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Venous thromboembolism — ABIM Board MCQ

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ModerateHematology/OncologyVenous thromboembolismABIM Board

A 47-year-old man completes 3 months of apixaban for a first unprovoked proximal deep venous thrombosis. He has had no bleeding, has a low estimated future bleeding risk, and has no active cancer or contraindication to anticoagulation. Which of the following is the most appropriate management?

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Correct answer: E — Continue anticoagulation as extended therapy, with periodic reassessment

The correct answer is E. A first unprovoked proximal DVT carries a substantial long-term recurrence risk, particularly in a man. In a patient with low bleeding risk, anticoagulation should therefore be continued as extended therapy without a prespecified stop date, incorporating patient preferences and periodic reassessment of bleeding risk and treatment burden. “Indefinite” therapy does not mean that treatment can never be stopped. Stopping routinely after 3 months or after another fixed 3-month course does not provide lasting protection once anticoagulation is withdrawn. Aspirin modestly reduces recurrence but is not equivalent to anticoagulation. An inferior vena cava filter is not indicated when anticoagulation is feasible and does not replace anticoagulant therapy.

Reference: American College of Cardiology. 2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy, VTE duration-of-therapy recommendations. Published 2021. https://cvquality.acc.org/docs/default-source/initiatives/reduce-the-risk-pci-bleed/2020-acc-expert-consensus-decision-pathway-for-anticoagulant-and-antiplatelet-therapy-in-patients-with-atrial-fibrillation-or-venous-thromboembolism-undergoin.pdf?sfvrsn=49b87bf_0