Prevalence and risk factors for venous thromboembolic complications in the Swiss Inflammatory Bowel Disease Cohort

Objective: Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is associated with the occurrence of venous thromboembolism (VTE) such as deep vein thrombosis (DVT) and pulmonary embolism (PE). We aimed to assess the prevalence and associated risk factors for VTE in a large national cohort of IBD patients.

Material and methods: Data from patients of the Swiss IBD Cohort Study (SIBDCS) enrolled between 2006 and 2013 were analyzed.

Results: A total of 2284 IBD patients were analyzed of which 1324 suffered from CD and 960 from UC. VTE prevalence was 3.9% (90/2284) overall and 3.4% (45/1324) in CD patients (whereof 2.4% suffered from DVT and 1.5% from PE) and 4.7% (45/960) in UC patients (whereof 3.2% suffered from DVT and 2.4% from PE). Median disease duration in CD patients with VTE was 12 years [IQR 8–23] compared to eight years [3–16] in CD patients without VTE (p?=?0.001). Disease duration in UC patients with VTE was seven years [4–18] compared to six years [2–13] in UC patients without VTE (p?=?0.051). Age at CD diagnosis ≥40 years (OR 1.851, p?=?0.073) and disease duration >10 years (OR 1.771, p?=?0.088) showed a trend to be associated with VTE. In UC patients, IBD-related surgery (OR 3.396, p?=?0.004) and pancolitis (OR 1.927, p?=?0.050) were significantly associated with VTE.

Conclusions: VTE are prevalent in CD and UC patients. Pancolitis and UC-related surgery are significantly associated with VTE in UC patients.     

Increased incidence of VTE in sickle cell disease patients: risk factors,recurrence and impact on mortality

Previous reports show increased incidence of venous thromboembolism [VTE, deep‐vein thrombosis (DVT) and pulmonary embolus (PE)] in sickle cell disease (SCD) patients but did not account for frequency of hospitalization. We determined the incidence of VTE in a SCD cohort versus matched controls. For SCD patients, risk factors for incident VTE, recurrence and the impact on mortality were also determined. Among 6237 patients with SCD, 696 patients (11·2%) developed incident‐VTE: 358 (51·6%) had PE (±DVT); 179 (25·7%) had lower‐extremity DVT only and 158 (22·7%) had upper‐extremity DVT. By 40 years of age, the cumulative incidence of VTE was 17·1% for severe SCD patients (hospitalized ≥3 times a year) versus 8·0% for the matched asthma controls. Amongst SCD patients, women (Hazard ratio [HR] = 1·22; 95% confidence interval [CI]: 1·05–1·43) and those with severe disease (HR = 2·86; 95% CI: 2·42–3·37) had an increased risk of VTE. Five‐year recurrence was 36·8% in patients with severe SCD. VTE was associated with increased risk of death (HR = 2·88, 95% CI: 2·35–3·52). In this population‐based study, the incidence of VTE was higher in SCD patients than matched controls and was associated with increased mortality. The high incidence of recurrent VTE in patients with severe SCD suggests that extended anticoagulation may be indicated.     

Venous thromboembolism prophylaxis for medical service-mostly cancer-patients at hospital discharge

Objective

Many hospitalized Medical Service patients remain at high risk for venous thromboembolism (VTE) after hospital discharge. Our aim was to compare the effect of the use or omission of extended pharmacologic VTE prophylaxis after hospital discharge among Medical Service patients on the incidence of symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) over the ensuing 3 months.

Methods

In this case-control study, we identified a case population of 461 patients for whom parenteral pharmacological VTE prophylaxis was prescribed to continue after discharge and matched them according to age, sex, and VTE risk score to a control group of 922 patients for whom VTE prophylaxis was not continued after discharge.

Results

The primary endpoint of symptomatic DVT or PE at 90 days occurred in 5.0% of patients receiving extended prophylaxis compared with 4.3% of patients who received no prophylaxis after discharge (P = .58). Fewer patients were alive at 90 days in patients receiving extended pharmacologic VTE prophylaxis, compared with those who received no prophylaxis after discharge (56.8% vs 68.4%, P <.001). Major bleeding, defined as those events requiring blood transfusion, medical, or surgical intervention, occurred more frequently in patients receiving extended VTE prophylaxis after discharge than in those patients who received no prophylaxis after discharge (3.9% vs 1.9%, P = .03).

