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Ciaccio AM, Tuttolomondo A. Epigenetics of cerebrovascular diseases: an update review of clinical studies. Epigenomics 2024:1-13. [PMID: 39072474 DOI: 10.1080/17501911.2024.2377947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 07/05/2024] [Indexed: 07/30/2024] Open
Abstract
Cerebrovascular diseases, especially stroke, are critical and heterogenous clinical conditions associated with high mortality and chronic disability. Genome-wide association studies reveal substantial stroke heritability, though specific genetic variants account for a minor fraction of stroke risk, suggesting an essential role for the epigenome. Epigenome-wide association studies and candidate gene approaches show that DNA methylation patterns significantly influence stroke susceptibility. Additionally, chromatin remodelers and non-coding RNA regulate gene expression in response to ischemic conditions. In this updated review, we summarized the progress of knowledge on epigenetics in the field of ischemic stroke underlying opportunities and challenges.
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Affiliation(s)
- Anna Maria Ciaccio
- Internal Medicine & Stroke Care Ward, PROMISE Department, University of Palermo, Piazza delle Cliniche n.2, 90127, Palermo, Italy
| | - Antonino Tuttolomondo
- Internal Medicine & Stroke Care Ward, PROMISE Department, University of Palermo, Piazza delle Cliniche n.2, 90127, Palermo, Italy
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Ribeiro JAM, Oliveira SG, Ocamoto GN, Thommazo-Luporini LD, Mendes RG, Borghi-Silva A, Phillips SA, Billinger SA, Russo TL. Hemispheric lateralization, endothelial function, and arterial compliance in chronic post-stroke individuals: a cross-sectional exploratory study. Int J Neurosci 2024; 134:481-491. [PMID: 36028987 DOI: 10.1080/00207454.2022.2118597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/29/2022] [Accepted: 08/17/2022] [Indexed: 10/15/2022]
Abstract
Purpose/Aim: Cardiovascular function is controlled and regulated by a functional brain-heart axis. Although the exact mechanism is not fully understood, several studies suggest a hemispheric asymmetry in the neural control of cardiovascular function. Thus, the purpose of this study was to examine whether endothelial function and arterial compliance differ between individuals with left- and right-sided strokes.Materials and Methods: This was a cross-sectional exploratory study. Thirty individuals more than 6 months after stroke participated in the study. The endothelial function was assessed by ultrasound-measured flow-mediated dilation of the nonparetic arm brachial artery (baFMD). The arterial stiffness was assessed by measuring carotid-femoral pulse wave velocity (cfPWV) and central aortic pulse wave analysis [augmentation index (AIx), augmentation index normalized to a heart rate of 75 bpm (AIx@75) and reflection magnitude (RM)] using applanation tonometry. Results: Participants with right-sided stroke had worse endothelial function than those with left-sided stroke. This difference (baFMD = 2.51%) was significant (p = 0.037), and it represented a medium effect size (r = 0.38). Likewise, they had higher arterial stiffness than those with left-sided stroke. This difference (AIx = 10%; RM = 7%) was significant (p = 0.011; p = 0.012), and it represented a medium effect size (r = 0.48; r = 0.47).Conclusions: Our findings suggest that individuals with right-sided stroke have reduced endothelial function and arterial compliance compared to those with left-sided stroke. These data may indicate that those with right-sided strokes are more susceptible to cardiovascular events.
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Affiliation(s)
| | | | | | | | | | - Audrey Borghi-Silva
- Department of Physical Therapy, Federal University of São Carlos, São Carlos, Brazil
| | - Shane A Phillips
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, USA
| | - Sandra A Billinger
- Department of Neurology, University of Kansas Medical Center, Kansas City, USA
- KU Alzheimer's Disease Research Center, Fairway, KS, USA
| | - Thiago Luiz Russo
- Department of Physical Therapy, Federal University of São Carlos, São Carlos, Brazil
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Tuttolomondo A, Baglio I, Riolo R, Todaro F, Parrinello G, Miceli S, Simonetta I. Molecular Pathogenesis of Central and Peripheral Nervous System Complications in Anderson-Fabry Disease. Int J Mol Sci 2023; 25:61. [PMID: 38203231 PMCID: PMC10779326 DOI: 10.3390/ijms25010061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 01/12/2024] Open
Abstract
Fabry disease (FD) is a recessive monogenic disease linked to chromosome X due to more than two hundred mutations in the alfa-galactosidase A (GLA) gene. Modifications of the GLA gene may cause the progressive accumulation of globotriaosylceramide (Gb3) and its deacylated form, globotriasylsphingosine (lyso-Gb3), in lysosomes of several types of cells of the heart, kidneys, skin, eyes, peripheral and central nervous system (not clearly and fully demonstrated), and gut with different and pleiotropic clinical symptoms. Among the main symptoms are acroparesthesias and pain crisis (involving the peripheral nervous system), hypohidrosis, abdominal pain, gut motility abnormalities (involving the autonomic system), and finally, cerebrovascular ischemic events due to macrovascular involvement (TIA and stroke) and lacunar strokes and white matter abnormalities due to a small vessel disease (SVS). Gb3 lysosomal accumulation causes cytoplasmatic disruption and subsequent cell death. Additional consequences of Gb3 deposits are inflammatory processes, abnormalities of leukocyte function, and impaired trafficking of some types of immune cells, including lymphocytes, monocytes, CD8+ cells, B cells, and dendritic cells. The involvement of inflammation in AFD pathogenesis conflicts with the reported poor correlation between CRP levels as an inflammation marker and clinical scores such as the Mainz Severity Score Index (MSSI). Also, some authors have suggested an autoimmune reaction is involved in the disease's pathogenetic mechanism after the α-galactosidase A deficiency. Some studies have reported a high degree of neuronal apoptosis inhibiting protein as a critical anti-apoptotic mediator in children with Fabry disease compared to healthy controls. Notably, this apoptotic upregulation did not change after treatment with enzymatic replacement therapy (ERT), with a further upregulation of the apoptosis-inducing factor after ERT started. Gb3-accumulation has been reported to increase the degree of oxidative stress indexes and the production of reactive oxygen species (ROS). Lipids and proteins have been reported as oxidized and not functioning. Thus, neurological complications are linked to different pathogenetic molecular mechanisms. Progressive accumulation of Gb3 represents a possible pathogenetic event of peripheral nerve involvement. In contrast, central nervous system participation in the clinical setting of cerebrovascular ischemic events seems to be due to the epitheliopathy of Anderson-Fabry disease with lacunar lesions and white matter hyperintensities (WMHs). In this review manuscript, we revised molecular mechanisms of peripheral and central neurological complications of Anderson-Fabry Disease. The management of Fabry disease may be improved by the identification of biomarkers that reflect the clinical course, severity, and progression of the disease. Intensive research on biomarkers has been conducted over the years to detect novel markers that may potentially be used in clinical practice as a screening tool, in the context of the diagnostic process and as an indicator of response to treatment. Recent proteomic or metabolomic studies are in progress, investigating plasma proteome profiles in Fabry patients: these assessments may be useful to characterize the molecular pathology of the disease, improve the diagnostic process, and monitor the response to treatment.
