For and Against
Anticoagulant therapy duration. In favor of short-term courses
Duración del tratamiento anticoagulante. A favor de plazos cortos
J.A. Nieto Rodríguez
, J.C. Ramírez Luna
Corresponding author
Servicio de Medicina Interna, Hospital Virgen de la Luz, Cuenca, Spain
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A favor de plazos cortos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "365" "paginaFinal" => "369" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Anticoagulant therapy duration. In favour of short-term courses" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1837 "Ancho" => 2344 "Tamanyo" => 125585 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Acontecimientos adversos durante el seguimiento en pacientes con enfermedad tromoboembólica venosa, tratados. Incidencia de fallecimientos por embolia pulmonar (líneas negras) y hemorragia (líneas claras) en 53.222 pacientes diagnosticados de embolia pulmonar y trombosis venosa profunda, a partir del tercer mes después del diagnóstico.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Las muertes por hemorragia en todo momento superan a las de embolia pulmonar. Para una comparación más ajustada, al número de fallecimientos por hemorragia hay que restar 0,14% (0,06-0,26%) de fallecimientos anuales que ocurrirían si estos pacientes no estuvieran anticoagulados.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">EP: embolia pulmonar; TVP: trombosis venosa profunda.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Fuente: registro RIETE (datos no publicados) y Castellucci et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.A. Nieto Rodríguez, J.C. Ramírez Luna" "autores" => array:2 [ 0 => array:2 [ "nombre" => "J.A." "apellidos" => "Nieto Rodríguez" ] 1 => array:2 [ "nombre" => "J.C." "apellidos" => "Ramírez Luna" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2254887417300401" "doi" => "10.1016/j.rceng.2017.04.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887417300401?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256517300759?idApp=WRCEE" "url" => "/00142565/0000021700000006/v1_201707280054/S0014256517300759/v1_201707280054/es/main.assets" ] ] "itemAnterior" => array:19 [ "pii" => "S225488741730053X" "issn" => "22548874" "doi" => "10.1016/j.rceng.2017.04.003" "estado" => "S300" "fechaPublicacion" => "2017-08-01" "aid" => "1386" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2017;217:359-64" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2 "PDF" => 2 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">For and against</span>" "titulo" => "Extended anticoagulation in venous thromboembolism disease. In favor" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "359" "paginaFinal" => "364" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anticoagulación extendida en la enfermedad tromboembólica venosa. A favor" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.C. Fernández" "autores" => array:1 [ 0 => array:2 [ "nombre" => "M.C." "apellidos" => "Fernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256517300978" "doi" => "10.1016/j.rce.2017.02.017" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256517300978?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S225488741730053X?idApp=WRCEE" "url" => "/22548874/0000021700000006/v1_201707280038/S225488741730053X/v1_201707280038/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">For and Against</span>" "titulo" => "Anticoagulant therapy duration. In favor of short-term courses" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "365" "paginaFinal" => "369" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.A. Nieto Rodríguez, J.C. Ramírez Luna" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J.A." "apellidos" => "Nieto Rodríguez" "email" => array:1 [ 0 => "joseanietor@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.C." "apellidos" => "Ramírez Luna" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital Virgen de la Luz, Cuenca, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Duración del tratamiento anticoagulante. A favor de plazos cortos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1837 "Ancho" => 2344 "Tamanyo" => 125486 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Adverse events during the follow-up and patients with treated venous thromboembolism. Incidence rate of death by pulmonary embolism (black lines) and hemorrhage (red lines) in 53,222 patients diagnosed with pulmonary embolism and deep vein thrombosis, after the third month following the diagnosis. The deaths by hemorrhage always exceeded those due to pulmonary embolism. For a more adjusted comparison, we must subtract 0.14% (0.06–0.26%) of annual deaths that occur if these patients were not anticoagulated from the number of deaths by hemorrhage. <span class="elsevierStyleItalic">Abbreviations</span>: PE: pulmonary embolism; DVT: deep vein thrombosis. <span class="elsevierStyleItalic">Source</span>: RIETE registry (unpublished data) and Castellucci et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a></p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years, we have observed a tendency to extend oral anticoagulation (OAC), both for patients with “provoked” venous thromboembolism (VTE) and those with “unprovoked” VTE. In the EINSTEIN study, only 12% of patients with deep vein thrombosis (DVT) and 5% with pulmonary embolism (PE) underwent treatment for 3 months.