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Chan A, Lensing AWA, Kubitza D, Brown G, Elorza D, Ybarra M, Halton J, Grunt S, Kenet G, Bonnet D, Santamaria A, Saracco P, Biss T, Climent F, Connor P, Palumbo J, Thelen K, Smith WT, Mason A, Adalbo I, Berkowitz SD, Hurst E, van Kesteren J, Young G, Monagle P. Clinical presentation and therapeutic management of venous thrombosis in young children: a retrospective analysis. Thromb J 2018; 16:29. [PMID: 30410424 PMCID: PMC6211549 DOI: 10.1186/s12959-018-0182-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 08/19/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) in young children is not well documented. METHODS Clinicians from 12 institutions retrospectively evaluated the presentation, therapeutic management, and outcome of VTE in children younger than 2 years seen in 2011-2016. Feasibility of recruiting these children in EINSTEIN-Jr. phase III, a randomized trial evaluating rivaroxaban versus standard anticoagulation for VTE, was assessed. RESULTS We identified 346 children with VTE, of whom 227 (65.6%) had central venous catheter-related thrombosis (CVC-VTE), 119 (34.4%) had non-CVC-VTE, and 156 (45.1%) were younger than 1 month. Of the 309 children who received anticoagulant therapy, 86 (27.8%) had a short duration of therapy (i.e. < 6 weeks for CVC-VTE and < 3 months for non-CVC-VTE) and 17 (5.5%) had recurrent VTE during anticoagulation (n = 8, 2.6%) or shortly after its discontinuation (n = 9, 2.9%). A total of 37 (10.7%) children did not receive anticoagulant therapy and 4 (10.5%) had recurrent VTE.The average number of children aged < 0.5 years and 0.5-2 years who would have been considered for enrolment in EINSTEIN-Jr is approximately 1.0 and 0.9 per year per site, respectively. CONCLUSIONS Young children with VTE most commonly have CVC-VTE and approximately one-tenth and one-fourth received no or only short durations of anticoagulant therapy, respectively. Recurrent VTE rates without anticoagulation, during anticoagulation or shortly after its discontinuation seem comparable to those observed in adults. Short and flexible treatment durations could potentially increase recruitment in EINSTEIN-Jr. phase III.
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Affiliation(s)
| | - Anthonie W. A. Lensing
- Bayer AG, Wuppertal, Germany
- Bayer U.S., LLC, Whippany, USA
- Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Dagmar Kubitza
- Bayer AG, Wuppertal, Germany
- Bayer U.S., LLC, Whippany, USA
| | - Grahaem Brown
- Competitive Drug Development International Ltd. (CDDI), London, UK
| | | | | | - Jacqueline Halton
- Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Canada
| | - Sebastian Grunt
- Division of Neuropaediatrics, Development and Rehabilitation, University Children’s Hospital, University of Bern, Bern, Switzerland
| | | | | | | | - Paola Saracco
- University Hospital, Città della Salute e della Scienza di Torino, Ospedale Infantile Regina Margherita, Torino, Italy
| | - Tina Biss
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Philip Connor
- The Noah’s Ark Children’s Hospital for Wales, University Hospital of Wales, Cardiff, UK
| | - Joseph Palumbo
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Kirstin Thelen
- Bayer AG, Wuppertal, Germany
- Bayer U.S., LLC, Whippany, USA
| | | | - Amy Mason
- Bayer AG, Wuppertal, Germany
- Bayer U.S., LLC, Whippany, USA
| | - Ivet Adalbo
- Bayer AG, Wuppertal, Germany
- Bayer U.S., LLC, Whippany, USA
| | | | - Eva Hurst
- Competitive Drug Development International Ltd. (CDDI), London, UK
| | | | - Guy Young
- Hemostasis and Thrombosis Center (HTC), Children’s Hospital Los Angeles, Los Angeles, USA
| | - Paul Monagle
- Department of Haematology, Royal Children’s Hospital, Department of Paediatrics, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Australia
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Albertsen IE, Nielsen PB, Søgaard M, Goldhaber SZ, Overvad TF, Rasmussen LH, Larsen TB. Risk of Recurrent Venous Thromboembolism: A Danish Nationwide Cohort Study. Am J Med 2018; 131:1067-1074.e4. [PMID: 30266273 DOI: 10.1016/j.amjmed.2018.04.042] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 04/20/2018] [Accepted: 04/20/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE In this study, we aimed to estimate recurrence risk after incident venous thromboembolism, stratified according to unprovoked, provoked, and cancer-related venous thromboembolism in a prospective cohort of inpatients and outpatients receiving routine care. METHODS We linked nationwide Danish health registries to identify all patients with incident venous thromboembolism from January 2000 through December 2015. Rates of recurrence were calculated and Cox regression was used to compute hazard ratios (HRs) with 95% confidence intervals (CIs) by incident venous thromboembolism type after adjusting for coexisting risk factors. RESULTS The study included 73,993 patients with incident venous thromboembolism (54.1% females; mean age, 62.3 years). At 6-month follow-up, rates per 100 person-years were 6.80, 6.92, and 9.06 for provoked, unprovoked, and cancer-related venous thromboembolism, respectively. At 10-year follow-up, corresponding rates were 2.22, 2.84, and 3.70, respectively. Additionally, at 6-month follow-up, hazard rates of recurrence were comparable for patients with unprovoked venous thromboembolism 1.01 (95% CI, 0.92-1.11) and provoked. At 10-year follow-up, unprovoked venous thromboembolism (HR, 1.17; 95% CI, 1.12-1.23) and cancer-related venous thromboembolism (HR, 1.21; 95% CI, 1.12-1.32) were associated with higher risk of recurrence compared with that found in provoked venous thromboembolism. CONCLUSIONS In this nationwide cohort, patients with cancer-related venous thromboembolism had the highest risk of recurrence. At 6-month follow-up, there were similar risks of recurrence for patients with unprovoked and provoked venous thromboembolism. At 10-year follow-up, recurrence risks were similar for patients with unprovoked venous thromboembolism and patients with cancer-related venous thromboembolism. High recurrence risks in all categories indicate that further research is needed to optimize duration of extended anticoagulation for these patients.
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Affiliation(s)
- Ida Ehlers Albertsen
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Aalborg University, Denmark; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA..
| | - Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | - Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | - Samuel Zachary Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA
| | | | | | - Torben Bjerregaard Larsen
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Aalborg University, Denmark
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53
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Obi A, Wakefield T. The Management of Venous Thromboembolic Disease: New Trends in Anticoagulant Therapy. Adv Surg 2018; 52:43-56. [PMID: 30098620 DOI: 10.1016/j.yasu.2018.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Andrea Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5372 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA.
| | - Thomas Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5463 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
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Jiang R, Shi Y, Zhang R, Pudasain B, Wang L, Zhao QH, Yuan P, Guo J, Zhu CT, Liu JM. Comparative efficacy and safety of low-intensity warfarin therapy in preventing unprovoked recurrent venous thromboembolism: A systematic review and meta-analysis. THE CLINICAL RESPIRATORY JOURNAL 2018; 12:2170-2177. [PMID: 29601145 DOI: 10.1111/crj.12795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 02/23/2018] [Accepted: 03/19/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although there exists potential risk of bleeding, extended 'lifelong' conventional-intensity [international normalized ratio (INR): 2.0-3.0] warfarin anticoagulation is recommended for unprovoked venous thromboembolism (VTE) patients because of risk of recurrent VTE. Whether long-term low-intensity (INR: 1.5-2.0) warfarin therapy reduced the risk of major bleeding without substantially lowered antithrombotic efficacy is not well understood. The aim of this study was to perform a systematic review and meta-analysis to evaluate the risk-benefits of low-intensity warfarin therapy. METHODS We conducted a comprehensive search of electronic databases and included randomized control trials (RCTs) that reported efficacy (recurrent VTE) and safety (bleeding episodes) of low-intensity warfarin therapy compared with conventional-intensity warfarin or placebo from inception through Jun 2016. RESULTS Four RCTs reporting high GRADE quality evidence were included. Although the relative risk of recurrent VTE with low-intensity therapy was significantly increased [2.96 (95% CI: 1.40 to 6.24), P < .004] compared to conventional-intensity warfarin, there was significant decrease of relative risk when compared with placebo [0.37 (95% CI: 0.24 to 0.56), P < .00001]. As per included publications, no significant major bleeding episodes were observed in low-intensity warfarin group. CONCLUSIONS Although less effective than conventional-intensity warfarin therapy this meta-analysis indicates that long-term low-intensity warfarin therapy is highly effective for preventing recurrent VTE than placebo, along with reduced risks of major bleeding and minimizing potential complications.
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Affiliation(s)
- Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Yu Shi
- Department of Cardiology, Yantai Yu-Huangding Hospital, Medical College of Qingdao University, Yantai 264000, China
| | - Rui Zhang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Bigyan Pudasain
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Chang-Tai Zhu
- Department of Transfusion Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Rd, Shanghai 200233, China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
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Salazar Adum JP, Golemi I, Paz LH, Diaz Quintero L, Tafur AJ, Caprini JA. Venous thromboembolism controversies. Dis Mon 2018; 64:408-444. [PMID: 29631864 DOI: 10.1016/j.disamonth.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | - Iva Golemi
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Luis H Paz
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Luis Diaz Quintero
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Alfonso J Tafur
- Cardiovascular Section, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL 60201.
| | - Joseph A Caprini
- The University of Chicago Pritzker School of Medicine, Chicago, IL
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Abstract
Major studies addressing various aspects of the treatment of deep vein thrombosis are reviewed. It has lately been demonstrated that heparin should be dosed according to body weight and is preferably given as subcutaneous injections twice daily. Alternatively, low-molecular-weight heparins may be given in a fixed dose once daily, which does not require monitoring. Oral anticoagulation should be started concomitantly with heparin and targeted at an international normalized ratio of 2.0-3.0. This treatment should continue for a longer duration than previously accepted, in many cases for 6 months. For patients with contraindications to oral anticoagulation, secondary prophylaxis with a low-molecular-weight heparin is also effective and safe.
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Affiliation(s)
- S Schulman
- Department of Internal Medicine, Karolinska Hospital, Stockholm, Sweden
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Abstract
Anticoagulation pharmacy has been dramatically altered with US Food and Drug Administration (FDA) approval of 5 direct oral anticoagulants, 1 novel reversal agent and, a second designated for fast-track approval. Trial data surrounding current trends in anticoagulant choice for VTE, reversal, and bridging are constantly redefining practice. Extended therapy for unprovoked VTE has expanded to include low-dose direct oral anticoagulants, aspirin, and the use of the HERDOO2 system to identify women who can stop anticoagulant therapy without increased risk of recurrent VTE. Trends in thromboprophylaxis include extended duration low-dose direct oral anticoagulants to prevent VTE in high-risk patients.
