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Schellack, Gustav, Tumelo Modau, and Natalie Schellack. "Clinical overview of venous thromboembolism." South African Family Practice 58, no. 1 (January 1, 2016): 7. http://dx.doi.org/10.4102/safp.v58i1.4373.
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Venous thromboembolism (VTE) encompasses two vascular conditions that are of significant importance, namely deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT is also the most common cause of PE. Medical and surgical patients, and individuals who are at increased risk of developing VTE through a variety of factors, require adequate thromboprophylaxis. Primary and secondary prevention, as well as the definitive treatment of VTE, are accomplished through the use of a variety of anticoagulant drugs. This article attempts to provide an overview of VTE, and its prevention and treatment.
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Kearon, Clive. "Diagnosis of suspected venous thromboembolism." Hematology 2016, no. 1 (December 2, 2016): 397–403. http://dx.doi.org/10.1182/asheducation-2016.1.397.
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Abstract The primary goal of diagnostic testing for venous thromboembolism (VTE) is to identify all patients who could benefit from anticoagulant therapy. Test results that identify patients as having a ≤2% risk of VTE in the next 3 months are judged to exclude deep vein thrombosis (DVT) or pulmonary embolism (PE). Clinical evaluation, with assessment of: (1) clinical pretest probability (CPTP) for VTE; (2) likelihood of important alternative diagnoses; and (3) the probable yield of D-dimer and various imaging tests, guide which tests should be performed. The combination of nonhigh CPTP and negative D-dimer testing excludes DVT or PE in one-third to a half of outpatients. Venous ultrasound of the proximal veins, with or without examination of the distal veins, is the primary imaging test for leg and upper-extremity DVT. If a previous test is not available for comparison, the positive predictive value of ultrasound is low in patients with previous DVT. Computed tomography pulmonary angiography (CTPA) is the primary imaging test for PE and often yields an alternative diagnosis when there is no PE. Ventilation-perfusion scanning is associated with less radiation exposure than CTPA and is preferred in younger patients, particularly during pregnancy. If DVT or PE cannot be “ruled-in” or “ruled-out” by initial diagnostic testing, patients can usually be managed safely by: (1) withholding anticoagulant therapy; and (2) doing serial ultrasound examinations to detect new or extending DVT.
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Spencer, Frederick A., Robert J. Goldberg, Cathy Emery, Darleen Lessard, Apar Bains, Richard C. Becker, and Frederick A. Anderson. "The Worcester Venous Thromboembolism Study: A Population Based Perspective of Venous Thromboembolism Attack Rates." Blood 106, no. 11 (November 16, 2005): 2242. http://dx.doi.org/10.1182/blood.v106.11.2242.2242.
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Abstract Background: Although increasingly recognized as a major clinical problem, most reported estimates of the attack rates of venous thromboembolism (VTE) are based on studies enrolling patients more than a decade ago. Given changes in patient characteristics, risk factor profiles, and prophylaxis strategies over time, more current estimates are needed if we are to better target high-risk patients and allocate limited health care resources. The purpose of this study was to describe crude, as well as age and gender adjusted, attack rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) in residents of the Worcester Statistical Metropolitan Area (SMSA) during the year 1999. Methods: The medical records of all male and female residents from the Worcester SMSA (2000 census = 478,000) diagnosed with ICD-9 codes consistent with possible DVT and/or PE at all 11 greater Worcester hospital during 1999 were reviewed by trained data abstractors. Characterization of each case of VTE was classified as definite, probable, or possible using prespecified criteria. For purposes of this analysis we approximated attack rates for the total Worcester SMSA population. However, for several specific analyses we have excluded 15 cases of validated VTE occurring in patients < 25 years of age. Age and sex-specific attack rates were calculated in a standard manner. Attack estimates were based on 2000 Massachusetts Census data for the Worcester SMSA which reported 287,631 residents 25 years of age or older. Results: There were a total of 590 recognized episodes of VTE in residents of the Worcester SMSA yielding an approximate attack rate of 123/100,000 population. Approximately one quarter of patients developed VTE during hospitalization for another indication while the remaining three quarters presented to the hospital with VTE. Excluding 15 cases of VTE occurring in patients < 25 years of age yields an attack rate of 200 per 100,000 population (95% C.I. 184, 216). Our study sample included 420 cases of isolated DVT (146/100,000 population), 140 cases of PE with or without DVT (49/100,000 population), and 74 cases of recurrent DVT (26/100,000 population). Overall, attack rates of DVT and PE for females were similar to those of men (DVT 152/100,000 vs 139/100,000; PE 51/100,000 vs 45/100,000). However attack rates in females age 75 years and older were significantly greater than those in men of the same age. The age and specific attack rates of clinically recognized VTE are shown in Figure 1. Conclusions: The annual overall attack rate of VTE in this community based study was slightly higher than that reported in the initial Worcester DVT study of 1985/1986 (107/100,000). In addition, if one excludes the small number of cases of VTE occurring in the young, attack rates/100,000 are almost doubled and increase rapidly with age particularly in women. These data have important implications for targeting of VTE prophylaxis and utilization of health care resources. Attack rate of clinical recognized VTE per 100,000 population: The Worcester Venous Thromboembolism Study 1999 Attack rate of clinical recognized VTE per 100,000 population: The Worcester Venous Thromboembolism Study 1999
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Okumus, Gulfer, Esen Kiyan, Orhan Arseven, Levent Tabak, Reyhan Diz-Kucukkaya, Yesim Unlucerci, Neslihan Abaci, Nihan Erginel Ünaltuna, and Halim Issever. "Hereditary Thrombophilic Risk Factors and Venous Thromboembolism in Istanbul, Turkey: The Role in Different Clinical Manifestations of Venous Thromboembolism." Clinical and Applied Thrombosis/Hemostasis 14, no. 2 (April 2008): 168–73. http://dx.doi.org/10.1177/1076029607305620.
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The aim of this study was to investigate the hereditary thrombophilic risk factors in patients with venous thromboembolism (VTE) and whether these risk factors play a different role in patients with isolated pulmonary embolism (PE) as compared with patients with deep vein thrombosis (DVT) and patients with PE + DVT. The protein C (PC), protein S, antithrombin activities, homocysteine levels, and factor V Leiden (FVL) G1691A and prothrombin G20210A mutations were evaluated in 191 patients with VTE and 191 controls. The prevalence of FVL and PC deficiency were higher in patients ( P = .003 and P = .02, respectively). There was no significant difference for the other risk factors. The combination of thrombophilic risk factors was significantly higher in patients with DVT + PE as compared with patients with isolated PE or DVT ( P = .04). In conclusion, the most important hereditary risk factors for VTE in this study were the FVL mutation and PC deficiency.
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Lim, Wendy, Grégoire Le Gal, Shannon M. Bates, Marc Righini, Linda B. Haramati, Eddy Lang, Jeffrey A. Kline, et al. "American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism." Blood Advances 2, no. 22 (November 27, 2018): 3226–56. http://dx.doi.org/10.1182/bloodadvances.2018024828.
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AbstractBackground:Modern diagnostic strategies for venous thromboembolism (VTE) incorporate pretest probability (PTP; prevalence) assessment. The ability of diagnostic tests to correctly identify or exclude VTE is influenced by VTE prevalence and test accuracy characteristics.Objective:These evidence-based guidelines are intended to support patients, clinicians, and health care professionals in VTE diagnosis. Diagnostic strategies were evaluated for pulmonary embolism (PE), deep vein thrombosis (DVT) of the lower and upper extremity, and recurrent VTE.Methods:The American Society of Hematology (ASH) formed a multidisciplinary panel including patient representatives. The McMaster University GRADE Centre completed systematic reviews up to 1 October 2017. The panel prioritized questions and outcomes and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. Test accuracy estimates and VTE population prevalence were used to model expected outcomes in diagnostic pathways. Where modeling was not feasible, management and accuracy studies were used to formulate recommendations.Results:Ten recommendations are presented, by PTP for patients with suspected PE and lower extremity DVT, and for recurrent VTE and upper extremity DVT.Conclusions:For patients at low (unlikely) VTE risk, using D-dimer as the initial test reduces the need for diagnostic imaging. For patients at high (likely) VTE risk, imaging is warranted. For PE diagnosis, ventilation-perfusion scanning and computed tomography pulmonary angiography are the most validated tests, whereas lower or upper extremity DVT diagnosis uses ultrasonography. Research is needed on new diagnostic modalities and to validate clinical decision rules for patients with suspected recurrent VTE.
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Bishop, Meghan, Matthew Astolfi, Eric Padegimas, Peter DeLuca, and Sommer Hammoud. "Venous Thromboembolism Within Professional American Sport Leagues." Orthopaedic Journal of Sports Medicine 5, no. 12 (December 1, 2017): 232596711774553. http://dx.doi.org/10.1177/2325967117745530.
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Background: Numerous reports have described players in professional American sports leagues who have been sidelined with a deep vein thrombosis (DVT) or a pulmonary embolism (PE), but little is known about the clinical implications of these events in professional athletes. Purpose: To conduct a retrospective review of injury reports from the National Hockey League (NHL), Major League Baseball (MLB), the National Basketball Association (NBA), and the National Football League (NFL) to take a closer look at the incidence of DVT/PE, current treatment approaches, and estimated time to return to play in professional athletes. Study Design: Descriptive epidemiology study. Methods: An online search of all team injury and media reports of DVT/PE in NHL, MLB, NBA, and NFL players available for public record was conducted by use of Google, PubMed, and SPORTDiscus. Searches were conducted using the professional team name combined with blood clot, pulmonary embolism, and deep vein thrombosis. Results: A total of 55 venous thromboembolism (VTE) events were identified from 1999 through 2016 (NHL, n = 22; MLB, n = 16; NFL, n = 12; NBA, n = 5). Nineteen athletes were reported to have an upper extremity DVT, 15 had a lower extremity DVT, 15 had a PE, and 6 had DVT with PE. Six athletes sustained more than 1 VTE. The mean age at time of VTE was 29.3 years (range, 19-42 years). Mean (±SD) time lost from play was 6.7 ± 4.9 months (range, 3 days to career end). Seven athletes did not return to play. Players with upper extremity DVT had a faster return to play (mean ± SD, 4.3 ± 2.7 months) than those with lower extremity DVT (5.9 ± 3.8 months), PE (10.8 ± 6.8 months), or DVT with PE (8.2 ± 2.6 months) ( F = 5.69, P = .002). No significant difference was found regarding time of return to play between sports. Conclusion: VTE in professional athletes led to an average of 6.7 months lost from play. The majority of athletes were able to return to play after a period of anticoagulation or surgery. Those with an upper extremity DVT returned to play faster than those with other types of VTE. Further study is needed to look into modifiable risk factors for these events and to establish treatment and return-to-play guidelines to ensure the safety of these athletes.
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Weitz, Jeffrey I., and Noel C. Chan. "Novel antithrombotic strategies for treatment of venous thromboembolism." Blood 135, no. 5 (January 30, 2020): 351–59. http://dx.doi.org/10.1182/blood.2019000919.
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Abstract Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cause of vascular death after heart attack and stroke. Anticoagulation therapy is the cornerstone of VTE treatment. Despite such therapy, up to 50% of patients with DVT develop postthrombotic syndrome, and up to 4% of patients with PE develop chronic thromboembolic pulmonary hypertension. Therefore, better therapies are needed. Although direct oral anticoagulants are more convenient and safer than warfarin for VTE treatment, bleeding remains the major side effect, particularly in cancer patients. Factor XII and factor XI have emerged as targets for new anticoagulants that may be safer. To reduce the complications of VTE, attenuation of thrombin activatable fibrinolysis inhibitor activity is under investigation in PE patients to enhance endogenous fibrinolysis, whereas blockade of leukocyte interaction with the vessel wall is being studied to reduce the inflammation that contributes to postthrombotic syndrome in DVT patients. Focusing on these novel antithrombotic strategies, this article explains why safer anticoagulants are needed, provides the rationale for factor XII and XI as targets for such agents, reviews the data on the factor XII– and factor XI–directed anticoagulants under development, describes novel therapies to enhance fibrinolysis and decrease inflammation in PE and DVT patients, respectively, and offers insights into the opportunities for these novel VTE therapies.
