Lifelong Anticoagulation for Patients with Two Pulmonary Embolisms

Recommendation Based on Number of VTE Episodes

Patients with a history of two pulmonary embolisms should receive indefinite anticoagulation therapy as long as their bleeding risk is not prohibitively high, according to the American College of Chest Physicians guidelines 1
For patients with a first episode of unprovoked PE, extended anticoagulation should be considered if bleeding risk is low or moderate, as recommended by the American College of Chest Physicians 2, 1
For patients with a second unprovoked venous thromboembolism, extended anticoagulant therapy is recommended for those with low bleeding risk (strong recommendation) and suggested for those with moderate bleeding risk, based on guidelines from the American College of Chest Physicians 1

If both PEs were provoked by temporary risk factors, consider limited duration therapy, as suggested by the Journal of Thrombosis and Haemostasis 2
If either PE was unprovoked, proceed with consideration for indefinite therapy, according to the American College of Chest Physicians and the Journal of Thrombosis and Haemostasis 2, 1
Low bleeding risk patients should be strongly recommended for indefinite anticoagulation, while moderate bleeding risk patients should be suggested for indefinite anticoagulation, based on guidelines from the American College of Chest Physicians 1
High bleeding risk patients should consider limited duration therapy (3 months) even with recurrent VTE, as recommended by the American College of Chest Physicians 1

Patients with unprovoked venous thrombosis have an annual risk of recurrence >5%, according to the Journal of Thrombosis and Haemostasis 2
The benefit of anticoagulation continues only as long as therapy is continued, as stated by the Journal of Thrombosis and Haemostasis 2

Indefinite anticoagulation refers to treatment with no defined stop date, which could be lifelong or until bleeding risk becomes prohibitive, as defined by the Journal of Thrombosis and Haemostasis 2
Regular monitoring of patients on indefinite anticoagulation is essential to reassess the risk-benefit ratio as patient circumstances change, according to the American College of Chest Physicians 1

If a patient has hormone-associated PE and discontinues hormonal therapy, extended anticoagulation may not be required, as suggested by the Journal of Thrombosis and Haemostasis 2
For patients with PE associated with persistent risk factors, extended anticoagulation is recommended regardless of the number of episodes, based on guidelines from the American College of Chest Physicians 1