D-Dimer Testing to Select Patients With a First Unprovoked Venous Thromboembolism Who Can Stop Anticoagulant Therapy: A Cohort Study | Journal Scan

Study Questions:

Can a negative D-dimer identify patients with a low risk of recurrence after a first unprovoked venous thromboembolism (VTE)?

Methods:

In a prospective management study with blinding of clinical outcomes assessment, 410 adults aged ≤75 years with a first unprovoked VTE underwent D-dimer testing after completing an initial 3-7 months of anticoagulation. Anticoagulation was stopped if D-dimer testing was negative. Anticoagulation was restarted if repeat D-dimer testing was positive 1 month later. The primary outcome was recurrent VTE during an average follow-up of 2.2 years.

Results:

Of the 410 adults who underwent the protocol, 319 (78%) had two negative D-dimer tests and were not restarted on anticoagulation therapy. Recurrent VTE occurred in 6.7% (95% confidence interval [CI], 4.8-9.0%) per patient-year. Recurrent rates were higher in men (9.7%; 95% CI, 6.7-13.7%) as compared to women who’s first VTE was not associated with estrogen (5.4%; 95% CI, 2.5-10.2%). Women with an estrogen-associated first VTE even had no recurrent events when two D-dimer tests were negative (0 of 58).

Conclusions:

The authors concluded that the risk for recurrence in patients with a first unprovoked VTE is sufficiently low in women who have two negative D-dimer tests to not restart anticoagulation therapy. However, the authors concluded that men have a sufficiently high VTE recurrence rate, despite negative D-dimer testing, that continued anticoagulation should be strongly considered.

Perspective:

This is a pragmatic management study for patients with provoked VTE. These findings support those of many prior studies including two key findings: 1) negative D-dimer testing identifies women who are at very low risk of VTE recurrence, and 2) men have a high rate of VTE recurrence, even when D-dimer testing is negative. This study provides helpful information for practitioners and patients to discuss regarding the benefits of extended anticoagulation after a first unprovoked VTE. Of note, the initial D-dimer test in this protocol was performed with patients still on anticoagulation, allowing for uninterrupted therapy if the test was positive.

Clinical Topics: Anticoagulation Management, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism

Keywords: Venous Thromboembolism, Anticoagulants, Risk, Recurrence, Estrogens, Fibrin Fibrinogen Degradation Products, Prospective Studies, Outcome Assessment (Health Care)


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