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Rai, Manoj P., Prabhjot Singh Bedi, Justin D. Kaner, Samanjit Kaur Kandola, Konchok Norgais, Nishant Tageja, Heather Laird-Fick, James B. Bussel, Stanley M. Marks, and Marwan S. Abougergi. "Venous Thromboembolism (VTE) in Hematological and Non-Hematological Cancers: A Nationwide Analysis." Blood 132, Supplement 1 (November 29, 2018): 3563. http://dx.doi.org/10.1182/blood-2018-99-115839.
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Abstract Introduction: Cancer patients tend to have a higher incidence of venous thromboembolism (VTE) - pulmonary embolism (PE) and deep venous thrombosis (DVT). There is conflicting data in the literature about the incidence of VTE in solid tumors versus hematological cancers. The purpose of this study was to analyze the prevalence of PE, DVT, and VTE in hospitalized patients with solid and hematologic malignancies using the National Inpatient Sample database. Methods: We performed a retrospective cohort analysis of the National Inpatient Sample 2014 Database (HCUP-NIS). Patients were included in the study if they had a principal diagnosis of DVT, PE, or both (VTE); primary or secondary diagnosis of solid tumors or hematological malignancy; and age 18 years or older. We performed univariate and multivariate regression to analyze the association of PE, DVT, and VTE with solid versus hematologic cancers. We performed univariate and multivariate regression to determine their statistical significance. We also performed univariate analysis for tumor type and saddle PE and upper extremity DVT. All analyses applied the HCUP-NIS weights. Results: We identified 27,410 patients with isolated DVT; 41,645 with isolated PE; and 69,055 with both DVT and PE (VTE). On multivariate analysis, hematologic malignancy had lower odds of DVT (OR 0.82, 95% CI 0.75-0.89), isolated PE (OR 0.65, 95% CI 0.60 - 0.71) and VTE (OR 0.72, 95% CI 0.67-0.76). Female sex and Charlson index were associated with modest increased odds of DVT, PE and VTE (OR <1.10 for all), while Asian/Pacific Islander race was associated with lower odds for each (OR 0.48-0.55). In contrast, black race was associated with greater odds of DVT (OR 1.49, 95% CI 1.37-1.62) and VTE (OR 1.27, 95% CI 1.2-1.34), but lower odds of isolated PE (OR 0.48, 95% CI 0.38-0.59). Native American and other race had lower odds of VTE (OR 1.27, 95% CI 1.2-1.34 and OR 0.82, 95% CI 0.71-0.95, respectively). Hispanic ethnicity had lower odds of PE (OR 0.66, 95% CI 0.59-0.73) and VTE (OR 0.76, 95% CI 0.70-0.82). Although, 91.1% of patients with malignancy and saddle PE had solid tumors, tumor type (solid versus hematological) was not statistically significant on univariate regression analysis (OR 0.83, 95% CI 0.58-1.18). Hematologic malignancy was associated with less upper extremity DVT (OR 0.69, 95% CI 0.54-0.88). Discussion: Based on the above data, patients with solid tumors are more likely to develop isolated DVT, PE, VTE, and upper extremity DVT. The analysis was likely underpowered to identify a difference for saddle PE, a relatively rare event with high mortality. Race appears to be associated in complex ways. In particular, it is unclear why black patients have increased odds of developing DVT or VTE, but lower odds for isolated PE. Two possible explanations are differences in health seeking behavior or increased outpatient mortality for isolated PE. As with saddle PE, it's likely the sample was too small to find differences for isolated DVT or PE for Native Americans and others. Additional studies to examine the reasons for differences by tumor type and race/ethnicity are needed. Table. Table. Disclosures Bussel: Rigel: Consultancy, Research Funding; Amgen Inc.: Consultancy, Research Funding; Protalex: Consultancy; Novartis: Consultancy, Research Funding; Momenta: Consultancy; Uptodate: Honoraria; Prophylix: Consultancy, Research Funding. Marks:Seattle Genetics: Equity Ownership; Heron: Membership on an entity's Board of Directors or advisory committees; Lilly: Membership on an entity's Board of Directors or advisory committees; Odonate: Membership on an entity's Board of Directors or advisory committees; UPMC: Employment.
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Lex, Johnathan R., Scott Evans, Paul Cool, Jonathan Gregory, Robert U. Ashford, Kenneth S. Rankin, Tom Cosker, Amit Kumar, Craig Gerrand, and Jonathan Stevenson. "Venous thromboembolism in orthopaedic oncology." Bone & Joint Journal 102-B, no. 12 (December 1, 2020): 1743–51. http://dx.doi.org/10.1302/0301-620x.102b12.bjj-2019-1136.r3.
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Aims Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients. Methods MEDLINE (PubMed), EMBASE (Ovid), Cochrane, and CINAHL databases were searched focusing on VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, or wound complication rates. Results In all, 17 studies published from 1998 to 2018 met the inclusion criteria for the systematic review. The mean incidence of all VTE events in orthopaedic oncology patients was 10.7% (1.1% to 27.7%). The rate of PE was 2.4% (0.1% to 10.6%) while the rate of lethal PE was 0.6% (0.0% to 4.3%). The overall rate of DVT was 8.8% (1.1% to 22.3%) and the rate of symptomatic DVT was 2.9% (0.0% to 6.2%). From the studies that screened all patients prior to hospital discharge, the rate of asymptomatic DVT was 10.9% (2.0% to 20.2%). The most common risk factors identified for VTE were endoprosthetic replacements, hip and pelvic resections, presence of metastases, surgical procedures taking longer than three hours, and patients having chemotherapy. Mean incidence of VTE with and without chemical prophylaxis was 7.9% (1.1% to 21.8%) and 8.7% (2.0% to 23.4%; p = 0.11), respectively. No difference in the incidence of bleeding or wound complications between prophylaxis groups was reported. Conclusion Current evidence is limited to guide clinicians. It is our consensus opinion, based upon logic and deduction, that all patients be considered for both mechanical and chemical VTE prophylaxis, particularly in high-risk patients (pelvic or hip resections, prosthetic reconstruction, malignant diagnosis, presence of metastases, or surgical procedures longer than three hours). Additionally, the surgeon must determine, in each patient, if the risk of haemorrhage outweighs the risk of VTE. No individual pharmacological agent has been identified as being superior in the prevention of VTE events. Cite this article: Bone Joint J 2020;102-B(12)1743:–1751.
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Veiraiah, A., HGM Shetty, and PA Routledge. "Prevention and treatment of venous thromboembolism in older people." Reviews in Clinical Gerontology 18, no. 3 (August 2008): 219–28. http://dx.doi.org/10.1017/s0959259809002871.
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The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively called venous thromboembolism (VTE), increases with age and has been reported to be higher in males. The annual incidence rates per 1000 for DVT and PE are 1.3 and 1.8, respectively, for people aged between 65 and 69 years, rising to 2.8 and 3.1, respectively, in those aged between 85 and 89 years. Older people are about eight times more likely to develop VTE in hospitals, nursing homes or other chronic care facilities than younger adults. About 1.7% develop PE within one year of treatment for DVT, whilst the one year recurrence rate for PE was 8.0%. About 3% of patients with DVT and 21% of those with PE die in hospital. One year mortality with DVT is 21% and that with PE is 39%.
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Kearon, Clive, and Susan R. Kahn. "Long-term treatment of venous thromboembolism." Blood 135, no. 5 (January 30, 2020): 317–25. http://dx.doi.org/10.1182/blood.2019002364.
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Abstract The most important decision in the long-term treatment of venous thromboembolism (VTE) is how long to anticoagulate. VTE provoked by a reversible risk factor, or a first unprovoked isolated distal deep vein thrombosis (DVT), generally should be treated for 3 months. VTE provoked by a persistent or progressive risk factor (eg, cancer), or a second unprovoked proximal DVT or PE, is generally treated indefinitely. First unprovoked proximal DVT or PE may be treated for 3 to 6 months or indefinitely. Male sex, presentation as PE (particularly if concomitant proximal DVT), a positive d-dimer test after stopping anticoagulation, an antiphospholipid antibody, low risk of bleeding, and patient preference favor indefinite anticoagulation. The type of indefinite anticoagulation is of secondary importance. Low-dose oral Xa inhibitors are convenient and are thought to have a lower risk of bleeding; they are less suitable if there is a higher risk for recurrence. For cancer-associated VTE, we now prefer full-dose oral Xa inhibitors over low-molecular-weight heparin, with gastrointestinal lesions being a relative contraindication. Graduated compression stockings are not routinely indicated after DVT, but are encouraged if there is persistent leg swelling or if a trial of stockings improves symptoms. Medications have a limited role in the treatment of postthrombotic syndrome. After PE, patients should have clinical surveillance for chronic thromboembolic pulmonary hypertension (CTEPH), with ventilation-perfusion scanning and echocardiography being the initial diagnostic tests if CTEPH is a concern. Patients with CTEPH and other symptomatic patients with extensive residual perfusion defects should be evaluated for endarterectomy, balloon pulmonary angioplasty, or vasodilator therapies.
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Sayegh, Faisal Al, Wael Almahmeed, Mahmoud Marashi, Ahmed Bahr, Hasan Al Mahdi, Sherif Bakir, Salah Al Humood, and Maha Al Farhan. "Global Risk Profile Verification in Patients with Venous Thromboembolism (GRIP VTE) in Five Gulf Countries." Blood 104, no. 11 (November 16, 2004): 4067. http://dx.doi.org/10.1182/blood.v104.11.4067.4067.
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Abstract Background: The Global Risk Profile Verification in Patients with Venous Thromboembolism (GRIP VTE) was the first prospective multicenter registry conducted in five Gulf countries to explore the epidemiology of venous thromboembolic (VTE) disorders and to provide data on diagnosis and disease management. Methods: Data on 242 patients with confirmed VTE were submitted between September 2003 and November 2003 by multidisciplinary specialists from 28 contributing hospitals in the Gulf region (Kuwait, Bahrain, Qatar, Oman, and the UAE). Patients with a suspected diagnosis of VTE were included. The data management team at a sponsor-independent study coordinating center ensured data quality. Differences between groups were assessed by the Chi square test or Fisher exact test for categorical variables. The Student t-test was used for testing proportions. A two-tailed P value <0.05 was considered significant. Doppler ultrasound and lung scans were the most preferred modalities in the diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE). Results: The table shows the incidence of VTE. The most common symptoms of DVT and DVT/PE patients were calf pain (72%), calf swelling (63.8%), and localized tenderness (52.2%). Calf pain and localized tenderness were significantly greater (P <0.001) in cases of DVT alone than in cases of DVT/PE. The most common symptoms in patients with PE alone and DVT/PE were dyspnea (83.6%), thoracic pain (69.1%), and cough (40%). Cough and hemoptysis occurred more frequently in PE cases than in cases of DVT/PE (P <0.001). Risk factors for VTE were immobilization >3 days (41.3%), age >65 years (28.9%), a history of VTE (20.7%), and trauma (19%). Surgical intervention in the previous year was an independent risk factor for VTE, 83.8% of such patients experiencing VTE within 4 weeks of surgery. There was a strong association between VTE and orthopedic procedures (P=0.0016). Among surgical interventions, orthopedic procedures induced the greatest number of VTE cases, followed by general surgical procedures and gynecological procedures. Low molecular weight heparins (LMWHs) were chosen to treat 33.7% of DVT cases, while unfractionated heparin (UFH) was used in 21.9% of cases. UFH use in PE and DVT/PE was 57.1% and 55%, respectively, and LMWHs use was 14.3% each for PE and DVT/PE. Oral anticoagulant use in DVT/PE, DVT, and PE was 30%, 19.8%, and 2.9%, respectively. Conclusion: The main risk factors predisposing to VTE are immobilization, age >65 years, a history of VTE, and trauma. The highest incidence was observed in medical patients, necessitating prophylaxis in patients at risk. Previous surgical interventions were independent risk factors for VTE, requiring extended prophylaxis, including outpatient thromboprophylaxis, in patients undergoing extensive surgical procedures. Incidence of DVT, PE, and DVT/PE DVT PE DVT/PE Frequency of cases - n (%) 187 (77.27%) 35 (14.46%) 20 (8.26%) Departments Medical 74 (39.5%) 19 (54.28%) 10 (50%) Surgical 61 (32.62%) 9 (25.71%) 6 (30%) Others 52 (27.8%) 7 (20%) 4 (20%)
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Aviña-Zubieta, Juan Antonio, Jonathan Chan, Mary De Vera, Eric C. Sayre, Hyon Choi, and John Esdaile. "Risk of venous thromboembolism in ankylosing spondylitis: a general population-based study." Annals of the Rheumatic Diseases 78, no. 4 (February 8, 2019): 480–85. http://dx.doi.org/10.1136/annrheumdis-2018-214388.
