Early stroke-related deep venous thrombosis: risk factors and influence on outcome

Deep venous thrombosis (DVT) is a serious complication of various medical conditions including acute stroke. Our aim was to identify the occurrence of early stroke-related DVT, risk factors for its development and the influence on outcome. The study involved consecutive patients admitted to our center due to acute ischaemic (n = 278) or haemorrhagic (n = 12) stroke during a 16-month period. We collected data on their pre-stroke health status, neurological deficit on admission and baseline serum CRP and fibrinogen level. Ultrasonographic imaging was performed at the 3rd (IQR: 2–4) and 9th (IQR: 8–9) day after stroke. Patients thrombosis occurring between the first and second examination comprised the newly developed early stroke-related DVT group. We found DVT in 8.0% (24/299) of patients at initial evaluation. Newly developed DVT was present in 3.0% (9/299) of patients, and was predominantly distal (7 of 9 cases). It was associated with elevated serum CRP level (OR 8.75; 95%CI: 1.61–47.6), which was verified in a model adjusted for stroke severity and pre-stroke dependency (3–5 pts. in mRS). In a multivariate model, newly developed DVT significantly increased the risk of 3-month mortality (OR 12.4; 95%CI: 1.72–89.4), without affecting the combined risk of dependency and death (OR 2.57; 95%CI: 0.39–17.0). Early stroke-related DVT is an infrequent complication. However, it may be an independent risk factor for 3-month mortality. Increased serum CRP level combined with normal fibrinogen level seems predictive for development of DVT. It may be reasonable to provide those patients with additional DVT prophylaxis.     

脑卒中后偏瘫患者症状性下肢深静脉血栓形成的临床特点

目的探讨脑卒中后偏瘫患者并发症状性下肢深静脉血栓(deep venous thrombosis,DVT)形成的临床特点。方法回顾2006年1月-2011年12月收治的822例脑卒中患者,对其中35例脑卒中后偏瘫并下肢红肿疼痛经静脉造影和/或超声证实的DVT患者资料分析,并通过与同期收治的35例非DVT卒中患者进行血同型半胱氨酸(Hcy)、C反应蛋白(CRP)水平对比,了解症状性DVT的发生率、发生时间及可能的危险因素。结果本院脑卒中后偏瘫患者症状性DVT的发病率为35/822(4.3%),DVT发生在瘫痪侧32例,其中同为左侧28例;脑卒中后发生症状性DVT的时间主要集中在住院2周～4周;肢体肌力0～Ⅱ级31例,Ⅲ级及以上者4例;年龄≥65岁28例;有股静脉置管史21例;合并高血压33例;有糖尿病19例;有心房纤颤者8例;合并高脂血症12例。脑卒中后DVT组血Hcy、CRP水平明显升高,与对照组相比有统计学意义。结论高龄、重度肢体瘫痪、高血压、糖尿病、房颤、高脂血症、股静脉置管、高同型半胱氨酸血症、炎症可能是脑卒中后偏瘫患者发生DVT的危险因素,为避免DVT的发生及其所产生的不良后果,临床上应对具有上述危险因素的脑卒中患者给予必要的预防。     

The incidence of venous thromboembolism following stroke and its risk factors in eastern China

