Extended Anticoagulation for Unprovoked PE — EECC MCQ

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ModeratePulmonary Vascular DiseaseExtended Anticoagulation for Unprovoked PEEECC

A 50-year-old man with PE is anticoagulated with apixaban. After 6 months, the decision about ongoing anticoagulation is discussed. His PE was unprovoked (no identifiable risk factor). What is the recommendation?

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Correct answer: B — Continue extended anticoagulation

Duration of anticoagulation after PE depends on whether the event was provoked or unprovoked: (1) Provoked by major transient risk factor (surgery, trauma, immobilisation): 3 months then stop; (2) Provoked by minor transient risk factor (OCP, travel): 3-6 months, consider stopping; (3) Unprovoked (no identifiable risk factor) or persistent risk factor (cancer, thrombophilia): extended anticoagulation recommended (Class I for unprovoked PE in ESC 2019 PE Guidelines). After the initial 6-month treatment period, reduced-dose regimens are available: apixaban 2.5 mg bd (AMPLIFY-EXT) or rivaroxaban 10 mg daily (EINSTEIN-CHOICE) — both significantly reduce VTE recurrence with a bleeding rate similar to placebo.

Reference: ESC (2019): PE Guidelines; AMPLIFY-EXT/EINSTEIN-CHOICE Trials: https://bnf.nice.org.uk/drugs/warfarin-sodium/