A 48-year-old woman comes to the clinic for follow-up. Three months ago, the patient experienced sudden-onset chest pain and dyspnea after undergoing an elective cholecystectomy. Examination revealed a left lower lobe segmental pulmonary embolism with co-existing right femoral deep venous thrombosis. Treatment with an oral factor Xa inhibitor was started and her symptoms have since resolved. The patient has had no bleeding or other adverse drug effects. She has no other medical problems and takes no other medications. She does not use tobacco, alcohol, or injection drugs. Family history is unremarkable.
Vital signs are within normal limits. BMI is 31 kg/m². Physical examination reveals normal heart sounds with no murmur. Lungs are clear to auscultation bilaterally. The bilateral lower extremities are normal. The remainder of the physical examination shows no abnormalities.
Which of the following is the most appropriate next step in management of this patient?

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11ec193a_98ed_a00c_853d_3fd46868095d_MD0002_00 This patient experienced a first-time venous thromboembolism (VTE) with abdominal surgery (ie, cholecystectomy) as a clear provoking factor. Anticoagulation reduces the risk of recurrent VTE and recurrence-associated mortality; these risks are greatest during the first several months following initial VTE onset. Most patients with a first-time, provoked VTE should receive 3 months of anticoagulation and then discontinue therapy. Finite extension of the duration of anticoagulation (eg, for a total of 6-12 months) is appropriate if there is temporary persistence of a provoking factor (eg, prolonged immobility following leg surgery). In patients with a first-time, unprovoked VTE, anticoagulation therapy is often continued indefinitely unless there is high bleeding risk. (Choice A) Elevated D-dimer at 4 weeks following cessation of anticoagulation has been associated with increased risk of recurrent VTE; therefore, testing has been suggested to aid in the risk-benefit analysis of indefinite anticoagulation in some patients with unprovoked VTE. However, indefinite anticoagulation is not a consideration in this patient with first-time provoked VTE, and D-dimer testing will not affect management. (Choice B) This patient received 3 months of anticoagulation following resolution of the VTE-provoking factor (surgery); therefore, extending the duration of anticoagulation is not indicated. (Choice D) Lower extremity ultrasonography at the time of anticoagulation cessation may be useful to document a baseline in some patients at elevated risk of recurrent VTE (eg, unprovoked VTE, ongoing provoking factor); otherwise, it does not play a role. (Choice E) Testing for an inherited thrombophilia (eg, protein C deficiency) is not recommended in most patients with VTE as it rarely alters the duration of anticoagulation therapy and does not affect outcomes. Testing is generally recommended only in patients at high risk of thrombophilia, including those with recurrent VTE, VTE in an unusual location (eg, portal vein, dural venous sinus), or family history of VTE at a young age, as it may influence VTE risk factor management (eg, perioperative anticoagulation, avoidance of hormonal contraception) in these patients. Educational objective: Most patients with a first-time, provoked venous thromboembolism should be treated with 3 months of anticoagulation. Finite extension of the treatment period (eg, for a total of 6-12 months) is appropriate if the provoking factor is temporarily persistent (eg, prolonged immobility following leg surgery). __________ References: Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/20975016)

A 48-Year-Old Woman Comes to the Clinic for Follow-Up