Few studies have documented the prevalence of venous thromboembolism (VTE) in the Chinese population. We aimed to investigate the incidence of VTE following stroke and to determine the potential risk factors for the onset of VTE in patients of eastern China. A prospective multi-center study was conducted. A total of 1,380 patients with acute stroke received venous duplex ultrasound (VDU) examination on both lower limbs. The National Institutes of Health Stroke Scale (NIHSS), Barthel index (BI), Wells, and modified Rankin scale scores were determined. Among 1,380 cases of acute stroke, 4.49 % (62 cases) had deep venous thrombosis (DVT) and 0.80 % (11 cases) had pulmonary thromboembolism (PTE). In the cases of DVT, 48.4 % had no clinical symptoms. The independent risk factors for the incidence of DVT, following the acute stage of stroke, were an age ≥ 70 years, bed-ridden, a Wells score ≥ 2, an NIHSS score of lower limbs ≥ 3, a low BI score, and an elevated concentration of D: -dimer. Rehabilitative and anti-coagulant therapy prevented the incidence of DVT following stroke. Moreover, an age ≥ 70 years, bed-ridden and having DVT were the independent risk factors for the incidence of PTE among stroke patients during the acute stage. Finally, 1.51 % of the patients had DVT whereas no PTE occurred during the period of the follow-up study. VDU examination is recommended for patients with acute stroke, which may help to diagnose and treat asymptomatic DVT early as well as prevent the subsequent incidence of PTE.     

急性脑卒中患者静脉血栓栓塞症调查及危险因素探讨

<正>静脉血栓栓塞症(venous thromboembolism,VTE)包括深静脉血栓形成(deep venous thrombosis,DVT)和肺血栓栓塞症(pulmonary thromboembolism,PTE)。脑卒中患者是VTE发生的高危人群,如果不给予任何干预措施,30%~40%的脑卒中患者会发生DVT,严重     

Delirium within three days of stroke in a cohort of elderly patients

OBJECTIVES: To evaluate the incidence of stroke, risk factors for stroke, and outcomes in elderly stroke patients with delirium. DESIGN: Cohort study with 12-month follow-up. SETTING: Bankstown-Lidcombe Hospital, a 450-bed teaching hospital of the University of New South Wales, Sydney, Australia. PARTICIPANTS: One hundred fifty-six stroke patients aged 65 and older recruited over 1 year. MEASUREMENTS: Incidence of delirium (defined in accordance with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria) within 3 days poststroke, length of hospital stay, discharge destination, short- and long-term mortality, Functional Independence Measure (FIM) scores, and Mini-Mental State Examination (MMSE) scores. RESULTS: Thirty-nine (25%) elderly stroke patients had delirium within 3 days after stroke. Logistic regression analysis found that older age (P=.04), hemorrhagic stroke (P=.02), metabolic disorders (P=.003), dementia prestroke (P=.02), Glasgow Coma Scale (GCS) score less than 15 on admission (P<.001), and inability to lift both arms on admission (P=.03) were independent predisposing factors for delirium. Patients who had a cardioembolic stroke (odds ratio (OR)=5.58) or total anterior circulation infarction (OR=3.42) were also more likely to develop delirium. Patients with delirium were associated with higher 6- and 12-month mortality (P<.05), lower 12-month FIM and MMSE scores, and a higher 12-month institutionalization rate. CONCLUSION: Delirium occurred frequently in acute stroke patients aged 65 and older. Factors independently associated with delirium included old age, intracerebral hemorrhage, metabolic factors, prestroke dementia, initial GCS less than 15, and inability to lift both arms on admission. Patients with delirium had higher long-term mortality and a worse functional outcome.     

Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry

BACKGROUND: There is little information on the clinical outcome of patients with upper-extremity deep vein thrombosis (DVT). METHODS: RIETE is an ongoing registry of consecutive patients with objectively confirmed, symptomatic, acute DVT or pulmonary embolism (PE). In this analysis, we analyzed the demographic characteristics, treatment, and 3-month outcome of all patients with DVT in the arm. RESULTS: Of the 11,564 DVT patients enrolled, 512 patients (4.4%) had arm DVT. They presented less often with clinically overt PE (9.0% vs 29%; odds ratio, 0.24; 95% confidence interval [CI], 0.18 to 0.33) than those with lower-limb DVT, but their 3-month outcome was similar. Of the 512 patients with arm DVT, 196 patients (38%) had cancer and 228 patients (45%) had catheter-related DVT. During follow-up, those with cancer DVT had an increased incidence of major bleeding (4.1% vs 0.9%; odds ratio, 4.4; 95% CI, 1.2 to 21), recurrent venous thromboembolism (6.1% vs 2.8%; odds ratio, 2.2; 95% CI, 0.91 to 5.6; p = 0.04), and death (22% vs 3.5%; odds ratio, 7.8; 95% CI, 4.0 to 16). Thirty patients had the composite event of recurrent DVT, symptomatic PE, or major bleeding. They were significantly older, more often had cancer, and presented more frequently with symptomatic PE on hospital admission. On multivariate analysis, only cancer patients with arm DVT had an increased risk for the composite event (odds ratio, 3.0; 95% CI, 1.4 to 6.4). CONCLUSIONS: At presentation, patients with arm DVT have less often clinically overt PE than those with lower-limb DVT, but their 3-month outcome is similar. Among patients with arm DVT, those with cancer have the worse outcome.     

