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Once anticoagulation is stopped, the risk of recurrent venous thromboembolism (VTE) over years approaches 50% of all patients with a first episode of unprovoked VTE. The persistence of residual vein thrombosis at ultrasound assessment has consistently been shown to increase the risk, as do persistently high values of D-dimer. Although the latest international guidelines suggest indefinite anticoagulation for most patients with the first episode of unprovoked VTE, strategies that incorporate the assessment of residual vein thrombosis and D-dimer have the potential to identify a substantial proportion of subjects in whom anticoagulation can be safely discontinued. For those patients in whom anticoagulation cannot be discontinued, new opportunities are offered by the availability of low-dose anti-Xa compounds, which have been found to possess an extremely favourable benefit/risk profile.

Rivaroxaban is an oral anticoagulant that acts as a direct, competitive factor Xa inhibitor. Large randomized clinical trials have shown that, at a daily dose of 20 mg, Rivaroxaban is at least as effective as dose-adjusted warfarin for the prevention of stroke or other embolic complications in patients with nonvalvular atrial fibrillation (AF). The safety and efficacy of combining Rivaroxaban with an antiplatelet agent for secondary stroke prevention has not been established. We report the case of an elderly patient with permanent AF and coronary heart disease, who had already suffered an ischemic stroke while on warfarin treatment, and was consequently switched to treatment with an association of Rivaroxaban and Aspirin. Her CHA2DS2-VASc score was 9. The patient developed a severe recurrent disabling ischemic stroke. This case goes to show that the novel direct anticoagulants may fail to prevent recurrent stroke in patients at particularly high risk, even when associated with antiplatelet drugs.

The separate nature of venous and arterial thrombotic disorders has recently been challenged. Patients with venous thromboembolism (VTE) have an increased risk of subsequent symptomatic arterial cardiovascular events, the risk being higher in those with unexplained episodes. Among the implications of this association, there is the potential for old and new antithrombotic drugs to impact on the development of both venous and arterial cardiovascular events. According to the results of recent studies, aspirin in low doses, when administered for the long-term management of patients with unprovoked VTE, reduces by approximately 35% the risk of recurrent VTE while offering a considerable protection against the development of arterial cardiovascular events. By contrast, there is no room to expect a reduction in the risk of subsequent arterial cardiovascular events in patients treated with vitamin K antagonists (VKA) in comparison to patients in whom VKAs are discontinued. According to the results from recent randomized clinical trials, the likelihood of arterial cardiovascular events in patients on the novel direct factor Xa inhibitors is unlikely to differ from that of patients receiving conventional anticoagulation. As dabigatran has been associated with a slight increase in the risk of myocardial infarction over warfarin, its use should be discouraged in patients with coronary heart disease. The long-term use of low-dose apixaban beyond the first months in patients with unprovoked VTE may decrease the long-term risk of arterial, as well as venous, thrombotic events., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

No difference in outcome between therapeutic and preventive anticoagulation in patients with superficial vein thrombosis involving the saphenous-femoral junction Keywords: anticoagulation; saphenous-femoral junction; superficial vein thrombosis (SVT); venous thromboembolism (VTE) EN anticoagulation saphenous-femoral junction superficial vein thrombosis (SVT) venous thromboembolism (VTE) 290 292 3 06/14/22 20220601 NES 220601 Following the demonstration that thrombosis involving the superficial veins of the lower extremities (SVT) is a less benign disease than previously thought,[1] several controlled studies have consistently shown that fondaparinux in preventive doses, low-molecular-weight heparins (LMWHs) in intermediate doses, and rivaroxaban in preventive doses are effective and safe strategies for preventing extension or recurrence of the disease, as well as progression to the deep vein system and migration to the pulmonary circulation.[2][3][4][5] [6] In all these clinical trials, patients with the thrombus head within 3 cm from the saphenous-femoral junction were not eligible for recruitment, as they were perceived as being at a higher risk of venous thromboembolic complications in the absence of an active drug, nor were they in studies addressing the treatment of deep vein thrombosis (DVT) because of the lack of involvement of the deep vein system. Prevention of thromboembolic complications in patients with superficial-vein thrombosis given rivaroxaban or fondaparinux: the open-label, randomised, non-inferiority SURPRISE phase 3b trial. [Extracted from the article]