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Affiliation(s)
- Margaret Smith
- General Surgery Residency, Department of Surgery, University of Michigan, 2207 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| | - Glenn Wakam
- General Surgery Residency, Department of Surgery, University of Michigan, 2207 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| | - Thomas Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5463 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| | - Andrea Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5372 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA.
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Popov Aleksandrov A, Mirkov I, Ninkov M, Mileusnic D, Demenesku J, Subota V, Kataranovski D, Kataranovski M. Effects of warfarin on biological processes other than haemostasis: A review. Food Chem Toxicol 2018; 113:19-32. [PMID: 29353071 DOI: 10.1016/j.fct.2018.01.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/29/2017] [Accepted: 01/12/2018] [Indexed: 02/07/2023]
Abstract
Warfarin is the world's most widely used anticoagulant drug. Its anticoagulant activity is based on the inhibition of the vitamin K-dependent (VKD) step in the complete synthesis of a number of blood coagulation factors that are required for normal blood coagulation. Warfarin also affects synthesis of VKD proteins not related to haemostasis including those involved in bone growth and vascular calcification. Antithrombotic activity of warfarin is considered responsible for some aspects of its anti-tumour activity of warfarin. Some aspects of activities against tumours seem not to be related to haemostasis and included effects of warfarin on non-haemostatic VKD proteins as well as those not related to VKD proteins. Inflammatory/immunomodulatory effects of warfarin indicate much broader potential of action of this drug both in physiological and pathological processes. This review provides an overview of the published data dealing with the effects of warfarin on biological processes other than haemostasis.
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Affiliation(s)
- Aleksandra Popov Aleksandrov
- Immunotoxicology Group, Department of Ecology, Institute for Biological Research "Sinisa Stankovic", University of Belgrade, 142 Bulevar Despota Stefana, 11000 Belgrade, Serbia
| | - Ivana Mirkov
- Immunotoxicology Group, Department of Ecology, Institute for Biological Research "Sinisa Stankovic", University of Belgrade, 142 Bulevar Despota Stefana, 11000 Belgrade, Serbia
| | - Marina Ninkov
- Immunotoxicology Group, Department of Ecology, Institute for Biological Research "Sinisa Stankovic", University of Belgrade, 142 Bulevar Despota Stefana, 11000 Belgrade, Serbia
| | - Dina Mileusnic
- Immunotoxicology Group, Department of Ecology, Institute for Biological Research "Sinisa Stankovic", University of Belgrade, 142 Bulevar Despota Stefana, 11000 Belgrade, Serbia
| | - Jelena Demenesku
- Immunotoxicology Group, Department of Ecology, Institute for Biological Research "Sinisa Stankovic", University of Belgrade, 142 Bulevar Despota Stefana, 11000 Belgrade, Serbia
| | - Vesna Subota
- Institute for Medical Biochemistry, Military Medical Academy, 17 Crnotravska, 11000 Belgrade, Serbia
| | - Dragan Kataranovski
- Immunotoxicology Group, Department of Ecology, Institute for Biological Research "Sinisa Stankovic", University of Belgrade, 142 Bulevar Despota Stefana, 11000 Belgrade, Serbia; Institute of Zoology, Faculty of Biology, University of Belgrade, 16 Studentski trg, 11000 Belgrade, Serbia
| | - Milena Kataranovski
- Immunotoxicology Group, Department of Ecology, Institute for Biological Research "Sinisa Stankovic", University of Belgrade, 142 Bulevar Despota Stefana, 11000 Belgrade, Serbia; Institute of Physiology and Biochemistry, Faculty of Biology, University of Belgrade, 16 Studentski trg, 11000 Belgrade, Serbia.
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Yamashita Y, Morimoto T, Amano H, Takase T, Hiramori S, Kim K, Konishi T, Akao M, Kobayashi Y, Inoue T, Oi M, Izumi T, Takahashi K, Tada T, Chen PM, Murata K, Tsuyuki Y, Sakai H, Saga S, Sasa T, Sakamoto J, Yamada C, Kinoshita M, Togi K, Ikeda T, Ishii K, Kaneda K, Mabuchi H, Otani H, Takabayashi K, Takahashi M, Shiomi H, Makiyama T, Ono K, Kimura T. Anticoagulation Therapy for Venous Thromboembolism in the Real World ― From the COMMAND VTE Registry ―. Circ J 2018; 82:1262-1270. [DOI: 10.1253/circj.cj-17-1128] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Toru Takase
- Department of Cardiology, Kindai University Hospital
| | | | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | - Takeshi Inoue
- Department of Cardiology, Shiga Medical Center for Adults
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | | | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital
| | | | | | - Hiroshi Sakai
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science
| | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital
| | | | - Chinatsu Yamada
- Department of Cardiovascular Medicine, Kyoto Okamoto Memorial Hospital
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kindai University Faculty of Medicine
| | | | | | | | | | - Hideo Otani
- Department of Cardiovascular Medicine, Sugita Genpaku Memorial Obama Municipal Hospital
| | | | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Tarango C, Schulman S, Betensky M, Goldenberg NA. Duration of anticoagulant therapy in pediatric venous thromboembolism: Current approaches and updates from randomized controlled trials. Expert Rev Hematol 2017; 11:37-44. [PMID: 29183221 DOI: 10.1080/17474086.2018.1407241] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Compared with the incidence of venous thromboembolism in the adult population, pediatric VTE is rare. Yet, recent data suggest that the incidence of VTE in children is increasing, and little is known about the optimal duration of anticoagulation in pediatrics. Areas covered: This review summarizes current evidence-based adult recommendations and associated clinical trials from which current guidelines on the duration of anticoagulation in children have been extrapolated. It also discusses pediatric expert consensus-based guidelines and current pediatric clinical trials on duration of therapy in pediatric VTE. Expert commentary: The vast majority of pediatric VTE are provoked, and evidence on duration of anticoagulation for pediatric VTE is highly limited, but suggests that a maximum duration of 3 months is reasonable for most patients with provoked VTE, whereas longer duration is likely appropriate for unprovoked VTE. Whether shorter duration than 3 months is optimal for pediatric provoked VTE is as yet unclear. Results from the multinational randomized controlled trial studying the duration of anticoagulant therapy for provoked VTE in patients <21 years old (Kids-DOTT) will be critical to inform the future standard of care in pediatric VTE treatment.
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Affiliation(s)
- Cristina Tarango
- a Division of Hematology, Cancer and Blood Diseases Institute , Cincinnati Children's Hospital Medical Center Cincinnati , Cincinnati , OH , USA.,b Department of Pediatrics , University of Cincinnati , Cincinnati , OH , USA
| | - Sam Schulman
- c Department of Medicine , McMaster University and Thrombosis and Atherosclerosis Research Institute , Hamilton , Canada
| | - Marisol Betensky
- d Department of Pediatrics , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Neil A Goldenberg
- c Department of Medicine , McMaster University and Thrombosis and Atherosclerosis Research Institute , Hamilton , Canada.,e Department of Medicine, Division of Hematology , Johns Hopkins University School of Medicine , Baltimore , MD , USA.,f All Children's Research Institute , Johns Hopkins All Children's Hospital , St. Petersburg , FL , USA
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61
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Huynh K. Milestone 11: Quest to find the optimal duration. Nat Rev Cardiol 2017:nrcardio.2017.181. [PMID: 29238057 DOI: 10.1038/nrcardio.2017.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Alfonso A, Jiménez D, Capitán CF, Prandoni P, Wells PS, Vidal G, Barillari G, Monreal M, Lecumberri R. Dynamics of case-fatalilty rates of recurrent thromboembolism and major bleeding in patients treated for venous thromboembolism. Thromb Haemost 2017; 110:834-43. [DOI: 10.1160/th13-02-0132] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 05/21/2013] [Indexed: 12/31/2022]
Abstract
SummaryIn patients with venous thromboembolism (VTE), assessment of the risk of fatal recurrent VTE and fatal bleeding during anticoagulation may help to guide intensity and duration of therapy. We aimed to provide estimates of the case-fatality rate (CFR) of recurrent VTE and major bleeding during anticoagulation in a ‘real life’ population, and to assess these outcomes according to the initial presentation of VTE and its etiology. The study included 41,826 patients with confirmed VTE from the RIETE registry who received different durations of anticoagulation (mean 7.8 ± 0.6 months). During 27,110 patient-years, the CFR was 12.1% (95% CI, 10.2–14.2) for recurrent VTE, and 19.7% (95% CI, 17.4–22.1) for major bleeding. During the first three months of anticoagulant therapy, the CFR of recurrent VTE was 16.1% (95% CI, 13.6–18.9), compared to 2.0% (95% CI, 0–4.2) beyond this period. The CFR of bleeding was 20.2% (95% CI, 17.5–23.1) during the first three months, compared to 18.2% (95% CI, 14.0–23.2) beyond this period. The CFR of recurrent VTE was higher in patients initially presenting with PE (18.5%; 95% CI, 15.3–22.1) than in those with DVT (6.3%; 95% CI, 4.5–8.6), and in patients with provoked VTE (16.3%; 95% CI, 13.6–19.4) than in those with unprovoked VTE (5.5%; 95% CI, 3.5–8.0). In conclusion, the CFR of recurrent VTE decreased over time during anticoagulation, while the CFR of major bleeding remained stable. The CFR of recurrent VTE was higher in patients initially presenting with PE and in those with provoked VTE.
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Legnani C, Cini M, Guazzaloca G, Palareti G, Cosmi B. D-dimer and residual vein obstruction as risk factors for recurrence during and after anticoagulation withdrawal in patients with a first episode of provoked deep-vein thrombosis. Thromb Haemost 2017; 105:837-45. [DOI: 10.1160/th10-08-0559] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 01/19/2011] [Indexed: 11/05/2022]
Abstract
SummaryD-dimer and residual venous obstruction (RVO) have been separately shown to be risk factors for recurrent venous thromboembolism (VTE) after a first episode of unprovoked proximal deep-vein thrombosis (DVT). It was the objective of this study to assess the predictive value of D-dimer and residual vein obstruction (RVO), alone and in combination, for recurrence after provoked DVT of the lower limbs. A total of 296 consecutive patients with a first episode of symptomatic provoked proximal DVT were evaluated at a university hospital in Bologna, Italy. On the day of anticoagulation withdrawal (T0), RVO was determined by compression ultrasonography. D-dimer levels (cut-off: 500 ng/ml) were measured at T0 and after 30 ±10 days (T1). The main outcome was recurrent VTE during a two-year follow-up. D-dimer was abnormal in 11.6% (32/276) and 31% (85/276) of subjects at T0 and at T1, respectively. RVO was present in 44.8% (132/294) of patients. Recurrence rate was 5.1% (15/296; 95% confidence interval [CI]: 3–8%; 3% patient-years; 95% CI: 2–5 %). An abnormal D-dimer either at T0 or at T1 was associated with an adjusted hazard ratio (HR) for recurrence of 4.2 (95% CI:1.2–14.2; p=0.02) and 3.8 (95%CI: 1.2–12.1; p=0.02), respectively, when compared with normal D-dimer. The HR for recurrence associated with RVO was not significant, and RVO did not increase the recurrence risk associated with an abnormal D-dimer either at T0 or T1. In conclusion, an abnormal D-dimer during vitamin K antagonist (VKA) treatment or at one month after VKA withdrawal is a risk factor for recurrence in patients with provoked DVT, while RVO at the time of anticoagulation withdrawal is not.