Conclusion

Extended pharmacologic thromboprophylaxis in high-risk Medical Service patients did not reduce symptomatic DVT and PE in the ensuing 90 days after hospital discharge. There was a higher incidence of all-cause death and major bleeding episodes in patients receiving extended prophylaxis. Our observations do not support the routine use of extended VTE prophylaxis in Medical Service patients. Further research is needed to identify patients who may benefit from extended pharmacologic VTE prophylaxis and those who may have too great a bleeding risk.     

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.     

Statins and risk of venous thromboembolic diseases: A two-sample mendelian randomization study

Background and aimsIn observational studies, statins have been suggested to have protective effects on venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). To this aim, we performed a two-sample mendelian randomization (MR) analysis to determine whether these associations were causal.Methods and resultsData on the single nucleotide polymorphisms (SNPs) related to statin medication were obtained from the FinnGen study, and data for VTE, PE and DVT of lower extremities (LEDVT) were from the UK Biobank study, respectively. Inverse variance weighted (IVW) method was used as the principal analysis of MR, and sensitivity analysis was performed to detect horizontal pleiotropy and heterogeneity. MR estimates showed an inverse causal association between statin medication and the risk of VTE (odds ratio [OR]: 0.999, 95% CI: 0.998–1.000, P = 0.004), PE (OR: 0.999, 95% CI: 0.999–1.000, P = 0.011) and LEDVT (OR: 0.999, 95% CI: 0.999–1.000, P = 0.008).ConclusionOur findings provide direct evidence that statins might decrease the risk of VTE, PE and LEDVT in agreement with observational studies. The specific mechanism of statin therapy for venous thromboembolism needs to be further studied.     

Body height and sex-related differences in incidence of venous thromboembolism: A Danish follow-up study

BackgroundSex-related differences in incidence rate of venous thromboembolism (VTE) have been reported. It is unclear whether these differences reflect sex-related differences in the incidence of deep venous thrombosis (DVT), pulmonary embolism (PE) or both and to which extent the differences are mediated by known risk factors for VTE.ObjectiveTo compare the incidence of DVT and PE between middle-aged men and women.MethodsWe computed sex-specific incidences of VTE, DVT and PE and estimated the crude and adjusted incidence rate ratios (IRR) of VTE, DVT and PE using Cox regression for men versus women participating in the prospective study Diet, Cancer and Health. We controlled for body mass index, body height, leisure-time physical activity and smoking dose.ResultsWe verified 641 VTE events during a median follow-up time of 10 years. The overall incidence of VTE was 1.15 [95%CI: 1.07–1.25] per thousand person years; it was higher for men than women (crude IRR: 1.55 [95%CI: 1.32–1.82]). The adjusted IRR for DVT was 1.06 [95%CI: 0.75–1.50] and for PE 0.60 [95%CI: 0.41–1.18] for men versus women. The higher rate among men appeared to be mediated mainly by body height.ConclusionsIn this middle-aged population, men experienced a higher incidence of VTE due to a higher incidence of DVT. The higher incidence among men appeared to be mediated by body height. Adjusted for body height, male sex was not associated with an excess risk of either VTE or DVT but the risk of PE was notably lower compared with women.     

Deep Vein Thrombosis and Pulmonary Embolism in Cirrhosis Patients

Background and Aims It is a commonly held notion that patients with cirrhosis do not suffer from deep vein thrombosis (DVT) or pulmonary embolism (PE) because they are naturally anticoagulated. However, to date, no studies have been carried out that objectively address this issue. We conducted a study to examine the relationship between cirrhosis and DVT/PE events. Methods A case–control study of patients seen at a tertiary care hospital was performed. Cases were hospitalized patients with biopsy and/or imaging plus clinical evidence of cirrhosis. Well-matched patients with no known evidence of cirrhosis served as controls. The DVT/PE events were identified by the international classification of disease-9 (ICD-9) codes and confirmed with radiographic/nuclear imaging. The Charlson Index was calculated to determine the comorbidity. The incidence of DVT/PE in cirrhotic patients was also compared to patients with chronic kidney disease (CKD), congestive heart failure (CHF), and solid organ cancers. Results This study consisted of 963 cirrhotics and 12,405 controls. Both the incidence of DVT/PE (1.8 vs. 0.9%, P = 0.007) and Charlson Index scores (3.2 ± 1.8 vs. 0.9 ± 1.5, P < 0.001) were higher in cirrhotics than in the controls. However, in the multivariate analysis, the presence of cirrhosis was not associated with DVT/PE [odds ratio (OR) 0.87, P = 0.06]. Partial thromboplastin time (PTT; OR 0.88, P = 0.04) and serum albumin (OR 0.47, P = 0.03) were the independent predictors of DVT/PE. The incidence of DVT/PE in cirrhotics (1.8%) was lower than that in patients with other medical illnesses: 7.1% in CKD, 7.8% in CHF, and 6.1% in cancers. Conclusion Patients with cirrhosis do not have a lower risk of DVT/PE than non-cirrhotic controls without other significant co-morbidities, such as CHF, CKD, and solid organ cancers. Partial thromboplastin time and serum albumin were found to be independently predictive of DVT/PE in cirrhotic patients.     

