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Gibson CM, Spyropoulos AC, Cohen AT, Hull RD, Goldhaber SZ, Yusen RD, Hernandez AF, Korjian S, Daaboul Y, Gold A, Harrington RA, Chi G. The IMPROVEDD VTE Risk Score: Incorporation of D-Dimer into the IMPROVE Score to Improve Venous Thromboembolism Risk Stratification. TH OPEN 2017; 1:e56-e65. [PMID: 31249911 PMCID: PMC6524839 DOI: 10.1055/s-0037-1603929] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background
The IMPROVE score is a validated venous thromboembolism (VTE) assessment tool to risk stratify hospitalized, medically ill patients based on clinical variables. It was hypothesized that addition of D-dimer measurement to derive a new IMPROVEDD score would improve identification of at risk of VTE.
Methods
The association of the IMPROVE score and D-dimer ≥ 2 × the upper limit of normal (ULN) with the risk of symptomatic deep vein thrombosis, nonfatal pulmonary embolism, or VTE-related death was evaluated in 7,441 hospitalized, medically ill patients randomized in the APEX trial. Based on the Cox regression analysis, the IMPROVEDD score was derived by adding two points to the IMPROVE score if the D-dimer was ≥ 2 × ULN.
Results
Baseline D-dimer was independently associated with symptomatic VTE through 77 days (adjusted HR: 2.22 [95% CI: 1.38–1.58],
p
= 0.001). Incorporation of D-dimer into the IMPROVE score improved VTE risk discrimination (ΔAUC: 0.06 [95% CI: 0.02–0.09],
p
= 0.0006) and reclassification (continuous NRI: 0.34 [95% CI: 0.17–0.51],
p
= 0.001; categorical NRI: 0.13 [95% CI: 0.03–0.23],
p
= 0.0159). Patients with an IMPROVEDD score of ≥2 had a greater VTE risk compared with those with an IMPROVEDD score of 0 to 1 (HR: 2.73 [95% CI: 1.52–4.90],
p
= 0.0007).
Conclusion
Incorporation of D-dimer into the IMPROVE VTE risk assessment model further improves risk stratification in hospitalized, medically ill patients who received thromboprophylaxis. An IMPROVEDD score of ≥2 identifies hospitalized, medically ill patients with a heightened risk for VTE through 77 days.
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Affiliation(s)
- C Michael Gibson
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra Northwell School of Medicine, Northwell Health System, Manhasset, New York, United States
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' Hospitals, King's College, London, United Kingdom
| | - Russell D Hull
- Division of Cardiology, Faculty of Medicine, University of Calgary, Alberta, Canada
| | - Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Adrian F Hernandez
- Department of Medicine, Duke University and Duke Clinical Research Institute, Durham, North Carolina, United States
| | - Serge Korjian
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Yazan Daaboul
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Alex Gold
- Portola Pharmaceuticals, Inc., South San Francisco, California, United States
| | - Robert A Harrington
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, United States
| | - Gerald Chi
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
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Abstract
Acutelly-ill hospitalised medical patients are at risk of venous thromboembolism (VTE), both in-hospital and in the immediate post-discharge period, and mortality from VTE is thought to be particularly high in this patient population. However, despite previous mandates from international antithrombotic guidelines such as those of the American College of Chest Physicians (ACCP) for the "universal" use of thromboprophylaxis in hospitalised medical patients, global audits suggest that implementation of thromboprophylaxis continues to be challenging because of the perceived higher risk of bleeding and lower risk of VTE than that reported in clinical trials. Recent population-based studies also reveal that a "universal" hospital-only thromboprophylactic strategy does not reduce the community burden of VTE from this population, which may constitute nearly one quarter of the attributable risk of VTE. Lastly, four large randomised placebo-controlled trials of extended thromboprophylaxis have failed to show a definitive net clinical benefit in hospitalised medical patients. Recent large-scale efforts in deriving and validating scored VTE and bleed risk assessment models (RAMs) have been completed in the medically-ill population. In addition, an elevated D-dimer as a new biomarker to identify at-VTE risk medically ill patients has also undergone prospective evaluation. This paper will review current concepts of VTE and bleed risk in hospitalised medical patients, both in the hospital as well as the post-hospital discharge period, and will discuss new paradigms of thromboprophylaxis in this population using an individualised, patient-centered approach.
