Table 5.

Summary of the effects of indefinite vs discontinued antithrombotic therapy for secondary prevention in patients with unprovoked VTE

Certainty assessmentSummary of findings
Participants
(studies)
follow-up
Risk of biasInconsistencyIndirectnessImprecisionPublication biasOverall certainty of evidenceStudy event rates (%)Relative effect
(95% CI)
Anticipated absolute effects
With discontinuation of antithrombotic therapyWith indefinite antithrombotic therapyRisk with discontinuation of antithrombotic therapyRisk difference with indefinite antithrombotic therapy
Mortality: anticoagulants (follow-up: mean 21 mo) 
7937
(12 RCTs) 26-29,31-38  
Not serious Not serious Not serious Not serious None ⨁⨁⨁⨁
HIGH 
57/3553 (1.6) 36/4384 (0.8) RR 0.54
(0.36-0.81) 
Study population: 19 mo 
16 per 1000 7 fewer per 1000
(from 10 fewer to 3 fewer) 
Mortality rate: 1 y 
7 per 1000  3 fewer per 1000
(from 4 fewer to 1 fewer) 
Mortality: antiplatelet agents (follow-up: mean 31 mo) 
1224
(2 RCTs)39,40  
Not serious Not serious Not serious Very serious  None ⨁⨁◯◯
LOW 
23/608 (3.8) 22/616 (3.6) RR 0.95
(0.53-1.68) 
Study population 
38 per 1000 2 fewer per 1000
(from 18 fewer to 26 more) 
Mortality rate: 1 y 
14 per 1000  1 fewer per 1000
(from 7 fewer to 10 more) 
Nonfatal PE-anticoagulants (follow up: mean 17 mo) 
7202
(10 RCTs)26-29,31-33,35,36,38  
Not serious Not serious Not serious Not serious None ⨁⨁⨁⨁
HIGH 
92/3189 (2.9) 24/4013 (0.6) RR 0.25
(0.16-0.41) 
Study population 
29 per 1000 22 fewer per 1000
(from 24 fewer to 17 fewer) 
Annualized risk for PE 
36 per 1000 (16, 17)§  27 fewer per 1000
(from 30 fewer to 21 fewer) 
Nonfatal PE: antiplatelet agents (follow-up: mean 31 mo) 
1224
(2 RCTs)39,40  
Not serious Not serious Not serious Serious  None ⨁⨁⨁◯
MODERATE 
44/608 (7.2) 29/616 (4.7) RR 0.65
(0.411.03) 
Study population 
72 per 1000 25 fewer per 1000
(from 42 fewer to 2 more) 
Annualized risk for PE 
36 per 1000 (16, 17)§  13 fewer per 1000
(from 21 fewer to 1 more) 
Deep venous thrombosis (DVT) - anticoagulants (follow up: mean 17 mo) 
7202
(10 RCTs)26-29,31-33,35,36,38  
Not serious Not serious Not serious Not serious None ⨁⨁⨁⨁
HIGH 
198/3189 (6.2) 33/4013 (0.8) RR 0.15
(0.10-0.21) 
Study population 
62 per 1000 53 fewer per 1000
(from 56 fewer to 49 fewer) 
Annualized risk for DVT 
44 per 1000 (16, 17)§  37 fewer per 1000
(from 40 fewer to 35 fewer) 
DVT: antiplatelet agents (follow-up: mean 30 mo) 
1347
(3 RCTs)30,39,40  
Not serious Not serious  Not serious Serious  None ⨁⨁⨁◯
MODERATE 
100/671 (14.9) 58/676 (8.6) RR 0.44
(0.17 to 1.13) 
Study population 
149 per 1000 83 fewer per 1000
(from 124 fewer to 19 more) 
Annualized risk for DVT 
44 per 1000 (16, 17)§  25 fewer per 1000
(from 37 fewer to 6 more) 
Major bleeding: anticoagulants (follow-up: mean 19 mo) 
8210
(13 RCTs)26-29,31-38,41  
Not serious Not serious Not serious Not serious None ⨁⨁⨁⨁
HIGH 
20/3687 (0.5) 50/4523 (1.1) RR 1.98
(1.18 to 3.30) 
Study population 
5 per 1000 5 more per 1000
(from 1 more to 12 more) 
Annualized risk for major bleeding 
4 per 1000#  4 more per 1000
(from 1 more to 9 more) 
Major bleeding: antiplatelet agents (follow-up: mean 31 mo) 
1224
(2 RCTs)39,40  
Not serious Not serious Not serious Very serious  None ⨁⨁◯◯
LOW 
7/608 (1.2) 9/616 (1.5) RR 1.28
(0.48-3.41) 
Study population 
12 per 1000 3 more per 1000
(from 6 fewer to 29 more) 
Annualized risk for major bleeding 
4 per 1000#  1 more per 1000
(from 2 fewer to 10 more) 
Certainty assessmentSummary of findings
Participants
(studies)
follow-up
Risk of biasInconsistencyIndirectnessImprecisionPublication biasOverall certainty of evidenceStudy event rates (%)Relative effect
(95% CI)
Anticipated absolute effects
With discontinuation of antithrombotic therapyWith indefinite antithrombotic therapyRisk with discontinuation of antithrombotic therapyRisk difference with indefinite antithrombotic therapy
Mortality: anticoagulants (follow-up: mean 21 mo) 
7937
(12 RCTs) 26-29,31-38  
Not serious Not serious Not serious Not serious None ⨁⨁⨁⨁
HIGH 
57/3553 (1.6) 36/4384 (0.8) RR 0.54
(0.36-0.81) 
Study population: 19 mo 
16 per 1000 7 fewer per 1000