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Moutzouris JP, Chow V, Chung T, Curnow J, Kritharides L, Chwan Ng AC. Acute pulmonary embolism during warfarin therapy and long-term risk of recurrent fatal pulmonary embolism. Thromb Haemost 2017; 110:523-33. [DOI: 10.1160/th13-04-0288] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 05/17/2013] [Indexed: 11/05/2022]
Abstract
SummaryThe clinical characteristics and long-term outcomes of patients presenting with acute pulmonary embolism (PE) during treatment with warfarin have not been described. Clinical details of all patients admitted to a tertiary institution from 2000-2007 with acute PE were retrieved retrospectively, baseline warfarin status and the international normalised ratio (INR) were recorded, and their outcomes tracked using a statewide death registry. Of 923 patients with clearly documented warfarin status included in this study, 83 (9%) were taking warfarin. Mean (± standard deviation) day-1 INR of those taking warfarin was 2.3 ± 0.9, with 67% of patients therapeutically anti-coagulated (INR ≥2.0) at presentation (49 patients with INR <2.5 and 34 with INR ≥2.5). Patients taking warfarin on admission were more likely to have heart failure, atrial fibrillation and valvular heart disease, with similar prevalence of malignancy and ischaemic heart disease, compared to patients not on warfarin. Total mortality of the cohort (mean follow-up 4.0 ± 2.5 years) was 31.6% (in-hospital mortality 1.5%), and was similar between warfarin and no warfarin groups. There was however a greater than four-fold increased risk of post-discharge death due to recurrent PE for the patients taking warfarin on admission (hazard ratio [HR] 4.43, 95% confidence interval [CI] 1.36-14.42, p=0.01). Among patients taking warfarin on admission, day-1 INR <2.5 significantly increased long-term all-cause mortality compared to INR ≥2.5 (adjusted HR 2.51, 95% CI 1.08-5.86, p=0.03). In conclusion, patients presenting with PE during treatment with warfarin have an increased risk of death from recurrent PE. Admission INR appears to have independent long-term prognostic importance in these patients.
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Barbar S, Milan M, Campello E, Spiezia L, Piovella C, Pesavento R, Prandoni P. Optimal duration of anticoagulation. Thromb Haemost 2017; 113:1210-5. [DOI: 10.1160/th14-04-0396] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/24/2014] [Indexed: 11/05/2022]
Abstract
SummaryOnce anticoagulation is stopped, the risk of recurrent venous thromboembolism (VTE) over years after a first episode is consistently around 30%. This risk is higher in patients with unprovoked than in those with (transient) provoked VTE, and among the latter in patients with medical than in those with surgical risk factors. Baseline parameters that have been found to be related to the risk of recurrent VTE are the proximal location of deep-vein thrombosis, obesity, old age, male sex and non-0 blood group, whereas the role of inherited thrombophilia is controversial. The persistence of residual vein thrombosis at ultrasound assessment has consistently been shown to increase the risk, as do persistently high values of D-dimer and the early development of the post-thrombotic syndrome. Although the latest international guidelines suggest indefinite anticoagulation for most patients with the first episode of unprovoked VTE, strategies that incorporate the assessment of residual vein thrombosis and D-dimer have the potential to identify subjects in whom anticoagulation can be safely discontinued. Moreover, new opportunities are offered by a few emerging anti-Xa and anti-IIa oral compounds, which are likely to induce fewer haemorrhagic complications than vitamin K antagonists while preserving the same effectiveness; and by low-dose aspirin, which has the potential to prevent the occurrence of both venous and arterial thrombotic events.
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Witmer CM, Sauck E, Raffini LJ. A survey of pediatric hematology/oncology specialists regarding management of central line associated venous thrombosis. Pediatr Blood Cancer 2017; 64. [PMID: 27905682 DOI: 10.1002/pbc.26383] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 11/07/2016] [Indexed: 11/11/2022]
Abstract
Central venous catheters (CVCs) account for the largest proportion of thrombotic events in pediatric patients. Questions remain regarding adequate treatment and prevention methods. We surveyed pediatric hematology/oncology specialists, using hypothetical cases to assess management strategies for acute CVC thrombosis and secondary prevention. Survey respondents varied in the use of the thrombophilia evaluation (33.3%, 41/123) and duration of treatment (6 weeks: 54.1%, 66/122). Secondary CVC prophylaxis was utilized by 36.6% (45/123) of respondents and by 24.4% (30/123) but only if there was a documented thrombophilia. This heterogeneity highlights the need for clinical studies to address these important clinical questions.
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Affiliation(s)
- Char M Witmer
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Sauck
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Leslie J Raffini
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Quel traitement anticoagulant au décours d’une embolie pulmonaire. Presse Med 2017; 46:728-738. [DOI: 10.1016/j.lpm.2017.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 06/27/2017] [Indexed: 01/22/2023] Open
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Tritschler T, Aujesky D. Venous thromboembolism in the elderly: A narrative review. Thromb Res 2017; 155:140-147. [DOI: 10.1016/j.thromres.2017.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 04/30/2017] [Accepted: 05/17/2017] [Indexed: 12/14/2022]
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Barco S, Corti M, Trinchero A, Picchi C, Ambaglio C, Konstantinides SV, Dentali F, Barone M. Survival and recurrent venous thromboembolism in patients with first proximal or isolated distal deep vein thrombosis and no pulmonary embolism. J Thromb Haemost 2017; 15:1436-1442. [PMID: 28439954 DOI: 10.1111/jth.13713] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Indexed: 12/11/2022]
Abstract
Essentials The long-term risk of recurrence and death after distal deep vein thrombosis (DVT) is uncertain. We included subjects with first proximal or isolated distal DVT (IDDVT) and no pulmonary embolism. The risk of symptomatic and asymptomatic recurrence is lower after IDDVT (vs. proximal). IDDVT may be associated with a lower long-term risk of death, especially after unprovoked DVT. SUMMARY Background A few studies have focused on the risk of recurrence after first acute isolated distal deep vein thrombosis (IDDVT) compared with proximal DVT (PDVT), whereas the incremental risk of death has never been explored beyond the first 3 years after acute event. Methods Our single-center cohort study included patients with first symptomatic acute PDVT or IDDVT. Patients were excluded if they had concomitant pulmonary embolism (PE) or prior venous thromboembolism. The primary outcomes were symptomatic objectively diagnosed recurrent PDVT or PE and all-cause death. Results In total, 4759 records were screened and 831 subjects included: 202 had symptomatic IDDVT and 629 had PDVT. The median age was 66 years and 50.5% were women. A total of 125 patients had recurrent PDVT or PE during 3175 patient-years of follow-up: 109 events occurred after PDVT (17.3%) and 16 after IDDVT (7.9%). Annual recurrence rates were 4.5% (95% confidence interval [CI], 3.7-5.4%) and 2.0% (95% CI, 1.1-3.2%), respectively, for an adjusted hazard ratio (aHR) for IDDVT patients of 0.32 (95% CI, 0.19-0.55). Death occurred in 263 patients (31.6% [95% CI, 28.6-34.9%]) during 5469 patient-years of follow-up for an overall annual incidence rate of 4.8% (95% CI, 4.2-5.4%). The mortality rate was 33.5% (n = 211) in PDVT patients and 25.7% (n = 52) in IDDVT patients. The long-term hazard of death appeared lower for IDDVT patients (aHR, 0.75 [95% CI, 0.55-1.02]), especially after unprovoked events (aHR, 0.58 [95% CI, 0.26-1.31]). Conclusions Compared with PDVT, IDDVT patients were at a lower risk of recurrent VTE. The risk of death appeared lower after IDDVT during a median follow-up of 7.6 years.
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Affiliation(s)
- S Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
| | - M Corti
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
| | - A Trinchero
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
| | - C Picchi
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
- Department of Internal Medicine, Presidio Ospedaliero 'Macedonio Melloni', ASST FBF 'Sacco', Milan, Italy
| | - C Ambaglio
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
| | - S V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - F Dentali
- Department of Clinical and Experimental Medicine, Ospedale di Circolo, Insubria University, Varese, Italy
| | - M Barone
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
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Schulman S, Ageno W, Konstantinides SV. Venous thromboembolism: Past, present and future. Thromb Haemost 2017; 117:1219-1229. [PMID: 28594049 DOI: 10.1160/th16-10-0823] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 12/02/2016] [Indexed: 12/28/2022]
Abstract
Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, is associated with a considerable disease burden which continues to grow along with the longer life expectancy of the population worldwide. In the past century, parenteral heparin prophylaxis was established for hospitalised patients at elevated risk of VTE. More recently, non-vitamin K antagonist oral anticoagulants (NOACs) with a direct inhibiting effect on factor Xa or thrombin, underwent extensive testing in clinical trials and have been approved for patients undergoing hip or knee replacement. Clinical investigation is ongoing in further areas of thromboprophylaxis, including medical prophylaxis in patients and high-risk situations in the outpatient setting. The diagnostic approach to suspected VTE is now based on advanced imaging techniques and robust diagnostic algorithms which ensure high sensitivity and specificity. Nevertheless, the role of clinical, or pre-test, probability assessment remains crucial to avoid overdiagnosis and treatment errors. Advances in reperfusion strategies, along progressive establishment of the NOACs as the new standard of anticoagulation treatment, have simplified the management of VTE, improving outcomes and particularly safety. While new molecular targets for anticoagulation are being investigated in the quest to further reduce bleeding risk, adjusting the initial regimen to the patient's risk and finding the optimal duration of anticoagulation after an index VTE event will be some of the top priorities in the years to come. Importantly, and in parallel to new drugs and technical advances in imaging, incentives such as hospital accreditation and funding based on evidence-based practice need to be implemented to increase guideline adherence.
