Short-term versus extended anticoagulant treatment for unprovoked venous thromboembolism: A survey on guideline adherence and physicians' considerations

BACKGROUND: In patients with unprovoked venous thromboembolism (VTE), anticoagulant treatment duration should be decided by weighing bleeding risk versus risk of recurrent VTE, considering patient's preference. Because both risks differ between individuals, this recommendation presumably leads to wide variation in clinical management. OBJECTIVES: To identify physician's considerations when deciding between short-term and extended anticoagulation and to assess how current guidelines are put to practice. MATERIALS AND METHODS: An online, 33-item survey was developed, containing questions on clinical management, considerations regarding treatment duration, risk scores, information tools and shared decision-making. It was distributed to internists, pulmonologists and residents treating patients with VTE in the Netherlands. RESULTS: 69 internists and 73 pulmonologists including 24 residents participated in the survey. Extended treatment was preferred by 73% (104/142) of participants. Most important reasons for extended treatment were, in descending order: patient's preference, active malignancy, low estimated bleeding risk, history of VTE and hemodynamic instability during previous VTE. Most important reasons for short-term treatment were frequent falls, history of major bleeding, previous bleeding during anticoagulation, patient's preference and thrombocytopenia. Although existing risk scores are infrequently used, physicians express their need for scores combining risks of recurrence and bleeding to aid individualized decision-making. CONCLUSION: Our results confirm a wide variety of considerations regarding treatment duration in patients with unprovoked VTE. Although most participants followed guidelines' recommendations to prescribe indefinite treatment in absence of contraindications, rationale is not always supported by evidence. A clinical decision tool to estimate and weigh risks of recurrence and bleeding is warranted.