Risk factors for deep vein thrombosis in inpatients aged 65 and older: a case-control multicenter study

OBJECTIVES: To identify independent risk factors of symptomatic deep vein thrombosis (DVT) in geriatric inpatients and to define high-risk patients likely to benefit from preventive treatment. DESIGN: Hospital-based case-control multicenter study with prospective data collection. SETTINGS: Geriatric university hospitals with long-, intermediate-, and short-term care facilities. PARTICIPANTS: All patients aged 65 and older in 19 geriatric departments were submitted to clinical surveillance over a 16-month period. MEASUREMENTS: Twenty-three potential risk factors of phlebitis were screened for. Comparison using logistic regression of 310 consecutive patients with symptomatic DVT versus 310 randomly selected controls was performed. The risk for symptomatic DVT in geriatrics was then scored from the clinical risk factors identified using multivariate analysis. This score is defined by the sum of the odds ratio (OR) of each risk factor present. RESULTS: Six factors were identified as independently related to the development of DVT: restriction of mobility (from OR=1.73, limited mobility without immobilization, to OR=5.64, bedridden during <15 days), aged 75 and older (OR=1.5/10 years), history of DVT or pulmonary embolism (OR=3.38), acute heart failure (OR=2.52), chronic edema of the lower limbs (OR=2.51), and paresis or paralysis of a lower limb (OR=2.06). The defined score of 8 or higher corresponded to an 88.7% probability of having symptomatic DVT. CONCLUSION: Treatments to prevent symptomatic DVT in hospitalized elderly should be evaluated on patients with these factors.     

老年深静脉血栓形成和转归中炎症因子的作用研究

目的 研究白细胞介素家族中的有关炎症反应因子和C-反应蛋白（CRP）在老年深静脉血栓（DVT）病人中的作用及其发病机理,探讨老年DVT病人的早期诊断和病程转归标志物。方法 选39例老年急性DVT病人。在治疗前2h和治疗后第1、3、7、14天,分别检测IL-2、sIL-2R、IL-4、IL-6、IL-8和CRP。结果 在急性DVT病人中sIL-2R、IL-6、IL-8和CRP在治疗前2h和治疗后第1天高于正常值（P〈0,01）,该两个阶段之间差异无统计学意义（P〉0．05）,与治疗后第3天,第7天和第14天差异有统计学意义（P〈0．01）,IL-2在治疗前后呈现下降趋势（P〈0．01）,IL-4治疗前后差异无统计学意义（P〉0．05）。结论 IL-2、sIL-2R、IL-6、IL-8和CRP,可作为老年DVT病人血液中早期炎症标志物的测定,也可以作为反映和病情转归的炎症标志物测定。     