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Affiliation(s)
- Sam Schulman
- Sam Schulman, MD, PhD, Thrombosis Service, HHS-General Hospital, 237 Barton St E, Hamilton, ON, L8L 2X2, Canada, Tel. : +1 905 5270271, ext 44479, Fax: +1 905 5211551, E-mail
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Franco L, Giustozzi M, Agnelli G, Becattini C. Anticoagulation in patients with isolated distal deep vein thrombosis: a meta-analysis. J Thromb Haemost 2017; 15:1142-1154. [PMID: 28316124 DOI: 10.1111/jth.13677] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Indexed: 11/27/2022]
Abstract
Essentials The optimal management of isolated distal deep vein thrombosis (IDDVT) is undefined. This meta-analysis aimed to assess the clinical benefit of anticoagulation for IDDVT. Anticoagulation reduced the rate of pulmonary embolism without increasing major bleeding risk. Recurrent thromboembolism was less common with more than 6 weeks vs. 6 weeks of anticoagulation. SUMMARY Background The optimal management of patients with isolated distal deep vein thrombosis (IDDVT), concerning both the need for anticoagulation and its duration, is undefined. Objectives We performed a meta-analysis of randomized and cohort studies in patients with IDDVT to assess the clinical benefit of: (i) anticoagulation versus no anticoagulation; and (ii) anticoagulant treatment for 6 weeks versus for > 6 weeks. Methods The primary outcome of this analysis was recurrent venous thromboembolism (proximal propagation, recurrence of deep vein thrombosis, and pulmonary embolism). Data were pooled and compared by the use of odds ratio (OR) and 95% confidence interval (CI). Results A reduction in the rate of recurrent venous thromboembolism was observed in patients who received anticoagulation relative to those who did not receive anticoagulation (either therapeutic or prophylactic) (20 studies, 2936 patients; OR 0.50, 95% CI 0.31-0.79), without an increase in the risk of major bleeding (OR 0.64, 95% CI 0.15-2.73). The rate of pulmonary embolism was lower in anticoagulant-treated patients than in controls (15 studies, 1997 patients; OR 0.48, 95% CI 0.25-0.91). A lower rate of recurrent venous thromboembolism was observed in patients who received > 6 weeks of anticoagulant therapy than in those who received 6 weeks of anticoagulant therapy (four studies, 1136 patients; OR 0.39, 95% CI 0.17-0.90). Conclusions In patients with IDDVT, anticoagulation (both therapeutic and prophylactic) reduces the rate of recurrent venous thromboembolism and the incidence of pulmonary embolism as compared with no anticoagulation, without an increased risk of major bleeding. Anticoagulation for > 6 weeks should be preferred over shorter durations.
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Affiliation(s)
- L Franco
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - M Giustozzi
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - G Agnelli
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - C Becattini
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
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Abstract
The natural history of isolated distal deep-vein thrombosis (IDDVT) is still uncertain, as well as the real clinical risks associated with the disease and the need for its diagnosis and treatment. While more and more IDDVTs are diagnosed in everyday clinical practice, their appropriate therapeutic management is, unfortunately, far from straightforward, and different recommendations on how patients with diagnosed IDDVT should be treated are present between expert professionals and even among international guidelines. The present article aims at briefly reviewing the issue of IDDVT therapy in general, particularly focusing on the different approaches to the treatment of the disease that have been suggested by recent guidelines, those that are currently adopted in clinical practice, and necessary future directions.
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Affiliation(s)
- Gualtiero Palareti
- Cardiovascular Diseases, University of Bologna, Bologna, Italy.
- Arianna Anticoagulation Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy.
| | - Michelangelo Sartori
- Unit of Angiology and Blood Coagulation, University Hospital of Bologna, Bologna, Italy
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73
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Characteristics of provoked deep venous thrombosis in a tertiary care center. J Vasc Surg Venous Lymphat Disord 2017. [PMID: 28623981 DOI: 10.1016/j.jvsv.2017.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Provoked deep venous thrombosis (DVT) is precipitated by a specific event. This paper compares the characteristics of provoked DVT in patients with transient risk (TR) factors and patients with continuous risk (CR) factors. METHODS A retrospective review of records of all consecutive patients diagnosed with DVT between January 2013 and August 2014 was performed. Patients with provoked DVT were included in the TR group if the provoking event resolved in 2 weeks and they did not have ongoing risk of thrombosis. Patients in the CR group had a provoked DVT with ongoing risk of thrombosis due to individual factors deemed to be ongoing risks of thrombosis, such as cancer, hypercoagulable disorder, and prolonged immobilization. Demographics, risk factors, association with pulmonary embolism (PE) and its severity, risk of recurrent venous thromboembolism (VTE), and mortality were compared between the two groups. RESULTS A total of 838 patients were diagnosed with DVT, and 50.7% (425) were provoked. There were 127 (29.9%) patients with TR and 298 (70.1%) with CR. TR patients were younger (60.4 ± 16.3 vs 65.9 ± 16.0; P = .001). TR was more likely to be provoked by surgery (70.9% vs 55.4%; P = .003), whereas CR was more likely to be provoked by immobilization (21.5% vs 12.6%; P = .032). CR patients were affected by cancer (48.7%) and hypercoagulable disorders (4.4%). TR patients were more likely to have calf DVTs (36.2% vs 26.2%; P = .047). There was a trend toward lower association with PE on presentation in TR (17.3% vs 21.1%; P = .072), but that did not reach statistical significance. However, TR factors were more likely to be associated with low-risk PE compared with CR factors (30.2% vs 54.6%; P = .040). After mean follow-up of 7.2 months, CR had higher risk of recurrent VTE (14.0% vs 6.8%; P = .045) and mortality (23.5% vs 7.1%; P < .0001). CONCLUSIONS Provoked DVT with CR factors affects older patients and is associated with high recurrence of VTE and mortality compared with provoked DVT with TR factors.
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Prandoni P, Ageno W, Mumoli N, Zanatta N, Imberti D, Visonà A, Ciammaichella M, Simioni L, Cappelli R, Bucherini E, Di Nisio M, Avruscio G, Camporese G, Parisi R, Cuppini S, Turatti G, Noventa F, Sarolo L. Recanalization rate in patients with proximal vein thrombosis treated with the direct oral anticoagulants. Thromb Res 2017; 153:97-100. [DOI: 10.1016/j.thromres.2017.03.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 03/19/2017] [Accepted: 03/25/2017] [Indexed: 01/01/2023]
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Bjøri E, Johnsen HS, Hansen JB, Braekkan SK. D-dimer at venous thrombosis diagnosis is associated with risk of recurrence. J Thromb Haemost 2017; 15:917-924. [PMID: 28166605 DOI: 10.1111/jth.13648] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Indexed: 11/27/2022]
Abstract
Essentials Whether D-dimer at incident venous thromboembolism (VTE) can predict recurrence-risk is unknown. We explored this association in 454 cancer-free patients with a first lifetime VTE. A low D-dimer at first VTE diagnosis was associated with a low recurrence risk. The association was predominant in patients with deep vein thrombosis and unprovoked VTE. Click to hear Dr Cannegieter's presentation on venous thrombosis: prediction of recurrence SUMMARY: Background Venous thromboembolism (VTE) is a common disease with a high recurrence rate. D-dimer measured after cessation of anticoagulant therapy predicts recurrence, and is used to decide on treatment prolongation. However, whether D-dimer measured at first VTE diagnosis can be used to assess recurrence-risk is unknown. Aims To investigate the association between D-dimer, measured at first VTE diagnosis and risk of recurrent VTE. Methods Information on clinical risk factors and laboratory markers were collected in 454 cancer-free patients with a first VTE. Recurrent VTEs and deaths during follow-up (1994-2012) were recorded. Results During a median follow-up of 3.9 years, 84 patients experienced a recurrent VTE. The crude recurrence rate was 1.7 (95% confidence interval [CI], 1.0-2.9) per 100 person-years in the lower quartile of D-dimer (≤ 1500 ng mL-1 ), and 4.9 (95% CI, 3.9-6.1) per 100 person-years in the upper three quartiles combined, yielding an absolute risk difference of 3.2 per 100 person-years. Patients with D-dimer ≤ 1500 ng mL-1 had 54% lower recurrence-risk than patients with D-dimer > 1500 ng mL-1 (HR, 0.46; 95% CI, 0.25-0.82). The association was particularly pronounced among patients with unprovoked events and deep vein thrombosis, showing a 66% (HR, 0.34; 95% CI, 0.15-0.74) and 68% (HR, 0.32; 95% CI, 0.14-0.71) lower recurrence risk among patients with D-dimer ≤ 1500 ng mL-1 , respectively. Conclusions A low D-dimer (≤ 1500 ng mL-1 ) measured at first VTE diagnosis was associated with a low recurrence risk, particularly among patients with DVT and unprovoked events. Our findings suggest that a clinical decision to avoid prolonged anticoagulant treatment could be considered based on low D-dimer at the time of VTE diagnosis.
