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    Oral Communication

    Venous Thromboembolism

    Management of Venous Thromboembolism II

    OC 40.5 - Risk of All-Cause Mortality following Anticoagulant Cessation for Unprovoked Venous Thromboembolism: A Systematic Review and Meta-Analysis

    Monday, June 26, 2023
    15:45 – 16:00 ET
    Room: 517
    Session Available As: Live-Stream and On-Demand
    Background: While guidelines recommend long-term anticoagulation after the first diagnosis of unprovoked venous thromboembolism (VTE), benefits and harms associated with this approach remain unclear among older adults at risk of non VTE-related mortality. While death is a competing event to recurrent VTE, the long-term risk of all-cause mortality following anticoagulant discontinuation has not been systematically quantified.

    Aims: 1) To examine risks of all-cause mortality following anticoagulant cessation among patients with first episode of unprovoked VTE, with stratification by age at treatment discontinuation and sex.

    2) To determine the contribution of fatal pulmonary embolism (PE) on mortality in this population.

    Methods: We performed a systematic review using MEDLINE, EMBASE, and CENTRAL to include randomized trials and prospective cohorts reporting recurrent VTE and all-cause mortality following anticoagulant discontinuation among patients with a first unprovoked VTE. Participants must had completed ≥3 months of initial treatment before anticoagulant discontinuation. Primary endpoint was incidence of all-cause mortality across age categories ( < 50 years, 50–64 years, 65–75 years, >75 years) at 1-, 2-, 5- and 10-years following anticoagulant discontinuation. We also determined the proportion of deaths attributable to fatal PE.

    Results: We identified nine studies with 13,906 person-years of follow-up. Cumulative incidence of all-cause mortality was 1.9% (95% CI 1.0-3.1), 4.3% (95% CI 2.1-7.3), 8.6% (95% CI 4.4–14.0) and 14.0% (95% CI 6.8–23.1) at 1, 2, 5 and 10 years following anticoagulant discontinuation, respectively. All-cause mortality risks increased with age (Figure), with the highest risk observed among men >75 years at time of anticoagulant discontinuation (Table). Fatal PE comprised 16.5% (95% CI 9.5–25.0) of mortality events.

    Conclusion(s): Patients with unprovoked VTE experience substantial risks of mortality following anticoagulant discontinuation; however, less than 20% of such events were related to fatal PE. All-cause mortality needs to be considered in shared decision-making about duration of anticoagulant treatment, especially among patients >75 years.

    Learning Objectives:

    • Describe all-cause mortality rates associated with patients who suffer an unprovoked venous thromboembolism who completed at least 3 months of anticoagulation.
    • Understand the contribution of fatal pulmonary embolism to the risk of all-cause mortality among patients who stopped anticoagulation for an unprovoked venous thromboembolism
    • To appreciate that analyses accounting for the competing risk of death is a crucial component to ensuring accurate estimation of venous thromboembolism recurrence risk