Heart failure in patients with deep vein thrombosis

Patients with heart failure (HF) are particularly vulnerable to the development of venous thromboembolism (VTE) and its related complications of pulmonary embolism and right ventricular failure. To improve our understanding of the clinical characteristics, prophylaxis, and initial management of patients with HF and deep vein thrombosis (DVT), we compared 685 patients with a history of HF with 3,890 patients without HF in a prospective registry of 5,451 consecutive patients with ultrasound-confirmed DVT. We excluded 876 patients for whom data regarding HF status were incomplete. Patients with HF had an increased frequency of co-morbid conditions such as neurologic disease including stroke (33% vs 26%, p = 0.0002), acute lung disease including pneumonia (31% vs 15%, p <0.0001), and acute coronary syndrome (11% vs 4%, p <0.0001) contributing to a higher medical acuity than in patients without HF. Furthermore, patients with HF were more likely to have VTE risk factors of immobilization (53% vs 42%, p <0.0001), acute infection (33% vs 27%, p = 0.01), and chronic obstructive pulmonary disease (29% vs 12%, p <0.0001). Patients with and without HF and DVT had a high frequency of recent hospitalization (48% vs 47%, p = 0.96). Fewer than 12 of patients with HF (46%) who subsequently developed DVT received any VTE prophylaxis. In conclusion, the combination of higher medical acuity, increased frequency of VTE risk factors, and low rate of VTE prophylaxis presents a "triple threat" to patients with HF.     

Fever and deep venous thrombosis. Findings from the RIETE registry

Fever is a presenting sign in some patients with acute deep venous thrombosis (DVT), but its influence on outcome has not been thoroughly investigated. RIETE is an ongoing, international, observational registry of consecutive patients with symptomatic, objectively confirmed, acute venous thromboembolism. The aim of the present study was to assess the prevalence of fever in patients with acute DVT, and to compare their outcome during the first month of therapy, according to the presence or absence of fever. As of September 2009, 14,480 patients with symptomatic DVT have been enrolled in RIETE. Of these, 707 (4.9%) had fever at presentation. During the 30-day study period, 448 patients (3.1%) died, 171 (1.2%) developed DVT recurrences, 376 (2.6%) had pulmonary embolism, and 384 (2.6%) had a major bleeding. Patients initially presenting with fever had a higher mortality (5.8% vs. 2.9%; odds ratio: 2.6; 95% CI 1.9–3.5) than those without fever. Among the causes of death, pulmonary embolism (0.7% vs. 0.1%) and infection (1.1% vs. 0.3%) were significantly more common in patients presenting with fever. Multivariate analysis confirmed that DVT patients with fever had an increased mortality (hazard ratio: 2.00; 95% CI 1.44–2.77) irrespectively of the patient’s age, body weight, and risk factors for VTE. Fever is not uncommon in patients with DVT, and carries a worse outcome.     

Factor V Leiden and prothrombin gene mutation may predispose to paradoxical embolism in subjects with patent foramen ovale.

The role of paradoxical embolism through patent foramen ovale as a mechanism of cryptogenic stroke is controversial. If a venous source of emboli is relevant, prothrombotic states should be associated with patent foramen ovale and cryptogenic stroke. We assessed the occurrence of several prothrombotic states (factor V Leiden, prothrombin G20210A, deficiencies in protein S, protein C and antithrombin, lupus anticoagulant, anticardiolipin antibodies, elevated factor VIII, resistance to activated protein C) and classical risk factors for venous thrombosis in 57 adult patients with cryptogenic stroke and patent foramen ovale and in 104 matched controls. Prothrombotic states [odds ratio (OR) 2.8; 95% confidence interval (CI), 1.2-6.5; P = 0.021], migraine with aura (OR 4.4; 95% CI 1.8-10.8; P = 0.001) and classical risk factors for venous thrombosis (OR 2.5; 95% CI 1.1-5.7; P = 0.037) were independent risk factors for cryptogenic stroke. In particular factor V Leiden or prothrombin G20210A associated with cryptogenic stroke (P = 0.022) whereas other coagulation abnormalities did not (P = 0.140). Among the patients with prothrombotic states, Valsalva manoeuvre was common at onset of stroke. Our results support the possibility of paradoxical embolism behind strokes in patients with patent foramen ovale.     