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Affiliation(s)
- Antonino Tuttolomondo
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties, “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.B.); (R.R.); (F.T.); (G.P.); (S.M.); (I.S.)
- Fabry Disease Regional Reference Centre, Internal Medicine and Stroke Care Ward, University Hospital Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Irene Baglio
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties, “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.B.); (R.R.); (F.T.); (G.P.); (S.M.); (I.S.)
- Fabry Disease Regional Reference Centre, Internal Medicine and Stroke Care Ward, University Hospital Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Renata Riolo
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties, “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.B.); (R.R.); (F.T.); (G.P.); (S.M.); (I.S.)
- Fabry Disease Regional Reference Centre, Internal Medicine and Stroke Care Ward, University Hospital Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Federica Todaro
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties, “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.B.); (R.R.); (F.T.); (G.P.); (S.M.); (I.S.)
- Fabry Disease Regional Reference Centre, Internal Medicine and Stroke Care Ward, University Hospital Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Gaspare Parrinello
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties, “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.B.); (R.R.); (F.T.); (G.P.); (S.M.); (I.S.)
| | - Salvatore Miceli
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties, “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.B.); (R.R.); (F.T.); (G.P.); (S.M.); (I.S.)
- Fabry Disease Regional Reference Centre, Internal Medicine and Stroke Care Ward, University Hospital Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Irene Simonetta
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties, “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.B.); (R.R.); (F.T.); (G.P.); (S.M.); (I.S.)
- Fabry Disease Regional Reference Centre, Internal Medicine and Stroke Care Ward, University Hospital Policlinico “P. Giaccone”, 90127 Palermo, Italy
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Tuttolomondo A, Simonetta I. Molecular Research on Migraine: From Pathogenesis to Treatment. Int J Mol Sci 2023; 24:ijms24108681. [PMID: 37240040 DOI: 10.3390/ijms24108681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Migraine is a common, multifactorial, disabling, recurrent, hereditary, neurovascular headache disorder [...].
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Affiliation(s)
- Antonino Tuttolomondo
- Internal Medicine and Stroke Care Ward, Policlinico University Hospital, proMISE Department, University of Palermo, 90127 Palermo, Italy
| | - Irene Simonetta
- Internal Medicine and Stroke Care Ward, Policlinico University Hospital, proMISE Department, University of Palermo, 90127 Palermo, Italy
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Waseem A, Rashid S, Rashid K, Khan MA, Khan R, Haque R, Seth P, Raza SS. Insight into the transcription factors regulating Ischemic Stroke and Glioma in Response to Shared Stimuli. Semin Cancer Biol 2023; 92:102-127. [PMID: 37054904 DOI: 10.1016/j.semcancer.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/28/2023] [Accepted: 04/09/2023] [Indexed: 04/15/2023]
Abstract
Cerebral ischemic stroke and glioma are the two leading causes of patient mortality globally. Despite physiological variations, 1 in 10 people who have an ischemic stroke go on to develop brain cancer, most notably gliomas. In addition, glioma treatments have also been shown to increase the risk of ischemic strokes. Stroke occurs more frequently in cancer patients than in the general population, according to traditional literature. Unbelievably, these events share multiple pathways, but the precise mechanism underlying their co-occurrence remains unknown. Transcription factors (TFs), the main components of gene expression programmes, finally determine the fate of cells and homeostasis. Both ischemic stroke and glioma exhibit aberrant expression of a large number of TFs, which are strongly linked to the pathophysiology and progression of both diseases. The precise genomic binding locations of TFs and how TF binding ultimately relates to transcriptional regulation remain elusive despite a strong interest in understanding how TFs regulate gene expression in both stroke and glioma. As a result, the importance of continuing efforts to understand TF-mediated gene regulation is highlighted in this review, along with some of the primary shared events in stroke and glioma.