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.     

Long-term effects of non-retrieved inferior vena cava filters on recurrences of venous thromboembolism in cancer and non-cancer patients: From the COMMAND VTE registry

BackgroundThere is a paucity of data comparing the long-term outcomes after inferior vena cava (IVC) filters placement for patients with acute venous thromboembolism (VTE) between those with and without active cancer.MethodsIn the COMMAND VTE Registry, we evaluated the effects of IVC filter use on the long-term clinical outcomes stratified by the presence and absence of active cancer.ResultsAmong 2,626 patients with acute symptomatic VTE, there were 604 patients with active cancer, and 2022 patients without active cancer. IVC filters were placed and not retrieved in 455 patients (17%) in the entire cohort, in 150 patients (24.8%) in the active cancer stratum, and in 305 patients (15.1%) in the non-cancer stratum. In the entire cohort, non-retrieved IVC filter placement was not associated with a lower adjusted risk for PE recurrence (HR 0.59, 95% CI 0.30–1.15, P = 0.122), but with an increased adjusted risk for DVT recurrence (HR 2.27, 95% CI 1.43–3.60, P<0.001). In the non-cancer stratum, the non-retrieved IVC filter placement was associated with a decreased risk for PE (HR 0.29, 95% CI 0.09–0.93, P = 0.037), but not with an increased risk for DVT (HR 1.73, 95% CI 0.89–3.38, P = 0.108), while in the active cancer stratum, it was associated with an increased risk for DVT (HR 2.47, 95% CI 1.24–4.91, P = 0.010), but not with a decreased risk for PE (HR 0.82, 95% CI 0.34-–1.96, P = 0.650).ConclusionsThere were some differences in the risk-benefit balance between VTE patients with and without active cancer.     

Subcutaneous fat accumulation and BMI associated with risk for pulmonary embolism in patients with proximal deep vein thrombosis: a population study based on 23 796 consecutive autopsies

Objective. Although deep vein thrombosis (DVT) and pulmonary embolism (PE) are manifestations of the same disease, far from all patients develop PE. Our objective was to investigate risk-modifying factors. Setting, subjects and design. Between 1970 and 1982, 23 796 autopsies, representing 84% of all in-hospital deaths in the Malmö City population, were performed, using a standardized procedure. In a case–control study nested in a population-based cohort of patients with proximal DVT, the relationship between PE and body mass index (BMI), thoracic and abdominal subcutaneous (SC) fat thickness was evaluated. Results. Proximal DVT was found in 15%, of which 58% were women. Mean age in men was 4.5 years lower than in women (P < 0.001). Fifty per cent of the patients had PE, half of which were fatal. Similar age- and gender distribution was found in cases and controls. Patients in the upper tertile of BMI, abdominal and thoracic SC fat thickness had, in comparison with mid-tertile, and independent of age, gender and death from cancer disease, an increased odds (95% CI) for PE of 1.24 (1.04–1.47) (P = 0.014), 1.28 (1.07–1.53) (P = 0.006) and 1.35 (1.13–1.61) (P = 0.001), respectively, whereas in patients of the lower tertiles, a negative association was found. Conclusions. We found no differences in age- and gender distribution between PE cases and controls. BMI and SC fat thickness were markers of disease progression from proximal DVT to PE. The highly significant and independent association indicates that SC obesity may be of greater importance in venous thromboembolism as compared with cardiovascular diseases related to visceral (abdominal) obesity with lipid- and glucose metabolic disturbances.     