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1,2</span></a> In the Computerized Registry of Thromboembolic Disease (<span class="elsevierStyleItalic">Registro Informatizado de Enfermedad Trombo-Embólica</span>, RIETE), which collects information from our clinical practice, more than 50% of patients with provoked VTE had treatment extended beyond 3 months (data not published). One of the reasons is that when discontinuing the anticoagulation, 22.6% of patients will have a new episode in 5 years.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> Additionally, the involvement of permanent risk factors, such as family history, obesity, neurological deficits, thrombophilia and post-thrombotic syndrome, raise doubts about the prognosis. This situation makes many clinicians feel more comfortable extending the anticoagulation, even in provoked VTE.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Balance of recurrence and hemorrhage</span><p id="par0010" class="elsevierStylePara elsevierViewall">VTE is a chronic recurring disease,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> and prolonged anticoagulation is an effective measure to prevent it.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">5,6</span></a> The objective of anticoagulant therapy is to reduce the incidence of recurrence to a minimum but maintaining the therapy as short as possible to prevent the hemorrhagic risk. It seems clear that OAC for only 4–6 weeks is associated with a high risk of recurrence after discontinuing the therapy.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">7</span></a> With somewhat longer periods of OAC, the risk of recurrence is reduced, and the number of treatment-related bleedings remains small compared with the number of new episodes of thromboembolism that are prevented.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> An analysis of 7 clinical trials with different anticoagulation times<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a> showed that 3 months is the time limit for OAC. Below this time, recurrences increase (HR, 1.52; 1.14–2.02). With durations between 3 and 6 months, there are no differences (HR, 1.19; 0.86–1.65). After the minimum duration, OAC only protects while the patient is anticoagulated,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> and prolonging the treatment does not confer extra protection when it is discontinued.</p><p id="par0015" class="elsevierStylePara elsevierViewall">When discontinuing OAC, the risk of recurrence for patients who continue anticoagulated is 2.23 (95% confidence interval [95% CI] 1.71–2.91) for the first 2 months and 1.49 (95% CI 1.08–2.05) between the second and fourth month,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a> which confirms that recurrences are concentrated in the first months.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a> The reduction in risk with the passage of time is probably due to the fact that exposure to temporary risk factors is also reduced over time. Rebound hypercoagulability when discontinuing the anticoagulants<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a> or the presence of asymptomatic prethrombotic lesions that would become clinically obvious when discontinuing the OAC could also explain part of the phenomenon.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Deaths by hemorrhage and pulmonary embolism</span><p id="par0020" class="elsevierStylePara elsevierViewall">In general, there is a benefit to OAC when recurrent VTE is reduced by a greater measure than that by which severe hemorrhages are increased; in particular, when the deaths by PE prevented by OAC exceed those caused by hemorrhage. We know that, after the first 10 days of anticoagulant therapy, deaths by hemorrhage exceed those of fatal PE,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a> especially in patients diagnosed with DVT. After the first 90 days of therapy, the difference is even more apparent in any of the presentations of VTE (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Although VTE-related mortality is small and decreases with time, the mortality due to hemorrhage remains constant. Therefore, the net benefit is progressively smaller.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Patients with unprovoked PE (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) who discontinue OAC have an approximate incidence rate of recurrent VTE of 7–15%<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">11–13</span></a> in the first year (7.5% in the form of symptomatic PE).<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a> The mortality of these episodes is 9–18%,<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">10–14</span></a> with an annual death rate of 0.7–1.3%. In the analysis of pooled data from clinical trials,<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">15,16</span></a> both the incidence of fatal PE and the mortality of the episodes are strikingly lower, approximately 0.13–0.3% and 3.6% (1.9–5.7%), respectively, probably due to the selection of the included patients. In contrast, the incidence rate of severe hemorrhage in anticoagulated patients is 1.35–3.4%<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">17</span></a> at 1 year, and the mortality rate for hemorrhage is 0.2–0.5%<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">18</span></a> (clinical trials and real life). It seems clear that anticoagulation is beneficial in these patients with unprovoked PE.