Long term use of anticoagulant therapy for patients with pulmonary embolism

INTRODUCTION: Anticoagulant treatment reduces recurrent venous thromboembolism (VTE) by about 90% after index pulmonary embolism. Whether anticoagulant treatment also reduces mortality in these patients remains to be defined. The main counterbalance for life long anticoagulation is the risk for anticoagulants-associated bleeding. AREAS COVERED: Literature search was performed in PubMed and Embase. We aimed to review the risk for recurrent VTE over time after discontinuation of anticoagulants and the risks for bleeding and for fatal bleeding over time during anticoagulant treatment. The efficacy and safety of different anticoagulant agents and regimes were reviewed. EXPERT OPINION: An increase in the proportion of candidates to extended anticoagulation has been claimed in the era of direct oral anticoagulants based on the safety profile and the practicality of these agents. The risk for non-major clinically relevant bleeding with direct oral anticoagulants is not negligible and is probably higher than the risk for recurrence over time in several patient categories. While awaiting further evidence on the clinical benefit of extended use of direct oral anticoagulants beyond the initial 12 months, the choice of this approach should be carefully based on the balance between the estimated risk of recurrent VTE and that of bleeding.