For the acute treatment of venous thromboembolism, the direct oral anticoagulants (DOACs) have increasingly replaced injectable anticoagulant therapy followed by warfarin. For patients with an unprovoked deep vein thrombosis or pulmonary embolism who may benefit from long-term extended prophylaxis for the secondary prevention of VTE, the choice is less clear. Should a DOAC be used? If so, which one and what's the best dose? What about low-dose aspirin? Is extended therapy needed at all? The EINSTEIN CHOICE study adds important new insights to the growing body of literature.
For over two decades LMWHs have been routinely used to provide therapeutic coverage in patients who must temporarily stop warfarin. Current guidelines suggest using injectable anticoagulants during warfarin interruption (aka bridging) in patients with atrial fibrillation based on patients’ risk of arterial thrombosis. Using the CHADS2 score to assess risk, the guidelines recommend (grade 2C) bridge therapy if the CHADS2 score is 5 or higher and not bridging if the CHADS2 score is 2 or lower. But what about patients with a CHADS2 score of 3 or 4?