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Affiliation(s)
- E Bjøri
- K.G. Jebsen Thrombosis Research and Expertise Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - H S Johnsen
- K.G. Jebsen Thrombosis Research and Expertise Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - J-B Hansen
- K.G. Jebsen Thrombosis Research and Expertise Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - S K Braekkan
- K.G. Jebsen Thrombosis Research and Expertise Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
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Marshall AL, Bartley AC, Ashrani AA, Pruthi RK, Durani U, Gonsalves WI, Kapoor P, Hashmi SK, Siddiqui MA, Go RS. Sex-based disparities in venous thromboembolism outcomes: A National Inpatient Sample (NIS)-based analysis. Vasc Med 2017; 22:121-127. [DOI: 10.1177/1358863x17693103] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Adam C Bartley
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Aneel A Ashrani
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Rajiv K Pruthi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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Current Status of Ventilation-Perfusion Scintigraphy for Suspected Pulmonary Embolism. AJR Am J Roentgenol 2017; 208:489-494. [DOI: 10.2214/ajr.16.17195] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Tew BY, Pal SK, He M, Tong T, Wu H, Hsu J, Liu X, Neuhausen SL, Jones JO. Vitamin K epoxide reductase expression and prostate cancer risk. Urol Oncol 2017; 35:112.e13-112.e18. [DOI: 10.1016/j.urolonc.2016.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 01/23/2023]
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Arshad N, Bjøri E, Hindberg K, Isaksen T, Hansen JB, Braekkan SK. Recurrence and mortality after first venous thromboembolism in a large population-based cohort. J Thromb Haemost 2017; 15:295-303. [PMID: 27943560 DOI: 10.1111/jth.13587] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Indexed: 08/31/2023]
Abstract
Essentials Reports on recurrence and mortality after a first venous thromboembolism (VTE) vary considerably. We describe rates of recurrence and mortality in patients with a first VTE from the Tromsø study. The overall recurrence rate was 3.9 per 100 person-years, but this varied widely with time. Despite advances in VTE management, the rates of adverse events are still fairly high. SUMMARY Background Previous reports on recurrence and mortality rates after a first episode of venous thromboembolism (VTE) vary considerably. Advances in the management and treatment of VTE during the last 15 years may have influenced the rates of clinical outcomes. Aim To estimate the rates of recurrence and mortality after a first VTE in patients recruited from a large population-based cohort. Method From the Tromsø study, patients (n = 710) with a first, symptomatic, objectively confirmed VTE were included and followed in the period 1994-2012. Recurrent episodes of VTE were identified from multiple sources and carefully validated by review of medical records. Incidence rates and cumulative incidence rates with 95% confidence intervals (CIs) of VTE recurrence and mortality were calculated. Results The mean age of the patients was 68 years (range 28-102 years), and 166 (23.4%) had cancer at the time of first VTE. There were 114 VTE recurrences and 333 deaths during a median study period of 7.7 years (range 0.04-18.2 years). The risk of recurrence was highest during the first year. The overall 1-year recurrence rate was 7.8 (95% CI 5.8-10.6) per 100 person-years (PY), whereas the recurrence rate in the remaining follow-up period (1-18 years) was 3.0 (95% CI 2.4-3.8) per 100 PY. The overall 1-year all-cause mortality rate was 29.9 (95% CI 25.7-34.8) per 100 PY, and in those without cancer the corresponding rate was 23.6 (95% CI 17.8-31.3) per 100 PY. Conclusion Despite advances in VTE management, the rates of adverse events remained fairly high, particularly in the first year following a first VTE.
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Affiliation(s)
- N Arshad
- K. G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - E Bjøri
- K. G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - K Hindberg
- K. G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - T Isaksen
- K. G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - J-B Hansen
- K. G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - S K Braekkan
- K. G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
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Gjonbrataj E, Kim JN, Gjonbrataj J, Jung HI, Kim HJ, Choi WI. Risk factors associated with provoked pulmonary embolism. Korean J Intern Med 2017; 32:95-101. [PMID: 27097772 PMCID: PMC5214719 DOI: 10.3904/kjim.2015.118] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 07/17/2015] [Accepted: 08/13/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS This study aimed to investigate the risk factors associated with provoked pulmonary embolism (PE). METHODS This retrospective cohort study included 237 patients with PE. Patients that had transient risk factors at diagnosis were classified as having provoked PE, with the remaining patients being classified as having unprovoked PE. The baseline clinical characteristics and factors associated with coagulation were compared. We evaluated the risk factors associated with provoked PE. RESULTS Of the 237 PE patients, 73 (30.8%) had provoked PE. The rate of respiratory failure and infection, as well as the disseminated intravascular coagulation score and ratio of right ventricular diameter to left ventricular diameter were significantly higher in patients with provoked PE than in those with unprovoked PE. The protein and activity levels associated with coagulation, including protein C antigen, protein S antigen, protein S activity, anti-thrombin III antigen, and factor VIII, were significantly lower in patients with provoked PE than in those with unprovoked PE. Multivariate analysis showed that infection (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 7.4) and protein S activity (OR, 0.97; 95% CI, 0.95 to 0.99) were significantly associated with provoked PE. CONCLUSIONS Protein S activity and presence of infection were important factors associated with provoked PE. We should pay attention to the presence of infection in patients with provoked PE.
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Affiliation(s)
- Endri Gjonbrataj
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Ji Na Kim
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Juarda Gjonbrataj
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Department of Internal Medicine, Mother Theresa University Hospital Centre, Tirana, Albania
| | - Hye In Jung
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hyun Jung Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Won-Il Choi
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
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81
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Franco-Moreno A, de Ancos-Aracil C, García-Navarro M. Riesgo de recurrencia en el tromboembolismo venoso idiopático. Rev Clin Esp 2016; 216:488-494. [DOI: 10.1016/j.rce.2016.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/17/2016] [Accepted: 04/19/2016] [Indexed: 11/16/2022]
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82
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Franco-Moreno A, de Ancos-Aracil C, García-Navarro M. Recurrence risk of idiopathic venous thromboembolism. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2016.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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83
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Anticoagulant therapy for symptomatic calf deep vein thrombosis (CACTUS): a randomised, double-blind, placebo-controlled trial. LANCET HAEMATOLOGY 2016; 3:e556-e562. [DOI: 10.1016/s2352-3026(16)30131-4] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 08/19/2016] [Accepted: 08/31/2016] [Indexed: 11/20/2022]
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84
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Bjøri E, Arshad N, Johnsen HS, Hansen JB, Braekkan SK. Hospital-related first venous thromboembolism and risk of recurrence. J Thromb Haemost 2016; 14:2368-2375. [PMID: 27589573 DOI: 10.1111/jth.13492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Indexed: 11/27/2022]
Abstract
Essentials Recurrence risk after a hospital-related venous thromboembolism (VTE) is underinvestigated. We explored this association in a cohort of patients with a first VTE from the Tromsø study. Stratification on hospital-related factors revealed considerable differences in recurrence risk. The recurrence risk was high in cases with a VTE related to hospitalization for medical illness. SUMMARY Background Hospitalization is a well-established risk factor for first venous thromboembolism (VTE), but the risk of recurrence, particularly in patients hospitalized for conditions other than cancer or surgery, has scarcely been investigated. The cumulative incidence of recurrence in hospital-related VTE may be influenced by the competing risk of death. Objectives To investigate the risk of recurrence and mortality among patients with a first hospital-related VTE in models with and without death as a competing event. Methods Information on hospital-related risk factors was collected in 822 patients with a first-lifetime VTE derived from the Tromsø study. Recurrent VTEs and deaths were recorded during follow-up (1994-2012). Results During a median of 2.79 years of follow-up, 132 patients experienced a recurrent VTE. Stratification on hospital-related factors revealed considerable differences in recurrence risk. The 5-year cumulative incidence of recurrence was 27.4%, 11.0% and 20.1% in patients with incident VTEs related to cancer, surgery or other medical illness, respectively, and 18.4% in patients with a non-hospital-related first VTE. The mortality rates were high for all subgroups of hospital-related VTE, except for surgery-related events. Consequently, the cumulative incidence of recurrence dropped in the competing risk analyses, showing a 5-year cumulative incidence of 14.4%, 11.7% and 9.7% in patients with a first VTE related to hospitalization for other medical illness, cancer or surgery, respectively. Conclusions Our findings suggest that patients with incident VTEs related to hospitalization for medical illness other than cancer or surgery have a high recurrence-risk, even in the presence of competing risk of death.
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Affiliation(s)
- E Bjøri
- Department of Clinical Medicine, K.G. Jebsen Thrombosis Research and Expertise Center, UiT - The Arctic University of Norway, Tromsø, Norway
| | - N Arshad
- Department of Clinical Medicine, K.G. Jebsen Thrombosis Research and Expertise Center, UiT - The Arctic University of Norway, Tromsø, Norway
| | - H S Johnsen
- Department of Clinical Medicine, K.G. Jebsen Thrombosis Research and Expertise Center, UiT - The Arctic University of Norway, Tromsø, Norway
| | - J-B Hansen
- Department of Clinical Medicine, K.G. Jebsen Thrombosis Research and Expertise Center, UiT - The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - S K Braekkan
- Department of Clinical Medicine, K.G. Jebsen Thrombosis Research and Expertise Center, UiT - The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
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85
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Yu J, Li D, Lei D, Yuan F, Pei F, Zhang H, Yu A, Wang K, Chen H, Chen L, Wu X, Tong X, Wang Y. Tumor-Specific D-Dimer Concentration Ranges and Influencing Factors: A Cross-Sectional Study. PLoS One 2016; 11:e0165390. [PMID: 27835633 PMCID: PMC5105993 DOI: 10.1371/journal.pone.0165390] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 09/20/2016] [Indexed: 11/18/2022] Open
Abstract
D-dimer level in cancer patients is associated with risk of venous thromboembolism and deep venous thrombosis. Most cancer patients have "abnormal" D-dimer levels based on the current normal reference range. To investigate tumor-specific D-dimer reference range, we compared D-dimer levels for nine different tumour types with healthy controls by using simultaneous quantile regression and constructing a median, 5th percentile, and 95th percentile model of normal tumour D-dimer concentration. Associations with tumour primary site, stage, pathological type, and treatment were also explored. Additionally, 190 patients were tracked to reveal the relevance of initial D-dimer levels to cancer prognosis. D-dimer ranges (median, 5th, 95th) in various cancers (mg/L) were: liver 1.12, 0.27, 5.25; pancreatic 0.96, 0.23, 4.81; breast 0.44, 0.2, 2.17; gastric 0.65, 0.22, 5.03; colorectal 0.73, 0.22, 4.45; lung 0.7, 0.25, 4.0; gynaecological 0.61, 0.22, 3.98; oesophageal 0.23, 0.7, 3.45; and head and neck 0.22, 0.44, 2.19. All were significantly higher than that of healthy controls (0.18, 0.07, 0.57). D-dimer peaked 1-2 days postoperatively but had decreased to the normal range by 1 week. Additionally, cancer patients with high initial D-dimer were shown a tendency of poor prognosis in survival rate. In conclusion, D-dimer levels in cancer depend on patient age, tumour primary site, and tumour stage. Thrombosis prevention is necessary if D-dimer has not decreased to the tumor-specific baseline a week after surgery.