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In the case of provoked PE, the figures are somewhat lower: 3–6%<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">11,12</span></a> of overall recurrence, 2–4% of recurrence as PE and 0.3–0.5% of mortality by PE. The last of these figures is similar to that of hemorrhage. If DVT is involved, the excess mortality by hemorrhage is more apparent (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Hemorrhage during therapy</span><p id="par0035" class="elsevierStylePara elsevierViewall">OAC increases the risk of severe hemorrhage 5-fold,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">17</span></a> especially during the first month of therapy. Intracranial hemorrhage has the highest mortality of all locations. Gastrointestinal bleeding is more common, but its mortality is much lower. In the RIETE patients,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">19</span></a> the incidence rate of severe and fatal hemorrhage during the first 3 months was 2.2% and 0.56%, respectively.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The new direct oral anticoagulants<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> reduce the incidence rate of severe hemorrhage by 40% and both intracranial hemorrhage and deaths by hemorrhage by 65%. Therefore, the assessment of the treatment time should be made specifically for the type of anticoagulant employed. It would not be surprising if future recommendations were less restrictive when more experience with these drugs becomes available.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Current recommendations</span><p id="par0045" class="elsevierStylePara elsevierViewall">The 2016 guidelines of the American College of Chest Physicians<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> (ACCP) recommended 3 months of OAC in general for all patients. Once this period has been completed, the guidelines recommend an individual assessment of the risk of recurrence and bleeding. This period has been established by considering the balance between the consequences of anticoagulant therapy and the natural evolution of the disease, which can change with time and should be reassessed periodically.</p><p id="par0050" class="elsevierStylePara elsevierViewall">For the categories of greater risk of VTE and low risk of bleeding, indefinite OAC is suggested.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> It is worth noting that the guidelines do not establish differences between DVT and PE, when the recurrence as PE (and the subsequent mortality) are more than 3-fold greater if the initial presentation was a PE.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">3,10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">For provoked VTE, 3 months of therapy can be sufficient if there are no additional factors to consider.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> The more apparent the trigger, the more likely it is that the risk of recurrence will decrease when the trigger's effect disappears. For example, in postsurgical VTE (a situation that increases the risk of VTE 22-fold), the recurrence rate in the 2 years following the discontinuation of OAC is only 0.7%.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a> In these cases, extending the anticoagulation exposes patients to a disproportionate risk of severe hemorrhage (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0060" class="elsevierStylePara elsevierViewall">In unprovoked DVT, the 3-month treatments are especially indicated if the thrombotic burden is low (e.g., distal DVT, which has a recurrence rate of 51% less than proximal DVT<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a>), the cardiopulmonary reserve is good and the risk of bleeding is high. However, in other cases, the decision is more complex. To clarify what to do in this scenario, 749 patients with VTE but with no associated risk factors were randomized to 2 arms and underwent OAC for 3 or 6 months.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a> The study showed that there were no differences between the 2 groups in terms of the number of deaths (2 and 3, respectively) or recurrences during the first year (totaling the time with or without OAC, deaths or recurrences were 8% in both groups), but there were more severe hemorrhages in the 6-month anticoagulated group (0% vs. 2.1%). The conclusion was that there were differences favoring short treatment. It would therefore be justified to limit the therapy to 3 months for many of the patients.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Measuring <span class="elsevierStyleSmallCaps">d</span>-dimer levels after discontinuing the therapy can help in the decision-making process. This datum, along with other risk considerations, can guide the decision to restart OAC (or prescribe low doses of new anticoagulants) or keep a patient off of OAC therapy. In any case, it is important to conduct checks during the period of greatest risk (the first year) and always take prevention measures for new episodes (e.g., immobility, surgery and travel).