At the same time, there is reluctance to diagnose recurrent VTE in patients who are already on LMWH because there is no attractive alternative treatment option. f Risk of recurrent VTE: Low corresponds to patients without cancer (3% estimate taken from recent large RCTs of acute treatment), intermediate to patients with local or recently resected cancer (appears to be consistent with Prandoni [particularly if low risk is increased to 4%]), and high to patients with locally advanced or distant metastatic cancer (Prandoni et al181 ). g CI includes both no effect and harm with LMWH. h 95% CIs for the risk ratio for major bleeding includes a potentially clinically important increase or decrease with LMWH, and may also vary with the dose of LMWH used during the extended phase of therapy i Risk of bleeding: Low corresponds to patients without risk factor for bleeding (ie, > 75 years, cancer, metastatic disease; chronic renal or hepatic failure; platelet count <80,0000; requires antiplatelet therapy; history of bleeding without a reversible cause) (Prandoni et al,180 Byeth et al182 ). Bibliography: Deitcher et al173 (ONCENOX), Hull et al174 (LITE), Hull et al175 (LITE Home), Lee et al170 (CLOT), Lopaciuk et al,176 Lopez-Beret et al,177 Meyer et al,178 Romera et al,179 Lee et al22 (CATCH) 322 Evidence-Based Medicine [ 1 4 9 # 2 C H E S T F E B R U A R Y 2 0 1 6 ] randomized trials have compared a NOAC (with23,24 or initial heparin therapy) with VKA therapy (with initial heparin therapy) for the acute and long- term treatment of VTE.23-26 The ndings of these studies have been analyzed in a number of systematic including a network meta-analysis.35 In addition, there is now extensive clinical experience using NOACs in patients with VTE and atrial brillation. 