Management of idiopathic venous thromboembolism

Idiopathic or unprovoked venous thromboembolism is an event occurring in the absence of any apparent provoking or triggering environmental risk factors, such as surgery, trauma, and immobilization. Areas covered: Unprovoked VTE can be associated with occult cancer, but only limited, and not extensive cancer screening, may be warranted, as the rate of occult cancer is low in such patients. Routine thrombophilia testing is not currently recommended as it does not influence the management of the disease. The duration of anticoagulation for unprovoked VTE after the first three months is still debated as the disease tends to recur regardless of treatment duration. Expert commentary: Prognostic scores incorporating patient related risk factors, such as age and sex, and global markers of hypercoagulability, such as D-dimer, have been proposed for identifying high risk patients who are candidates for extended anticoagulation beyond three months. Direct oral anticoagulants, aspirin and sulodexide could be alternative to vitamin K antagonists (VKA) for long term treatment in such patients. The most up to date guidelines suggest DOACs over VKA for non-cancer VTE in the first three months and also long-term in subjects at low or moderate risk of bleeding, albeit with grade 2B strength of recommendation.