Association between blood pressure and C-reactive protein levels in acute ischemic stroke

Among patients with acute stroke, high blood pressure (BP) and higher levels of circulating C-reactive protein (CRP) at the entry are often associated with poor outcome, although the reason is unclear. If the link between BP and stroke outcome is indeed mediated by inflammatory response, one would expect to see positive associations between BP and CRP. In a prospective observational stroke data bank involving 535 first-ever ischemic stroke patients, we studied the association between BP and baseline concentrations of CRP within 24 hours after stroke onset. The association between BP components and the odds of having an elevated CRP level (> or =1.5 mg/dL) was assessed by logistic regression analysis. An increase in systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), or pulse pressure (PP) was significantly associated with an increase in the odds of having an elevated CRP level, independent of other associated study factors. For each 10 mm Hg increase in SBP, DBP, MAP, or PP, the odds of having a high CRP level increased by 72% (P<0.0001), 10% (P<0.0001), 21% (P<0.0001), and 10% (P<0.0001), respectively. When the same model was rerun, adjusting for all considered BP components, only SBP significantly increased the odds of an elevated CRP level by 77% (P<0.0001). Increased SBP was significantly associated with elevated levels of circulating CRP in ischemic stroke patients. These findings support a possible role of acute hypertension after stroke as an inflammatory stimulus contributing to ischemic brain inflammation.     

Elevated troponin T and C-reactive protein predict impaired outcome for 4 years in patients with refractory unstable angina, and troponin T predicts benefit of treatment with abciximab in combination with PTCA.

AIMS: Treatment with the glycoprotein IIb/IIIa receptor antagonist abciximab before and during coronary intervention in refractory unstable angina improves early outcome. We collected 4-year follow-up data to assess whether this benefit is sustained. Additionally, we investigated the predictive value of baseline troponin T and CRP for long-term cardiovascular events. METHODS AND RESULTS: Of 1265 patients enrolled in the CAPTURE trial follow-up was available in 94% of the patients alive after 6 months (median 48 months). Survival was similar in both groups. Both elevated troponin T and CRP were associated with impaired outcome, independently of other established risk factors, but with a different time course. Elevated troponin was associated with increased procedure related risk, and elevated CRP with increased risk for subsequent events. Lower rates of the composite end-point of death or myocardial infarction with abciximab vs. placebo were sustained during long-term follow up: 15.7% vs 17.2% at 4 years (P=ns), particularly in patients with elevated troponin T: 16.9% with abciximab vs 28.4% with placebo: P=0.015. Elevated CRP was not associated with specific benefit of abciximab. CONCLUSION: Troponin T as a marker of thrombosis and CRP as a marker of inflammation are independent predictors of impaired outcome at 4 years follow-up. The initial benefit from abciximab with regard to death and myocardial infarction was preserved at 4 years. No specific benefit with abciximab was observed for patients with elevated CRP, suggesting that a chronic inflammatory process is not affected by abciximab. In contrast the benefit of treatment in patients with elevated troponin T implies that the acute thrombotic process in refractory unstable angina is treated effectively.     

Clinical presentation and outcome of venous thromboembolism in COPD

Chronic obstructive pulmonary disease (COPD) is a moderate risk factor for venous thromboembolism (VTE), but neither the clinical presentation nor the outcome of VTE in COPD patients is well known. The clinical presentation of VTE, namely pulmonary embolism (PE) or deep venous thrombosis (DVT), and the outcome at 3 months (death, recurrent VTE or bleeding) were compared between 2,984 COPD patients and 25,936 non-COPD patients included in the RIETE (Registro Informatizado de la Enfermedad TromboEmbólica) registry. This ongoing international, multi-centre registry includes patients with proven symptomatic PE or DVT. PE was the more frequent VTE presentation in COPD patients (n = 1,761, 59%). PE presentation was more significantly associated with COPD patients than non-COPD patients (OR 1.64, 95% CI 1.49-1.80). During the 3-month follow-up, mortality (10.8% versus 7.6%), minor bleeding (4.5% versus 2.3%) or first VTE recurrences as PE (1.5% versus 1.1%) were significantly higher in COPD patients than in non-COPD patients. PE was the most common cause of death. COPD patients presented more frequently with PE than DVT. It may explain the worse prognosis of COPD patients, with a higher risk of death, bleeding or VTE recurrences as PE compared with non-COPD patients. Further therapeutic options are needed.     