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Affiliation(s)
- Alex C Spyropoulos
- Alex C. Spyropoulos, MD, FACP, FCCP, FRCPC, Professor of Medicine - Hofstra Northwell School of Medicine, Professor - The Merinoff Center for Patient-Oriented Research, The Feinstein Institute for Medical Research, System Director - Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, 130 E 77th St, New York, NY 10075, USA, Tel.: +1 212 434 6776, Fax: +1 212 434 6781, E-mail:
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53
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Dentali F, Mumoli N, Prisco D, Fontanella A, Di Minno MND. Efficacy and safety of extended thromboprophylaxis for medically ill patients. A meta-analysis of randomised controlled trials. Thromb Haemost 2017; 117:606-617. [PMID: 28078350 DOI: 10.1160/th16-08-0595] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 12/10/2016] [Indexed: 01/08/2023]
Abstract
Compelling evidence suggests that the risk of pulmonary embolism (PE) and deep-vein thrombosis (DVT) persists after hospital discharge in acutely-ill medical patients. However, no studies consistently supported the routine use of extended-duration thromboprophylaxis (ET) in this setting. We performed a meta-analysis to assess efficacy and safety of ET in acutely-ill medical patients. Efficacy outcome was defined by the prevention of symptomatic DVT, PE, venous thromboembolism (VTE) and VTE-related mortality. Safety outcome was the occurrence of major bleeding (MB) and fatal bleeding (FB). Pooled odds ratios (ORs) and 95 % confidence intervals (95 %CI) were calculated for each outcome using a random effects model. Four RCTs for a total of 28,105 acutely-ill medical patients were included. ET was associated with a significantly lower risk of DVT (0.3 % vs 0.6 %, OR 0.504, 95 %CI: 0.287-0.885) and VTE (0.5 % vs 1.0 %, OR: 0.544, 95 %CI: 0.297-0.997); a non-significantly lower risk of PE (0.3 % vs 0.4 %, OR 0.633, 95 %CI: 0.388-1.034) and of VTE-related mortality (0.2 % vs 0.3 %, OR 0.687, 95 %CI: 0.445-1.059) and with a significantly higher risk of MB (0.8 % vs 0.4 %, OR 2.095, 95 %CI: 1.333-3.295). No difference in FB was found (0.06 % vs 0.03 %, OR 1.79, 95 %CI: 0.384-8.325). The risk benefit analysis showed that the NNT for DVT was 339, for VTE was 239, and the NNH for MB was 247. Results of our meta-analyses focused on clinical important outcomes did not support a general use of antithrombotic prophylaxis beyond the period of hospitalization in acutely-ill medical patients.
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Affiliation(s)
- Francesco Dentali
- Francesco Dentali, MD, U. O. Medicina Interna, Ospedale di Circolo, Viale Borri 57, 21100 Varese, Italy, Tel.: +39 0332 278594, Fax: +39 0332 278229, E-mail:
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54
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Rafizadeh R, Turgeon RD, Batterink J, Su V, Lau A. Characterization of Venous Thromboembolism Risk in Medical Inpatients Using Different Clinical Risk Assessment Models. Can J Hosp Pharm 2016; 69:454-459. [PMID: 28123191 DOI: 10.4212/cjhp.v69i6.1608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Symptomatic venous thromboembolism (VTE) occurs in about 1% of patients within 3 months after admission to a medical unit. Recent evidence for thromboprophylaxis in an unselected medical inpatient population has suggested only a modest net benefit. Consequently, guidelines recommend careful risk stratification to guide thromboprophylaxis. OBJECTIVES To compare candidacy for thromboprophylaxis according to 4 risk stratification models: a regional preprinted order (PPO) set used in the study institution, the Padua Prediction Score, and the IMPROVE predictive and associative risk assessment models. METHODS A retrospective review of health records was undertaken for patients with no contraindication to pharmacologic thromboprophylaxis who were admitted to the internal medicine service of a teaching hospital between April and July 2013. RESULTS Of the 298 patients in the study cohort, 238 (80.0%) received pharmacologic thromboprophylaxis on admission, ordered according to the regional PPO. However, according to the Padua and the IMPROVE predictive risk assessment models, only 64 (21.5%) and 21 (7.0%) of the patients, respectively, were eligible for thromboprophylaxis at the time of admission. On the basis of risk factors identified during the subsequent hospital stay, 54 (18.1%) of the patients were eligible for thromboprophylaxis according to the IMPROVE associative model. Chance-corrected agreement between the PPO and the published risk assessment models was generally poor, with kappa coefficients of 0.109 for the PPO compared with the Padua Prediction Score and 0.013 for the PPO compared with the IMPROVE predictive model. CONCLUSIONS These data suggest that quantitative models such as the Padua Prediction Score and the IMPROVE models identify more patients at low risk of venous thromboembolism than do in-hospital qualitative risk assessment models. Adoption of these guideline-based risk assessment models for predicting thromboembolic risk in medical inpatients could reduce the use of pharmacologic thromboprophylaxis from 80% to as low as 7%. Further external prognostic validation of risk assessment models and impact analysis studies may show improvements in safety and resource utilization.