Risk factors and short-term mortality of venous thromboembolism diagnosed in the primary care setting in the United Kingdom

BACKGROUND: Venous thromboembolism (VTE) manifesting as deep vein thrombosis (DVT) and pulmonary embolism (PE) remains a common vascular disease with high mortality and morbidity. Our aim was to study the clinical spectrum of VTE, assess its incidence in the general population, and evaluate potential risk factors. METHODS: Prospective cohort study with nested case-control analysis using the General Practice Research Database (1994-2000). Venous thromboembolism was newly diagnosed in 6550 patients. Cases were compared with a random sample of 10,000 controls and frequency-matched by age, sex, and year. RESULTS: The incidence rate of VTE was 74.5 per 100,000 person-years. Overweight, varicose veins, inflammatory bowel disease, cancer, and oral corticosteroid use were associated with a greater risk of VTE. Ischemic heart disease, heart failure, and cerebrovascular diseases were associated with an increased risk of PE but not with DVT. Venous thromboembolism was strongly associated with fractures (odds ratio [OR], 21.3; 95% confidence interval [CI], 15.7-28.9) and surgery (OR, 25.0; 95% CI, 14.4-43.5). In women, the risk of VTE was 1.9 (95% CI, 1.5-2.3) among those receiving opposed hormone therapy (in which the woman takes estrogen throughout the month and progesterone for 10-14 days later in the month) and 1.9 (95% CI, 1.4-2.5) among those taking oral contraceptives. Cancer and cerebrovascular diseases presented a greater relative risk of fatal PE compared with nonfatal PE. CONCLUSIONS: Overweight, varicose veins, cancer, inflammatory bowel disease, fractures, surgery, and use of oral corticosteroids, oral contraceptives, and opposed hormone therapy were independent risk factors for both DVT and PE. The magnitude of the association with some risk factors varied between DVT and PE, as well as between fatal and nonfatal PE.     

Real world data on clinical profile,management and outcomes of venous thromboembolism from a tertiary care centre in India

ObjectivesVenous thromboembolism (VTE) is a major cause of mortality and morbidity worldwide. This study describes a real-world scenario of VTE presenting to a tertiary care hospital in India.MethodsAll patients presenting with acute VTE or associated complications from January 2017 to January 2020 were included in the study.ResultsA total of 330 patient admissions related to VTE were included over 3 years, of which 303 had an acute episode of VTE. The median age was 50 years (IQR 38–64); 30% of patients were younger than 40 years of age. Only 24% of patients had provoked VTE with recent surgery (56%) and malignancy (16%) being the commonest risk factors. VTE manifested as isolated DVT (56%), isolated pulmonary embolism (PE; 19.1%), combined DVT/PE (22.4%), and upper limb DVT (2.3%). Patients with PE (n = 126) were classified as low-risk (15%), intermediate-risk (55%) and high-risk (29%). Reperfusion therapy was performed for 15.7% of patients with intermediate-risk and 75.6% with high-risk PE. In-hospital mortality for the entire cohort was 8.9%; 35% for high-risk PE and 11% for intermediate-risk PE. On multivariate analysis, the presence of active malignancy (OR = 5.8; 95% CI: 1.1–30.8, p = 0.038) and high-risk PE (OR = 4.8; 95% CI: 1.6–14.9, p = 0.006) were found to be independent predictors of mortality.ConclusionOur data provides real-world perspectives on the demographic sand management of patients presenting with acute VTE in a referral hospital setting. We observed relatively high mortality for intermediate-risk PE, necessitating better subclassification of this group to identify candidates for more aggressive approaches.     

Impact of no,distal, and proximal deep vein thrombosis on clinical outcomes in patients with acute pulmonary embolism: From the COMMAND VTE registry