Joint effects of C-reactive protein and other risk factors on acute coronary events

BACKGROUND: Elevated serum C-reactive protein (CRP) is a predictor of coronary heart disease in population samples. We studied the contribution of the simultaneous presence (joint effects) of elevated CRP and the classic as well as some new risk factors on acute coronary events. METHODS: With a nested case-control design and logistic regression analyses, we measured baseline and pre-event CRP levels in patients who had myocardial infarction or coronary death (cases) during an 8.5-year follow-up in the Helsinki Heart Study, a coronary primary prevention trial in dyslipidemic middle-aged men. The control patients were participants remaining free of coronary events. RESULTS: Baseline and pre-event CRP levels were higher in cases than in control patients (4.4 vs 2.0 mg/L, P <.001 and 6.0 vs 3.6 mg/L, P <.001). The relative risk attributed to elevated CRP was 40% higher with chronic elevation (odds ratio [OR], 3.34) compared with high baseline (OR, 2.24) or pre-event (OR, 2.26) level only. Hypertension, low high-density lipoprotein cholesterol, and high leukocyte count increased the risk only marginally without simultaneous occurrence of high CRP, whereas the joint effects of CRP and these classic risk factors suggested additive effects on coronary risk. In contrast, high levels of immunoglobulin G-class antibodies to oxidized low-density lipoprotein and antiprothrombin antibodies as well as high total immunoglobulin G level increased the risk irrespective of CRP. CONCLUSIONS: Elevated CRP enhances the risks attributed to classic coronary risk factors.     

Association of clinical and laboratory variables with in-hospital incidence of deep vein thrombosis in patients after acute ischemic stroke: A retrospective study

Deep vein thrombosis (DVT) is a serious complication in patients with acute ischemic stroke (AIS). Early prediction of DVT could enable physicians to perform a proper prevention strategy. We analyzed the association of clinical and laboratory variables with DVT to evaluate the risk of DVT in patients after AIS.AIS patients admitted to the Changsha Central Hospital between January 2017 and December 2019 with length of stay in hospital ≥7 days were included. Clinical and laboratory variables for DVT at baseline were collected, and the diagnosis of DVT was confirmed by ultrasonography. Independent factors were developed by Multivariate logistic regression analysis.A total of 101 patients were included in the study. The in-hospital incidence of DVT after AIS was 19.8%(20/101). The average level of D-dimer when DVT detected was significant increased around 4-fold than that on admission (P < .001). Pulmonary infection (odds ratio [OR] = 5.4, 95%CI:1.10–26.65, P = .037)) and increased muscle tone (OR = 0.11, 95%CI:0.02–0.58, P = .010) as independent relevant factors for DVT were confirmed.Pulmonary infection as a risk factor and increased muscle tone as a protective factor for DVT were identified in patients after AIS. The level of D-dimer which increased around 4-fold compared to the initial level could be an indicator for DVT occurrence.     

