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Previous Volume 355:1780-1789 October 26, 2006 Number 17 Next

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ABSTRACT

Background The optimal duration of oral anticoagulation in patients with idiopathic venous thromboembolism is uncertain. Testing of D-dimer levels may play a role in the assessment of the need for prolonged anticoagulation.

Methods We performed D-dimer testing 1 month after the discontinuation of anticoagulation in patients with a first unprovoked proximal deep-vein thrombosis or pulmonary embolism who had received a vitamin K antagonist for at least 3 months. Patients with a normal D-dimer level did not resume anticoagulation, whereas those with an abnormal D-dimer level were randomly assigned either to resume or to discontinue treatment. The study outcome was the composite of recurrent venous thromboembolism and major bleeding during an average follow-up of 1.4 years.

Results The D-dimer assay was abnormal in 223 of 608 patients (36.7%). A total of 18 events occurred among the 120 patients who stopped anticoagulation (15.0%), as compared with 3 events among the 103 patients who resumed anticoagulation (2.9%), for an adjusted hazard ratio of 4.26 (95% confidence interval [CI], 1.23 to 14.6; P=0.02). Thromboembolism recurred in 24 of 385 patients with a normal D-dimer level (6.2%). Among patients who stopped anticoagulation, the adjusted hazard ratio for recurrent thromboembolism among those with an abnormal D-dimer level, as compared with those with a normal D-dimer level, was 2.27 (95% CI, 1.15 to 4.46; P=0.02).

Conclusions Patients with an abnormal D-dimer level 1 month after the discontinuation of anticoagulation have a significant incidence of recurrent venous thromboembolism, which is reduced by the resumption of anticoagulation. The optimal course of anticoagulation in patients with a normal D-dimer level has not been clearly established. (ClinicalTrials.gov number, NCT00264277 [ClinicalTrials.gov] .)

Source Information

From the S. Orsola-Malpighi University Hospital, Bologna, (G.P., B.C., C.L., C.B.); S. Bortolo Hospital, Vicenza (A. Tosetto); the University of Perugia, Perugia (A.I.); the University Hospital, Padua (V.P.); Arcispe-dale Santa Maria Nuova, Reggio Emilia (A.G.); General Hospital, Parma (C.P.); General Hospital, Cremona (S.T.); and Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Istituto di Ricovero e Cura a Carattere Scientifico, Maggiore Hospital, Milan (A. Tripodi) — all in Italy; and the Academic Medical Center, Amsterdam (A.W.A.L.).

Address reprint requests to Dr. Palareti at the Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Via Albertoni 15, 40138 Bologna, Italy, or at palareti{at}tin.it.

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Related Letters:

D-Dimer and Duration of Anticoagulation
Pernod G., Sevestre M.-A., Labarere J., Mannarino E., Schillaci G., Kevorkian J.-P., Virally M.-L., Bergmann J.-F., Glynn R. J., Goldhaber S. Z., Ridker P. M., Palareti G., Cosmi B., Iorio A.
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N Engl J Med 2007; 356:421-423, Jan 25, 2007. Correspondence

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