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Affiliation(s)
- Arshi Waseem
- Laboratory for Stem Cell & Restorative Neurology, Department of Biotechnology, Era's Lucknow Medical College and Hospital, Era University, Sarfarazganj, Lucknow-226003, India
| | - Sumaiya Rashid
- Department of Pharmacology & Toxicology, College of Pharmacy, Prince Sattam Bin Abdulaziz University, P.O. Box 173, Al-Kharj 11942, Saudi Arabia
| | - Khalid Rashid
- Department of Cancer Biology, Vontz Center for Molecular Studies, Cincinnati, OH 45267-0521
| | | | - Rehan Khan
- Chemical Biology Unit, Institute of Nano Science and Technology, Knowledge City,Mohali, Punjab 140306, India
| | - Rizwanul Haque
- Department of Biotechnology, Central University of South Bihar, Gaya -824236, India
| | - Pankaj Seth
- Molecular and Cellular Neuroscience, Neurovirology Section, National Brain Research Centre, Manesar, Haryana-122052, India
| | - Syed Shadab Raza
- Laboratory for Stem Cell & Restorative Neurology, Department of Biotechnology, Era's Lucknow Medical College and Hospital, Era University, Sarfarazganj, Lucknow-226003, India; Department of Stem Cell Biology and Regenerative Medicine, Era's Lucknow Medical College Hospital, Era University, Sarfarazganj, Lucknow-226003, India
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Pacinella G, Ciaccio AM, Tuttolomondo A. Endothelial Dysfunction and Chronic Inflammation: The Cornerstones of Vascular Alterations in Age-Related Diseases. Int J Mol Sci 2022; 23:ijms232415722. [PMID: 36555364 PMCID: PMC9779461 DOI: 10.3390/ijms232415722] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Vascular diseases of the elderly are a topic of enormous interest in clinical practice, as they have great epidemiological significance and lead to ever-increasing healthcare expenditures. The mechanisms underlying these pathologies have been increasingly characterized over the years. It has emerged that endothelial dysfunction and chronic inflammation play a diriment role among the most relevant pathophysiological mechanisms. As one can easily imagine, various processes occur during aging, and several pathways undergo irreversible alterations that can promote the decline and aberrations that trigger the diseases above. Endothelial dysfunction and aging of circulating and resident cells are the main characteristics of the aged organism; they represent the framework within which an enormous array of molecular abnormalities occur and contribute to accelerating and perpetuating the decline of organs and tissues. Recognizing and detailing each of these dysfunctional pathways is helpful for therapeutic purposes, as it allows one to hypothesize the possibility of tailoring interventions to the damaged mechanism and hypothetically limiting the cascade of events that drive the onset of these diseases. With this paper, we have reviewed the scientific literature, analysing the pathophysiological basis of the vascular diseases of the elderly and pausing to reflect on attempts to interrupt the vicious cycle that connotes the diseases of aging, laying the groundwork for therapeutic reasoning and expanding the field of scientific research by moving from a solid foundation.
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Lu JF, Fan ZX, Li Y, Wang ZY, Ma L, Yuan BY, Yang TT, Liu PJ, Liu GZ. Risk factors, clinical features, and outcomes of patients with hypertrophic cardiomyopathy complicated by ischemic stroke: A single-center retrospective study. Front Cardiovasc Med 2022; 9:1054199. [PMID: 36568560 PMCID: PMC9772473 DOI: 10.3389/fcvm.2022.1054199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Objective This study aimed to explore risk factors, clinical features, and prognosis of patients with hypertrophic cardiomyopathy (HCM) complicated by ischemic stroke (IS). Methods We conducted a retrospective analysis of all HCM patient data and a 1-year follow-up study. Results Totally, 506 patients with HCM, including 71 with IS, were enrolled. Older age (≥63 years) was associated with an increased risk of IS in HCM patients (OR = 1.045, 95% CI: 1.018-1.072, p = 0.001). Among 37 patients complicated by IS, 22 (59.5%, 22/37) manifested as cardioembolism (CE) subtype, and 13 (35.1%, 3/37) small artery occlusion (SAO) subtype, according to TOAST classification. In the acute phase, the IS patients presented with NIHSS 4 (interquartile range: 1, 10). Multi-infarction was more common than single infarction (72.7 vs. 27.3%), while cortical + subcortical infarction (CE group: 50%) or subcortical infarction (SAO group: 53.8%) constituted most IS cases. Additionally, the blood supply areas of anterior circulation (CE group: 45.5%; SAO group: 92.3%) or anterior + posterior circulation (CE group: 50%) were mainly involved. The 1-year survival rate of HCM patients with concomitant IS was 81.8%, and IS was associated with 1-year all-cause death in HCM patients (HR = 5.689, 95% CI: 1.784-18.144, p = 0.003). Conclusion Older age is a risk factor for IS occurrence in HCM patients. Patients with HCM complicated by IS had mild or moderate neurologic deficits at disease onset. CE and SAO subtypes predominate in patients with concomitant IS, especially the former. Multiple cortical and subcortical infarctions are their neuroimaging characteristics, mainly involving the anterior circulation or anterior + posterior circulation. Is is a risk factor for all-cause death in HCM patients within 1 year.
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Advances in Noninvasive Carotid Wall Imaging with Ultrasound: A Narrative Review. J Clin Med 2022; 11:jcm11206196. [PMID: 36294515 PMCID: PMC9604731 DOI: 10.3390/jcm11206196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Abstract
Carotid atherosclerosis is a major cause for stroke, with significant associated disease burden morbidity and mortality in Western societies. Diagnosis, grading and follow-up of carotid atherosclerotic disease relies on imaging, specifically ultrasound (US) as the initial modality of choice. Traditionally, the degree of carotid lumen stenosis was considered the sole risk factor to predict brain ischemia. However, modern research has shown that a variety of other imaging biomarkers, such as plaque echogenicity, surface morphology, intraplaque neovascularization and vasa vasorum contribute to the risk for rupture of carotid atheromas with subsequent cerebrovascular events. Furthermore, the majority of embolic strokes of undetermined origin are probably arteriogenic and are associated with nonstenosing atheromas. Therefore, a state-of-the-art US scan of the carotid arteries should take advantage of recent technical developments and should provide detailed information about potential thrombogenic (/) and emboligenic arterial wall features. This manuscript reviews recent advances in ultrasonographic assessment of vulnerable carotid atherosclerotic plaques and highlights the fields of future development in multiparametric arterial wall imaging, in an attempt to convey the most important take-home messages for clinicians performing carotid ultrasound.
