{"id":1283,"date":"2017-04-24T13:15:45","date_gmt":"2017-04-24T13:15:45","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1283"},"modified":"2017-08-21T10:16:53","modified_gmt":"2017-08-21T10:16:53","slug":"primary-care-corner-with-geoffrey-modest-md-dvt-recurrence-in-unprovoked-dvts-herdoo2-tool","status":"publish","type":"post","link":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2017\/04\/24\/primary-care-corner-with-geoffrey-modest-md-dvt-recurrence-in-unprovoked-dvts-herdoo2-tool\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Dvt recurrence in unprovoked dvts — HERDOO2 tool"},"content":{"rendered":"

\u200bby Dr Geoffrey Modest<\/strong><\/p>\n

One perplexing issue in primary care is the appropriate\u00a0duration of anticoagulation for people with unprovoked venous thromboses. A recent international study found that a specific clinical decision rule was effective in predicting recurrent DVT in women and could permit individualizing\u00a0different therapies\u00a0(see\u00a0<\/strong>doi.org\/10.1136\/bmj.j1065\u200b).<\/p>\n

Details:<\/p>\n

— 2747 participants with a 1st<\/sup> unprovoked venous thromboembolism, VTE (either DVT with a noncompressible segment in the popliteal vein or more proximal leg veins and\/or documented pulmonary embolism) who had completed 5 to 12 months of short-term anticoagulant treatment were followed prospectively from 44 healthcare centers in 7 countries (from North America, Europe, India, Australia), from 2008 to 2015.<\/p>\n

— Mean age 54, 84% white, 75% on vitamin K antagonists for anticoagulation, VTE\u00a0event\u00a0was\u00a0isolated DVT 41%\/isolated PE 40%\/DVT and PE 21%<\/p>\n

— They used the HERDOO2 clinical decision rule: Hyperpigmentation, Edema, or Redness in either leg; D-dimer level \u2265 250\u00a0\u00b5g\/L; Obesity with BMI \u2265 30; or Older age\u00a0\u2265 65. D-dimer levels were drawn during anticoagulant treatment.<\/p>\n

—\u00a0Of these components: 24% had hyperpigmentation, edema or redness of leg\/50% D-dimer \u2265250 \u00b5g\/\u00a032% >65 yo\/\u00a043% BMI \u226530.<\/p>\n

— Low risk patients (women with HERDOO2 score \u22641) were to discontinue anticoagulants (and almost all did);\u00a0for high risk women and men it was left to the discretion of the clinicians and patients<\/p>\n

— primary outcome was an adjudicated symptomatic major VTE<\/p>\n

Results:<\/p>\n

— of 1213 women, 631 (51.3%) were classified as low risk<\/p>\n

— 17 who discontinued anticoagulants developed a recurrent VTE during 564 patient years of follow-up (3.0% per patient year)<\/p>\n

— of\u00a0323 high risk women and men who\u00a0discontinued anticoagulants, 25 had VTE during 309 patient years of follow-up (8.1% per patient year).<\/p>\n

–7.4% in high risk women and 8.4% in high-risk men.<\/p>\n

— of 1802 high risk women and men who continued anticoagulants, 28 had recurrent VTE during 1758 patient years of follow-up (1.6% for patient year)<\/p>\n

— secondary outcomes:<\/p>\n

–1 recurrent PE death\u00a0(in a high-risk person who continued anticoagulation); risk of major bleeds was nonsignificant in any who stopped anticoagulation, and\u00a0was 1.2% per patient year in men and high risk women who continued oral anticoagulants. 2 major bleeds were fatal.<\/p>\n

–subgroup analyses: in women <50 yo\u00a0(n=429) rate of recurrent VTE was 2.0% (not related to estrogen use) vs 5.7% in those >50\u00a0yo. No difference by country, type of index VTE, or type of anticoagulation<\/p>\n