BackgroundThe majority of acute pulmonary embolism (PE) is caused by thrombus developed from leg veins. However, impact of concomitant deep venous thrombosis (DVT) on clinical outcomes has not been fully evaluated in patients with acute PE.MethodsThe COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic venous thromboembolism (VTE) in Japan. The current study population consisted of 655 acute PE patients who underwent lower extremities ultrasound examination at diagnosis for the assessment of concomitant DVT status.ResultsThere were 424 patients with proximal DVT (64.7%), 162 patients with distal DVT (24.7%), and 69 patients with no DVT (10.5%). The cumulative 90-day incidence of all-cause death was higher in proximal DVT patients than in distal DVT and no DVT patients (7.9%, 2.5%, and 1.4%, p = 0.01). Regarding the causes of death, the cumulative 90-day incidence of PE-related death was low, and not significantly different across the 3 groups (1.4%, 0.6%, and 1.7%, p = 0.62). The most frequent cause of death was cancer in proximal and distal DVT patients. There were no significant differences in 90-day rates of recurrent VTE and major bleeding, regardless of the status of concomitant DVT (2.9%, 3.2%, and 2.2%, p = 0.79, and 1.5%, 4.4%, and 4.9%, p = 0.46, respectively).ConclusionsAcute PE with proximal DVT at diagnosis was associated with a higher risk for short-term mortality than in patients without DVT, while the risk for short-term mortality was not significantly different between distal DVT patients and patients without DVT.     

Double trouble for 2,609 hospitalized medical patients who developed deep vein thrombosis: prophylaxis omitted more often and pulmonary embolism more frequent

BACKGROUND: Hospitalized patients with medical illness are especially susceptible to the development of venous thromboembolism (VTE). METHODS: To improve our understanding of the demographics, comorbidities, risk factors, clinical presentation, prophylaxis, and treatment of hospitalized medical patients with deep vein thrombosis (DVT), we evaluated hospitalized medical patients in a prospective registry of 5,451 consecutive ultrasound-confirmed DVT patients at 183 institutions in the United States. RESULTS: Of those patients who participated in the registry, 2,609 (48%) were hospitalized medical patients. Compared with 1,953 hospitalized nonmedical patients with DVT, medical patients with DVT experienced pulmonary embolism (PE) more often (22.2% vs 15.5%, respectively; p < 0.0001). However, medical patients in whom DVT developed had received VTE prophylaxis far less frequently than nonmedical patients (25.4% vs 53.8%, respectively; p < 0.0001). The underutilization of VTE prophylaxis among hospitalized medical patients extended to both pharmacologic and mechanical modalities. In a multivariable logistic regression analysis of all hospitalized VTE patients, status as a medical patient was negatively associated with receiving prophylaxis (adjusted odds ratio, 0.47; 95% confidence interval, 0.28 to 0.78). CONCLUSIONS: Hospitalized medical patients face "double trouble." First, during hospitalization for a reason other than VTE, VTE prophylaxis is omitted in medical patients more often than in nonmedical patients. Second, when VTE develops as a complication of hospitalization, hospitalized medical patients experience PE more often. Further studies should focus on understanding why prophylaxis is often omitted in hospitalized medical patients and on improving its implementation in this vulnerable population.     

Rates of pharmacologic venous thromboembolism prophylaxis in hospitalized patients with active ulcerative colitis: Results from a tertiary care center

BackgroundInflammatory bowel disease (IBD) patients are at increased risk for venous thromboembolism (VTE) compared to the general population. Practice guidelines recommend pharmacologic prophylaxis for IBD inpatients.AimOur aim was to determine the rates of pharmacologic VTE prophylaxis in ulcerative colitis (UC) inpatients at a tertiary referral center. We also assessed potential predictors of pharmacologic prophylaxis.MethodsWe conducted a retrospective cohort study of 377 UC patients between January 1st, 2007 and December 31st, 2011. The medical record of each patient was examined to determine whether pharmacologic VTE prophylaxis was ordered and administered. We conducted multiple logistic regression to determine predictors of pharmacologic prophylaxis.ResultsThe overall VTE pharmacologic prophylaxis rate was 67.6%. The rate of patients admitted to the medical service was 57.4% compared to 93.5% for those admitted to surgery. In medical patients who received pharmacologic VTE prophylaxis, 34.0% of ordered doses were not given compared to 17.4% of doses in surgical patients (P < 0.001). In the multiple logistic regression analysis, having an additional VTE risk factor (OR 2.46, 95% CI 1.41–4.30), extensive colitis (OR 2.26, 95% CI 1.32–3.87) or being admitted to a surgical service (OR 12.03, 95% CI 5.29–27.38) was associated with VTE pharmacologic prophylaxis.ConclusionsA substantial proportion of medical patients admitted with UC were not ordered for VTE pharmacologic prophylaxis despite current guidelines. Even in patients who were ordered for pharmacologic prophylaxis, one third of doses were not given. Inappropriate prophylaxis may lead to unnecessary morbidity and mortality.     