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Wu F, Wang Q, Qiao Y, Yu Q, Wang F. A new marker of short-term mortality and poor outcome in patients with acute ischemic stroke: Mean platelet volume-to-lymphocyte ratio. Medicine (Baltimore) 2022; 101:e30911. [PMID: 36221422 PMCID: PMC9542671 DOI: 10.1097/md.0000000000030911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The mean platelet volume-to-lymphocyte ratio (MPVLR), as a novel marker of thrombosis and inflammation, has been demonstrated to be closely linked to poor cardiovascular disease prognosis. However, the correlation between MPVLR and acute ischemic stroke (AIS) remains unclear. This study, therefore, aimed to clarify the relationship between MPVLR and the short-term prognosis of AIS. METHODS A total of 315 patients with first-time AIS diagnoses were recruited and divided into 3 groups based on the tri-sectional quantiles for MPVLR on admission: group 1 (N = 105) with a MPVLR ≤ 4.93, group 2 (N = 105) with a MPVLR of 4.94 to 7.21, and group 3 (N = 105) with a MPVLR ≥ 7.22. All patients were followed-up for 3 months, and death within 3 months was defined as the endpoint. Baseline characteristics, stroke severity, and functional outcomes were evaluated. RESULTS The Spearman's correlation coefficient test showed that MPVLR was significantly positively correlated with the National Institutes of Health Stroke Scale score (R = 0.517, P < .001). Multivariate analysis revealed that MPVLR was an independent predictor of both short-term mortality (adjusted odds ratio [OR] 1.435, P < .001) and poor outcome (adjusted OR 1.589, P < .001). The receiver operating characteristic (ROC) curve analysis showed that the best cutoff value of MPVLR for short-term mortality and poor outcome were 6.69 (sensitivity: 86.4%, specificity: 68.6%) and 6.38 (sensitivity: 78.8%, specificity: 72.3%), respectively. CONCLUSIONS MPVLR on admission was positively associated with stroke severity. An elevated MPVLR is an independent predictor of short-term mortality and poor outcome after AIS.
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Affiliation(s)
- Fan Wu
- Department of Clinical Laboratory, Central China Cardiovascular Hospital of Fu-wai, Zhengzhou, Henan, China
- *Correspondence: Fan Wu, Department of Clinical Laboratory, Central China Cardiovascular Hospital of Fu-wai, 450052, Zhengzhou, Henan, China (e-mail: )
| | - Qian Wang
- Department of Clinical Laboratory, Central China Cardiovascular Hospital of Fu-wai, Zhengzhou, Henan, China
| | - Yingli Qiao
- Department of Clinical Laboratory, Central China Cardiovascular Hospital of Fu-wai, Zhengzhou, Henan, China
| | - Qing Yu
- Department of Clinical Laboratory, Central China Cardiovascular Hospital of Fu-wai, Zhengzhou, Henan, China
| | - Fuyuan Wang
- Department of Clinical Laboratory, Central China Cardiovascular Hospital of Fu-wai, Zhengzhou, Henan, China
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Xie D, Li Y, Xu M, Zhao X, Chen M. Effects of dulaglutide on endothelial progenitor cells and arterial elasticity in patients with type 2 diabetes mellitus. Cardiovasc Diabetol 2022; 21:200. [PMID: 36199064 PMCID: PMC9533545 DOI: 10.1186/s12933-022-01634-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Randomised controlled trial showed that dulaglutide can reduce the risk of atherosclerotic cardiovascular disease (ASCVD) in patients with type 2 diabetes mellitus (T2DM), but the underlying mechanisms remain unclear. This study aimed to investigate the effect of dulaglutide on the number and function of endothelial progenitor cells (EPCs) in the peripheral blood of patients with T2DM and its role in improving arterial elasticity, so as to determine potential mechanisms of preventive effect of dulaglutide on ASCVD. Methods Sixty patients with T2DM were treated with 1000 mg/day of metformin and randomly divided into two groups for 12 weeks: metformin monotherapy group (MET group, n = 30), and metformin combined with dulaglutide group (MET-DUL group, n = 30). Before and after treatment, the number of CD34+CD133+KDR+ EPCs and the brachial–ankle pulse wave velocity (baPWV) of the participants were measured, and EPC proliferation, adhesion, migration, and tubule formation were assessed in vitro. Results There were no significant differences in the number and function of EPCs and baPWV changes in MET group (P > 0.05). In MET-DUL group, nitric oxide (NO) levels and the number of EPCs increased after treatment (P < 0.05), while the levels of C-reactive protein (CRP), interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α), advanced glycation end products (AGEs), and baPWV decreased (P < 0.05). EPC proliferation, adhesion, migration, and tubule formation abilities were significantly enhanced (P < 0.05). Correlation analysis showed that in MET-DUL group, the changes in CRP, IL-6, TNF-α, and AGEs were negatively correlated with the number of EPCs and their proliferation and migration abilities (P < 0.05). Body weight, NO, CRP, and IL-6 levels were independent factors affecting the number of EPCs (P < 0.05). The changes in number of EPCs, proliferation and migration abilities of EPCs, and NO and IL-6 levels were independent influencing factors of baPWV changes (P < 0.05). Conclusion Dulaglutide can increase the number and function of EPCs in peripheral blood and improve arterial elasticity in patients with T2DM; it is accompanied by weight loss, inflammation reduction, and high NO levels. Dulaglutide regulation of EPCs may be a mechanism of cardiovascular protection.
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Affiliation(s)
- Dandan Xie
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China
| | - Yutong Li
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China
| | - Murong Xu
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China
| | - Xiaotong Zhao
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China
| | - Mingwei Chen
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China.
