ESC Congress 2016 - 31

Your FREE access to ESC Congress content all year long www.escardio.org/365 ESC CONGRESS 2016 IN REVIEW to prospectively validate the "Men Continue and HERDOO2" CDR. This study enrolled 2785 patients with unprovoked major VTE in 44 centers. At 5 to 12 months, the patients were classified as low risk (women with ≤ 1 HERDOO criteria; n = 631) or high risk (all men and women with ≥ 2 HERDOO criteria; n = 2148) for recurrent VTE. The HERDOO criteria are shown in Figure 1. Continued anticoagulation was recommended for highrisk patients and anticoagulation was stopped in lowrisk patients. The primary endpoint was recurrent major VTE at 12 months in low-risk women who discontinued anticoagulants. Figure 1. HERDOO Criteria for Determining Risk of Recurrent VTE ♀ HERDOO Points in +1 Hyperpigmentation Edema or Redness (HER) in either leg +1 D-Dimer (Vidas) > 250 ug/L +1 Obesity, BMI ≥ 30 +1 Older age ≥ 65 =___ HERDOO points Simplified YEARS Algorithm Reduces Utilization of CT Scan in Patients With Suspected Acute Pulmonary Embolism Reproduced with permission from MA Rodger, MD. Written by Maria Vinall At the 12-month follow-up, among the high-risk patients, 1802 continued and 323 discontinued anticoagulants (Figure 2). In high-risk patients who discontinued anticoagulants, 25 had recurrent VTE in 309 patient years of follow-up (8.1%; 95% CI, 5.2 to 11.9) and 28 who continued anticoagulants had recurrent VTE in 1758 patient years (1.6%; 95% CI, 1.1 to 2.3). In the low-risk group, 31 women continued (patient preference) and 591 women Figure 2. Results at 12 Months Follow-Up Men and High-Risk Women (n = 2148) Continued Anticoagulant (n = 1802) Recurrent VTE: 1.6 per 100 patient years 95% CI: 1.1-2.3 HERDOO2 Classification 12-month Follow-Up Discontinued Anticoagulants (n = 323) Recurrent VTE: 8.1 per 100 patient years 95% CI: 5.2-11.9 Low-Risk Women (n = 631) Discontinued Anticoagulants (n = 591) Recurrent VTE: 3.0 per 100 patient years 95% CI: 1.8-4.8 Reproduced with permission from MA Rodger, MD. discontinued anticoagulants. Seventeen low-risk women who discontinued anticoagulants developed recurrent major VTE during 564 patient years of follow-up (3.0%; 95% CI, 1.8 to 4.8). There were no cases of recurrent VTE in the small group of low-risk women who continued anticoagulants. REVERSE II is the largest prospective cohort management study of patients with unprovoked VTE conducted to date. The study showed that it is safe to discontinue anticoagulants in women at low risk (0 or 1 HERDOO points) of recurrent VTE. About 50% of the women with unprovoked VTE can be spared the burdens, costs, and risks of lifelong anticoagulation. The authors concluded that women with a first unprovoked VTE and ≤ 1 HERDOO2 criterion have a low-risk of recurrent VTE and can safely discontinue anticoagulants after completing short-term treatment. Continued Anticoagulant (n = 31) Recurrent VTE: None The algorithm currently used for the diagnostic management of patients with clinically suspected acute pulmonary embolism (PE) is often incorrectly applied leading to an excess of diagnostic tests and misdiagnoses. Tom van der Hulle, MD, Leiden University Medical Center, Leiden, The Netherlands, reported that a simplified clinical decision rule derived from the Wells rule-the YEARS Algorithm-leads to a large reduction in the use of computed tomography pulmonary angiography (CTPA). Management of patients with suspected PE without shock or hypotension starts with an assessment of the clinical probability of PE based on the Wells rule or revised Geneva Score [Konstantinides SV et al. Eur Heart J. 2014]. Those patients with unlikely PE and a low (< 500 ng/mL) D-dimer value should not receive treatment, while those with likely PE or a high (≥ 500 ng/mL) D-dimer should receive a CTPA to confirm PE. Using this algorithm can exclude PE in about 30% of patients without having a CTPA. Despite the ability of this algorithm to exclude PE, in clinical practice adherence to this standard management approach is variable, probably due its complexity [Newnham M et al. BMJ. 2013]. PE patients receiving inappropriate management have a significantly higher risk of thromboembolic events (P < .001) and unexplained sudden death (P < .001) [Roy PM et al. Ann Intern Med. 2006]. Official Peer-Reviewed Highlights From ESC Congress 2016 31 http://www.escardio.org/365

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