Anticoagulation Duration in Pulmonary Embolism

Initial Treatment Duration

The American College of Cardiology recommends that patients with pulmonary embolism (PE) provoked by surgery should receive 3 months of anticoagulation and then stop therapy 2, 4
Patients with PE associated with non-surgical transient risk factors should receive 3 months of anticoagulation 2, 5
For hormone-associated PE in women, 3 months of anticoagulation is sufficient if hormone therapy is discontinued 6
Patients with unprovoked PE should receive initial anticoagulation for 3-6 months 2, 3
After the initial treatment period, patients with unprovoked PE should be considered for long-term (indefinite) anticoagulation due to high recurrence risk (>5% annually) 2, 3, 5

Unprovoked proximal deep vein thrombosis (DVT) or PE (first episode) is a factor favoring extended anticoagulation 2
Recurrent unprovoked venous thromboembolism (VTE) is a factor favoring extended anticoagulation 5
Low bleeding risk is a factor favoring extended anticoagulation 1, 2
High bleeding risk is a factor against extended anticoagulation 1, 2

Women with hormone-associated PE should discontinue hormonal therapy before stopping anticoagulation 6
If hormonal therapy must be continued for clinical reasons, anticoagulation should be continued for the duration of hormonal therapy 6

The bleeding risk should be continuously monitored in patients on extended anticoagulation 1, 2
For patients on extended anticoagulation, the risk-benefit ratio should be periodically reassessed 5

Failing to distinguish between provoked and unprovoked PE when determining anticoagulation duration is a common pitfall 2, 5
Not considering patient-specific bleeding risk factors when deciding on extended anticoagulation is a common pitfall 1, 2
The benefit of anticoagulation continues only as long as therapy is continued 3, 7