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Yoo DY, Choi JK, Baek CY, Shin JB. Impact of intensive rehabilitation on long-term prognosis after stroke: A Korean nationwide retrospective cohort study. Medicine (Baltimore) 2022; 101:e30827. [PMID: 36197214 PMCID: PMC9509033 DOI: 10.1097/md.0000000000030827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
An increasing number of patients are receiving rehabilitation after stroke. But the impact of intensive rehabilitation on the long-term prognosis of patients with stroke remains to be elucidated. The purpose of this study was to identify the impact of intensive rehabilitation on the long-term prognosis of patients with stroke using data from the National Health Insurance Service database. This is a register-based, retrospective cohort study. Using data from the National Health Insurance Service database, we included the patients who received rehabilitation for stroke from 2006 to 2013. Of the 14,984 patients diagnosed with stroke, 2483 died within 1 year, and 2866 did not receive rehabilitation; hence, they were also excluded. The final sample included 9635 (49.2% men, 50.8% women) patients. After correcting for covariates, the Cox model was used to evaluate the effects of physical therapy (PT) and occupational therapy (OT) on survival. We estimated the independent contribution of each factor to the risk of death from the initiation of rehabilitation. Significant differences in mortality were observed according to age, Charlson comorbidity index (CCI), income level, and stroke type. Patients with stroke who received both PT and OT had a better long-term prognosis than those who received either treatment alone. Therapy performed by a physical therapist with more than 120 hours of training effectively improved the patients' long-term prognosis. Intensive PT and OT will help improve the long-term prognosis of patients with stroke. This study emphasizes the importance of intensive rehabilitation in these patients.
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Affiliation(s)
- Dong-Yup Yoo
- Department of Rehabilitation Medicine, National Health Insurance Ilsan Hospital, Goyang, South Korea
| | - Jung-Kyu Choi
- Health Insurance Research Institute, National Health Insurance Service, Wonju, South Korea
| | - Chang-Yoon Baek
- Department of Rehabilitation Medicine, National Health Insurance Ilsan Hospital, Goyang, South Korea
| | - Jung-Bin Shin
- Department of Rehabilitation Medicine, Good Balance Yonsei Clinic, Seoul, South Korea
- *Correspondence: Jung-Bin Shin, Department of Rehabilitation Medicine, Good Balance Yonsei Clinic, Seoul, South Korea (e-mail: )
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Puleo MG, Miceli S, Di Chiara T, Pizzo GM, Della Corte V, Simonetta I, Pinto A, Tuttolomondo A. Molecular Mechanisms of Inflammasome in Ischemic Stroke Pathogenesis. Pharmaceuticals (Basel) 2022; 15:1168. [PMID: 36297283 PMCID: PMC9612213 DOI: 10.3390/ph15101168] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/01/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
Ischemic stroke (also called cerebral ischemia) is one of the leading causes of death and severe disability worldwide. NLR inflammasomes play a crucial role in sensing cell damage in response to a harmful stimuli and modulating the inflammatory response, promoting the release of pro-inflammatory cytokines such as IL-18 and IL-1β following ischemic injury. Therefore, a neuroprotective effect is achieved by inhibiting the expression, assembly, and secretion of inflammasomes, thus limiting the extent of brain detriment and neurological sequelae. This review aims to illustrate the molecular characteristics, expression levels, and assembly of NLRP3 (nucleotide-binding oligomerization domain-like receptor [NLR] family pyrin-domain-containing 3) inflammasome, the most studied in the literature, in order to discover promising therapeutic implications. In addition, we provide some information regarding the contribution of NLRP1, NLRP2, and NLRC4 inflammasomes to ischemic stroke pathogenesis, highlighting potential therapeutic strategies that require further study.
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Affiliation(s)
| | | | | | | | | | | | | | - Antonino Tuttolomondo
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties, “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy
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13
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Del Cuore A, Pacinella G, Riolo R, Tuttolomondo A. The Role of Immunosenescence in Cerebral Small Vessel Disease: A Review. Int J Mol Sci 2022; 23:ijms23137136. [PMID: 35806140 PMCID: PMC9266569 DOI: 10.3390/ijms23137136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/20/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
Cerebral small vessel disease (CSVD) is one of the most important causes of vascular dementia. Immunosenescence and inflammatory response, with the involvement of the cerebrovascular system, constitute the basis of this disease. Immunosenescence identifies a condition of deterioration of the immune organs and consequent dysregulation of the immune response caused by cellular senescence, which exposes older adults to a greater vulnerability. A low-grade chronic inflammation status also accompanies it without overt infections, an “inflammaging” condition. The correlation between immunosenescence and inflammaging is fundamental in understanding the pathogenesis of age-related CSVD (ArCSVD). The production of inflammatory mediators caused by inflammaging promotes cellular senescence and the decrease of the adaptive immune response. Vice versa, the depletion of the adaptive immune mechanisms favours the stimulation of the innate immune system and the production of inflammatory mediators leading to inflammaging. Furthermore, endothelial dysfunction, chronic inflammation promoted by senescent innate immune cells, oxidative stress and impairment of microglia functions constitute, therefore, the framework within which small vessel disease develops: it is a concatenation of molecular events that promotes the decline of the central nervous system and cognitive functions slowly and progressively. Because the causative molecular mechanisms have not yet been fully elucidated, the road of scientific research is stretched in this direction, seeking to discover other aberrant processes and ensure therapeutic tools able to enhance the life expectancy of people affected by ArCSVD. Although the concept of CSVD is broader, this manuscript focuses on describing the neurobiological basis and immune system alterations behind cerebral aging. Furthermore, the purpose of our work is to detect patients with CSVD at an early stage, through the evaluation of precocious MRI changes and serum markers of inflammation, to treat untimely risk factors that influence the burden and the worsening of the cerebral disease.
