What is the recommended management plan for a patient with a history of Deep Vein Thrombosis (DVT) and Factor V Leiden, currently in normal sinus rhythm (NSR), and on anticoagulation therapy?

From the Guidelines

For a patient with a history of DVT and Factor V Leiden mutation who is currently in normal sinus rhythm and on anticoagulation therapy, long-term anticoagulation is generally recommended. The preferred treatment is typically a direct oral anticoagulant (DOAC) such as apixaban (5 mg twice daily), rivaroxaban (20 mg daily with food), or dabigatran (150 mg twice daily) 1. Alternatively, warfarin with a target INR of 2-3 can be used if DOACs are contraindicated or not tolerated. This anticoagulation should be continued indefinitely given the patient's combination of a previous DVT and Factor V Leiden mutation, which creates a persistent hypercoagulable state.

Key considerations in the management plan include:

• Regular follow-up every 3-6 months to assess for bleeding complications, medication adherence, and to evaluate the need for continued therapy
• Patient education about bleeding risks, medication interactions, and the importance of consistent dosing
• The rationale for indefinite anticoagulation is that Factor V Leiden causes resistance to activated protein C, increasing thrombin generation and creating a lifelong elevated risk of recurrent thrombosis, especially after a previous DVT event, as supported by the most recent guidelines 1.

Given the patient's current status and the presence of Factor V Leiden, continuing the current anticoagulation therapy at the current dosing and scheduling an expedited follow-up with cardiology for heart rate evaluation is a reasonable approach. Additionally, educating the patient on emergency precautions such as going to the ER immediately if experiencing chest pain, shortness of breath, dizziness, palpitations, syncope, or worsening tachycardia, and maintaining adequate hydration while avoiding excessive caffeine or stimulants, is crucial for managing potential complications. The decision to continue anticoagulation therapy should be reevaluated at least on an annual basis, taking into consideration the patient's values and preferences, as recommended by the latest guidelines 1.

From the Research

Management Plan for Patient with DVT and Factor V Leiden

The patient's current management plan includes continuing anticoagulation therapy at the current dosing and scheduling an expedited follow-up with cardiology for heart rate evaluation 2, 3.

Education on Emergency Precautions

The patient has been educated on emergency precautions, including going to the ER immediately if experiencing chest pain, shortness of breath, dizziness, palpitations, syncope, or worsening tachycardia 4.

Lifestyle Modifications

The patient has been advised to maintain adequate hydration and avoid excessive caffeine or stimulants 5, 6.

Anticoagulation Therapy

• The patient is currently in normal sinus rhythm (NSR) and on anticoagulation therapy, which is the first line and drug of choice for both the treatment and prophylaxis of venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) 2.
• Anticoagulation therapy is often extended beyond the initial three- to six-month acute phase after an incident of venous thromboembolism to decrease the risk of recurrent thrombosis 3.
• The risk of recurrent venous thromboembolism in patients with heterozygous Factor V Leiden mutation is documented as an approximate 1.4-fold increase compared to patients without thrombophilia 6.

Follow-up and Monitoring

• The patient is scheduled for an expedited follow-up with cardiology on 06/30/25 @ 1:30pm for heart rate evaluation [@1@, @2@].
• Regular monitoring of the patient's condition and adjustment of the anticoagulation therapy as needed is crucial to prevent recurrent thrombosis and minimize the risk of bleeding [@3@, @4@].

Considerations for Anticoagulation Duration

• The decision to extend anticoagulation therapy should be based on the patient's individual risk factors, including the presence of Factor V Leiden mutation, history of DVT, and other reversible or non-reversible risk factors [@4@, @5@].
• A comprehensive review of the patient's risk factors should be conducted to determine the optimal duration of anticoagulation therapy [@5