Weekly Journal Scan: Balancing reduced thromboembolic recurrence with enhanced bleeding liability associated with extended low-dose anticoagulation

This comment refers to ‘Apixaban for extended treatment of provoked venous thromboembolism’ presented at the European Society of Cardiology Congress 2025 and simultaneously published in The New England Journal of Medicine, https://doi.org/10.1056/NEJMoa2509426. Venous thromboembolism, including DVT and PE, is a common condition, affecting 900 000 patients in the USA and leading to 100 000 deaths annually.2 The incidence of the disease increases with age and is associated with a high rate of recurrence, considerable burden on the health care system, and high mortality.3 Despite available treatments and knowledge of VTE recurrence risk factors, up to 10% of patients experience recurrence within the first 6 months and as many as 30% within the first year.4 Management of VTE has long relied on the provoked/unprovoked dichotomy to determine anticoagulation duration. Contemporary guidelines recommend or suggest extended anticoagulation for patients with active cancer and those with ongoing inflammatory disease or unprovoked PE (although with varying strengths of recommendation). Patients with provoked VTE—after surgery, trauma, or immobility—are typically treated for only 3 months, assuming low residual risk. This paradigm ignores patients with persisting prothrombotic substrates (e.g. obesity, chronic inflammatory or autoimmune disease, chronic obstructive pulmonary disease, and ASCVD), who do not biologically revert to low risk once the transient trigger resolves.4