Pattern of Venous Thromboembolism Occurrence in Gynecologic Malignancy: Incidence,Timing, and Distribution a 10-Year Retrospective Single-institutional Study

The aim of this single-institutional 10-year retrospective study was to investigate the clinical pattern (incidence, type, timing, and location) of venous thromboembolism (VTE) in Chinese patients with gynecologic cancer.Cases were identified by searching institutional Electronic Discharge Database. A comprehensive review of medical documentation was then performed to collect relevant data. The detection of VTE was symptom-triggered.A total of 155 VTE events were identified out of 7562 cases over the past 10-year period in our hospital. The incidence of clinically significant VTE was 2.0% in gynecologic malignancy, with vulvar cancer (3.7%) and ovarian cancer (2.5%) being the high-risk types (P = 0.01, Chi-square test). Perioperative period (35.1%) and preoperation (29.1%) were the 2 incidence peaks. Seventeen cases of pulmonary embolism (PE) occurred prior to surgery. Ovarian cancer patients were more likely to present preoperative PE compared to other site of cancer (76.4%; P = 0.01, Chi-square test). More preoperative VTE cases were complicated by PE than those in the perioperative period (39.5% vs 17.3%, P = 0.02, Chi-square test). Bilateral lower extremity deep vein thrombosis (DVT) accounted for 32.6% and there existed a preponderance of left-sided DVT (47.5% vs 17.0%, ratio 2.79:1). Femoral vein (36.6%) was the most common location for DVT.About 2.0% of the Chinese patients with gynecologic carcinoma developed clinical VTE, mostly during perioperative period and the time of diagnosis. The true incidence might have been under-estimated due to several reasons. The need for increased patient education and awareness of VTE is of importance.     

The prevention of venous thromboembolism in older adults: guidelines

The rationale for thromboprophylaxis is based on the high prevalence of venous thromboembolism (VTE), a disorder involving deep vein thrombosis (DVT) and pulmonary embolism (PE), among hospitalized patients, the clinically silent nature of VTE in most patients, and the morbidity, cost, and potential mortality associated with unprevented thromboembolism. Both DVT and PE cause few specific symptoms, and the clinical diagnosis is unreliable. Since the first clinical manifestation of VTE may be fatal PE, it is inappropriate to wait for symptoms before treatment. Unrecognized and untreated DVT may also cause the postphlebitic syndrome and predispose patients to subsequent episodes of recurrent VTE. Routine screening for VTE has also not been shown to reduce the incidence of symptomatic VTE or fatal PE. Use of effective methods of prophylaxis is more cost effective and is safer than selective, intensive screening for VTE. This article reviews current recommendations for the prevention of VTE as they apply to older adults. The recommendations discussed are based on the Sixth American College of Chest Physicians Consensus Conference on Antithrombotic Therapy reported in Chest. 2001;119:132S-175S.     

Isolated calf deep vein thrombosis in the community setting: the Worcester Venous Thromboembolism study

The prevalence of isolated calf deep vein thrombosis (DVT) in the community setting is relatively unexplored. Confusion remains with regards to its management and contemporary natural history. The purpose of this investigation was to describe the number of cases of calf DVT in the community, use of early management strategies, and rates of venous thromboembolism (VTE) recurrence and major bleeding. The medical records of residents of the Worcester (MA) metropolitan area with ICD-9 codes consistent with potential VTE during 4 study years (1999/2001/2003/2005) were validated by trained nurses. Patient demographic/clinical characteristics, treatment practices, and outcomes were evaluated. Isolated calf DVT was diagnosed in 166 (11.1%) of 1,495 patients with lower extremity DVT. Patients with calf DVT were less likely to be discharged on anticoagulants or with an IVC filter than patients with proximal DVT (84.1 vs. 92.3%). The rates of VTE recurrence and pulmonary embolism did not differ significantly between patients with calf DVT and proximal DVT at 6 months (11.0 vs. 8.7%, 2.6 vs. 1.8%, respectively). Patients with calf DVT had higher adjusted risk of early (14-day) VTE recurrence/extension (OR 2.34, 95% CI 1.01–5.44). Patients with calf DVT had lower rates of major bleeding at 6 months compared to patients with proximal DVT (5.2 vs. 9.3%, P = 0.04). Rates of recurrent VTE and major bleeding following calf DVT in the community are much higher than in randomized clinical trials of patients with proximal or calf DVT. Further study of management strategies for isolated calf DVT is needed.     