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres875325" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec863520" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres875324" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec863519" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Balance of recurrence and hemorrhage" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Deaths by hemorrhage and pulmonary embolism" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Hemorrhage during therapy" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Current recommendations" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-29" "fechaAceptado" => "2017-02-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec863520" "palabras" => array:5 [ 0 => "Venous thromboembolism" 1 => "Treatment duration" 2 => "Anticoagulation" 3 => "Relapses" 4 => "Hemorrhages" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec863519" "palabras" => array:5 [ 0 => "Tromboembolia venosa" 1 => "Duración del tratamiento" 2 => "Anticoagulación" 3 => "Recurrencias" 4 => "Hemorragias" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In recent years, we have observed a tendency to extend anticoagulant therapy for patients with venous thromboembolism disease (VTE). This practice exposes patients to a greater risk of severe and fatal hemorrhage, which, in certain conditions, outweighs the benefits related to the reduction in disease recurrence. This review examines the evidence in favor of reducing anticoagulant therapy as much as possible, especially for patients with VTE “caused” by temporary risk factors, with isolated deep vein thrombosis and with unprovoked VTE and a high risk of hemorrhage.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Durante los últimos años se ha observado una tendencia a prolongar la duración del tratamiento anticoagulante en los pacientes con enfermedad tromboembólica venosa (ETEV). Esto expone a los pacientes a un mayor riesgo de hemorragias graves y mortales que, en determinadas situaciones, superan los beneficios relacionados con la reducción de recurrencias de la enfermedad. En esta revisión se repasan las evidencias a favor de reducir al mínimo el tratamiento anticoagulante, especialmente en los pacientes con ETEV «provocada» por factores de riesgo transitorios, con trombosis venosa profunda aislada, y con ETEV «no provocada» y riesgo alto de hemorragia.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Rodríguez JN, Luna JR. Duración del tratamiento anticoagulante. A favor de plazos cortos. Rev Clin Esp. 2017;217:365–369.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1837 "Ancho" => 2344 "Tamanyo" => 125486 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Adverse events during the follow-up and patients with treated venous thromboembolism. Incidence rate of death by pulmonary embolism (black lines) and hemorrhage (red lines) in 53,222 patients diagnosed with pulmonary embolism and deep vein thrombosis, after the third month following the diagnosis. The deaths by hemorrhage always exceeded those due to pulmonary embolism. For a more adjusted comparison, we must subtract 0.14% (0.06–0.26%) of annual deaths that occur if these patients were not anticoagulated from the number of deaths by hemorrhage. <span class="elsevierStyleItalic">Abbreviations</span>: PE: pulmonary embolism; DVT: deep vein thrombosis. <span class="elsevierStyleItalic">Source</span>: RIETE registry (unpublished data) and Castellucci et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a></p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: DVT: deep vein thrombosis; PE: pulmonary embolism; VTE: venous thromboembolism.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">A. Incidence without anticoagulant treatment</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">B. Incidence with anticoagulant treatment</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recurrent VTE<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recurrent symptomatic PE \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fatal PE \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Severe hemorrhage<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fatal hemorrhage<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Idiopathic</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.74% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1–0.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7–15% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7–1.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8–3.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3–0.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DVT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7–15% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1–0.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4–2.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3–0.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Provoked</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3–6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3–0.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8–3.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3–0.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DVT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3–6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15–0.23% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4–2.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3–0.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Postsurgical PE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.05–0.09% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8–3.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3–0.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1477445.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Incidence (without counting sudden deaths) during the first year after discontinuing oral anticoagulation; in the subsequent years, the incidence rate reduces by approximately half.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Approximate values, if the patients maintained anticoagulation with antivitamin K drugs. 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