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BackgroundVenous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT), can be life threatening. An increased frequency of VTE has been found in inflammatory conditions. To date, evidence assessing whether this risk is also greater in patients with ankylosing spondylitis (AS) is scarce.MethodsUsing the provincial British Columbia, Canada healthcare database that encompasses all residents within the province, we conducted matched cohort analyses of incident PE, DVT and overall VTE among incident cases of AS and compared them with individuals randomly selected from the general population without AS. We calculated incidence rates (IRs) of VTE and multivariable analyses after adjusting for traditional risk factors using Cox models.ResultsAmong 7190 incident cases of AS, 35 developed PE and 47 developed DVT. IRs of PE, DVT and overall VTE per 1000 person-years for patients with AS were 0.79, 1.06, 1.56 compared with 0.40, 0.50, 0.77 in the control cohort. Corresponding fully adjusted HRs (95% CI) of PE, DVT and VTE were 1.36 (0.92 to 1.99), 1.62 (1.16 to 2.26) and 1.53 (1.16 to 2.01), respectively. The risks of PE, DVT and VTE were highest in the first year of diagnosis with HR (95% CI) of 2.88 (0.87 to 9.62), 2.20 (0.80 to 6.03) and 2.10 (0.88 to 4.99), respectively.ConclusionsThese findings demonstrate an increased risk of VTE in the general AS population. This risk appears the most prominent in the first year after diagnosis.
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Patel, Harish, Haozhe Sun, Ali N. Hussain, and Trupti Vakde. "Advances in the Diagnosis of Venous Thromboembolism: A Literature Review." Diagnostics 10, no. 6 (June 2, 2020): 365. http://dx.doi.org/10.3390/diagnostics10060365.
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The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.
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Meyer, Guy, Hervé Decousus, Giancarlo Agnelli, and Joseph Emmerich. "Role of fibrinolysis and interventional therapy for acute venous thromboembolism." Thrombosis and Haemostasis 96, no. 09 (2006): 251–07. http://dx.doi.org/10.1160/th06-05-0244.
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SummaryThe initial goals of treatment for venous thromboembolism (VTE) are usually achieved with anticoagulation. This reviewfocuses on fibrinolysis and interventional therapy in VTE, treatments whose indications are much more controversial. The benefit-to-risk ratio of fibrinolysis in deep vein thrombosis (DVT) is dubious. Thrombolytic treatment is recommended forunstable patients with pulmonary embolism (PE), although these patients represent less than 5% of all patients hospitalized for PE. The use of thrombolytic treatment in patients with sub-massive PE remains controversial. Two indications are widely recognized for inferior vena cava filters: the first isa permanent or temporary contraindication to anticoagulation, in patients with proximal DVT or PE. The second is the occurrence of PE or propagation of the thrombus in patients treated for DVT or recurrence in patients with PE. The PREPIC study demonstrated that in acute VTE, vena cava filters reduced the risk of PE but increased that of DVT and had no effect on survival. The fact that prevention of PE is mainly observed during the short initial period following the diagnosis of an acute VTE event justifies a new randomized study with the use of retrievable filters as an adjuvant to anticoagulation in high risk patients with PE.
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Khaldi, Ahmad, Naseem Helo, Michael J. Schneck, and Thomas C. Origitano. "Venous thromboembolism: deep venous thrombosis and pulmonary embolism in a neurosurgical population." Journal of Neurosurgery 114, no. 1 (January 2011): 40–46. http://dx.doi.org/10.3171/2010.8.jns10332.
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Object Venous thromboembolism (VTE), a combination of deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity and death in neurosurgical patients. This study evaluates 1) the risk of developing lower-extremity DVT following a neurosurgical procedure; 2) the timing of initiation of pharmacological DVT prophylaxis upon the occurrence of VTE; and 3) the relationship between DVT and PE as related to VTE prophylaxis in neurosurgical patients. Methods The records of all neurosurgical patients between January 2006 and December 2008 (2638 total) were reviewed for clinical documentation of VTE. As part of a quality improvement initiative, a subgroup of 1638 patients was studied during the implementation of pharmacological prophylaxis. A high-risk group of 555 neurosurgical patients in the intensive care unit underwent surveillance venous lower-extremity duplex ultrasonography studies twice weekly. All patients throughout the review received mechanical DVT prophylaxis. Pharmacological DVT prophylaxis, consisting of 5000 U of subcutaneous heparin twice daily (initially started within 48 hours of a neurosurgical procedure and subsequently within 24 hours of a procedure) was implemented in combination with mechanical prophylaxis. The DVT and PE rates were calculated for each group. Results In the surveillance group (555 patients), 84% of the DVTs occurred within 1 week and 92% within 2 weeks of a neurosurgical procedure. There was a linear correlation between the duration of surgery and DVT development. The use of subcutaneous heparin reduced the rate of DVT from 16% to 9% when medication was given at either 24 or 48 hours postoperatively, without any increase in hemorrhagic complications. In the overall group (2638 patients), there were 94 patients who exhibited clinical signs of a possible PE and therefore underwent spiral CT; 22 of these patients (0.8%) had radiological confirmation of PE. There was no correlation between the use of pharmacological prophylaxis at either time point and the occurrence of PE, despite a 43% reduction in the lower-extremity DVT rate with pharmacological intervention. Conclusions The majority of DVTs occurred within the first week after a neurosurgical procedure. There was a linear correlation between the duration of surgery and DVT occurrence. Use of early subcutaneous heparin (at either 24 or 48 hours) was associated with a 43% reduction of developing a lower-extremity DVT, without an increase in surgical site hemorrhage. There was no association of pharmacological prophylaxis with overall PE occurrence.
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Puhr, Hannah C., Lisbeth Eischer, Hana Šinkovec, Ludwig Traby, Paul A. Kyrle, and Sabine Eichinger. "Circumstances of provoked recurrent venous thromboembolism: the Austrian study on recurrent venous thromboembolism." Journal of Thrombosis and Thrombolysis 49, no. 4 (October 17, 2019): 505–10. http://dx.doi.org/10.1007/s11239-019-01965-z.
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Abstract Patients with unprovoked deep-vein thrombosis (DVT) of the leg or pulmonary embolism (PE) have a high recurrence risk. How often these recurrences are provoked by a temporary risk condition is unknown. In a cohort of patients with unprovoked venous thromboembolism (VTE), we evaluated the clinical circumstances of recurrence. We studied patients with DVT of the leg and/or PE. End point was recurrence of objectively verified symptomatic VTE. Provoked recurrence was defined according to guidance criteria. 1188 patients were followed for a median of 8.9 years after withdrawal of oral anticoagulants. 312 patients had recurrent VTE, which was provoked in 42 (13%). Recurrence was related to a major risk factor in 19, to a minor risk factor in 22, and to a persistent risk factor in one patient(s). 14 recurrences occurred after major surgery and 5 during hospitalization. Ten recurrences occurred after minor surgery, eight after trauma and three during female hormone intake. Four recurrences occurred during heparin prophylaxis. The incidence of provoked VTE recurrence appears to be low. VTE can recur when prevention is stopped or even during thromboprophylaxis. Surgery and trauma are frequent risk factors.
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Hajouli, Said. "Massive Fatal Pulmonary Embolism While on Therapeutic Heparin Drip." Journal of Investigative Medicine High Impact Case Reports 8 (January 2020): 232470962091478. http://dx.doi.org/10.1177/2324709620914787.
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Venous thromboembolism (VTE) includes deep venous thrombosis (DVT) and pulmonary embolism (PE). In this article, we present a case of a patient with an acute DVT who was treated with a therapeutic heparin drip, then developed syncope while in the hospital and found to have massive bilateral PEs. This case aims to arouse the medical staff’s awareness of the VTE diagnosis even if the patient is fully anticoagulated. We review the indications for DVT hospitalization, heparin infusion monitoring, risk factors for developing PE from DVT, mechanisms of developing PE from DVT while on therapeutic anticoagulation, and signs and treatment of massive PE.
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Kondal, Dimple, Vicky Tagalakis, Antonio Ciampi, and Susan Kahn. "Seasonal Variation In the Occurrence of Venous Thromboembolism In Canada." Blood 116, no. 21 (November 19, 2010): 5120. http://dx.doi.org/10.1182/blood.v116.21.5120.5120.
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Abstract Abstract 5120 Background. The evidence in support of a seasonal variation in the occurrence of venous thromboembolism (VTE) is conflicting and based on studies of mostly small or moderate size, often single centered and moreover, have never included data from Canada which has clearly-defined seasons with wide temperature differences between winter and summer months. Objectives. We used discharge data from a population-level hospital registry to assess the occurrence of a seasonal pattern in hospital admissions with VTE (deep vein thrombosis (DVT) or pulmonary embolism (PE)), DVT alone and PE alone in the province of Quebec, Canada. Methods. Using data from the province of Quebec's hospital discharge database (Med-Echo) which systematically records information on all hospital admissions in Quebec since 1967, we constructed a retrospective cohort of all individuals who had a first-time discharge diagnosis of DVT or PE between January 1, 1996 and December 31, 2004 and no prior discharge diagnosis for DVT or PE back to 1983. DVT and PE were defined based on the International Classification of Diseases, 9th edition, Clinical Modification. VTE cases were grouped according to season and month of occurrence, and statistical significance of seasonal variation was determined using the Edwards' and Walter & Elwood test. Results. The cohort comprised of 45,588 (26,076 (57%) women and 19,512 (43%) men) admitted patients with incident VTE. The mean age was 62.5 years (SD 17.6) and 26,537 (58%) patients had DVT alone, 12,758 (28%) had PE alone and 6,239 (14%) had DVT with PE. Data by season showed a statistically significant difference with the lowest proportion of hospital VTE admissions in summer months (24.1%) and highest in winter (25.9%) months (p<0.0001). Seasonal variation in number of admissions by month was statistically significant for PE alone (p=0.0084; adjusted for total number of monthly hospital admissions for the Quebec province) with peak occurrence in November-December. There was no seasonal variation in monthly VTE (p=0.12) and DVT alone (p=0.87) admissions. Conclusion. Our large-scale population study provides evidence that in Quebec, Canada there is a seasonal variation in PE hospital admissions with an annual autumn peak. The underlying pathophysiologyic mechanisms are unknown and deserve further study. Disclosures: Tagalakis: Pfizer: Research Funding; Sanofi Aventis: Honoraria. Kahn:Sigvaris: Research Funding; sanofi-aventis: Advisory Board, Research Funding; Boehringer Ingelheim:.
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Bates, Shannon, and Jack Hirsh. "Treatment of Venous Thromboembolism." Thrombosis and Haemostasis 82, no. 08 (1999): 870–77. http://dx.doi.org/10.1055/s-0037-1615925.
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IntroductionVenous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common clinical problem. If untreated or inadequately treated, there is a high risk of fatal PE1 and recurrent venous thrombosis.2-4 The objectives of treatment are to prevent local extension of thrombus, embolization, and recurrent thrombosis.It is now widely accepted that VTE is a single disorder and, therefore, the treatment of venous thrombosis and PE is essentially the same. Four treatment modalities are available. Anticoagulant therapy prevents the growth of an existing thrombus or embolus, thrombolytic therapy accelerates the rate of dissolution of thrombi or emboli, caval interruption intercepts venous thrombi that break off and embolize, thereby preventing dangerous PE, and surgical therapy removes thrombi or emboli.
