Durée optimale du traitement anticoagulant au décours d'une maladie veineuse thrombo-embolique

The optimal duration of anticoagulation after venous thromboembolism (VTE) is determined according to the risk of recurrent VTE after stopping anticoagulant therapy and the risk of anticoagulant-related bleeding while on antivitamin K. Clinical risk factors appears to be determinant to predict the risk of recurrence whereas the influence of biochemical and morphological tests is uncertain. The risk of recurrent venous thromboembolism is low when the initial episode was provoked by a reversible major risk factor (surgery) : 3 months of anticoagulation is optimal. Conversely, this risk is high when venous thromboembolism was unprovoked or associated with persistent risk factor (cancer) : 6 months or more prolonged anticoagulation is warranted. After this first estimation, the duration of anticoagulation may be modulated according to the presence of additional minor risk factors (major thrombophilia, chronic pulmonary hypertension, massive pulmonary embolism) : 6 months if VTE was provoked and 12 to 24 months if VTE was unprovoked. If the risk of anticoagulant related bleeding is high, the duration of anticoagulation should be shortened (3 months if VTE was provoked and 6 or 3 months if it was unprovoked). Lastly, if VTE occurred in the setting of a cancer, anticoagulation should be conducted for 6 months or more while cancer is active or on ongoing treatment. Despite an increasing knowledge of the risk factors of recurrent VTE, a number of issues remain unresolved ; randomised trial comparing different duration of anticoagulation are needed.