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Affiliation(s)
- Reza Rafizadeh
- , BScPharm, ACPR, is a Clinical Pharmacist, Mental Health and Substance Use, Burnaby Hospital, Burnaby, British Columbia
| | - Ricky D Turgeon
- , BScPharm, ACPR, PharmD, is a Pharmacotherapeutic Specialist, Neurosurgery, Vancouver General Hospital, Vancouver, British Columbia
| | - Josh Batterink
- , BScPharm, ACPR, is Coordinator with LMPS Informatics and Automation, Langley, British Columbia
| | - Victoria Su
- , BScPharm, ACPR, PharmD, BCPS, is a Clinical Pharmacy Specialist, St Paul's Hospital, Vancouver, British Columbia
| | - Anthony Lau
- , BScPharm, is a Pharmacist with Surrey Memorial Hospital, Surrey, British Columbia
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55
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Venous thromboembolism: A Call for risk assessment in all hospitalised patients. Thromb Haemost 2016; 116:777-779. [PMID: 27734070 DOI: 10.1160/th16-09-0732] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 01/19/2023]
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56
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Schulman S. Matching genes with constitution and environment. Thromb Haemost 2016; 116:592-4. [PMID: 27609118 DOI: 10.1160/th16-08-0634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 08/17/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Sam Schulman
- Dr. Schulman, Thrombosis Service, HHS-General Hospital, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada, Tel.: +1 905 5270271, ext 44479, Fax: +1 905 52115511, E-mail:
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57
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Greene MT, Spyropoulos AC, Chopra V, Grant PJ, Kaatz S, Bernstein SJ, Flanders SA. Validation of Risk Assessment Models of Venous Thromboembolism in Hospitalized Medical Patients. Am J Med 2016; 129:1001.e9-1001.e18. [PMID: 27107925 DOI: 10.1016/j.amjmed.2016.03.031] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/21/2016] [Accepted: 03/21/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Patients hospitalized for acute medical illness are at increased risk for venous thromboembolism. Although risk assessment is recommended and several at-admission risk assessment models have been developed, these have not been adequately derived or externally validated. Therefore, an optimal approach to evaluate venous thromboembolism risk in medical patients is not known. METHODS We conducted an external validation study of existing venous thromboembolism risk assessment models using data collected on 63,548 hospitalized medical patients as part of the Michigan Hospital Medicine Safety (HMS) Consortium. For each patient, cumulative venous thromboembolism risk scores and risk categories were calculated. Cox regression models were used to quantify the association between venous thromboembolism events and assigned risk categories. Model discrimination was assessed using Harrell's C-index. RESULTS Venous thromboembolism incidence in hospitalized medical patients is low (1%). Although existing risk assessment models demonstrate good calibration (hazard ratios for "at-risk" range 2.97-3.59), model discrimination is generally poor for all risk assessment models (C-index range 0.58-0.64). CONCLUSIONS The performance of several existing risk assessment models for predicting venous thromboembolism among acutely ill, hospitalized medical patients at admission is limited. Given the low venous thromboembolism incidence in this nonsurgical patient population, careful consideration of how best to utilize existing venous thromboembolism risk assessment models is necessary, and further development and validation of novel venous thromboembolism risk assessment models for this patient population may be warranted.
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Affiliation(s)
- M Todd Greene
- The Michigan Hospital Medicine Safety Consortium Data Coordinating Center, Ann Arbor; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
| | | | - Vineet Chopra
- The Michigan Hospital Medicine Safety Consortium Data Coordinating Center, Ann Arbor; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor; VA Ann Arbor Health Care System, Mich
| | - Paul J Grant
- The Michigan Hospital Medicine Safety Consortium Data Coordinating Center, Ann Arbor; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Steven J Bernstein
- The Michigan Hospital Medicine Safety Consortium Data Coordinating Center, Ann Arbor; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor; VA Ann Arbor Health Care System, Mich
| | - Scott A Flanders
- The Michigan Hospital Medicine Safety Consortium Data Coordinating Center, Ann Arbor; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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58
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Appelmann I, Kreher S, Parmentier S, Wolf HH, Bisping G, Kirschner M, Bergmann F, Schilling K, Brümmendorf TH, Petrides PE, Tiede A, Matzdorff A, Griesshammer M, Riess H, Koschmieder S. Diagnosis, prevention, and management of bleeding episodes in Philadelphia-negative myeloproliferative neoplasms: recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO) and the Society of Thrombosis and Hemostasis Research (GTH). Ann Hematol 2016; 95:707-18. [PMID: 26916570 DOI: 10.1007/s00277-016-2621-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 12/31/2022]
Abstract
Philadelphia-negative myeloproliferative neoplasms (Ph-negative MPN) comprise a heterogeneous group of chronic hematologic malignancies. The quality of life, morbidity, and mortality of patients with MPN are primarily affected by disease-related symptoms, thromboembolic and hemorrhagic complications, and progression to myelofibrosis and acute leukemia. Major bleeding represents a common and important complication in MPN, and the incidence of such bleeding events will become even more relevant in the future due to the increasing disease prevalence and survival of MPN patients. This review discusses the causes, differential diagnoses, prevention, and management of bleeding episodes in patients with MPN, aiming at defining updated standards of care in these often challenging situations.
