Postoperative Joint Replacement Complications in Swedish Patients With a Family History of Venous Thromboembolism

Familial risk of vasospastic angina: a nationwide family study in Sweden

OBJECTIVES

Vasospastic angina (VSA) is a complex coronary vasomotor disorder associated with an increased risk of myocardial infarction and sudden death. Despite considerable advances in understanding VSA pathophysiology, the interplay between genetic and environmental factors remains elusive. Accordingly, we aimed to determine the familial VSA risk among first-degree relatives of affected individuals.

METHODS

A population-based multigenerational cohort study was conducted, including full-sibling pairs born to Swedish parents between 1932 and 2018. Register-based diagnoses were ascertained through linkage to the Swedish Multigeneration Register and National Patient Register. Incidence rate ratios (IRRs) and adjusted HRs were calculated for relatives of individuals with VSA compared with relatives of individuals without VSA.

RESULTS

The total study population included 5 764 770 individuals. Overall, 3461 (0.06%) individuals (median age at disease onset 59 years, IQR: 63-76) were diagnosed with VSA. Of these, 2236 (64.61%) were women. The incidence rate of VSA for individuals with an affected sibling was 0.31 (95% CI: 0.24 to 0.42) per 1000 person-years compared with 0.04 (95% CI: 0.04 to 0.04) per 1000 person-years for those without an affected sibling, yielding an IRR of 7.58 (95% CI: 5.71 to 10.07). The risk of VSA for siblings with an affected sibling was significantly increased in the fully adjusted model (HR: 2.56; 95% CI: 1.73 to 3.79). No increased risk of VSA was observed in spouses of affected individuals (HR: 0.63; 95% CI: 0.19 to 2.09).

CONCLUSIONS

In this nationwide family study, we identified high familial risk for VSA independent of shared environmental risk factors. Our findings indicate that VSA tends to cluster in families, emphasising the need to explore genetic and non-genetic factors that may contribute.

Familial aggregation of multimorbidity in Sweden: national explorative family study

Objectives

To examine whether multimorbidity aggregates in families in Sweden.

Design

National explorative family study.

Setting

Swedish Multigeneration Register linked to the National Patient Register, 1997-2015. Multimorbidity was assessed with a modified counting method of 45 chronic non-communicable diseases according to ICD-10 (international classification of diseases, 10th revision) diagnoses.

Participants

2 694 442 Swedish born individuals (48.73% women) who could be linked to their Swedish born first, second, and third degree relatives. Twins were defined as full siblings born on the same date.

Main outcome measures

Multimorbidity was defined as two or more non-communicable diseases. Familial associations for one, two, three, four, and five or more non-communicable diseases were assessed to examine risks depending on the number of non-communicable diseases. Familial adjusted odds ratios for multimorbidity were calculated for individuals with a diagnosis of multimorbidity compared with relatives of individuals unaffected by multimorbidity (reference). An initial principal component decomposition followed by a factor analysis with a principal factor method and an oblique promax rotation was used on the correlation matrix of tetrachoric correlations between 45 diagnoses in patients to identify disease clusters.

Results

The odds ratios for multimorbidity were 2.89 in twins (95% confidence interval 2.56 to 3.25), 1.81 in full siblings (1.78 to 1.84), 1.26 in half siblings (1.24 to 1.28), and 1.13 in cousins (1.12 to 1.14) of relatives with a diagnosis of multimorbidity. The odds ratios for multimorbidity increased with the number of diseases in relatives. For example, among twins, the odds ratios for multimorbidity were 1.73, 2.84, 4.09, 4.63, and 6.66 for an increasing number of diseases in relatives, from one to five or more, respectively. Odds ratios were highest at younger ages: in twins, the odds ratio was 3.22 for those aged ≤20 years, 3.14 for those aged 21-30 years, and 2.29 for those aged >30 years at the end of follow-up. Nine disease clusters (factor clusters 1-9) were identified, of which seven aggregated in families. The first three disease clusters in the principal component decomposition were cardiometabolic disease (factor 1), mental health disorders (factor 2), and disorders of the digestive system (factor 3). Odds ratios for multimorbidity in twins, siblings, half siblings, and cousins for the factor 1 cluster were 2.79 (95% confidence interval 0.97 to 8.06), 2.62 (2.39 to 2.88), 1.52 (1.34 to 1.73), and 1.31 (1.23 to 1.39), and for the factor 2 cluster, 5.79 (4.48 to 7.48) 3.24 (3.13 to 3.36), 1.51 (1.45 to 1.57), and 1.37 (1.341.40).

Conclusions

The results of this explorative family study indicated that multimorbidity aggregated in Swedish families. The findings suggest that map clusters of diseases should be used for the genetic study of common diseases to show new genetic patterns of non-communicable diseases.

Meta-analysis and systematic review of randomized controlled trials assessing the role of thromboprophylaxis after vascular surgery

BACKGROUND

Venous thromboembolism (VTE) is a well-known complication associated with surgical procedures. The implementation of thromboprophylaxis in this population has become a vital aspect of perioperative care to decrease VTE-associated morbidity and mortality risk. However, data assessing the role of thromboprophylaxis for patients undergoing vascular surgery are sparse. Assessing the role of thromboprophylaxis by low-molecular-weight heparin or unfractionated heparin in vascular surgery.