Commentary:<\/p>\n

— patients with provoked VTE, such as after surgical procedure, have a 1% chance of VTE recurrence, whereas those with unprovoked VTE have a 10% chance in the 1st<\/sup> year after stopping short-term anticoagulants, 5% in the subsequent year, and 30% at 8 years. 3.6% of\u00a0recurrent VTEs are fatal. Oral anticoagulation reduces the risk of recurrent VTE by 80-90%.<\/p>\n

— The International Society on Thrombosis and Hemostasis suggest that it is safe to discontinue anticoagulants if\u00a0the risk of recurrent VTE is <5% at one year after discontinuing treatment (with an upper bound of the 95% confidence interval being <8%).<\/p>\n

— The HERDOO2 clinical decision rule has been found to be clinically\u00a0effective in discriminating low risk versus high risk women, though not for men. This study was a large randomized trial in patients with unprovoked VTE.<\/p>\n

—\u00a0of note,\u00a0over \u00bd of the women with unprovoked VTE in their study were low risk and could stop their anticoagulants (ie, less than the 5% cutpoint that they noted above)\u200b. So, the potential effect of this decision rule is quite high for women.<\/p>\n

— so, where does this HERDOO2 rule come from??\u00a0A study done in 2008 (see\u00a0doi:10.1503\/ cmaj.080493\u200b ) prospectively looked at 600 people with first unprovoked VTE and followed 18 months, finding\u00a0an overall\u00a0annual recurrent DVT rate of 9.3%. They\u00a0focused on the\u00a091 patients with\u00a0confirmed recurrent DVTs to assess potential risk factors, and developed the HERDOO2 clinical rule, finding annual recurrent VTEs in\u00a01.6% with scores\u00a0\u22641 and 14.1% in those with higher scores.<\/p>\n

—\u00a0issues about generalizability:<\/p>\n

–this study had only an 11.6 month followup (and the original study was only a bit\u00a0longer), and, as per the above statisitics, lots of recurrent VTE events happen after the 1-year mark<\/p>\n

–they excluded the few people with known high-risk thrombophilia (this is not routinely assess after a first event, so not sure why those patients had the test done and if this exclusion could affect the results)<\/p>\n

–there were few non-white patients,\u00a0and the\u00a0risk of thrombophilia may vary by groups, though\u00a0there are large deficits in our knowledge here, but\u00a0there are some data suggesting that factor V Leiden and the prothrombin G20210A mutation are less common in African-Americans, though Black Africans in another study of\u00a0patients who had strokes tended to have lower levels of protein S, protein C, and antithrombin III levels.<\/p>\n

–subgroup analysis in the above study\u00a0of women >50 yo\u00a0had a higher VTE recurrence\u00a0rate of 5.8% and would be good to see if this were a better cutpoint than the\u00a0\u2265 65\u200b in\u00a0the HERDOO2 algorithm<\/p>\n

–continuing anticoagulants in the high risk groups was left to the discretion of the clinicians\/patients, so unclear who the group was who continued or\u00a0discontinued the meds and how that might skew those results.<\/p>\n

—\u00a0Overall, would be great to have another study of longer duration and including a more mixed group of patients, to assess generalizability of the results<\/p>\n

so, bottom line: this study may well have far-reaching implications, given that a large number of women (not men) might be able to stop long-term (perhaps life-long)\u00a0anticoagulation for unprovoked first VTE (including PEs, where the risk of a recurrent PE is higher). And, I would add the results of this study\u00a0to my general gestalt in discussing the pros and cons of stopping anticoagulation.\u00a0But, to me, this is still such a difficult clinical decision, with potentially life-threatening implications either way, that there should be another confirmatory study in a more mixed population of patients.<\/p>\n

See here\u00a0<\/a>for a slew of articles on VTE, with my concerns about the novel anticoagulants (NOACs)<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

Dvt recurrence in unprovoked dvts — HERDOO2 tool […]<\/p>\n

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