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Cohen, Alexander, and Mark Dobromirski. "The use of rivaroxaban for short- and long-term treatment of venous thromboembolism." Thrombosis and Haemostasis 107, no. 06 (2012): 1035–43. http://dx.doi.org/10.1160/th11-12-0859.
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SummaryVenous thromboembolism (VTE) is a major healthcare concern and affects more than 1.6 million individuals each year worldwide. Long-term complications include recurrent VTE, chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Rivaroxaban is an oral, direct factor Xa inhibitor that has advantages over traditional VTE therapies, including minimal drug and food interactions and no requirement for routine coagulation monitoring. It is currently approved for VTE prevention in adult patients undergoing elective hip or knee replacement surgery. This review evaluates the potential clinical implications of the multicentre, randomised EINSTEIN studies (EINSTEIN DVT and EINSTEIN EXT), which investigated rivaroxaban for the treatment and prevention of recurrent VTE. In EINSTEIN DVT, rivaroxaban was non-inferior to the standard of care (enoxaparin plus a vitamin K antagonist) for recurrent VTE in patients with acute deep-vein thrombosis (DVT) without pulmonary embolism (PE). In EINSTEIN EXT, extended-duration rivaroxaban had superior efficacy to placebo in patients with confirmed DVT or PE who had received 6–12 months of prior VTE treatment. Rivaroxaban was associated with an acceptable safety profile in both studies. The net clinical benefit (efficacy and safety end-points combined) of rivaroxaban was significantly greater than its comparators. The EINSTEIN studies are the first demonstration that a single drug - rivaroxaban - can be effective for both the initial treatment of DVT and prevention of recurrent VTE. Moreover, the simple, once-daily oral administration of rivaroxaban could potentially improve adherence to extended-duration VTE treatment compared with the current standard of care in individuals with confirmed DVT or PE.
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Spyropoulos, Alex, Mohamed Hussein, Jay Lin, and David Battleman. "Rates of Venous Thromboembolism in Commercially Insured US Surgical Patients." Blood 112, no. 11 (November 16, 2008): 526. http://dx.doi.org/10.1182/blood.v112.11.526.526.
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Abstract Introduction: Venous thromboembolism (VTE) constitutes a major healthcare burden in the United States (US), despite being effectively prevented by VTE prophylaxis. However, many patients at risk for VTE receive inadequate prophylaxis, and this has prompted the development of national performance measures to help improve prescribing practices. This study investigates the rates of post-operative VTE prevention in a real-world population of commercially-insured US surgical patients, and identifies VTE risk factors in this group. Methods: Discharges from the PharMetrics database (January 2001–December 2005) that had ICD-9 codes for orthopedic or abdominal surgery and were aged ≥18 years were included in the study. Patients aged ≥65 years and not in a Medicare Risk group and those without complete records or health plan coverage were excluded. The primary outcome measure for this study was the rate of (and time to) symptomatic VTE following surgery (as identified by ICD-9 codes), and the secondary outcome measure was the identification of independent VTE risk factors using logistic regression analysis to control for patient and hospital characteristics. Results: 172,320 discharges met the study criteria, of which 23.9% underwent orthopedic surgery and 76.1% underwent abdominal surgery. Primary outcome measures are shown in Table 1. In summary, orthopedic discharges had a higher incidence of clinically symptomatic VTE (4.7%) than abdominal discharges (3.1%). Both types of surgery had a similar distribution of VTE into deep-vein thrombosis (DVT, 72.5–75.0% of all VTE respectively), pulmonary embolism (PE, 22.5–25.0% of all VTE respectively), or both DVT and PE (2.5% of all VTE). The median time to a VTE event was shorter in orthopedic discharges (median 30 days) than their abdominal surgery counterparts (median 65 days). When considering all discharges in a logistic regression analysis, a prior history of VTE was found to be the strongest independent predictor of VTE (odds ratio [OR] 10.2; 95% confidence interval [CI] 9.2–11.4; p<0.001). Other significant variables associated with VTE outcomes included orthopedic surgery rather than abdominal surgery (OR 1.4; 95% CI 1.4–1.6), increasing age (per year) (OR 1.02; 95% CI 1.01–1.02), male gender (OR 1.18; 95% CI 1.09–1.28), increasing index hospitalization length of stay (per day) (OR 1.06; 95% CI 1.05–1.06), and pre-index Charlson comorbidity index (OR 1.12; 95% CI 1.09–1.14). Conclusions: Many patients undergoing orthopedic or abdominal surgery are at risk for VTE, with approximately 1 in 25 patients in this analysis experiencing a clinical VTE event. Improved implementation of national performance measures may help reduce the overall burden of VTE in the United States. Table 1 – VTE event rates Total (N=172,320) Orthopedic Surgery (N=41,139) Abdominal Surgery (N=131,181) Event, n (%) VTE 5956 (3.5) 1944 (4.7) 4012 (3.1) DVT 4367 (2.5) 1458 (3.5) 2909 (2.2) PE 1439 (0.8) 438 (1.1) 1001(0.8) DVT + PE 150 (0.1) 48 (0.1) 102 (0.1) Time to VTE Event: (days, median) VTE 51 30 65 DVT 70 34 83 PE 46 20 26 DVT+PE 31 17 27.5
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Bezgin, Tahir, Cihangir Kaymaz, Özgür Akbal, Fatih Yılmaz, Hacer Ceren Tokgöz, and Nihal Özdemir. "Thrombophilic Gene Mutations in Relation to Different Manifestations of Venous Thromboembolism: A Single Tertiary Center Study." Clinical and Applied Thrombosis/Hemostasis 24, no. 1 (October 11, 2016): 100–106. http://dx.doi.org/10.1177/1076029616672585.
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Background: Venous thromboembolism (VTE) is a common and potentially lethal disorder that manifests mainly as deep vein thrombosis (DVT) of the extremities or pulmonary embolism (PE) and occurs as a consequence of genetic and environmental risk factors. We aimed to assess the role of inherited thrombophilia as a causative or additive factor in the development of VTE. Methods: The study included 310 patients (female: 154; mean age: 52.3 ± 16.9 years) with a first episode of VTE and 289 age- and sex-matched healthy controls. All participants underwent screening for thrombophilia-associated polymorphisms including factor V Leiden (FVL), prothrombin G20210A (PTG), factor V H1299 R (factor V HR2), factor XIII V34 L, β-fibrinogen-455 G>A, plasminogen activator inhibitor-1 4G/5G, human platelet antigen-1 a/b, methylene tetrahydrofolate reductase (MTHFR) C677 T, MTHFR A1298C, angiotensin-converting enzyme I/D, apolipoprotein B R3500Q, and apolipoprotein E (Apo E). In addition, serum homocysteine (Hcy) levels were measured. Results: In the patient group, 247 (80%) had isolated DVT, 43 (14%) had DVT plus PE, and 20 (6%) had isolated PE. The mean Hcy levels were similar in VTE subgroups and controls. Compared to controls, patients with isolated DVT, DVT plus PE, and isolated PE showed significantly higher frequencies for the following—heterozygous FVL mutation, isolated DVT (28.3%), DVT plus PE (44.2%), isolated PE (50%), controls (8.3%; P < .001); heterozygous PTG mutation, isolated DVT (11.3%), DVT plus PE (20.9%), isolated PE (25%), controls (5.9%; P < .01); Apo E 2/4, isolated DVT (9.7%), DVT plus PE (9.3%), isolated PE (5%), controls (1%; P < .01).The MTHFR A1298C mutation showed a significantly higher frequency in isolated patients with PE than in those with isolated DVT ( P = .006) and in controls ( P = .008). The frequencies of other genetic mutations or polymorphisms showed similar frequencies in all comparisons. In logistic regression analysis, heterozygous FVL mutation was the only independent predictor of VTE (odds ratio: 3.9, 95% confidence interval: 1.3-11.2; P = .012). Conclusion: Except than FVL, PTG, and Apo E 2/4 mutations, many of aforementioned thrombophilic factors known to be associated with VTE did not demonstrate any relationship with VTE. Heterozygous mutation of FVL was an independent predictor for VTE.
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Gromadziński, Leszek, Agnieszka Skowrońska, Piotr Holak, Michał Smoliński, Ewa Lepiarczyk, Anna Żurada, Mariusz Krzysztof Majewski, Mariusz Tomasz Skowroński, and Marta Majewska. "A New Experimental Porcine Model of Venous Thromboembolism." Journal of Clinical Medicine 10, no. 9 (April 25, 2021): 1862. http://dx.doi.org/10.3390/jcm10091862.
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Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a severe disease affecting the human venous system, accompanied by high morbidity and mortality rates. The aim of the study was to establish a new porcine VTE model based on the formation of the thrombus in vivo. The study was performed on 10 castrated male pigs: thrombus was formed in each closed femoral vein and then successfully released from the right femoral vein into the circulation of animals. In six pigs PE was confirmed via both computed tomography pulmonary angiography and an autopsy. Our research presents a novel experimental porcine model of VTE that involves inducing DVT and PE in the same animal in vivo, making it suitable for advanced clinical research and testing of future therapies.
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Rodger, Marc. "Evidence Base for the Management of Venous Thromboembolism in Pregnancy." Hematology 2010, no. 1 (December 4, 2010): 173–80. http://dx.doi.org/10.1182/asheducation-2010.1.173.
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Abstract Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a leading cause of maternal mortality during pregnancy. DVT and PE are commonly suspected due to many mimicking signs and symptoms that are normal in pregnancy. However, validated diagnostic approaches are lacking, and a fear of teratogenic/oncogenic exposure from imaging procedures affects the acceptability of diagnostic approaches used for VTE during pregnancy. DVT and PE treatment in pregnancy is also challenging due to this lack of validated diagnostic approaches, changes in maternal physiology, and the need for intact hemostasis at the time of delivery/epidural analgesia. Prevention requires an optimal balancing of absolute increased bleeding risk from pharmacologic thromboprophylaxis and the absolute benefit of reduced DVT and PE, which, while serious, are relatively uncommon.
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Moheimani, Fatemeh, and Denise E. Jackson. "Venous Thromboembolism: Classification, Risk Factors, Diagnosis, and Management." ISRN Hematology 2011 (October 17, 2011): 1–7. http://dx.doi.org/10.5402/2011/124610.
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Venous thromboembolism (VTE) is categorised as deep venous thrombosis (DVT) and pulmonary embolism (PE). VTE is associated with high morbidity and causes a huge financial burden on patients, hospitals, and governments. Both acquired and hereditary risks factors contribute to VTE. To diagnose VTE, noninvasive cost-effective diagnostic algorithms including clinical probability assessment and D-dimer measurement may be employed followup by compression ultrasonography for suspected DVT patients and multidetector computed tomography angiography for suspected PE patients. There are pharmacological and mechanical interventions to manage and prevent VTE. The pharmacological approaches mainly target pathways in coagulation cascade nonspecifically: conventional anticoagulants or specifically: new generation of anticoagulants. Excess bleeding is one of the major risk factors for pharmacological interventions. Hence, nonpharmacological or mechanical approaches such as inferior vena cava filters, graduated compression stockings, and intermittent pneumatic compression devices in combination with pharmacological interventions or alone may be a good approach to manage VTE.
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Ząbczyk, Michał, Joanna Natorska, and Anetta Undas. "Factor XIII and Fibrin Clot Properties in Acute Venous Thromboembolism." International Journal of Molecular Sciences 22, no. 4 (February 5, 2021): 1607. http://dx.doi.org/10.3390/ijms22041607.
