Abstract and Introduction
Immediate intense anticoagulation with parenteral anticoagulants (heparin or fondaparinux) followed by vitamin K antagonists is the current standard therapy for deep vein thrombosis (DVT) or nonmassive pulmonary embolism. In the future, new oral anticoagulants may replace not only vitamin K antagonists but also initial parenteral anticoagulation. Duration of anticoagulation should be at least 3 months because shorter courses double the recurrence rates. More prolonged anticoagulation therapy may be warranted in the presence of specific clinical risk factors. Global markers of coagulation, particularly D-dimer, may discriminate low- and high-risk patients. Models that combine clinical characteristics and laboratory markers further improve prediction of the recurrence risk in individual patients, but these models await validation before they can be applied in routine care.
The main goals in the treatment of VTE, which comprises DVT and PE, are to restore perfusion of the occluded vessel, to inhibit progression and embolization of the thrombus, and to prevent recurrence. Immediate perfusion can be achieved only by interventional methods, including (catheter-guided) thrombolysis, vena cava filters, or thrombosuction, all of which are beyond the scope of this article and are covered elsewhere. DVT and PE are regarded as two entities of the same syndrome, namely VTE; thus medical treatment follows the same principles for both diseases.
To prevent progression, embolization, and early recurrence, immediate intense anticoagulation is required, which can be achieved only by parenteral administration of heparin or fondaparinux. In the future, oral anticoagulants may be available for the initial treatment of VTE. The risk of recurrence is particularly high during the first weeks after the acute event, but it remains increased for years thereafter. Thus prolonged anticoagulation is required in patients with an acute VTE. Vitamin K antagonists are the drugs of choice for prolonged anticoagulation; they are orally administered and evidence for their efficacy and safety is abundant. Novel oral anticoagulants may also be available for long-term anticoagulation in the future.