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Affiliation(s)
- Alessandro Del Cuore
- Department of Promoting Health, Maternal-Infant, Excellence and Internal and Specialised Medicine (PROMISE) G. D’Alessandro, University of Palermo, 90133 Palermo, Italy; (G.P.); (R.R.); (A.T.)
- Internal Medicine and Stroke Care Ward, Policlinico “P. Giaccone”, 90127 Palermo, Italy
- Correspondence: ; Tel.: +39-091-655-2197
| | - Gaetano Pacinella
- Department of Promoting Health, Maternal-Infant, Excellence and Internal and Specialised Medicine (PROMISE) G. D’Alessandro, University of Palermo, 90133 Palermo, Italy; (G.P.); (R.R.); (A.T.)
- Internal Medicine and Stroke Care Ward, Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Renata Riolo
- Department of Promoting Health, Maternal-Infant, Excellence and Internal and Specialised Medicine (PROMISE) G. D’Alessandro, University of Palermo, 90133 Palermo, Italy; (G.P.); (R.R.); (A.T.)
- Internal Medicine and Stroke Care Ward, Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Antonino Tuttolomondo
- Department of Promoting Health, Maternal-Infant, Excellence and Internal and Specialised Medicine (PROMISE) G. D’Alessandro, University of Palermo, 90133 Palermo, Italy; (G.P.); (R.R.); (A.T.)
- Internal Medicine and Stroke Care Ward, Policlinico “P. Giaccone”, 90127 Palermo, Italy
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Simonetta I, Riolo R, Todaro F, Tuttolomondo A. New Insights on Metabolic and Genetic Basis of Migraine: Novel Impact on Management and Therapeutical Approach. Int J Mol Sci 2022; 23:3018. [PMID: 35328439 PMCID: PMC8955051 DOI: 10.3390/ijms23063018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Migraine is a hereditary disease, usually one-sided, sometimes bilateral. It is characterized by moderate to severe pain, which worsens with physical activity and may be associated with nausea and vomiting, may be accompanied by photophobia and phonophobia. The disorder can occur at any time of the day and can last from 4 to 72 h, with and without aura. The pathogenic mechanism is unclear, but extensive preclinical and clinical studies are ongoing. According to electrophysiology and imaging studies, many brain areas are involved, such as cerebral cortex, thalamus, hypothalamus, and brainstem. The activation of the trigeminovascular system has a key role in the headache phase. There also appears to be a genetic basis behind the development of migraine. Numerous alterations have been identified, and in addition to the genetic cause, there is also a close association with the surrounding environment, as if on the one hand, the genetic alterations may be responsible for the onset of migraine, on the other, the environmental factors seem to be more strongly associated with exacerbations. This review is an analysis of neurophysiological mechanisms, neuropeptide activity, and genetic alterations that play a fundamental role in choosing the best therapeutic strategy. To date, the goal is to create a therapy that is as personalized as possible, and for this reason, steps forward have been made in the pharmacological field in order to identify new therapeutic strategies for both acute treatment and prophylaxis.
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Affiliation(s)
- Irene Simonetta
- Internal Medicine and Stroke Care Ward, Department of Promoting Health, Maternal-Infant Excellence and Internal and Specialized Medicine (ProMISE) G. D’Alessandro, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.S.); (R.R.); (F.T.)
- Molecular and Clinical Medicine PhD Programme, University of Palermo, P.zza delle Cliniche n.2, 90127 Palermo, Italy
| | - Renata Riolo
- Internal Medicine and Stroke Care Ward, Department of Promoting Health, Maternal-Infant Excellence and Internal and Specialized Medicine (ProMISE) G. D’Alessandro, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.S.); (R.R.); (F.T.)
| | - Federica Todaro
- Internal Medicine and Stroke Care Ward, Department of Promoting Health, Maternal-Infant Excellence and Internal and Specialized Medicine (ProMISE) G. D’Alessandro, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.S.); (R.R.); (F.T.)
| | - Antonino Tuttolomondo
- Internal Medicine and Stroke Care Ward, Department of Promoting Health, Maternal-Infant Excellence and Internal and Specialized Medicine (ProMISE) G. D’Alessandro, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (I.S.); (R.R.); (F.T.)
- Molecular and Clinical Medicine PhD Programme, University of Palermo, P.zza delle Cliniche n.2, 90127 Palermo, Italy
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Di Chiara T, Del Cuore A, Daidone M, Scaglione S, Norrito RL, Puleo MG, Scaglione R, Pinto A, Tuttolomondo A. Pathogenetic Mechanisms of Hypertension-Brain-Induced Complications: Focus on Molecular Mediators. Int J Mol Sci 2022; 23:ijms23052445. [PMID: 35269587 PMCID: PMC8910319 DOI: 10.3390/ijms23052445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
There is growing evidence that hypertension is the most important vascular risk factor for the development and progression of cardiovascular and cerebrovascular diseases. The brain is an early target of hypertension-induced organ damage and may manifest as stroke, subclinical cerebrovascular abnormalities and cognitive decline. The pathophysiological mechanisms of these harmful effects remain to be completely clarified. Hypertension is well known to alter the structure and function of cerebral blood vessels not only through its haemodynamics effects but also for its relationships with endothelial dysfunction, oxidative stress and inflammation. In the last several years, new possible mechanisms have been suggested to recognize the molecular basis of these pathological events. Accordingly, this review summarizes the factors involved in hypertension-induced brain complications, such as haemodynamic factors, endothelial dysfunction and oxidative stress, inflammation and intervention of innate immune system, with particular regard to the role of Toll-like receptors that have to be considered dominant components of the innate immune system. The complete definition of their prognostic role in the development and progression of hypertensive brain damage will be of great help in the identification of new markers of vascular damage and the implementation of innovative targeted therapeutic strategies.