血清可溶性CD40配体水平与缺血性卒中发病风险、严重程度和梗死体积的相关性

目的探讨血清可溶性CD40配体(soluble CD40 ligand,sCD40L)水平与缺血性卒中发病风险、严重程度和梗死体积的相关性.方法纳入连续住院的急性缺血性卒中患者作为病例组,健康体检者作为对照组.收集病例组和对照组人口统计学、血管危险因素和临床资料.采用酶联免疫吸附法测定血清sCD40L水平.缺血性卒中患者根据基线美国国立卫生研究院卒中量表(National Institutes of Health Stroke scale,NIHSS)评分分为轻度卒中组(＜8分)和中重度卒中组(≥8分),根据梗死体积中位数分为大梗死组和小梗死组.结果 共纳入106例急性缺血性卒中患者,其中男性59例(55.7％),女性47例(44.3％),平均年龄(71.31±11.27)岁;对照组86例,其中男性45例(52.3％),女性41例(47.7％),平均年龄(73.56 ±9.32)岁;大梗死组(≥1.8 cm3)41例(38.7％),小梗死组(＜1.8 cm3)65例(61.3％);轻度卒中69例(65.1％),中重度卒中37例(34.9％).缺血性卒中组基线血清sCD40L水平显著高于对照组[(5.61±1.68) mg/L对(3.56±1.32)mg/L;扣9.236,P＜0.01],缺血性卒中组入院14 d时血清sCD40L水平[(4.19±1.45)mg/L]较基线水平显著降低(P＜0.01),但仍然显著高于对照组(P＜0.01).多变量logistic回归分析显示,低密度脂蛋白胆固醇[优势比(odds ratio,OR)3.358,95％可信区间(confidence interval,CI)2.681 ～4.056;P ＜0.001]和血清sCD40L(OR5.103,95％ CI2.317 ～8.903;P ＜0.001)水平较高是缺血性卒中的独立危险因素;血清sCD40L水平较高(第4四分位数对第1四分位数,OR4.017,95％ CI1.608 ～ 10.037;P=0.003)、大动脉粥样硬化性卒中(OR2.321,95％ CI1.014 ～ 5.314;P=0.046)、皮质-皮质下梗死(OR 2.679,95％ CI1.111 ～6.460;P=0.028)和梗死灶体积较大(OR 3.216,95％ CI1.398～7.395;P=0.006)为中重度卒中的独立危险因素;血清sCD40L水平较高(第4四分位数对第1四分位数,OR 3.142,95％ CI1.274 ～7.745;P =0.013)、大动脉粥样硬化性卒中(OR 2.965,95％CI1.299 ～6.767;P=0.010)、皮质-皮质下梗死(OR4.750,95％ CI 1.909～11.818;P＜0.001)和基线NIHSS评分≥8分(OR 8.509,95％ CI3.432 ～21.094;P ＜0.001)为大梗死的独立危险因素.结论血清sCD40L 水平与缺血性卒中发病、梗死体积和严重程度密切相关.     

Deep vein thrombosis in elderly patients hospitalized in subacute care facilities: a multicenter cross-sectional study of risk factors, prophylaxis, and prevalence

BACKGROUND: The efficacy of venous thromboembolism prophylaxis has not been established, to our knowledge, in elderly patients hospitalized in subacute care facilities. OBJECTIVES: To describe risk factors and physician practices in the prevention of venous thromboembolism and to estimate the prevalence of deep vein thrombosis. METHODS: A multicenter cross-sectional study was conducted in the subacute care departments of 36 French hospitals. The study population included 852 inpatients older than 64 years. Systematic ultrasound examination was performed by angiologists. RESULTS: Of the 852 inpatients, 178 (20.9%; 95% confidence interval [CI], 18.2%-23.8%) had 3 or more risk factors other than age, while 144 patients (16.9%; 95% CI, 14.4%-19.6%) had none. The rate of prophylactic anticoagulant treatment was 56.1%, ranging from 20.0% to 86.9%, depending on the department. In multivariate analysis, prophylaxis use was associated with acute immobilization (odds ratio [OR], 4.17; 95% CI, 2.48-7.01), chronic immobilization (OR, 3.19; 95% CI, 2.22-4.60), major surgical procedure (OR, 6.81; 95% CI, 4.26-10.88), and congestive heart failure (OR, 1.65; 95% CI, 1.02-2.67). Prophylaxis use was low in patients who had cancer (OR, 0.49; 95% CI, 0.29-0.84) or myocardial infarction (OR, 0.39; 95% CI, 0.14-1.00). It was not significantly associated with paralytic stroke or history of venous thromboembolism. Deep vein thrombosis was detected in 135 patients (15.8%; 95% CI, 13.4%-18.5%): 50 (5.9%; 95% CI, 4.4%-7.7%) had proximal vein thrombosis and 85 (10.0%; 95% CI, 8.0%-12.2%) had calf vein thrombosis. CONCLUSIONS: The prevalence of deep venous thrombosis is high in these patients, despite wide use of prophylaxis. Further prospective studies assessing the clinical benefit of extended duration prophylaxis are needed in elderly patients hospitalized in subacute care settings.     

