Wie hoch muss das jährliche VTE-Rezidivrisiko sein, damit eine Langzeitantikoagulation

sinnvoll ist?

Sabine Eichinger

Univ. Klinik für Innere Medizin IMedizinische Universität Wien

Inzidenz (%), n= 28 781

<180 Tage 5.6

181 - 365 Tage 4.1

1 - <2 Jahre 4.6

2 - <3 Jahre 3.2

3 - <4 Jahre 2.9

4 - <5 Jahre 2.6

5 - <6 Jahre 2.1

6 - <7 Jahre 2.2

7 - <8 Jahre 2.4

8 - <9 Jahre 1.6

9 - <10 Jahre 1.4

Jährliches Risiko

Martinez, Thromb Haemost 2014

Rezidivrisiko nach venöser Thromboembolie

Duration of anticoagulation

Boutitie, BMJ 2011

Recurrence risk after VTE

6 12 18 months

Iorio, Arch Int Med 2010

Transient risk factor

Recurrence risk after VTE

3.3%/year

ISTH/SSC Recommendation

Kearon, J Thromb Haemost 2010

• In patients with VTE provoked by a transient provoking factor, the recurrence risk of 5% at 1 year and 15% at 5 years is acceptable by most physicians.

ISTH/SSC Recommendation

Kearon, J Thromb Haemost 2010

• In patients with VTE provoked by a transient provoking factor, the recurrence risk of 5% at 1 year and 15% at 5 years is acceptable for most physicians.

STOP after 3 months

Spontane venöse Thromboembolie

Kyrle & Eichinger, Lancet 2010

Rezidivrisiko nach VTE

ISTH/SSC Recommendation

Kearon, J Thromb Haemost 2010

• In patients with unprovoked VTE a recurrence risk of 10% at 1 year and 30% at 5 years is unacceptably high for many physicians.

GO, GO, GO

Prandoni, Blood 2002

Cancer patients

Recurrence during VKA

Anticoagulation after VTE

Major bleeding during VKA

Anticoagulation after venous thrombosis

• We suggest that a risk of recurrence appreciably higher than 5% at 1 year and 15% at 5 years would not be acceptable to many physicians and patients, and would usually discourage stopping anticoagulant therapy.

Kearon, J Thromb Haemost 2010

Anticoagulation after venous thrombosis

3 months long term

distal DVT provoked* VTE

unprovoked VTE

* Surgery, trauma, immobilisation, pregnancy/puerperium, female hormone intake, long haul travel

AWMF online, 6/20109th ACCP Consensus Conference on Antithrombotic Therapy; Kearon, Chest 2012

Linkins, Ann Intern Med 2003

Time period of AC

Major bleeding (%, 95% CI)

Intracranial bleeding(%, 95% CI)

Initial 3 months 2.06 (2.04-2.08) 1.48 (1.40–1.56)

> 3 months 2.74 (2.71-2.77)/yr 0.65 (0.63–0.68)/yr

Bleeding during anticoagulation for VTE

Case fatality rate after 3 mo 9.1% (95% CI 2.5–21.7%)

Any Bleeding

REMEDY – dabigatran vs warfarin for long term prophylaxis after VTE

Schulman, N Engl J Med 2013

Case fatality of recurrent VTE

Schulman; EINSTEIN Investigators; Agnelli; all N Engl J Med 2013, 2010, 2013

StudyRecurrences,

nFatal, n (%)

Case fatality (%)

RESONATE(Dabigatran)

37 2 (0.3) 0.54

EINSTEIN ext.(Rivaroxaban)

56 1 (0.2) 0.17

AMPLIFY ext.(Apixaban)

73 7 (0.8) 0.96

Rezidivrisiko

Mortalität

H. Nitsch, 1992

Blutungsrisiko

Mortalität

Risk factors for bleeding in VTE patients

Kearon, Chest 2012

Kein validiertes Model zur Abschätzung des Blutungsrisikos

Validierung: VALID-Studie

Ende der Antikoagulation beiPatienten mit < 180 Punkten

Vienna Prediction Model

Eichinger, Circulation 2010

VALID - Studie

Einschlusskriterien

Erste spontane tiefe Beinvenenthrombose oder Pulmonalembolie Laufende orale Antikoagulation von weniger als 7 Monaten

Kontakt: Dr. Eischer 40400-4496 oder 4522; Email: lisbeth.eischer@meduniwien.ac.at

Prof. Eichinger 40400-4410Prof. Kyrle 40400-4951