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Maida CD, Daidone M, Pacinella G, Norrito RL, Pinto A, Tuttolomondo A. Diabetes and Ischemic Stroke: An Old and New Relationship an Overview of the Close Interaction between These Diseases. Int J Mol Sci 2022; 23:ijms23042397. [PMID: 35216512 PMCID: PMC8877605 DOI: 10.3390/ijms23042397] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 12/12/2022] Open
Abstract
Diabetes mellitus is a comprehensive expression to identify a condition of chronic hyperglycemia whose causes derive from different metabolic disorders characterized by altered insulin secretion or faulty insulin effect on its targets or often both mechanisms. Diabetes and atherosclerosis are, from the point of view of cardio- and cerebrovascular risk, two complementary diseases. Beyond shared aspects such as inflammation and oxidative stress, there are multiple molecular mechanisms by which they feed off each other: chronic hyperglycemia and advanced glycosylation end-products (AGE) promote ‘accelerated atherosclerosis’ through the induction of endothelial damage and cellular dysfunction. These diseases impact the vascular system and, therefore, the risk of developing cardio- and cerebrovascular events is now evident, but the observation of this significant correlation has its roots in past decades. Cerebrovascular complications make diabetic patients 2–6 times more susceptible to a stroke event and this risk is magnified in younger individuals and in patients with hypertension and complications in other vascular beds. In addition, when patients with diabetes and hyperglycemia experience an acute ischemic stroke, they are more likely to die or be severely disabled and less likely to benefit from the one FDA-approved therapy, intravenous tissue plasminogen activator. Experimental stroke models have revealed that chronic hyperglycemia leads to deficits in cerebrovascular structure and function that may explain some of the clinical observations. Increased edema, neovascularization, and protease expression as well as altered vascular reactivity and tone may be involved and point to potential therapeutic targets. Further study is needed to fully understand this complex disease state and the breadth of its manifestation in the cerebrovasculature.
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Affiliation(s)
- Carlo Domenico Maida
- Molecular and Clinical Medicine PhD Programme, University of Palermo, 90127 Palermo, Italy; (C.D.M.); (A.T.)
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (G.P.); (R.L.N.); (A.P.)
| | - Mario Daidone
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (G.P.); (R.L.N.); (A.P.)
- Correspondence:
| | - Gaetano Pacinella
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (G.P.); (R.L.N.); (A.P.)
| | - Rosario Luca Norrito
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (G.P.); (R.L.N.); (A.P.)
| | - Antonio Pinto
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (G.P.); (R.L.N.); (A.P.)
| | - Antonino Tuttolomondo
- Molecular and Clinical Medicine PhD Programme, University of Palermo, 90127 Palermo, Italy; (C.D.M.); (A.T.)
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy; (G.P.); (R.L.N.); (A.P.)
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Khan F, Tritschler T, Kimpton M, Wells PS, Kearon C, Weitz JI, Büller HR, Raskob GE, Ageno W, Couturaud F, Prandoni P, Palareti G, Legnani C, Kyrle PA, Eichinger S, Eischer L, Becattini C, Agnelli G, Vedovati MC, Geersing GJ, Takada T, Cosmi B, Aujesky D, Marconi L, Palla A, Siragusa S, Bradbury CA, Parpia S, Mallick R, Lensing AWA, Gebel M, Grosso MA, Shi M, Thavorn K, Hutton B, Le Gal G, Rodger M, Fergusson D. Long-term risk of recurrent venous thromboembolism among patients receiving extended oral anticoagulant therapy for first unprovoked venous thromboembolism: A systematic review and meta-analysis. J Thromb Haemost 2021; 19:2801-2813. [PMID: 34379859 DOI: 10.1111/jth.15491] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The long-term risk for recurrent venous thromboembolism (VTE) during extended anticoagulation for a first unprovoked VTE is uncertain. OBJECTIVES To determine the incidence of recurrent VTE during extended anticoagulation of up to 5 years in patients with a first unprovoked VTE. METHODS MEDLINE, EMBASE, and the Cochrane CENTRAL were searched to identify randomized trials and prospective cohort studies reporting recurrent VTE among patients with a first unprovoked VTE who were to receive anticoagulation for a minimum of six additional months after completing ≥3 months of initial treatment. Unpublished data on number of recurrent VTE and person-years, obtained from authors of included studies, were used to calculate study-level incidence rate, and random-effects meta-analysis was used to pool results. RESULTS Twenty-six studies and 15 603 patients were included in the analysis. During 11 631 person-years of follow-up, the incidence of recurrent VTE and fatal pulmonary embolism per 100 person-years was 1.41 (95% CI, 1.03-1.84) and 0.09 (0.04-0.16), with 5-year cumulative incidences of 7.1% (3.0%-13.2%) and 1.2% (0.4%-4.6%), respectively. The incidence of recurrent VTE was 1.08 (95% CI, 0.77-1.44) with direct oral anticoagulants and 1.55 (1.01-2.20) with vitamin K antagonists. The case-fatality rate of recurrent VTE was 4.9% (95% CI, 2.2%-8.7%). CONCLUSIONS In patients with a first unprovoked VTE, the long-term risk of recurrent VTE during extended anticoagulation is low but not negligible. Thus, clinicians and patients should be aware of this risk and take appropriate and timely action in case of suspicion of recurrent VTE. Estimates from this study can be used to advise patients on what to expect while receiving extended anticoagulation, and estimate the net clinical benefit of extended treatment to guide long-term management of unprovoked VTE.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Miriam Kimpton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Philip S Wells
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, OK, USA
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Brest University Hospital, Brest, France
| | | | | | | | - Paul A Kyrle
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sabine Eichinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Lisbeth Eischer
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Benilde Cosmi
- Department of Specialty, Diagnostic and Experimental Medicine, Division of Angiology and Blood Coagulation, S. Orsola Malpighi University Hospital, Bologna, Italy
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Letizia Marconi
- Department of Surgical, Medical and Molecular Pathology, and Critical Care, University of Pisa, Pisa, Italy
| | - Antonio Palla