METHODS

We searched MEDLINE, Embase, and the Cochrane Collaboration Central Register of Controlled Trials from inception until December 2020, for randomized controlled trials assessing the role of thromboprophylaxis in vascular surgery.

RESULTS

Eight randomized controlled trials met inclusion criteria, including 3130 patients, with a mean age of 55.35 years and 45% were females. Compared with placebo, anticoagulant use was associated with a decrease in deep venous thrombosis (DVT) (risk ratio [RR], 0.34; 95% confidence interval [CI], 0.11-1.05; P = .06; I² = 68%) and pulmonary embolism (PE) (RR, 0.17; 95% CI, 0.02-1.22; P = .08; I² = 41%), but this trend did not attain statistical significance. There was no difference for bleeding outcomes between anticoagulants and placebo (RR, 0.90; 95% CI, 0.05-15.01; P = .94; I² = 76%). There was no significant difference in outcomes when low-molecular-weight heparin was compared directly with unfractionated heparin. In a sensitivity analysis, anticoagulant use was associated with a significant decrease in DVT or PE in patients undergoing venous surgeries, but was not associated with a significant decrease in DVT or PE in patients undergoing arterial surgeries, although this analysis was limited by the small number of studies in each group.

CONCLUSIONS

Among patients undergoing vascular surgery, thromboprophylaxis with anticoagulants showed a trend toward a lesser incidence of VTE when compared with placebo, although this difference was not statistically significant. Bleeding outcomes were comparable between both treatment groups.

Thromboprophylaxis for orthopedic surgery; An updated meta-analysis

BACKGROUND

Venous thromboembolism (VTE) is a serious complication of orthopedic surgery. Low molecular weight heparin (LMWH) has been the standard of care for thromboprophylaxis in this population. However, direct oral anticoagulants (DOACs) are increasingly being used as alternatives.

OBJECTIVE

To assess the efficacy and safety of DOACs versus LMWH for thromboprophylaxis in orthopedic surgery.

METHODS

We searched MEDLINE, Embase, and the Cochrane Collaboration Central Register of Controlled Trials from inception until April 2020, for randomized controlled trials (RCTs) comparing DOACs with LMWH for thromboprophylaxis in orthopedic surgery.

RESULTS

Twenty-five RCTs met inclusion criteria, including 40,438 patients, with a mean age of 68 years and 50% were males. Compared to LMWH, DOACs were associated with a significant reduction of major VTE; defined as the composite events of proximal deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE-related mortality (RR 0.33; 95% CI: 0.20-0.53; P<0.01), and total DVT (RR: 0.59; 95% CI: 0.48-0.73; P<0.01), but not PE (RR 0.81; 95% CI: 0.49-1.34; P=0.42). There was no statistically significant difference between both groups on the incidence of major bleeding (RR 0.99; 95% CI: 0.77-1.27; P=0.92), clinically relevant non-major bleeding (RR 1.04; 95% CI: 0.92-1.17; P=0.52), all-cause mortality (RR 1.06; 95% CI: 0.64-1.76; P=0.83), VTE-related mortality (RR 0.84; 95% CI: 0.40-1.74; P=0.64) and bleeding-related mortality (RR 1.24; 95% CI: 0.30-5.18; P=0.77).

CONCLUSION

For patients undergoing orthopedic surgery, thromboprophylaxis with DOACs is associated with a significant reduction of major VTE and DVT, compared to LMWH. Safety outcomes were not significantly different between both treatment groups.

What's new in VTE risk and prevention in orthopedic surgery

A State of the Art lecture titled "What's New in VTE Risk and Prevention in Orthopedic Surgery" was presented at the ISTH congress in 2019. Patients undergoing orthopedic surgery have long been recognized to be at increased risk of venous thromboembolism (VTE) and were among the first patient groups to be studied in VTE prophylaxis trials. From the late 1950s to 2010s, prophylaxis trials in major orthopedic surgery tended to focus on venographic deep vein thrombosis and assessed thromboprophylaxis in all patients based on a population approach. In general, anticoagulants were favored over mechanical prophylaxis or aspirin, and longer-duration prophylaxis was favored over shorter durations. As discussed in this paper, more recently, orthopedic prophylaxis has started to become more nuanced and individualized. Modern trials are focusing on symptomatic VTE as outcomes; there has been a resurgence in interest in aspirin for prophylaxis, and there has been a slow move to studying ways to evaluate VTE risk in patients undergoing orthopedic surgery and recommending thromboprophylaxis to patients based on individual attributes, in whom risk stratification and weighing of benefit versus risk of thromboprophylaxis is becoming key. We also touch on VTE risk and guideline recommendations to prevent VTE in 2 other commonly encountered orthopedic populations: patients undergoing knee arthroscopy and those with distal leg fractures. Finally, we summarize relevant new data on this topic presented during the 2019 ISTH annual congress in Melbourne.