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Coagulation factor XIII (FXIII) is converted by thrombin into its active form, FXIIIa, which crosslinks fibrin fibers, rendering clots more stable and resistant to degradation. FXIII affects fibrin clot structure and function leading to a more prothrombotic phenotype with denser networks, characterizing patients at risk of venous thromboembolism (VTE). Mechanisms regulating FXIII activation and its impact on fibrin structure in patients with acute VTE encompassing pulmonary embolism (PE) or deep vein thrombosis (DVT) are poorly elucidated. Reduced circulating FXIII levels in acute PE were reported over 20 years ago. Similar observations indicating decreased FXIII plasma activity and antigen levels have been made in acute PE and DVT with their subsequent increase after several weeks since the index event. Plasma fibrin clot proteome analysis confirms that clot-bound FXIII amounts associated with plasma FXIII activity are decreased in acute VTE. Reduced FXIII activity has been associated with impaired clot permeability and hypofibrinolysis in acute PE. The current review presents available studies on the role of FXIII in the modulation of fibrin clot properties during acute PE or DVT and following these events. Better understanding of FXIII’s involvement in the pathophysiology of acute VTE might help to improve current therapeutic strategies in patients with acute VTE.
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Díaz, Gema, Elena Marín, Rafael Vidal, Antonio Sueiro, Roger Yusen, and David Jiménez. "The risk of recurrent venous thromboembolism in patients with unprovoked symptomatic deep vein thrombosis and asymptomatic pulmonary embolism." Thrombosis and Haemostasis 95, no. 03 (2006): 562–66. http://dx.doi.org/10.1160/th05-10-0677.
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SummaryPatients with a first episode of symptomatic pulmonary embolism (PE) havea higher risk of recurrent venous thromboembolism (VTE) than patients with a first episode of proximal lower extremity deep vein thrombosis (DVT). Patients with symptomatic DVT and silent PE may havea different risk of VTE recurrence than patients that have symptomatic DVT without PE. Therefore, it was the aim of this prospective cohort study to compare the risk of recurrent symptomaticVTE in patients with proximal lower extremity DVT and silent PE to the risk in patients that only have proximal lower extremity DVT. Ninty-one consecutive outpatients presenting to the emergency department of a university hospital subsequently hospitalised with a first episode of unprovoked symptomatic proximal lower extremity DVT, and without new pulmonary symptoms were included. Standard initial treatment consisted of intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin for 5–7 days, overlapped with oral vitamin-K antagonist therapy, with long-term oral vitamin-K antagonist therapy (goal INR 2.5 [2.0–3.0]). Study endpoints were: symptomatic recurrent DVT, new PE, and recurrent PE, evaluated by standard objective testing. At enrolment, 28 of 91 (31%) patients with DVT had silent PE. In the patients with DVT and silent PE, there were 3 VTE recurrences during 20 person-years of follow-up, while there were no VTE recurrences during 61 person-years of follow-up in the patients with isolated DVT. The Kaplan-Meier estimated VTE recurrence rate at 1 year after the diagnosis of DVT was 11% (95% CI: 2–28%) for patients with symptomatic DVT and silent PE, compared to 0% in patients with isolated symptomatic DVT (p = 0.0045). In patients with a first episode of unprovoked symptomatic acute proximal lower extremity DVT, the risk of recurrent VTE was significantly higher in those with silent PE compared to those without PE.
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Akpinar, Evrim Eylem, Derya Hosgun, Burak Akan, Can Ates, and Meral Gulhan. "Does thromboprophylaxis prevent venous thromboembolism after major orthopedic surgery?" Jornal Brasileiro de Pneumologia 39, no. 3 (June 2013): 280–86. http://dx.doi.org/10.1590/s1806-37132013000300004.
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OBJECTIVE: Pulmonary embolism (PE) is an important complication of major orthopedic surgery. The aim of this study was to evaluate the incidence of venous thromboembolism (VTE) and factors influencing the development of VTE in patients undergoing major orthopedic surgery in a university hospital. METHODS: Patients who underwent major orthopedic surgery (hip arthroplasty, knee arthroplasty, or femur fracture repair) between February of 2006 and June of 2012 were retrospectively included in the study. The incidences of PE and deep vein thrombosis (DVT) were evaluated, as were the factors influencing their development, such as type of operation, age, and comorbidities. RESULTS: We reviewed the medical records of 1,306 patients. The proportions of knee arthroplasty, hip arthroplasty, and femur fracture repair were 63.4%, 29.9%, and 6.7%, respectively. The cumulative incidence of PE and DVT in patients undergoing major orthopedic surgery was 1.99% and 2.22%, respectively. Most of the patients presented with PE and DVT (61.5% and 72.4%, respectively) within the first 72 h after surgery. Patients undergoing femur fracture repair, those aged ≥ 65 years, and bedridden patients were at a higher risk for developing VTE. CONCLUSIONS: Our results show that VTE was a significant complication of major orthopedic surgery, despite the use of thromboprophylaxis. Clinicians should be aware of VTE, especially during the perioperative period and in bedridden, elderly patients (≥ 65 years of age).
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Farrell, Michael Steven, M. Margaret Knudson, and Deborah M. Stein. "Venous ligation versus venous repair: does the procedure impact venous thromboembolism risk?" Trauma Surgery & Acute Care Open 6, no. 1 (March 2021): e000687. http://dx.doi.org/10.1136/tsaco-2021-000687.
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BackgroundTraumatic lower extremity venous injuries are most commonly managed with either a vein ligation or repair procedure. Venous injuries are associated with an increased risk of developing venous thromboembolisms (VTE), but little is understood with regard to how specific surgical treatments may impact the risk of developing either a deep vein thrombosis (DVT) or a pulmonary embolism (PE). In this study of lower extremity venous injuries, we hypothesized that venous ligation would be associated with an increased risk of DVT but a lower risk of PE when compared with venous repair.MethodsPatients were identified from the National Trauma Data Bank (2008 to 2014) with at least one iliac, femoral, popliteal, or tibial venous injury and who received either a vein ligation or repair. The patients were then compared based on the type of procedure and the location of the injury to assess the risk of DVT and PE between the groups.ResultsA total of 1214 patients were identified. There was no difference between patients who received a vein ligation versus a repair with respect to age, injury severity score, or initial systolic blood pressure. There was no difference in the odds of developing either a DVT or PE between patients who were treated with vein ligation versus repair. There was also no difference in VTE rates when stratified by the location of the injury.ConclusionsIn individuals with lower extremity venous injuries, there is no difference in the rate of DVT or PE complications when comparing venous repair and ligation procedures. The role of anticoagulation remains to be elucidated following operative treatment.Level of evidenceTherapeutic/Care Management, Level IV.
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Matta, Fadi, Ravinder Singala, Abdo Yaekoub, Reiad Najjar, and Paul Stein. "Risk of venous thromboembolism with rheumatoid arthritis." Thrombosis and Haemostasis 101, no. 01 (2009): 134–38. http://dx.doi.org/10.1160/th08-08-0551.
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SummaryRheumatoid arthritis is not generally considered to be a risk factor for venous thromboembolism (VTE), although abnormalities of coagulation factors have been found in patients with rheumatoid arthritis. Sparse data in a few patients suggest that patients with rheumatoid arthritis may have higher rates of VTE. The purpose of this investigation was to determine if the incidences of pulmonary embolism (PE) and deep venous thrombosis (DVT) are increased in hospitalized patients with rheumatoid arthritis. The number of patients discharged from non-Federal short-stay hospitals throughout the United States from 1979 through 2005 with a discharge code for rheumatoid arthritis was obtained from the National Hospital Discharge Survey (NHDS). Among hospitalized patients with rheumatoid arthritis who did not have joint surgery, 41,000 of 4,818,000 (0.85%) had PE compared with 3,366,000 of 891,055,000 (0.38%) among patients who did not have rheumatoid arthritis and who did not have operations or joint surgery (relative risk =2.25). Deep venous thrombosis was diagnosed in 79,000 of 4,818,000 (1.64%) patients with rheumatoid arthritis and no joint operation, versus 7,681,000 of 891,055,000 (0.86%) who did not have rheumatoid arthritis or a joint operation (relative risk=1.90). The relative risk of venous thromboembolism (PE and/or DVT) in these patients was 1.99. The data suggest that rheumatoid arthritis is a risk factor for VTE in hospitalized medical patients. A heightened awareness of the risks for VTE and a lower threshold for evaluation of patients for possible DVT or PE would be appropriate in caring for hospitalized patients with rheumatoid arthritis.
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Chen, Chien-Hua, Cheng-Li Lin, and Chia-Hung Kao. "The Risk of Venous Thromboembolism in Patients with Gallstones." International Journal of Environmental Research and Public Health 17, no. 8 (April 23, 2020): 2930. http://dx.doi.org/10.3390/ijerph17082930.
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The objective of this study is to assess the relationship between gallstones and venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), and the risk of VTE after cholecystectomy for gallstones. This nationwide population-based cohort study retrieved the hospitalization database from the Longitudinal Health Insurance Research Database (LHID2000), a database belonging to the National Health Insurance (NHI) program of Taiwan. A total of 345,793 patients aged ≥ 18 years with gallstones diagnosed between 2000 and 2010 were identified as the study cohort. The beneficiaries without gallstones were randomly selected as the control cohort by propensity score matching with the study cohort at a 1:1 ratio based on age, sex, urbanization, occupation, comorbidities, and year of the index date. We compared the risk of VTE between both cohorts and measured the risk differences of VTE between the gallstones patients with (n = 194,187) and without cholecystectomy (n = 151,606). Each patient was examined from the index date until the occurrence of DVT or PE, death or withdrawal from the NHI program, or the end of 2011. The incidence rate of DVT was 7.94/10,000 person-years for the non-gallstones cohort and 9.64/10,000 person-years for the gallstones cohort (hazard ratio (HR) = 1.35, 95% confidence interval (CI) = 1.25–1.47), respectively (p < 0.001). The incidence rate of PE was 3.92/10,000 person-years for the non-gallstones cohort and 4.65/10,000 person-years for the gallstones cohort (HR = 1.35, 95% CI = 1.20–1.53), respectively (p < 0.001). The cumulative incidence of DVT (6.54/10,000 person-years vs 14.6/10,000 person-years, adjusted hazard ratio (aHR) = 0.60, 95% CI = 0.54–0.67) and PE (3.29/10,000 person-years vs 6.84/10,000 person-years, aHR = 0.67, 95% CI = 0.58–0.77) for gallstones patients was lower in the cholecystectomy cohort than that in the non-cholecystectomy cohort after adjustment for age, sex, urbanization level, occupation, frequency of medical visits, history of pregnancy, and comorbidities (log-rank test, p < 0.001). Our findings indicate that the risk of DVT or PE in patients with gallstones was greater than those without gallstones. However, the risk of DVT and PE in the patients with gallstones would decrease after cholecystectomy. This area of research needs more studies to ascertain the pathogenesis for the contribution of gallstones to the development of VTE and the protective mechanisms of cholecystectomy against the development of VTE.
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Gauthier, Karine, Melanie Tan, Gregoire Le Gal, and Marc A. Rodger. "Clinical Predictors of Confirmed Venous Thromboembolism in Patients with a Suspected Recurrent Venous Thromboembolism: A Retrospective Study of the Reverse I Cohort." Blood 120, no. 21 (November 16, 2012): 1153. http://dx.doi.org/10.1182/blood.v120.21.1153.1153.
