Management of Anticoagulation for Venous Thromboembolism

A 74-year-old man presents to the emergency department with progressive shortness of breath for the previous two days. His past medical history is notable for hypertension and coronary artery disease status post remote bare metal left anterior descending (LAD) artery stent placement. Outpatient medications include low-dose aspirin, atenolol, and lisinopril. Initial physical examination reveals normal vital signs and is otherwise unremarkable. Labs are notable for normal renal function, N-terminal pro b-type natriuretic peptide (NT-proBNP) of 2378, and troponin-T of 0.08. Chest radiograph is without any abnormalities; electrocardiogram shows normal sinus rhythm with new T-wave inversions in the early precordial leads as compared to prior. Subsequent CT angiogram demonstrates large bilateral pulmonary emboli. Of note, the patient has no history of trauma, immobilization, recent surgery, hypercoagulable states, malignancy, or hemorrhagic events.

Based on current evidence and guidelines, which of the following anticoagulation strategies would lead to the lowest rate of recurrent venous thromboembolism, without exposing the patient to excessive risk of clinically significant bleeding?

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