(from 10 fewer to 3 fewer) 
Mortality rate: 1 y 
7 per 1000  3 fewer per 1000
(from 4 fewer to 1 fewer) 
Mortality: antiplatelet agents (follow-up: mean 31 mo) 
1224
(2 RCTs)39,40  
Not serious Not serious Not serious Very serious  None ⨁⨁◯◯
LOW 
23/608 (3.8) 22/616 (3.6) RR 0.95
(0.53-1.68) 
Study population 
38 per 1000 2 fewer per 1000
(from 18 fewer to 26 more) 
Mortality rate: 1 y 
14 per 1000  1 fewer per 1000
(from 7 fewer to 10 more) 
Nonfatal PE-anticoagulants (follow up: mean 17 mo) 
7202
(10 RCTs)26-29,31-33,35,36,38  
Not serious Not serious Not serious Not serious None ⨁⨁⨁⨁
HIGH 
92/3189 (2.9) 24/4013 (0.6) RR 0.25
(0.16-0.41) 
Study population 
29 per 1000 22 fewer per 1000
(from 24 fewer to 17 fewer) 
Annualized risk for PE 
36 per 1000 (16, 17)§  27 fewer per 1000
(from 30 fewer to 21 fewer) 
Nonfatal PE: antiplatelet agents (follow-up: mean 31 mo) 
1224
(2 RCTs)39,40  
Not serious Not serious Not serious Serious  None ⨁⨁⨁◯
MODERATE 
44/608 (7.2) 29/616 (4.7) RR 0.65
(0.411.03) 
Study population 
72 per 1000 25 fewer per 1000
(from 42 fewer to 2 more) 
Annualized risk for PE 
36 per 1000 (16, 17)§  13 fewer per 1000
(from 21 fewer to 1 more) 
Deep venous thrombosis (DVT) - anticoagulants (follow up: mean 17 mo) 
7202
(10 RCTs)26-29,31-33,35,36,38  
Not serious Not serious Not serious Not serious None ⨁⨁⨁⨁
HIGH 
198/3189 (6.2) 33/4013 (0.8) RR 0.15
(0.10-0.21) 
Study population 
62 per 1000 53 fewer per 1000
(from 56 fewer to 49 fewer) 
Annualized risk for DVT 
44 per 1000 (16, 17)§  37 fewer per 1000
(from 40 fewer to 35 fewer) 
DVT: antiplatelet agents (follow-up: mean 30 mo) 
1347
(3 RCTs)30,39,40  
Not serious Not serious  Not serious Serious  None ⨁⨁⨁◯
MODERATE 
100/671 (14.9) 58/676 (8.6) RR 0.44
(0.17 to 1.13) 
Study population 
149 per 1000 83 fewer per 1000
(from 124 fewer to 19 more) 
Annualized risk for DVT 
44 per 1000 (16, 17)§  25 fewer per 1000
(from 37 fewer to 6 more) 
Major bleeding: anticoagulants (follow-up: mean 19 mo) 
8210
(13 RCTs)26-29,31-38,41  
Not serious Not serious Not serious Not serious None ⨁⨁⨁⨁
HIGH 
20/3687 (0.5) 50/4523 (1.1) RR 1.98
(1.18 to 3.30) 
Study population 
5 per 1000 5 more per 1000
(from 1 more to 12 more) 
Annualized risk for major bleeding 
4 per 1000#  4 more per 1000
(from 1 more to 9 more) 
Major bleeding: antiplatelet agents (follow-up: mean 31 mo) 
1224
(2 RCTs)39,40  
Not serious Not serious Not serious Very serious  None ⨁⨁◯◯
LOW 
7/608 (1.2) 9/616 (1.5) RR 1.28
(0.48-3.41) 
Study population 
12 per 1000 3 more per 1000
(from 6 fewer to 29 more) 
Annualized risk for major bleeding 
4 per 1000#  1 more per 1000
(from 2 fewer to 10 more) 

We used the median in the discontinued treatment arm from eligible RCTs as the baseline risk and estimated an annualized mortality of 0.7%.

The optimal information size was not met and the wide CI around absolute estimates does not rule out substantial benefit or substantial harm, and therefore we downrated the quality by 2 levels for impression.

We used the median in the discontinued treatment arm from eligible RCTs as the baseline risk and estimated an annualized mortality of 1.4%.

§

A meta-analysis18 reported that the cumulative incidence of recurrent VTE was 16% at 2 years for patients with unprovoked VTE, and because the median follow-up of our included studies was 24 months, we calculated the baseline risk to be 8% per patient-year. Assuming that 45% of the VTE events were PE and 55% were DVT,17 we estimated that, for patients with unprovoked VTE, the risk for PE recurrence was 3.6 per 100 patient-years and DVT recurrence was 4.4 per 100 patient-years.

The CI around absolute estimates does not rule out substantial benefit or substantial harm, and therefore we downrated the quality by 1 level for impression.

Although I2 = 85%, the treatment effects were all in favor of indefinite antithrombotic therapy, and we therefore did not downrate the quality for inconsistency.

#

We used the median in the discontinued treatment arm from eligible RCTs as the baseline risk and estimated the annualized risk for bleeding to be 0.4%.

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