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Affiliation(s)
- Jing Yu
- The State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, Hubei 430072, China
| | - Dongqing Li
- Department of Microbiology, School of Basic Medical Sciences, Wuhan University; Wuhan, China
| | - Dansheng Lei
- Department of Laboratory, Hubei Cancer Hospital, Wuhan, China
| | - Feng Yuan
- Department of Laboratory, Hubei Cancer Hospital, Wuhan, China
| | - Feng Pei
- Department of Laboratory, Hubei Cancer Hospital, Wuhan, China
| | - Huifeng Zhang
- Department of Laboratory, Hubei Cancer Hospital, Wuhan, China
| | - Anming Yu
- Stago Diagnosis Company, Wuhan, China
| | - Kun Wang
- Department of Laboratory, Hubei Cancer Hospital, Wuhan, China
| | - Hu Chen
- Department of Laboratory, Hubei Cancer Hospital, Wuhan, China
| | - Liang Chen
- Department of Orthopaedics, Renmin Hospital, Wuhan University, Wuhan, China
| | - Xianglei Wu
- Laboratory of Immunology, University of Lorraine, Lorraine, France
| | - Xianli Tong
- Department of Laboratory, Hubei Cancer Hospital, Wuhan, China
| | - Yefu Wang
- The State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, Hubei 430072, China
- * E-mail:
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Abstract
INTRODUCTION Idiopathic or unprovoked venous thromboembolism is an event occurring in the absence of any apparent provoking or triggering environmental risk factors, such as surgery, trauma, and immobilization. Areas covered: Unprovoked VTE can be associated with occult cancer, but only limited, and not extensive cancer screening, may be warranted, as the rate of occult cancer is low in such patients. Routine thrombophilia testing is not currently recommended as it does not influence the management of the disease. The duration of anticoagulation for unprovoked VTE after the first three months is still debated as the disease tends to recur regardless of treatment duration. Expert commentary: Prognostic scores incorporating patient related risk factors, such as age and sex, and global markers of hypercoagulability, such as D-dimer, have been proposed for identifying high risk patients who are candidates for extended anticoagulation beyond three months. Direct oral anticoagulants, aspirin and sulodexide could be alternative to vitamin K antagonists (VKA) for long term treatment in such patients. The most up to date guidelines suggest DOACs over VKA for non-cancer VTE in the first three months and also long-term in subjects at low or moderate risk of bleeding, albeit with grade 2B strength of recommendation.
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Affiliation(s)
- Benilde Cosmi
- a Department of Angiology & Blood Coagulation , S.Orsola-Malpighi University Hospital , Bologna , Italy
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87
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Kinnunen PTT, Murtola TJ, Talala K, Taari K, Tammela TLJ, Auvinen A. Warfarin use and prostate cancer risk in the Finnish Randomized Study of Screening for Prostate Cancer. Scand J Urol 2016; 50:413-419. [PMID: 27628763 DOI: 10.1080/21681805.2016.1228085] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Anticoagulants, especially vitamin K antagonists (VKAs) such as warfarin, have been hypothesized to have antitumor properties, and use of VKAs has been associated with a lower prostate cancer (PCa) risk. This study estimated PCa risk among users of warfarin and other anticoagulants. MATERIALS AND METHODS All anticoagulant use among 78,615 men during 1995-2009 was analyzed. Cox regression, adjusted for age, screening trial arm and use of other medications, with medication use as a time-dependent variable, was used to estimate PCa risk overall, and by tumor grade and stage. RESULTS In total, 6537 men were diagnosed with PCa during 1995-2009 (1210 among warfarin users). Compared to non-users, warfarin use was associated with an increased risk of PCa [multivariable-adjusted hazard ratio (HR) = 1.11, 95% confidence interval (CI) 1.01-1.22]. This was limited to short-term, low-dose use, and was not observed in long-term use. A similar overall risk increase was observed for Gleason grade 7-10 PCa. Low-dose, short-term use of warfarin was associated with an increased risk of metastatic PCa. However, the increase in risk vanished with continued use. Compared to other anticoagulants, low-dose use of warfarin was associated with a slightly elevated overall PCa risk (HR = 1.19, 95% CI 1.00-1.43). The increase in risk disappeared in long-term, high-dose use. CONCLUSIONS This study, which included a larger number of PCa cases with warfarin exposure than previous studies, does not support previous notions of decreased risk of PCa among warfarin users. A similar risk of PCa was found among warfarin users and the general population, and no difference in risk was found between warfarin and other anticoagulants.
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Affiliation(s)
| | - Teemu J Murtola
- a School of Medicine , University of Tampere , Tampere , Finland.,b Department of Urology , Tampere University Hospital , Tampere , Finland
| | | | - Kimmo Taari
- d Department of Urology , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Teuvo L J Tammela
- a School of Medicine , University of Tampere , Tampere , Finland.,b Department of Urology , Tampere University Hospital , Tampere , Finland
| | - Anssi Auvinen
- e School of Health Sciences , University of Tampere , Tampere , Finland
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88
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Bellosta R, Ferrari P, Luzzani L, Carugati C, Cossu L, Talarico M, Sarcina A. Home Therapy With LMWH in Deep Vein Thrombosis: Randomized Study Comparing Single and Double Daily Administrations. Angiology 2016; 58:316-22. [PMID: 17626986 DOI: 10.1177/0003319707301757] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to assess the effectiveness of low-molecular-weight heparin (LMWH) treatment of deep vein thrombosis (DVT) in terms of the evolution of thrombosis, the incidence of adverse events, and compliance with heparin treatment using 2 types of LMWH available on the market administered in therapeutic doses throughout the period of treatment (Nadroparin) or at therapeutic doses only during the first month of treatment followed by a prophylactic phase at half dose (Parnaparin). A randomized prospective study was carried out on patients under observation with a recent diagnosis of DVT. The objectives of the study were to confirm the effectiveness of therapy with LMWH in terms of prevention of the risk of thromboembolism, of relapse of DVT, and of hemorrhagic complications, and to complete an evaluation of venous recanalization and residual valve competence in the 2 groups of patients. From December 2002 to June 2005, we randomized a total of 91 patients (51 in the Parnaparin group and 40 in the Nadroparin group). Overall, there was 1 case of nonfatal pulmonary embolism (1.1%) at 7 days into therapy with LMWH. There were 3 cases (3.3%) of progression of thrombosis despite therapy with LMWH, 2 cases (5%) in the Nadroparin group, and 1 case (2%) in the Parnaparin group (P = NS), and after suspension of the therapy, there was 1 case of relapse of thrombosis. Three of the 4 thrombotic events occurred in patients with active neoplasia. Moreover, only 1 major hemorrhagic event (1.1%) required blood transfusion. The Doppler ultrasound in the follow-up showed a complete resolution of 56% of the vein thromboses at an average of 6.1 ± 4.6 (mean ± SD) months. Valve competence recovered in 65.9% of cases with no significant difference between the 2 heparin groups. Home treatment of sural and femoral-popliteal DVT using LMWH represents a safe and effective method in the prevention of pulmonary embolism and encourages the process of recanalization of the thrombosed vessel, especially in cases of sural and/or popliteal DVT. Administration can be carried out with the same degree of safety at the therapeutic dose throughout the period of treatment or can be halved after the first month of treatment. In patients with active neoplasia, treatment with oral anticoagulant therapy must be considered.
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89
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Yamaki T. Post-thrombotic syndrome – Recent aspects of prevention, diagnosis and clinical management. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.rvm.2016.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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90
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Porfidia A, Carnicelli A, Bonadia N, Pola R, Landolfi R. Controversies in venous thromboembolism: the unique case of isolated distal deep vein thrombosis. Intern Emerg Med 2016; 11:775-9. [PMID: 27126683 DOI: 10.1007/s11739-016-1453-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/07/2016] [Indexed: 01/08/2023]
Abstract
Venous thromboembolism (VTE) represents the third leading cause of cardiovascular mortality, and it is the main cause of preventable mortality in hospitalized patients. Among VTE, there is the unique case of isolated distal deep vein thrombosis (IDDVT), which still lacks an agreement in terms of optimal therapeutic strategy. Although most IDDVTs are self-limiting and associated with a very low risk of embolic complications, still not all IDDVTs can be safely identified as stable. Lack of strong scientific evidence, fear of thromboembolic complications, and risk of bleeding upon initiation of anticoagulant treatment result in very heterogeneous therapeutic strategies among physicians. Here, we provide a comprehensive review of the literature, highlight the many controversial issues regarding IDDVTs, and call for a consensus of experts aimed to shed new light on the gray areas of IDDVT management and therapy.
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Affiliation(s)
- Angelo Porfidia
- Division of Internal Medicine and Vascular Diseases, Department of Medicine, A. Gemelli University Hospital, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Annamaria Carnicelli
- Division of Internal Medicine and Vascular Diseases, Department of Medicine, A. Gemelli University Hospital, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Nicola Bonadia
- Division of Internal Medicine and Vascular Diseases, Department of Medicine, A. Gemelli University Hospital, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Roberto Pola
- Division of Internal Medicine and Vascular Diseases, Department of Medicine, A. Gemelli University Hospital, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Raffaele Landolfi
- Division of Internal Medicine and Vascular Diseases, Department of Medicine, A. Gemelli University Hospital, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy.
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91
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Martinez C, Katholing A, Folkerts K, Cohen AT. Risk of recurrent venous thromboembolism after discontinuation of vitamin K antagonist treatment: a nested case-control study. J Thromb Haemost 2016; 14:1374-83. [PMID: 27079164 DOI: 10.1111/jth.13337] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Indexed: 01/22/2023]
Abstract
UNLABELLED Essentials Vitamin K antagonists (VKA) in venous thromboembolism (VTE) lower the risk of recurrences. 41 841 VKA-treated VTE patients had 1242 recurrent VTEs on therapy or early after cessation. An increased risk of recurrence was found in the first 120 days after VKA cessation. Patient education for the early detection of recurrent VTE after VKA cessation is recommended. SUMMARY Background The standard treatment for venous thromboembolism (VTE) and the prevention of recurrent VTE (rVTE) consists of anticoagulant therapy. The optimal duration of anticoagulation depends on the presence of risk factors for rVTE. Objectives To estimate the risk of rVTE in association with time since discontinuation of vitamin K antagonist (VKA) treatment. Methods From the UK Clinical Practice Research Datalink with linked information on hospitalization and cause of death, a cohort of patients with a first VTE receiving initial VKA treatment between 2001 and 2013 was formed. With a nested case-control approach, patients with incident rVTE (cases) were matched to patients with VTE but without rVTE (controls). Adjusted rate ratios (RRs) of rVTE associated with time since VKA discontinuation relative to current VKA use were estimated from conditional logistic regression. Results The VTE cohort comprised 41 841 patients with 1242 rVTEs and 6205 matched controls. The RR of rVTE was increased within 60 days following VKA discontinuation (RR 2.23, 95% confidence interval [CI] 1.71-2.91) and within 61-120 days following VKA discontinuation (RR 1.49, 95% CI 1.08-2.05) relative to current VKA use. The increased RR corresponded to excess incidence rates of 6.72 (95% CI 3.90-10.06) rVTE cases per 100 person-years within 60 days, and of 2.68 (95% CI 0.42-5.58) rVTE cases per 100 person-years within 61-120 days after VKA discontinuation. Conclusions VKA discontinuation results in a transient increased risk of rVTE, which peaks within 60 days and lasts for up to 120 days after VKA discontinuation. Specific patient education for increased vigilance for signs and symptoms of recurrences is recommended in this period.