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Affiliation(s)
- Iris Appelmann
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Stephan Kreher
- Department of Hematology and Oncology, Charite Berlin, Berlin, Germany
| | - Stefani Parmentier
- Department of Hematology, Oncology, and Palliative Medicine, Rems-Murr-Klinikum Winnenden, Winnenden, Germany
| | - Hans-Heinrich Wolf
- Department of Internal Medicine IV, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Guido Bisping
- Department of Medicine I, Mathias Spital Rheine, Rheine, Germany
| | - Martin Kirschner
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Frauke Bergmann
- Medizinisches Versorgungszentrum Wagnerstibbe, Hannover, Germany
| | - Kristina Schilling
- Department of Hematology and Oncology, University Hospital Jena, Jena, Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Petro E Petrides
- Hematology Oncology Centre, Ludwig Maximilians University of Munich Medical School, Munich, Germany
| | - Andreas Tiede
- Department of Haematology, Haemostasis, Oncology and Stem-Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Axel Matzdorff
- Clinic for Internal Medicine II, Dept. of Hematology, Oncology, Asklepios Clinic Uckermark, Schwedt/Oder, Germany
| | | | - Hanno Riess
- Department of Hematology and Oncology, Charite Berlin, Berlin, Germany
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany.
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59
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Raskob GE, Spyropoulos AC, Zrubek J, Ageno W, Albers G, Elliott CG, Halperin J, Haskell L, Hiatt WR, Maynard GA, Peters G, Spiro T, Steg PG, Suh EY, Weitz JI. The MARINER trial of rivaroxaban after hospital discharge for medical patients at high risk of VTE. Design, rationale, and clinical implications. Thromb Haemost 2016; 115:1240-8. [PMID: 26842902 DOI: 10.1160/th15-09-0756] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/16/2015] [Indexed: 11/05/2022]
Abstract
Hospital-associated venous thromboembolism (VTE) is a leading cause of premature death and disability worldwide. Evidence-based guidelines recommend that anticoagulant thromboprophylaxis be given to hospitalised medical patients at risk of VTE, but suggest against routine use of thromboprophylaxis beyond the hospital stay. The MARINER study is a randomised, double-blind, placebo-controlled trial to evaluate the efficacy and safety of thromboprophylaxis using rivaroxaban, begun at hospital discharge and continued for 45 days, for preventing symptomatic VTE in high-risk medical patients. Eligible patients are identified using the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE VTE) risk score, combined with a laboratory test, D-dimer. The rivaroxaban regimen is 10 mg once daily for patients with CrCl ≥ 50 ml/min, or 7.5 mg once daily for patients with CrCl ≥ 30 ml/min and < 50 ml/min. The primary efficacy outcome is the composite of symptomatic VTE (lower extremity deep-vein thrombosis and non-fatal pulmonary embolism) and VTE-related death. The principal safety outcome is major bleeding. A blinded clinical events committee adjudicates all suspected outcome events. The sample size is event-driven with an estimated total of 8,000 patients to acquire 161 primary outcome events. Study design features that distinguish MARINER from previous and ongoing thromboprophylaxis trials in medically ill patients are: (i) use of a validated risk assessment model (IMPROVE VTE) and D-dimer determination for identifying eligible patients at high risk of VTE, (ii) randomisation at the time of hospital discharge, (iii) a 45-day treatment period and (iv) restriction of the primary efficacy outcome to symptomatic VTE events.