Retrospective review of d-dimer testing for venous thrombosis recurrence risk stratification: is this a useful test in the real world?

Predicting the risk of recurrence after venous thromboembolism (VTE) remains an important clinical challenge. Post-anticoagulation cessation d-dimer has previously been shown to be associated with increased VTE recurrence in unprovoked major VTE, however this is not routinely used clinically and has not been validated in provoked VTE and isolated distal DVT (IDDVT). We aimed to retrospectively evaluate this practice in the real-world setting including examining its use in provoked VTE and IDDVT. Consecutive patients diagnosed with DVT or PE between January 2013 and December 2016 were retrospectively evaluated. Clinical features, VTE risk factors, recurrence and bleeding rates were evaluated for patients with normal and abnormal post-anticoagulation d-dimer, as well as those patients who did not undergo D-dimer testing. Patients with active malignancy, superficial vein thrombosis and inadequate follow-up were excluded. Of the 1033 patients with a diagnosis of VTE in the study period, 173 were included in the “d-dimer tested” group, and 254 in the “d-dimer un-tested” comparison group. Abnormal post-anticoagulation d-dimer was significantly associated with VTE recurrence (HR 5.96, 95% CI 2.15–14.57, p?<?0.001). Abnormal d-dimer was also associated with high risk of VTE recurrence in travel-provoked VTE (67.61 events per 100 patient-years), and unprovoked IDDVT (HR 14.37, 95% CI 1.75–117.83, p?=?0.013). Males with abnormal post-anticoagulation d-dimer were associated with the highest risk of VTE recurrence (HR 12.95, 95% CI 2.78–60.20, p?=?0.001). Patients with unprovoked proximal DVT and/or PE who underwent d-dimer testing had a lower VTE recurrence rate compared to those who did not have d-dimer testing (HR 0.28, 95% CI 0.10–0.80, p?=?0.017). We confirm the utility of post-anticoagulation cessation d-dimer testing to stratify VTE recurrence risk in the real-world setting, including potentially a role of this assay for predicting subsequent VTE in travel-provoked VTE and unprovoked IDDVT.

     

Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study

BACKGROUND: Because reported survival after venous thromboembolism (VTE) varies widely, we performed a population-based retrospective cohort study to estimate survival, compare observed with expected survival, and determine predictors of short-term (< or =7 days) and long-term survival (>7 days) after VTE. METHODS: We followed the 25-year (1966-1990) inception cohort (n = 2218) of Olmsted County, Minnesota, patients with deep vein thrombosis alone (DVT) or pulmonary embolism with or without deep vein thrombosis (PE+/-DVT) forward in time until death or the last clinical contact. RESULTS: During 14 629 person-years of follow-up, 1333 patients died. Seven-day, 30-day, and 1-year VTE survival rates were 74.8% (DVT, 96.2%; PE+/-DVT, 59.1%), 72.0% (DVT, 94.5%; PE+/-DVT, 55.6%), and 63.6% (DVT, 85.4%; PE+/-DVT, 47.7%), respectively. Observed survival after DVT, PE+/-DVT, and overall was significantly worse than expected for Minnesota whites of similar age and sex (P<.001). More than one third of deaths occurred on the date of onset or after VTE that was unrecognized during life. Short-term survival improved during the 25-year study period, while long-term survival was unchanged. After adjusting for comorbid conditions, PE+/-DVT was an independent predictor of reduced survival for up to 3 months after onset compared with DVT alone. Other independent predictors of both short- and long-term survival included age, body mass index, patient location at onset, malignancy, congestive heart failure, neurologic disease, chronic lung disease, recent surgery, and hormone therapy. Additional independent predictors of long-term survival included tobacco smoking, other cardiac disease, and chronic renal disease. CONCLUSIONS: Survival after VTE, and especially after PE+/-DVT, is much worse than reported, and significantly less than expected survival. Compared with DVT alone, symptomatic PE+/-DVT is an independent predictor of reduced survival for up to 3 months after onset, implying that treatment for the 2 disorders should be different.