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Affiliation(s)
- C Martinez
- Institute for Epidemiology, Statistics and Informatics, Frankfurt, Germany
| | - A Katholing
- Institute for Epidemiology, Statistics and Informatics, Frankfurt, Germany
| | - K Folkerts
- Bayer Pharma AG, Global Market Access GHEOR GM, Wuppertal, Germany
| | - A T Cohen
- Department of Haematological Medicine, Guys and St Thomas' Hospitals, King's College Hospital, London, UK
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92
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Joseph L, Bartholomew JR. Managing Extended Oral Anticoagulation After Unprovoked Venous Thromboembolism. J Cardiovasc Pharmacol Ther 2016; 22:28-39. [PMID: 27250719 DOI: 10.1177/1074248416652236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, is a major public health problem associated with increased morbidity and mortality. Despite the high recurrence risk associated with unprovoked VTE, extended anticoagulation remains controversial. Oral antithrombotic agents for extended VTE treatment comprise the vitamin K antagonists, aspirin, and the direct oral anticoagulants (also known as target-specific oral anticoagulants and formerly known as the new or novel oral anticoagulants) including rivaroxaban, dabigatran, apixaban, and edoxaban. The efficacy of these anticoagulants in reducing the risk of VTE recurrence (>80%-90% relative risk reduction) is offset by the risk of major bleeding that approaches 3% per year. Stratifying risks of recurrence and bleeding to identify patients at low, intermediate, or high risk and carefully considering the pharmacologic profile of the antithrombotic agents will help clinicians in choosing the optimal anticoagulant and duration and/or surveillance strategy. This review will discuss the current guidelines for extended VTE treatment, review the clinical trials involving the direct oral anticoagulants, and present the clinical considerations and concerns involving extended therapy.
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Affiliation(s)
- Lee Joseph
- 1 Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - John R Bartholomew
- 2 Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA.,3 Section Head of Vascular Medicine, Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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93
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Jin YW, Ye H, Li FY, Xiong XZ, Cheng NS. Compression Stockings for Prevention of Postthrombotic Syndrome: A Systematic Review and Meta-Analysis. Vasc Endovascular Surg 2016; 50:328-34. [PMID: 27260750 DOI: 10.1177/1538574416652242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The present meta-analysis aimed to evaluate the efficacy and safety of compression stockings for postthrombotic syndrome (PTS) prevention in patients with deep venous thrombosis (DVT). METHODS Randomized controlled trials (RCTs) regarding the use of compression stockings for prevention of PTS were identified from the Medline, PubMed, and Embase databases as well as the Cochrane library. The resulting manuscripts were analyzed according to the criteria in the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS Six RCTs involving 1465 patients with DVT were included. The meta-analysis indicated no statistical differences between the compression stocking and the control groups in PTS incidence, using either the Villalta scale (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.23-1.74) or the Ginsberg scale (OR, 1.13; 95% CI, 0.72-1.77). Based on the Villalta scale categorization, there were no differences in the incidence of mild-moderate PTS (OR, 0.71; 95% CI, 0.36-1.41) or incidence of severe PTS (OR, 0.68; 95% CI, 0.15-3.11). The difference in the recurrence of venous thromboembolism (OR, 0.89; 95% CI, 0.61-1.30) was also not significant. In the 3 RCTs that reported side effects of compression stockings, they were primarily related to discomfort, including itching, erythema, and rash. CONCLUSION The present meta-analysis has indicated that compression stockings may not prevent PTS, as determined by either the Villalta or the Ginsberg scale, in patients with DVT. However, owing to the limited number of trials, the evidence is not strong enough to draw a reliable conclusion. Further larger, randomized, double-blind, placebo-controlled, multicenter trials are needed.
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Affiliation(s)
- Y W Jin
- General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - H Ye
- General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - F Y Li
- General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - X Z Xiong
- General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - N S Cheng
- General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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94
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Wells PS, Prins MH, Levitan B, Beyer-Westendorf J, Brighton TA, Bounameaux H, Cohen AT, Davidson BL, Prandoni P, Raskob GE, Yuan Z, Katz EG, Gebel M, Lensing AWA. Long-term Anticoagulation With Rivaroxaban for Preventing Recurrent VTE: A Benefit-Risk Analysis of EINSTEIN-Extension. Chest 2016; 150:1059-1068. [PMID: 27262225 DOI: 10.1016/j.chest.2016.05.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 04/04/2016] [Accepted: 05/23/2016] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Short-term anticoagulant treatment for acute DVT or pulmonary embolism (PE) effectively reduces the risk of recurrent disease during the first 6 to 12 months of therapy. Continued anticoagulation often is not instituted because of the perception among physicians that the risk of major bleeding will outweigh the risk of new venous thrombotic episodes. METHODS The authors performed a benefit-risk analysis by using the randomized EINSTEIN-Extension trial, which compared continued rivaroxaban with placebo in 1,197 patients with symptomatic DVT or PE who had completed 6 to 12 months of anticoagulation and in whom physicians had equipoise with respect to the need for continued anticoagulation. One-year Kaplan-Meier rates and rate differences of recurrent VTE and major bleeding were calculated. Benefits and risks were assessed using rate differences scaled to a population size of 10,000 patients treated for 1 year. RESULTS Recurrent VTE occurred in eight recipients of rivaroxaban and 42 patients receiving placebo. In a population of 10,000 patients treated for 1 year, rivaroxaban treatment would have resulted in 665 (95% CI, 246-1,084) fewer recurrent VTEs than would placebo (number needed to treat = 15). Major bleeding occurred in four (0.7%) and zero patients, respectively. Rivaroxaban treatment would have resulted in 68 (95% CI, 2-134) more major bleeding events than would placebo (number needed to harm = 147). Kaplan-Meier analysis showed early recurrent VTE reduction with rivaroxaban that continued to improve throughout treatment; major bleeding increased gradually, plateauing at approximately 100 days. CONCLUSIONS A clinically important benefit and a favorable benefit-risk profile of continued rivaroxaban anticoagulation was observed. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00439725; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Philip S Wells
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, ON, Canada.
| | - Martin H Prins
- Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bennett Levitan
- Janssen Pharmaceutical Research & Development LLC, Titusville, NJ
| | - Jan Beyer-Westendorf
- Department of Vascular Medicine, University Hospital Carl-Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Timothy A Brighton
- Department of Haematology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Henri Bounameaux
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Alexander T Cohen
- Department of Haematological Medicine, Guys and St Thomas' Hospitals, King's College Hospital, London, England
| | | | - Paolo Prandoni
- Department of Cardiovascular Sciences, University of Padua, Padua, Italy
| | - Gary E Raskob
- College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Zhong Yuan
- Janssen Pharmaceutical Research & Development LLC, Titusville, NJ
| | - Eva G Katz
- Janssen Pharmaceutical Research & Development LLC, Raritan, NJ
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95
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Kooiman J, den Exter PL, Kilicsoy I, Cannegieter SC, Eikenboom J, Huisman MV, Klok FA, Versteeg HH. Association between micro particle-tissue factor activity, factor VIII activity and recurrent VTE in patients with acute pulmonary embolism. J Thromb Thrombolysis 2016; 40:323-30. [PMID: 25665657 PMCID: PMC4546691 DOI: 10.1007/s11239-015-1180-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Studies on the association between microparticle expressing tissue factor (MP-TF) activity, FVIII activity (FVIII:C) and recurrent VTE yielded inconclusive results. We studied these associations in patients diagnosed with acute pulmonary embolism. Plasma levels of MP-TF and FVIII activity were measured in 277 patients with a first and 72 patients with a recurrent VTE. All patients were categorized based on the quintiles of MP-TF and FVIII activity in those with a single VTE. For both markers, odds ratios (ORs) for recurrent VTE were computed using patients in the lowest quintile as a reference group. No association was observed between MP-TF activity and recurrent VTE, with an OR of 1.4 (95 % CI 0.7–2.9) in the highest quintile of MP-TF activity. Compared with the reference group, patients in the highest quintile of FVIII:C were at increased risk of recurrent VTE, OR 4.2 (95 % CI 1.4–12.2). MP-TF activity was not associated with recurrent VTE whereas high FVIII:C levels were associated with a 4-fold increased risk of VTE recurrence. Future prospective studies are necessary to explore the potential of FVIII:C as a tool for risk stratification, either by itself or in combination with other pro-thrombotic markers.
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Affiliation(s)
- Judith Kooiman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, C7-Q, P.O. Box 9600, 2300 RC, Leiden, The Netherlands,
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96
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Las trombosis venosas profundas distales de los miembros inferiores: un problema controvertido. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2015.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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97
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Wang KL, Chu PH, Lee CH, Pai PY, Lin PY, Shyu KG, Chang WT, Chiu KM, Huang CL, Lee CY, Lin YH, Wang CC, Yen HW, Yin WH, Yeh HI, Chiang CE, Lin SJ, Yeh SJ. Management of Venous Thromboembolisms: Part I. The Consensus for Deep Vein Thrombosis. ACTA CARDIOLOGICA SINICA 2016; 32:1-22. [PMID: 27122927 DOI: 10.6515/acs20151228a] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNLABELLED Deep vein thrombosis (DVT) is a potentially catastrophic condition because thrombosis, left untreated, can result in detrimental pulmonary embolism. Yet in the absence of thrombosis, anticoagulation increases the risk of bleeding. In the existing literature, knowledge about the epidemiology of DVT is primarily based on investigations among Caucasian populations. There has been little information available about the epidemiology of DVT in Taiwan, and it is generally believed that DVT is less common in Asian patients than in Caucasian patients. However, DVT is a multifactorial disease that represents the interaction between genetic and environmental factors, and the majority of patients with incident DVT have either inherited thrombophilia or acquired risk factors. Furthermore, DVT is often overlooked. Although symptomatic DVT commonly presents with lower extremity pain, swelling and tenderness, diagnosing DVT is a clinical challenge for physicians. Such a diagnosis of DVT requires a timely systematic assessment, including the use of the Wells score and a D-dimer test to exclude low-risk patients, and imaging modalities to confirm DVT. Compression ultrasound with high sensitivity and specificity is the front-line imaging modality in the diagnostic process for patients with suspected DVT in addition to conventional invasive contrast venography. Most patients require anticoagulation therapy, which typically consists of parenteral heparin bridged to a vitamin K antagonist, with variable duration. The development of non-vitamin K oral anticoagulants has revolutionized the landscape of venous thromboembolism treatment, with 4 agents available,including rivaroxaban, dabigatran, apixaban, and edoxaban. Presently, all 4 drugs have finished their large phase III clinical trial programs and come to the clinical uses in North America and Europe. It is encouraging to note that the published data to date regarding Asian patients indicates that such new therapies are safe and efficacious. Ultimately, our efforts to improve outcomes in patients with DVT rely on the awareness in the scientific and medical community regarding the importance of DVT. KEY WORDS Combination therapy; Hypertension; α1-blocker.