Massive pulmonary embolism in a woman with leiomyomatous uterus causing pelvic deep venous thrombosis

Deep venous thrombosis (DVT) is a serious illness sometimes causing death due to acute pulmonary thromboembolism (PTE). Blood stasis of the pelvic vein is a major etiologic factor for DVT. Occasionally a large myomatous uterus can cause compression of the pelvic venous system leading to DVT. We describe a very rare case of massive pulmonary embolism in a 39-year-old woman with multiple uterine myomas and no other recognized risk factors for PTE and DVT. The patient was successfully treated with thrombolytic and anticoagulation therapy associated with total hysterectomy.     

Clinical risk factors and timing of recurrent venous thromboembolism during the initial 3 months of anticoagulant therapy

BACKGROUND: In patients with venous thromboembolism (VTE), identifying clinical risk factors for recurrence during the initial 3 months of anticoagulant therapy and knowledge of the time course of recurrence may help clinicians decide about the frequency of clinical surveillance and the appropriateness of outpatient treatment. METHODS: Analysis of a randomized controlled trial database involving 1021 patients with VTE (750 with deep vein thrombosis [DVT] and 271 with pulmonary embolism [PE]) who were followed up for 3 months after the start of anticoagulant therapy. All patients received initial treatment with unfractionated heparin or a low-molecular-weight heparin (reviparin) and a coumarin derivative starting the first or second day of treatment, with a target international normalized ratio of 2.0 to 3.0. RESULTS: Four independent clinical risk factors for recurrent VTE were identified: (1) cancer (odds ratio [OR], 2.72; 95% confidence interval [CI], 1. 39-5.32), (2) chronic cardiovascular disease (OR, 2.27; 95% CI, 1. 08-4.97), (3) chronic respiratory disease (OR, 1.91; 95% CI, 0.85-4. 26), and (4) other clinically significant medical disease (OR, 1.79; 95% CI, 1.00-3.21). Older age was associated with a decreased risk for recurrent VTE (OR, 0.76; 95% CI, 0.64-0.92). Previous VTE, sex, and idiopathic VTE were not risk factors for recurrence. In patients with DVT or PE, there was no significant difference in the rates of recurrent nonfatal VTE (4.8% vs 4.1%; P =.62), major bleeding (2.9% vs 2.2%; P =.53), and non-VTE death (6.4% vs 7.8%; P =.45), but recurrent fatal PE was more frequent in patients with PE than DVT (2. 2% vs 0%; P<.01). There was a clustering of recurrent VTE episodes during the initial 2 to 3 weeks after the start of treatment. CONCLUSIONS: During the initial 3 months of anticoagulant therapy, recurrent VTE is more likely to occur in patients with cancer, chronic cardiovascular disease, chronic respiratory disease, or other clinically significant medical disease. Patients with PE are as likely to develop recurrent VTE as those with DVT; however, recurrence is more likely to be fatal in patients who initially present with PE. Arch Intern Med. 2000;160:3431-3436.