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Abstract Abstract 1153 Background: Many clinical decision rules (CDR), such as the Wells models for deep vein thrombosis of the legs (DVT) and pulmonary embolism (PE), have been established for patients with suspected first venous thromboembolism (VTE). However these rules may have limitations for patients with suspected recurrent VTE. First, patients with suspected PE and a history of VTE have their diagnosis more likely confirmed than patients with a suspected PE without a history of VTE (40.3 vs. 20.6%) (Le Gal G et al. Arch Intern Med, 2006), suggesting a different pre-test probability. Furthermore, patients who had a previous pulmonary embolism often have complaints of chronic dyspnea (Klok FA et al. Eur J Intern Med, 2008), which could complicate the risk estimation of recurrent PE. A similar scenario arises for patients who suffered a DVT, as 30–50% of patients will show signs and symptoms of post-thrombotic syndrome (PTS) following a deep vein thrombosis (Kahn SR. Curr Opin Pulm Med, 2006). In addition, the value of D-dimer testing is still uncertain in patients with suspected recurrent VTE. Finally, imaging has limitations, as residual thrombosis may be present and may be misdiagnosed as an acute recurrent event. Hence, because pre-test probability, laboratory testing and diagnostic imaging performances differ in patients with a suspected recurrent VTE, a different approach may be needed for effective management of these patients. Our objective was to study clinical predictors for the diagnosis of recurrent VTE in patients with a history of VTE. Methods: The REVERSE I study enrolled patients with a first unprovoked, objectively proven VTE (Rodger M et al. CMAJ, 2008). Each patient in the REVERSE I cohort that had a suspected recurrent VTE during follow-up was screened for eligibility. Only first adjudicated suspected recurrent events were studied. All these events were blindly adjudicated by an independent committee. Potential clinical predictors of recurrent VTE consisted of clinical predictors collected at the baseline visit (5–7 months after the unprovoked event), and of information collected in physicians' clinical notes, laboratory or imaging results at the time of the suspected recurrent VTE. The predictive value of each predictor was determined by the Chi-square test for nominal data and the unpaired 2-tailed T-test for continuous data. Results: In the REVERSE I cohort, out of the 646 patients who were followed, 402 patients had a suspected recurrent VTE within a mean of 20.2 months (range: 0 – 97 months) of follow-up. After screening, 376 patients were enrolled in our study: 52.7 % of patients were males, and the mean age was 53.1 years (± 17.5). Among all suspected recurrent VTE events, male gender and a positive d-dimer result at the time of suspected recurrent VTE (p < 0.01), as well as symptoms occurring for 10 days or less at the time of presentation (p < 0.05) were in favor of a recurrent VTE diagnosis. In addition, mean age was higher in patients with a confirmed recurrent VTE (p < 0.05). In patients with suspected DVT, the presence of leg swelling was in favor of a confirmed diagnosis (p < 0.01), while leg pain was not associated with a higher rate of confirmed DVT. A suspected DVT in the same leg as the previous event seemed less likely to have a confirmed diagnosis of recurrent DVT. However this trend was not statistically significant. In patients with suspected PE, mean oxygen saturation was lower among patients with a new PE diagnosis (p < 0.05). Chest pain and shortness of breath were not important predictors. Finally, in the case of a suspected DVT and PE event, shortness of breath was a significant predictor (p < 0.05) for the diagnosis of recurrent VTE. Conclusion: This is the first study to show that predictors for the diagnosis of a recurrent VTE may be different than predictors for the diagnosis of a first VTE. For instance, our results show that male gender is not only a risk factor for recurrent VTE (McRae S et al. Lancet, 2006), but is also an important predictor for confirmed VTE among patients with suspected recurrent VTE, while none of the existing CDRs take this in consideration. A CDR specific to patients with a history of VTE may be needed for better management of these patients. Disclosures: Le Gal: Bayer, bioMérieux, GSK, Leo Pharma, Sanofi Aventis: Honoraria.
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Carrier, Marc, Gregoire Le Gal, Philip Wells, and Marc Rodger. "Case Fatality Rates of Recurrent Venous Thromboembolism during and Following Anticoagulation Therapy." Blood 112, no. 11 (November 16, 2008): 3032. http://dx.doi.org/10.1182/blood.v112.11.3032.3032.
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Abstract Background: The optimal duration of anticoagulation treatment in patients with unprovoked VTE is unknown. In order to counsel VTE patients on the risks and benefits of discontinuing anticoagulants, clinicians need to balance the long-term risk of recurrent VTE with major bleeding on anticoagulants. For all VTE patients on oral anticoagulant, the case-fatality rate of major bleeding was previously reported to be 13.4% (95% confidence intervals (CI): 9.4% to 17.4%). A major knowledge gap exists regarding the case-fatality rate of recurrent pulmonary embolism (PE) during and following anticoagulation therapy for VTE. Purpose: To summarize the case fatality rate of recurrent VTE during and following anticoagulation therapy. Data Source: A systematic literature search strategy was conducted using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and all EBM Reviews. Study Outcome: We selected 62 studies that reported the rates of fatal PE in patients with recurrent VTE. Fatal PE was defined as confirmed autopsy report; death preceding with confirmed deep vein thrombosis (DVT) or non-fatal PE; sudden death not explained by a condition other than PE. Measurements: Pooled case fatality rates were generated. Ninety-five percent CI were calculated for each case fatality rate using averaged, inverse variance-weighted estimates from each study. Data Synthesis: 30,885 VTE patients were included (17,650 DVT, 8801 PE and 4434 DVT or PE Limitations: Unable to determine the case fatality rate by etiology of VTE (i.e. provoked, unprovoked). Conclusion: Case fatality rates for recurrent VTE are elevated during and following anticoagulation treatment for VTE but appear lower than the case-fatality rate for major bleeding with oral anticoagulants. This information must be considered by clinicians when counseling patients on whether to continue or discontinue anticoagulant therapy following VTE. Not only must absolute recurrent VTE and major bleeding rates be compared between groups that continue and discontinue anticoagulants but the relative consequences (i.e. case fatality rates) must be also considered with more weight placed on major bleeding episodes. Initial event During anticoagulation Treatment (%, 95% CI) Following anticoagulation Treatment (%, 95% CI) DVT 10.6 (8.3–13.0) 7.3 (5.0–9.7) PE 12.3 (5.9–18.7) 12.5 (6.4–28.7) Any event 10.2 (7.9–12.5) 9.0 (7.3–10.8)
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Li, Lingyi, Natalie McCormick, Eric C. Sayre, John M. Esdaile, Diane Lacaille, Hui Xie, Hyon K. Choi, and J. Antonio Aviña-Zubieta. "Trends of venous thromboembolism risk before and after diagnosis of gout: a general population-based study." Rheumatology 59, no. 5 (September 19, 2019): 1099–107. http://dx.doi.org/10.1093/rheumatology/kez398.
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Abstract Objective To estimate the overall risk and the temporal trend of venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolism (PE) before and after gout diagnosis in an incident gout cohort compared with the general population. Methods We conducted a matched cohort study using a province-wide population-based administrative health database in Canada. We calculated incidence rates (IRs) and multivariable adjusted hazard ratios (HRs) for the risk of VTE, DVT and PE before and after gout diagnosis. Results Among 130 708 incident individuals with gout (64% male, mean age 59 years), 2071 developed VTE, 1377 developed DVT and 1012 developed PE. IRs per 1000 person-years for gout were 2.63, 1.74 and 1.28 compared with 2.03, 1.28 and 1.06 for non-gout, respectively. The fully adjusted HRs (95% CI) for VTE, DVT and PE were 1.22 (1.13, 1.32), 1.28 (1.17, 1.41) and 1.16 (1.05, 1.29). For the pre-gout period, the fully adjusted HRs (95% CI) were 1.51 (1.38, 1.64), 1.55 (1.40, 1.72) and 1.47 (1.31, 1.66) for VTE, DVT and PE. During the third, second and first years preceding gout, the fully adjusted HRs for VTE were 1.44, 1.56 and 1.62. During the first, second, third, fourth and fifth years after gout, the fully adjusted HRs were 1.63, 1.29, 1.33, 1.28 and 1.22. Similar trends were also seen for DVT and PE. Conclusion Increased risks of VTE, DVT and PE were found both before and after gout diagnosis. The risk increased gradually before gout, peaking in the year prior to diagnosis, and then progressively declined. Gout-associated inflammation may contribute to venous thrombosis risk.
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Mattiuzzi, Camilla, Massimo Franchini, and Giuseppe Lippi. "Sleep apnea and venous thromboembolism." Thrombosis and Haemostasis 114, no. 11 (2015): 958–63. http://dx.doi.org/10.1160/th15-03-0188.
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SummaryRecent evidence suggests that obstructive sleep apnea is a significant and independent risk factor for a number of cardiovascular disorders. Since the association between obstructive sleep apnea and cardiovascular disease is mediated by endothelial dysfunction, hypercoagulability and platelet abnormalities, we sought to investigate whether sleep apnea may also be considered a risk factor for venous thromboembolism (VTE). We carried out an electronic search in Medline and Scopus using the keywords “apnea” OR “apnoea” AND “venous thromboembolism” OR “deep vein thrombosis” OR “pulmonary embolism” in “Title/Abstract/Keywords”, with no language or date restriction. Fifteen studies (8 case-control, 4 retrospective observational, 2 prospective case-control and 1 prospective observational) were finally selected for this systematic review. In all studies except one (14/15; 93%), obstructive sleep apnea was found to be an independent risk factor for VTE, either deep-vein thrombosis (DVT) or pulmonary embolism (PE). In the two prospective case-control studies the risk of DVT or PE was found to be two-to three-fold higher in patients with obstructive sleep apnea than in those without. In conclusion, the current epidemiological evidence supports the hypothesis that obstructive sleep apnea may be an independent risk factor for VTE.
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Lamberti, James P. "Controversies in the management of venous thromboembolism." Journal of Precision Respiratory Medicine 2, no. 1 (December 1, 2019): 48–52. http://dx.doi.org/10.2500/jprm.2019.190001.
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Background: Venous thromboembolism (VTE) includes pulmonary embolism (PE) and deep vein thrombosis (DVT), and is frequently encountered in both inpatient and outpatient settings. Methods: This review examines three significant controversies in the management of VTE. Results: Thrombolytic therapy has been available for >50 years, yet its role in the management of acute PE remains controversial. The role of interruption of the venous system by insertion of an inferior vena cava filter into a VTE is a therapeutic challenge for hospital-based physicians. The duration of anticoagulation as therapy for VTE is a challenge for many outpatient physicians. Conclusion: Review of recent literature will guide clinicians in the management of venous thromboembolism.
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Shetty, HGM, PK Pooviah, and PA Routledge. "Prevention and treatment of venous thromboembolism in older people." Reviews in Clinical Gerontology 12, no. 1 (February 2002): 31–39. http://dx.doi.org/10.1017/s0959259802012157.
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The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) increases with age and it has been reported to be higher in males. The annual incidence rates per 1000 for DVT and PE are 1.3 and 1.8 respectively for people aged between 65 and 69 years, rising to 2.8 and 3.1 respectively in those aged between 85 and 89 years. Older people are about eight times more likely to develop venous thromboembolism (VTE) in hospitals, nursing homes or other chronic care facilities. About 1.7% develop PE and 8% develop recurrent PE within one year of treatment for DVT. About 3% of patients with DVT and 21% of those with PE die in hospital. One year mortality with DVT is 21% and that with PE is 39%. The diagnosis of PE is often missed in older people and it is often detected only at postmortem.
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Behravesh, Sasan, Peter Hoang, Alisha Nanda, Alex Wallace, Rahul A. Sheth, Amy R. Deipolyi, Adnan Memic, Sailendra Naidu, and Rahmi Oklu. "Pathogenesis of Thromboembolism and Endovascular Management." Thrombosis 2017 (January 5, 2017): 1–13. http://dx.doi.org/10.1155/2017/3039713.
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Venous thromboembolism (VTE), a disease that includes deep venous thrombosis (DVT) and pulmonary embolism (PE), is associated with high mortality, morbidity, and costs. It can result in long-term complications that include postthrombotic syndrome (PTS) adding to its morbidity. VTE affects 1/1000 patients, costs $13.5 billion annually to treat, and claims 100,000 lives annually in the US. The current standard of care for VTE is anticoagulation, though thrombolysis may be performed in patients with PE and threatened limb. This review discusses pathogenesis and medical treatment of VTE and then focuses on endovascular treatment modalities. Mechanical- and catheter-directed thrombolysis (CDT) is discussed, as well as patient selection criteria, and complications. The first prospective study (CaVenT) comparing CDT with anticoagulation alone in acute DVT, despite study shortcomings, corroborates the existing literature indicating improved outcomes with CDT. The potential of the ongoing prospective, multicenter, randomized ATTRACT trial is also highlighted.
