A 28-year-old woman presents with sudden-onset pleuritic chest pain and dyspnea while on oral contraceptive pills. CT pulmonary angiography confirms a right lower lobe pulmonary embolism. She has no prior VTE, no cancer, and no other provoking factors apart from OCP use. After completing 3 months of anticoagulation, what is the MOST appropriate next step?

• A Continue anticoagulation indefinitely
• B Switch to aspirin for long-term thromboprophylaxis
• C Discontinue OCP and stop anticoagulation ✓
• D Test for thrombophilia before any decision

Explanation

OCP use is a major transient provoking factor for VTE. A first PE provoked by a reversible risk factor (combined OCP) warrants only 3 months of anticoagulation followed by discontinuation of both the anticoagulant and the provoking factor. The recurrence risk after stopping anticoagulation when the precipitant is removed is low (< 5% per year), comparable to the population risk. Indefinite anticoagulation is reserved for unprovoked PE or VTE with persistent risk factors. Aspirin does not provide adequate protection against recurrent VTE. Thrombophilia testing may be considered in selected cases but is not required before stopping anticoagulation for a provoked first PE.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.