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Affiliation(s)
- Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital; School of Medicine, National Yang-Ming University
| | - Pao-Hsien Chu
- Division of Cardiology, Department of Internal Medicine, Heart Failure Center, Healthcare Center, Chang Gung Memorial Hospital; College of Medicine, Chang Gung University
| | - Cheng-Han Lee
- Department of Internal Medicine, National Cheng Kung University Hospital; College of Medicine, National Cheng Kung University
| | - Pei-Ying Pai
- Division of Cardiology, Department of Internal Medicine, China Medical University Hospital; School of Medicine, China Medical University
| | - Pao-Yen Lin
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital
| | - Kou-Gi Shyu
- Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Hospital
| | - Kuan-Ming Chiu
- Division of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital
| | - Chien-Lung Huang
- Division of Cardiology, Department of Internal Medicine, Cheng Hsin General Hospital
| | - Chung-Yi Lee
- Department of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital
| | - Chun-Chieh Wang
- Department of Cardiology, Chang Gung Memorial Hospital; College of Medicine, Chang Gung University
| | - Hsueh-Wei Yen
- Division of Cardiology, Department of Internal Medicine; Kaohsiung Medical University Hospital
| | - Wei-Hsian Yin
- Division of Cardiology, Department of Internal Medicine, Cheng Hsin General Hospital
| | - Hung-I Yeh
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital; Mackay Medical College
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital; School of Medicine, National Yang-Ming University
| | - Shing-Jong Lin
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital
| | - San-Jou Yeh
- Division of Cardiology, Department of Internal Medicine, Heart Failure Center, Healthcare Center, Chang Gung Memorial Hospital; College of Medicine, Chang Gung University
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98
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Bishop MA, Streiff MB. Effects of anticoagulation provider continuity on time in therapeutic range for warfarin patients. J Thromb Thrombolysis 2016; 42:283-7. [PMID: 27085542 DOI: 10.1007/s11239-016-1359-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Anticoagulation (AC) clinics use the percentage of time in the therapeutic INR range (%TTR) to characterize the quality of management for patients treated with warfarin. In order to guide policy and procedure changes, the purpose of this quality improvement (QI) study was to characterize the AC patient population at The Johns Hopkins Hospital (JHH). We set out to investigate the impact of AC clinic provider continuity on the quality of anticoagulation management. This QI study is a retrospective chart review of 525 warfarin patients managed by pharmacists in the Hematology AC Management Clinic at JHH from June 28, 2013 to November 1, 2014. We recorded patient demographic and clinical characteristics and the quality of AC management using %TTR, and compared these parameters between patients with (Group A) and without a primary AC (Group B). Group A patients had a significantly higher %TTR than Group B patients (53.2 vs. 46.5 %, p = 0.008). In conclusion, we found that patients with a primary AC clinic provider had a higher %TTR than patients with multiple providers. If confirmed prospectively, this approach to warfarin management could represent one technique for AC clinics to optimize patient management and clinical outcomes.
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Affiliation(s)
- Martin A Bishop
- Division of Ambulatory and Care Transitions, Department of Pharmacy, The Johns Hopkins Hospital, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD, 21287, USA.
| | - Michael B Streiff
- Departments of Medicine and Pathology, Johns Hopkins University School of Medicine, 1830 Monument Street, Suite 7300, Baltimore, MD, 21205, USA
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99
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Ho P, Lim HY, Chua CC, Sleeman M, Tacey M, Donnan G, Nandurkar H. Retrospective review on isolated distal deep vein thrombosis (IDDVT) - A benign entity or not? Thromb Res 2016; 142:11-6. [PMID: 27093232 DOI: 10.1016/j.thromres.2016.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 03/25/2016] [Accepted: 04/02/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Isolated distal deep venous thrombosis (IDDVT) is traditionally associated with less severe clinical sequelae, with ongoing debate on multiple aspects of its management. Despite numerous studies evaluating its acute management, there remains a paucity of data evaluating long-term complications such as recurrence and subsequent malignancy. We aim to evaluate the characteristics of IDDVT in institutions that routinely perform whole leg ultrasonography, and the risks of recurrence and complications in comparison to major venous thromboembolism (major VTE; defined as above-knee or proximal DVT and pulmonary embolism (PE)). METHODS Retrospective evaluation of consecutive IDDVT and major VTE from July 2011 to December 2012 in a hospital network in Melbourne, Australia. Patients were followed up for a minimum of 24months. Patients with active malignancy were excluded. RESULTS Of 1024 VTE cases, there were 164 non-cancer patients (92 males, 72 females, median age of 61years) with IDDVT. Compared to major VTE, IDDVT was more likely to be provoked (73% vs 59%, p<0.01), has shorter duration of anticoagulation (median 3.5months vs 6.0months, p<0.01) and less clinically significant bleeding (2.4% vs 6.7%, p=0.05), independent of duration of therapy. Recurrence was non-inferior compared to major VTE (10% vs 7%, p=0.36) and 60% recurred with major VTE. Three (1.8%) were subsequently diagnosed with cancer (vs 1.9% in major VTE, p=0.97). CONCLUSIONS IDDVT has non-inferior rates of recurrence and subsequent cancer detection compared to major VTE and hence, its clinical significance should not differ from major VTE. Further studies are required to determine the adequate length of anticoagulation.
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Affiliation(s)
- Prahlad Ho
- Northern Health, Epping, Melbourne, VIC, Australia; Austin Health, Heidelberg, Melbourne, VIC, Australia; Florey Institute of Neurosciences and Mental Health, Parkville, VIC, Australia; University of Melbourne, Parkville, VIC, Australia.
| | - Hui Y Lim
- Northern Health, Epping, Melbourne, VIC, Australia; Austin Health, Heidelberg, Melbourne, VIC, Australia
| | - Chong C Chua
- Austin Health, Heidelberg, Melbourne, VIC, Australia
| | | | - Mark Tacey
- Northern Health, Epping, Melbourne, VIC, Australia; University of Melbourne, Parkville, VIC, Australia
| | - Geoffrey Donnan
- Florey Institute of Neurosciences and Mental Health, Parkville, VIC, Australia
| | - Harshal Nandurkar
- Australian Centre for Blood Diseases, Prahran, VIC, Australia; Monash University, Clayton, VIC, Australia
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100
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Franco Moreno AI, García Navarro MJ, Ortiz Sánchez J, Martín Díaz RM, Madroñal Cerezo E, de Ancos Aracil CL, Cabello Clotet N, Perales Fraile I, Gimeno García S, Montero Hernández C, Zapatero Gaviria A, Ruiz Giardín JM. A risk score for prediction of recurrence in patients with unprovoked venous thromboembolism (DAMOVES). Eur J Intern Med 2016; 29:59-64. [PMID: 26775136 DOI: 10.1016/j.ejim.2015.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/12/2015] [Accepted: 12/16/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In patients with unprovoked venous thromboembolism (VTE), the optimal duration of anticoagulation is anchored on estimating the risk of disease recurrence. We aimed to develop a simple risk assessment model that improves prediction of the recurrence risk. METHODS In a prospective cohort study, 398 patients with a first unprovoked VTE were followed up for a median of 21.3months after discontinuation of anticoagulation. We excluded patients with a strong thrombophilic defect. Preselected clinical and laboratory variables were analyzed based on the independent confirmation of the impact on the recurrence risk, simplicity of assessment, and reproducibility. Multivariable Cox regression analysis was used to develop a recurrence score that was subsequently internally validated by bootstrap analysis. RESULTS A total of 65 patients (16.3%) had recurrent VTE. In all patients, VTE recurred spontaneously. Male sex (HR=2.89 [95% CI 1.21-6.90] P=0.016), age (HR=1.0310 per additional decade [95% CI 1.01-1.07] P=0.011), obesity (HR=3.92 [95% CI 1.75-8.75] P=0.0001), varicose veins (HR=4.14 [95% CI 1.81-9.43] P=0.0001), abnormal D-dimer during anticoagulation (HR=13.66 [95% CI 4.74-39.37] P=0.0001), high factor VIII coagulant activity (HR=1.01 [95% CI 1.00-1.02] P=0.028) and heterozygous of factor V Leiden and/or Prothrombin G20210A mutation (HR=13.86 [95% CI 5.87-32.75] P=0.0001) were related to a higher recurrence risk. Using these variables, we developed a nomogram [hereafter referred to as DAMOVES score (D-dimer, Age, Mutation, Obesity, Varicose veins, Eight, Sex)] for prediction of recurrence in an individual patient. CONCLUSIONS The DAMOVES score can be used to predict recurrence risk in patients with a first unprovoked VTE and may be useful to decide whether anticoagulant therapy should be continued indefinitely or stopped after an initial treatment period of at least 3months.
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Affiliation(s)
- A I Franco Moreno
- Internal Medicine Department, Torrejón University Hospital, Torrejón de Ardoz, Madrid, Spain.
| | - M J García Navarro
- Internal Medicine Department, Torrejón University Hospital, Torrejón de Ardoz, Madrid, Spain
| | - J Ortiz Sánchez
- Internal Medicine Department, Torrejón University Hospital, Torrejón de Ardoz, Madrid, Spain
| | - R M Martín Díaz
- Internal Medicine Department, Torrejón University Hospital, Torrejón de Ardoz, Madrid, Spain
| | - E Madroñal Cerezo
- Internal Medicine Department, Fuenlabrada University Hospital, Fuenlabrada, Madrid, Spain
| | - C L de Ancos Aracil
- Internal Medicine Department, Fuenlabrada University Hospital, Fuenlabrada, Madrid, Spain
| | - N Cabello Clotet
- Internal Medicine Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - I Perales Fraile
- Internal Medicine Department, Rey Juan Carlos University Hospital, Móstoles, Madrid, Spain
| | - S Gimeno García
- Internal Medicine Department, Torrejón University Hospital, Torrejón de Ardoz, Madrid, Spain
| | - C Montero Hernández
- Internal Medicine Department, Torrejón University Hospital, Torrejón de Ardoz, Madrid, Spain
| | - A Zapatero Gaviria
- Internal Medicine Department, Fuenlabrada University Hospital, Fuenlabrada, Madrid, Spain
| | - J M Ruiz Giardín
- Internal Medicine Department, Fuenlabrada University Hospital, Fuenlabrada, Madrid, Spain
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