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Zhang, Ping, Yi Bian, Feng Xu, Lifei Lian, Suiqiang Zhu, Zhouping Tang, and Furong Wang. "The Incidence and Characteristics of Venous Thromboembolism in Neurocritical Care Patients: A Prospective Observational Study." Clinical and Applied Thrombosis/Hemostasis 26 (January 1, 2020): 107602962090795. http://dx.doi.org/10.1177/1076029620907954.
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Risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is presumed to be high for neurologic intensive care unit (NICU) patients. However, exact incidences of VTE have yet to be reported. In this prospective observational study, we consecutively enrolled 126 neurocritical care patients who had an NICU stay ≥1 week with paralysis and/or unconsciousness. All patients received DVT prevention strategies. Patients were screened for VTE after 1 week of hospitalization, using venous ultrasonography and computed tomography pulmonary angiography. Following 1 week of NICU hospitalization, DVT incidence was 35.7% and PE incidence was 17.5%. Of the DVTs, 75.6% were in the muscular calf vein. Of the PEs, 22.7% were in main pulmonary arteries, while 77.3% were in branches. Approximately 96% of the DVTs and 86% of the PEs were asymptomatic. Approximately 24% of patients with DVT had a concurrent PE, while 50% of PE patients had a DVT. Paralysis, raised d-dimer on admission, and pulmonary infection were found to be independent risk factors for DVT. Paraplegia, femoral vein thrombosis, and pulmonary infection were found to be independent risk factors for PE. Despite active preventive measures, incidences of VTE in NICU patients were high. Most VTEs were asymptomatic, meaning they could have led to a missed diagnosis. Attention should be paid to the VTE events of critically ill neurological patients.
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Marozoff, Shelby, Alice Mai, Natasha Dehghan, Eric C. Sayre, Hyon K. Choi, and J. Antonio Aviña-Zubieta. "Increased risk of venous thromboembolism in patients with granulomatosis with polyangiitis: A population-based study." PLOS ONE 17, no. 6 (June 17, 2022): e0270142. http://dx.doi.org/10.1371/journal.pone.0270142.
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We assessed the risk and time trends of venous thromboembolism (VTE) including pulmonary embolism (PE) and deep venous thrombosis (DVT) in new granulomatosis with polyangiitis (GPA) cases compared to the general population. Using a population-level database from the entire province of British Columbia, Canada, we conducted a matched cohort study of all patients with incident GPA with up to ten age-, sex-, and entry time-matched individuals randomly selected from the general population. We compared incidence rates of VTE, PE, and DVT between the two groups, and calculated hazard ratios (HR), adjusting for relevant confounders. Among 549 individuals with incident GPA (57.6% female, mean age 55.4 years), the incidence rates for VTE, PE, and DVT were 7.22, 2.73, and 6.32 per 1,000 person-years, respectively; the corresponding rates were 1.36, 0.74, and 0.81 per 1,000 person-years among the 5,490 non-GPA individuals. Compared with the non-GPA cohort, the fully adjusted HRs among GPA patients were 2.90 (95% CI, 1.10–7.64), 4.70 (95% CI, 1.74–12.69), and 1.66 (95% CI, 0.52–5.27) for VTE, PE, and DVT, respectively. The risks of VTE, PE, and DVT were highest during the first year after GPA diagnosis with HR (95% CI) of 11.04 (1.37–88.72), 26.94 (4.56–159.24), and 2.68 (0.23–31.21), respectively. GPA patients are at significantly increased risk of PE, but not DVT. Monitoring for these complications is particularly warranted in this patient population, especially early after diagnosis.
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Arnason, Thomas, Philip Wells, and Alan Forster. "Appropriateness of diagnostic strategies for evaluating suspected venous thromboembolism." Thrombosis and Haemostasis 97, no. 02 (2007): 195–201. http://dx.doi.org/10.1160/th06-10-0596.
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SummaryIt was the objective of this study to determine the proportion of patients who undergo an appropriate diagnostic work-up following a D-dimer test performed to evaluate suspected pulmonary embolism (PE) or deep vein thrombosis (DVT). We performed a retrospective cohort study at a tertiary care hospital. We included patients if they underwent D-dimer testing between 2002 and 2005, if the D-dimer was performed for evaluation of VTE, and if the D-dimer test was successful. We classified: the patients’ clinical probability of DVT or PE according to theWells models,the imaging results,and the appropriateness of the testing algorithm. Of 1,000 randomly selected patients, 863 met our study criteria. Seven hundred nineteen patients (83%) had testing during an emergency department visit, while 144 were tested as inpatients (17%). Physicians performed the D-dimer test to evaluate DVT and PE in 238 (28%) and 625 (72%) patients, respectively. Overall, the testing strategy was appropriate in 69% (95% confidence interval [CI]: 66%–72%) of cases. The testing strategy was more likely to be appropriate for emergency department versus inpatients (75% vs. 39%, p < 0.05) and for DVT versus PE patients (84% vs. 63%, p < 0.05). Of all inappropriately tested patients, under-utilization of diagnostic imaging was more common than over-utilization (90% vs. 10%, p < 0.05). VTE was confirmed in 37 of 138 ‘DVT patients’ and 35 of 625 ‘PE patients’ (16% [95% CI: 11%–21%] and 6% [95% CI: 4%–8%], respectively). In conclusion, physicians often fail to use diagnostic testing strategies for VTE correctly following a D-dimer test.
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Kim, Kyoung Ha, Seug Yun Yoon, Jina Yoon, Han Jo Kim, Se Hyung Kim, Hyun Jung Kim, Sang-Cheol Lee, et al. "Venous Thromboembolism (VTE) In Patients With Pancreatic Cancer." Blood 122, no. 21 (November 15, 2013): 4801. http://dx.doi.org/10.1182/blood.v122.21.4801.4801.
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Background Venous thromboembolism (VTE) is a critical complication of malignant disease. Pancreatic cancer is one of the cancers most commonly associated VTE. In general, the VTE incidence rate of Asians is lower than that of Caucasians. In 2007, a Korean study reported that only four cases of VTE (5.3%) occurred in Seventy five patients with advanced pancreatic adenocarcinoma. We evaluated VTE incidence in pancreatic cancer and characteristics of pancreatic cancer patients with VTE. (We found out that VTE incidence rate among Asians was not lower, and the event of VTE was poor prognosis.) Method We retrospectively reviewed the medical records of patients with histopathologically proven pancreatic cancer from January 2006 to December 2012 at Soonchunhyang university hospital. We detected VTE through CT (chest CT, pulmonary embolism CT) and low extremity ultrasoundgraphy. Results Five hundred and fourteen patients with pancreatic adenocarcinoma were enrolled. (M: F, 300:214, localized: locally advanced: metastatic=31:230:253, mean age: 66.7 years). Ninety six of 514 patients (18.6%, symptomatic: aymptomatic=38:58, PE: DVT: PE+DVT: visceral thrombosis=20:19:19:38) were diagnosed as VTE. At the time of DVT diagnosis, cancer status of 50 patients cancer was progression, and that of 15 was stable. Thirty one patients were diagnosed with the pancreatic cancer and VTE, at the same time. They all had metastatic lesions. Fifty VTE patients were treated with antithrombotic therapy. Ninety three of 96 patients died, and three of them have probability that cause of death was VTE. The others died of pancreatic cancer progression. From pancreatic cancer diagnosis to VTE diagnosis, the period is 1.7month. (95%CI 1.1-2.3 month). Median overall survival (OS) was not significantly different between pancreatic cancer with VTE or without VTE. OS was significantly longer VTE patients after pancreatic cancer diagnosis than VTE patients with pancreatic cancer at the same time (10.73m vs. 1.7, p=0.00). Conclusion The incidence of VTE (18.6%) in Soonchunhyang university hospital with pancreatic cancer was not lower than that in western groups. Disclosures: No relevant conflicts of interest to declare.
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Undas, Anetta. "Prothrombotic Fibrin Clot Phenotype in Patients with Deep Vein Thrombosis and Pulmonary Embolism: A New Risk Factor for Recurrence." BioMed Research International 2017 (2017): 1–9. http://dx.doi.org/10.1155/2017/8196256.
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Prothrombotic fibrin clot phenotype, involving faster formation of dense meshwork composed of thinner and highly branched fibers that are relatively resistant to plasmin-induced lysis, has been reported in patients with not only myocardial infarction or stroke, but also venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT), and/or pulmonary embolism (PE). Prothrombotic fibrin clot phenotype, in particular prolonged clot lysis time, is considered a novel risk factor for VTE as well as venous thrombosis at unusual location, for example, cerebral sinus venous thrombosis, retinal vein obstruction, and Budd-Chiari syndrome. Growing evidence from observational studies indicates that abnormal fibrin clot properties can predict recurrent DVT and PE and they are involved in serious complications of VTE, for example, thromboembolic pulmonary hypertension and postthrombotic syndrome. The purpose of this article is to review our current understanding of the role of fibrin clot structure and function in venous thrombosis with emphasis on clinical issues ranging from prognosis to therapy.
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Jang, Moon, Soo-Mee Bang, and Doyeun Oh. "Incidence of Venous Thromboembolism In Korea: From Health Insurance Review and Assessment Service Database." Blood 116, no. 21 (November 19, 2010): 3676. http://dx.doi.org/10.1182/blood.v116.21.3676.3676.
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Abstract Abstract 3676 Background: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), represents a major health concern with an annual incidence of 70 to 113 cases per 100,000 Caucasians. Although historically lower than in Caucasians, its incidence among Asians is anticipated to increase rapidly with widespread Westernization of diet and lifestyle. Methods: This population-based study investigated the incidence of VTE in Korea. The National Health Insurance (NHI) is the only public medical insurance system operated by the Ministry of Health and Welfare in Korea. All Korean are required to possess NHI service. Health Insurance Review and Assessment Service (HIRA) is a government-affiliated organization to build an accurate claims review and quality assessment system for the NHI. Using the Korean HIRA database, VTE patients from 2004 to 2008 were retrospectively identified by both diagnostic codes and medication codes for drugs used in initial treatment of VTE. Results: The respective age- and sex-adjusted annual incidences of VTE, DVT alone, and PE (with or without DVT) per 100,000 individuals increased significantly from 8.83, 3.91, and 3.74 in 2004 to 13.8, 5.31, and 7.01 in 2008 (P = 0.0001) with successive increments each year. The annual incidence of VTE, DVT alone, and PE (with or without DVT) for both men and women steadily increased over time (Fig 1). Specifically, the annual incidence of PE (with or without DVT) for both sexes significantly increased during the last 2 years studied (2007 to 2008). All three annual incidences also increased steadily with age (P = 0.0001 for all) particularly among those over 60 years old. Conclusions: This represents the largest epidemiologic study which demonstrate the lower incidence of VTE and increasing incidence of VTE in Korean population. Disclosures: No relevant conflicts of interest to declare.
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Serhal, Maya, and Geoffrey D. Barnes. "Venous thromboembolism: A clinician update." Vascular Medicine 24, no. 2 (April 2019): 122–31. http://dx.doi.org/10.1177/1358863x18821159.
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Venous thromboembolism (VTE) is a common vascular condition. New medications are available to prevent hospital-associated VTE. Strategies are being studied to increase appropriate diagnostic testing utilization. Management of deep vein thrombosis (DVT) and pulmonary embolism (PE) has evolved with the advent of new anticoagulant options and catheter-directed intervention. In light of this, providers are commonly challenged with the decision regarding inpatient versus outpatient management. Which patients require long-term (> 3 months) anticoagulation is challenging and multiple clinical prediction models may be used to help determine the risk–benefit ratio in each patient. The management of VTE is an ongoing area of research and is rapidly evolving.
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Tagalakis, Vicky, Valerie Patenaude, Susan R. Kahn, and Samy Suissa. "High Mortality After Venous Thromboembolism: A Population-Based Cohort Study." Blood 120, no. 21 (November 16, 2012): 1140. http://dx.doi.org/10.1182/blood.v120.21.1140.1140.
