designed by the authors. Results: At the beginning, 287 (44.4%) of the participants declared that they would have glucose challenge test, 169 (26.1%) would not and 191 (29.5%) were undecided. The rejection rate was lower in those who had knowledge about the screening tests. After a short information about the content of tests, 30% of the women who decided not to have the test and 78.3% of those who were undecided at the beginning, decided to have the test (p=0.001). Conclusion: The knowledge level of pregnant women about diabetes screening and diagnosis influences their decision-making. Organizing well-planned trainings for patients and healthcare professionals using public institutions and media may be effective in reducing the burden of diabetes on social health and the economic indicators. 

Gestational Diabetes Screening Refusal in Pregnant Women: A Cross-Sectional Survey Study

BACKGROUND  After 3 months of anticoagulation for unprovoked venous thromboembolism (VTE), a decision must be made to stop or continue indefinitely by weighing risks of recurrence and bleeding through shared decision-making (SDM). Despite the importance of patient involvement, patients' perspectives on treatment duration are understudied. AIM  To describe the knowledge of VTE and anticoagulation, need for education, perception of risks and benefits of extended treatment, and factors influencing patient's preference to stop or continue treatment after unprovoked VTE. METHODS  Semistructured interviews were conducted between May 2019 and August 2020 with adults with unprovoked VTE in one university hospital and one general hospital. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using conventional content analysis. RESULTS  Eighteen patients were interviewed (median age 64, range: 32-83 years). Three major themes were identified: diagnosis and initial treatment, SDM, and perception of treatment. Education, knowledge, coping, and attitude toward health care suffused major themes. The impact of VTE on daily life varied between individuals, as did the preferred extent of SDM. Overall, patients who felt involved and informed were more satisfied with received care, more aware of risks and benefits of treatment, and more likely to be treatment adherent. Generally, patients were more concerned with risk of recurrent VTE than with risk of bleeding during anticoagulation. We identified a multitude of aspects important to patients when deciding to stop or continue anticoagulation. CONCLUSION  Sufficient information and an individualized extent of SDM are of crucial importance for patients when deciding on treatment duration after unprovoked VTE.

Deciding on treatment duration for unprovoked venous thromboembolism: what is important to patients?

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Deciding on treatment duration for unprovoked venous thromboembolism: what is important to patients?