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Affiliation(s)
- Gary E Raskob
- Gary E. Raskob, PhD, Dean, College of Public Health and Regents' Professor, Epidemiology and Medicine, University of Oklahoma Health Sciences Center, College of Public Health, 801 NE 13th Street, Oklahoma City, OK 73104, USA, Tel.: +1 405 271 2232, Fax: +1 405 271 3039, E-mail:
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60
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Hale G, Brenner M. Risks and benefits of low molecular-weight heparin and target-specific oral anticoagulant use for thromboprophylaxis in medically ill patients. Am J Cardiovasc Drugs 2015; 15:311-22. [PMID: 25957095 DOI: 10.1007/s40256-015-0122-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Venous thromboembolism is the third most common cardiovascular disease and a major cause of inpatient mortality as over 50 % of deep vein thrombosis and pulmonary embolism are undetected in medically treated patients. Several agents are approved for thromboprophylaxis, including warfarin, unfractionated heparin, low molecular-weight heparins, fondaparinux, and target-specific oral anticoagulants. The purpose of this literature review is to discuss the increased risk of venous thromboembolism in medically ill patients and the literature surrounding the efficacy and tolerability of low molecular-weight heparins and target-specific oral anticoagulants for this indication. PubMed, MEDLINE, EBSCOhost, and clinicaltrials.gov were used as search engines in the literature review. Search limits included articles containing human subjects, scholarly (peer-reviewed) journals written in English, and publication dates from 2004 to 2014. Animal studies, non-English articles, and publications dated prior to 2004 were excluded. Recurrent venous thromboembolism remains an ongoing problem affecting thousands of people in the non-surgical population annually. With limited data, it is not likely that target-specific oral anticoagulants will soon replace low molecular-weight heparins or even be considered an alternative until efficacy and tolerability have been established. Until further evidence is disclosed, low molecular-weight heparins and fondaparinux (in the absence of renal dysfunction and low body weight) should continue to be utilized as first-line agents for thromboprophylaxis in medically ill patients. The use of apixaban and rivaroxaban is discouraged for thromboprophylaxis in medically ill patients.
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61
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Rosenberg D, Eichorn A, Alarcon M, McCullagh L, McGinn T, Spyropoulos AC. External validation of the risk assessment model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for medical patients in a tertiary health system. J Am Heart Assoc 2014; 3:e001152. [PMID: 25404191 PMCID: PMC4338701 DOI: 10.1161/jaha.114.001152] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hospitalized medical patients are at risk for venous thromboembolism (VTE). Universal application of pharmacological thromboprophylaxis has the potential to place a large number of patients at increased bleeding risk. In this study, we aimed to externally validate the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE risk assessment model in a hospitalized general medical population. Methods and Results We identified medical discharges that met the IMPROVE protocol. Cases were defined as hospital‐acquired VTE and confirmed by diagnostic study within 90 days of index hospitalization; matched controls were also identified. Risk factors for VTE were based on the IMPROVE risk assessment model (aged >60 years, prior VTE, intensive care unit or coronary care unit stay, lower limb paralysis, immobility, known thrombophilia, and cancer) and were measured and assessed. A total of 19 217 patients met the inclusion criteria. The overall VTE event rate was 0.7%. The IMPROVE risk assessment model identified 2 groups of the cohort by VTE incidence rate: The low‐risk group had a VTE event rate of 0.42 (95% CI 0.31 to 0.53), corresponding to a score of 0 to 2, and the at‐risk group had a VTE event rate of 1.29 (95% CI 1.01 to 1.57), corresponding to a score of ≥3. Low‐risk status for VTE encompassed 68% of the patient cohort. The area under the receiver operating characteristic curve was 0.702, which was in line with the derivation cohort findings. Conclusions The IMPROVE VTE risk assessment model validation cohort revealed good discrimination and calibration for both the overall VTE risk model and the identification of low‐risk and at‐risk medical patient groups, using a risk score of ≥3. More than two thirds of the entire cohort had a score ≤2.
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Affiliation(s)
- David Rosenberg
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Ann Eichorn
- Krasnoff Quality Management Institute, North Shore LIJ Health System, Manhasset, NY (A.E.)
| | - Mauricio Alarcon
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Lauren McCullagh
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Thomas McGinn
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Alex C Spyropoulos
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
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62
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Squizzato A, Ageno W. A new era for venous thromboembolism prevention in medical inpatients. Thromb Haemost 2014; 112:627-8. [PMID: 25078363 DOI: 10.1160/th14-07-0604] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 07/15/2014] [Indexed: 11/05/2022]
Affiliation(s)
| | - Walter Ageno
- Walter Ageno, U.O. Degenza Internistica Breve, Ospedale di Circolo, Viale Borri 57, 21100 Varese, Italy, Tel.: +39 0332 278831, E-mail:
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