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Abstract Abstract 1140 Background: Current estimates on mortality after venous thromboembolism (VTE) are limited and are based largely on randomized clinical studies with select populations of relatively health patient groups. Objectives: We estimated the mortality following a first VTE event in the general population, and compared survival rates among patients with idiopathic, cancer-associated, and secondary non-cancer associated VTE. Methods: This retrospective, observational study used the linked administrative healthcare databases of the province of Québec, Canada, including the province-wide hospitalization database (MED-ÉCHO), the healthcare services database of RAMQ which is a governmental agency that administers the Québec universal healthcare program and oversees all physician reimbursement claims, and the vital statistics database of the Institut de la Statistique du Québec (ISQ). From a source population of all RAMQ beneficiaries with a physician visit or a hospitalization associated with an ICD-9-CM or ICD-10-CA diagnosis code for deep vein thrombosis (DVT) or pulmonary embolism (PE) recorded between January 1, 2000 and December 31, 2009 and without a DVT or PE code prior to January 1, 2000, we identified a cohort of Québec residents with definite incident VTE and a cohort with definite or probable incident VTE. We used a priori determined diagnostic algorithms using RAMQ and MED-ÉCHO data to identify definite and probable cases of VTE. Subjects were followed forward in time from fist-time VTE occurrence until the earliest of either death or end of study period (December 31, 2009). Death was identified from MED-ÉCHO and ISQ. Thirty-day and 1-year case-fatality rates and associated 95% confidence intervals (CI) for VTE, DVT alone, and PE with or without DVT were calculated using all-cause deaths as the numerator and the number of patients with VTE as the denominator. Kaplan Meier curves were used to represent crude survival following a VTE episode, stratified by VTE risk factor group (idiopathic, cancer-associated, and secondary). The log-rank test was used to determine the significance of differences in the survival curves. Results: From the 245 452 Québec residents between 2000 and 2009 with at least 1 VTE diagnosis in RAMQ or MED-ÉCHO, we identified 67 410 cases with definite VTE, and an additional 35 123 cases with probable VTE. The cohort of definite VTE included 56% women, 46.5% patients aged 70 years or older, and 28.3% idiopathic VTE cases. The cohort of definite or probable VTE also included 56% women, 42.3% patients aged 70 years or older, and 34% idiopathic VTE cases. In the year following the VTE event, 14 407 (30%) deaths occurred in the definite VTE cohort, and 15 395 (25%) in the definite or probable VTE cohort. Among definite VTE cases, the 30-day case fatality rate was 14.1% (95% CI: 13.9–14.4), and the 1-year case fatality rate was 29.2% (95% CI: 28.9–29.6). The corresponding rates in the definite or probable VTE cohort were lower with a 30-day and 1-year case-fatality rate of 10.61% (95% CI: 10.41–10.81) and 23.04% (95% CI: 22.77–23.31), respectively. The 30-day case fatality was almost 2-fold higher in patients with PE with or without DVT vs. patients with DVT alone (RR 1.92, 95% CI: 1.85–1.99), and this difference in mortality was less at 1 year (RR 1.20, 95% CI: 1.17–1.23). The Kaplan-Meier overall survival plot showed a 1-year survival rate of 42% (95% CI: 41–43%) among definite VTE cases with cancer (Figure 1). The 1-year survival rates following definite VTE in patients with idiopathic and secondary VTE were different (90% vs. 81%, respectively; p<0.0001). Similar survival rates were observed in the definite or probable VTE cohort. Conclusion: In a large unselected general population, VTE is associated with a high mortality and patients with PE are at a higher risk of death than patients with DVT alone. Among cancer patients with VTE, long-term survival remains poor. The observed lower survival in patients with secondary VTE as opposed to idiopathic VTE may be explained by the advanced age of our patient population. These data highlight the need for optimization of current VTE treatment strategies, especially in cancer patients. Disclosures: No relevant conflicts of interest to declare.
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Delluc, Aurélien, Cécile Tromeur, Florent Le Ven, Maelenn Gouillou, Nicolas Paleiron, Luc Bressollette, Michel Nonent, et al. "Current incidence of venous thromboembolism and comparison with 1998: a community-based study in Western France." Thrombosis and Haemostasis 116, no. 11 (September 2016): 967–74. http://dx.doi.org/10.1160/th16-03-0205.
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SummaryIn 1998 we estimated the incidence of venous thromboembolism (VTE) to be 1.8/1,000 per year. The aim of this study was to compare current VTE incidence to that observed in 1998. We prospectively recorded all cases of symptomatic pulmonary embolism (PE) and deep vein thrombosis (DVT) of the lower limbs diagnosed between March 1, 2013 and February 28, 2014 in hospitals and in the community, using the same method and geographic area than in 1998. The 2013 incidence rates of VTE were computed and compared with those of 1998 using age- and sex-specific standardised incidence ratios (SIRs). In 2013, we recorded 576 VTE cases (279 isolated DVT and 297 PE ± DVT). Among 367,911 inhabitants, the overall incidence of VTE was 1.57/1,000 (95 % CI 1.44–1.69). The overall VTE incidence was significantly lower in 2013 as compared with 1998: SIR 0.72 (95 % CI 0.67–0.79) as well as the incidence of isolated DVT: SIR 0.53 (95 % CI 0.47–0.60); conversely, the overall incidence of PE was unchanged: SIR 1.10 (95 % CI, 0.98–1.23) despite an increase in the incidence of isolated PE: SIR 1.29 (95 % CI, 1.10–1.52). In 1998, 4.4 % of PE cases were diagnosed using CTPA as compared with 73.7 % in 2013 (p < 0.001). In conclusion, between 1998 and 2013, the incidence of symptomatic DVT decreased. Conversely, we found no similar reduction in the incidence of symptomatic PE; whether this is due to changes in diagnostic tests and algorithms in the management of suspected PE requires further investigations.Supplementary Material to this paper is available online at www.thrombosis-online.com.
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Bosson, Jean Luc, Marie Antoinete Sevestre, Jose Labarere, Joel Constans, Isabelle Quere, and Gilles Pernod. "Recurrence and Mortality of DVT-Associated PE Is Greater Than Isolated PE Alone: Results of the 7532-Patients Prospective OPTIMEV Cohort Study." Blood 110, no. 11 (November 16, 2007): 700. http://dx.doi.org/10.1182/blood.v110.11.700.700.
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Abstract Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is associated with a significant mortality and life-long morbidity. A large number of studies have focused on VTE, contributing to better improving its management. Especially studies have provided accurate estimates of 3-month mortality rates for PE and have identified prognostic factors that may guide the physician’s initial treatment decision for these patients. However, improvements in the prevention of venous thromboembolism (VTE) and diagnosis have changed the epidemiology of VTE over the last twenty years. Advances in imaging technology have resulted in more frequent diagnosis and treatment of early presentation of VTE, including isolated distal DVT or isolated PE. However, the clinical signification and the prognosis of these forms of VTE are unknown. Therefore we prospectively investigated the 3-month overall for isolated distal DVT, proximal DVT, PE with DVT and PE without DVT, among a large in and out population study. Between November 2004 and January 2006, all patients over 18 years old who were referred to 359 french board-certified vascular physicians for a clinical suspicion of VTE were included. VTE presentations were categorized using validated clinical decision rules and objective tests including ultrasonography, lung scan and helical CT scan. Subjects without an objectively confirmed diagnosis of VTE were used as controls. All patients with confirmed VTE and a random sample of controls were followed-up at 3 months. We estimated 3 months survival for each type of VTE 8256 patients entered the study, among which 7532 were analysed. The median age for all patients was 65 years (49–77 years), 2923 (39%) were men, 2925 were inpatients (39%), and 1884 (25%) had a previous history of VTE. 933 had isolated distal DVT (12%), 710 proximal DVT (9.4%), 426 PE with DVT (5.7%), 148 PE without DVT (2.0%) and 5315 had no VTE (70.6%). Overall, 4290 patients were followed up at 3 months. At 3 months, VTE recurrence was not significantly different between the 5 groups of patients. By contrast, 95/2407 control patients (4%), 35/787 (4.4%) distal DVT, 48/598 (8%) proximal DVT, 48/371 (12.9%) PE with DVT, and 6/130 (4.6%) died. In multivariate analysis, the 3-months mortality adjusted hazard ratio [95% CI] was 1.1 [0.7–1.7] for distal DVT (P 0.59), 1.6 [1.1–2.3] for proximal DVT (P 0.013), 2.1 [1.4–3.0] for DVT-associated PE (p<0.01), and 0.5 [0.2–1.1] for isolated PE (P 0.084). Kaplan-Meier survival estimates were 96% [95% CI 95–97] for controls as compared with 95% [94–97], 92% [90–94], 87% [83–90] and 95% [90–98] for isolated distal DVT, proximal DVT, PE with DVT, and PE without DVT cases, respectively (Figure 1). Therefore, compared to controls, only patients with proximal DVT or PE with DVT were at increased risk of death, while patients with isolated PE without DVT were not. Figure Figure
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Roopkumar, Joanna, Ann S. Kim, Thapa Bicky, Brian P. Hobbs, and Alok A. Khorana. "Venous Thromboembolism in Cancer Patients Receiving Immunotherapy." Blood 132, Supplement 1 (November 29, 2018): 2510. http://dx.doi.org/10.1182/blood-2018-99-116439.
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Abstract Background Venous thromboembolism (VTE) is known to complicate several classes of anti-cancer therapies including chemotherapy and anti-angiogenic agents. Immunotherapy is a novel and growing approach to systemic treatment of cancer, but little is known about incidence or prevalence of VTE in cancer patients on immunotherapy. The objective of this study was to describe rates of VTE in cancer patients on various immunotherapy regimens. Methods We conducted a single institution, retrospective cohort study at Taussig Cancer Center of the Cleveland Clinic. The study was approved by the institutional review board. The study cohort was created using our center's pharmacy database of patients who received any of the six FDA approved immunotherapy agents (ipilimumab, nivolumab, pembrolizumab, atezolizumab, avelumab or durvalumab) between July 2015 and December 2017. VTE events including deep venous thrombosis (DVT) and pulmonary embolism (PE) were identified by chart review. Overall survival (OS) was estimated by the Kaplan-Meier method and evaluated for association with VTE following immunotherapy using Cox proportional hazard regression with two-sided Wald test and adjustment for age at diagnosis and presence/absence of metastases. Patients receiving combination therapies were matched 1:3 to patients receiving monotherapy based on demographic and clinical attributes including: gender, race, ethnicity, primary cancer site, age at diagnosis, and stage. The incidence of VTE following immunotherapy was compared between single and combination therapy cohorts using the Pearson chi-squared test. Results The study population comprised 522 patients, of whom a small majority (n=307, 58.8%) were males with a median age at cancer diagnosis of 64 years (range 10 to 91 years). The vast majority of patients (n=463, 88.7%) had metastatic disease. Lung (n= 259, 49.6%) was the most common primary site of cancer. Nivolumab was the most commonly used single drug immunotherapy (n=273, 52.3%) and nivolumab + ipilimumab was the most common multidrug regimen (n=34, 6.5%). VTE occurred in 30.3% of patients (n=158), including DVT in 34.8% (n=55), PE in 34.2% (n=54), DVT+PE in 18.4% (n=29), visceral vein thrombosis in 8.9% (n=14), DVT +PE+ visceral vein in 2.5% (n=4). Using the matched subset of patients receiving single (n=129) and combination (n=43) immunotherapies, the rate of VTE in single vs. combination immunotherapy was 36% vs. 28% (p value = 0.45). VTE in patients on immunotherapy was associated with worse survival, but this association was not statistically significant when adjusting for age and metastases [HR = 1.215, (95%CI 0.94 to 1.55) p value = 0.121]. Conclusions VTE is common in cancer patients receiving immunotherapy either as single-agent or combination regimens, affecting nearly one-third of all patients and may potentially be associated with worsened survival. Further work is necessary to identify pathophysiology, risk factors and benefit of thromboprophylaxis in this setting. Figure. Figure. Disclosures Khorana: Janssen: Consultancy; Bayer: Consultancy; Pfizer: Consultancy; Sanofi: Consultancy.