- Department of Surgical, Medical and Molecular Pathology, and Critical Care, University of Pisa, Pisa, Italy
| | - Sergio Siragusa
- Department Pro.Mi.Se., University of Palermo, Palermo, Italy
| | | | - Sameer Parpia
- Departments of Oncology, and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | | | - Minggao Shi
- Daiichi-Sankyo Pharma Development, Basking Ridge, NJ, USA
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gregoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Marc Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Dean Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
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Khan F, Tritschler T, Kimpton M, Wells PS, Kearon C, Weitz JI, Büller HR, Raskob GE, Ageno W, Couturaud F, Prandoni P, Palareti G, Legnani C, Kyrle PA, Eichinger S, Eischer L, Becattini C, Agnelli G, Vedovati MC, Geersing GJ, Takada T, Cosmi B, Aujesky D, Marconi L, Palla A, Siragusa S, Bradbury CA, Parpia S, Mallick R, Lensing AWA, Gebel M, Grosso MA, Thavorn K, Hutton B, Le Gal G, Fergusson DA, Rodger MA. Long-Term Risk for Major Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism : A Systematic Review and Meta-analysis. Ann Intern Med 2021; 174:1420-1429. [PMID: 34516270 DOI: 10.7326/m21-1094] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The long-term risk for major bleeding in patients receiving extended (beyond the initial 3 to 6 months) anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. PURPOSE To determine the incidence of major bleeding during extended anticoagulation of up to 5 years among patients with a first unprovoked VTE, overall, and in clinically important subgroups. DATA SOURCES MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to 23 July 2021. STUDY SELECTION Randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding among patients with a first unprovoked VTE who were to receive oral anticoagulation for a minimum of 6 additional months after completing at least 3 months of initial anticoagulant treatment. DATA EXTRACTION Two reviewers independently abstracted data and assessed study quality. Unpublished data required for analyses were obtained from authors of included studies. DATA SYNTHESIS Among the 14 RCTs and 13 cohort studies included in the analysis, 9982 patients received a vitamin K antagonist (VKA) and 7220 received a direct oral anticoagulant (DOAC). The incidence of major bleeding per 100 person-years was 1.74 events (95% CI, 1.34 to 2.20 events) with VKAs and 1.12 events (CI, 0.72 to 1.62 events) with DOACs. The 5-year cumulative incidence of major bleeding with VKAs was 6.3% (CI, 3.6% to 10.0%). Among patients receiving either a VKA or a DOAC, the incidence of major bleeding was statistically significantly higher among those who were older than 65 years or had creatinine clearance less than 50 mL/min, a history of bleeding, concomitant use of antiplatelet therapy, or a hemoglobin level less than 100 g/L. The case-fatality rate of major bleeding was 8.3% (CI, 5.1% to 12.2%) with VKAs and 9.7% (CI, 3.2% to 19.2%) with DOACs. LIMITATION Data were insufficient to estimate incidence of major bleeding beyond 1 year of extended anticoagulation with DOACs. CONCLUSION In patients with a first unprovoked VTE, the long-term risks and consequences of anticoagulant-related major bleeding are considerable. This information will help inform patient prognosis and guide decision making about treatment duration for unprovoked VTE. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research. (PROSPERO: CRD42019128597).
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Affiliation(s)
- Faizan Khan
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Tobias Tritschler
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T., D.A.)
| | - Miriam Kimpton
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Philip S Wells
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Clive Kearon
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (C.K., J.I.W.)
| | - Jeffrey I Weitz
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (C.K., J.I.W.)
| | - Harry R Büller
- Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (H.R.B.)
| | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, Oklahoma (G.E.R.)
| | | | | | - Paolo Prandoni
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Gualtiero Palareti
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Cristina Legnani
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Paul A Kyrle
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | - Sabine Eichinger
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | - Lisbeth Eischer
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | | | | | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (G.G., T.T.)
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (G.G., T.T.)
| | - Benilde Cosmi
- Sant'Orsola-Malpighi University Hospital, Bologna, Italy (B.C.)
| | - Drahomir Aujesky
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T., D.A.)
| | | | | | | | | | - Sameer Parpia
- McMaster University, Hamilton, Ontario, Canada (S.P.)
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (R.M.)
| | | | | | | | - Kednapa Thavorn
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Brian Hutton
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Gregoire Le Gal
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Dean A Fergusson
- University of Ottawa, Ottawa Hospital Research Institute, and The Ottawa Hospital, Ottawa, Ontario, Canada (D.A.F.)
| | - Marc A Rodger
- Ottawa Hospital Research Institute, Ottawa, Ontario, and McGill University, Montreal, Quebec, Canada (M.A.R.)
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Rossetti P, Goldoni M, Pengo V, Vescovini R, Mozzoni P, Tassoni MI, Lombardi M, Rubino P, Bernuzzi G, Verzicco I, Manotti C, Quintavalla R. MiRNA 126 as a New Predictor Biomarker in Venous Thromboembolism of Persistent Residual Vein Obstruction: A Review of the Literature Plus a Pilot Study. Semin Thromb Hemost 2021; 47:982-991. [PMID: 34243207 DOI: 10.1055/s-0041-1726341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Venous thromboembolism (VTE) is the third most common cardiovascular disease. Interleukins (ILs) and micro-ribonucleic acids (miRNAs) have been proposed as molecules able to modulate endothelial inflammation and platelet hyperactivity. At present, no early biomarkers are available to predict the outcome of VTE. We investigated in a pilot study a selected number of miRNAs and ILs as prognostic VTE biomarkers and reviewed literature in this setting. Twenty-three patients (aged 18-65) with a new diagnosis of non-oncological VTE and free from chronic inflammatory diseases were enrolled. Twenty-three age- and sex-matched healthy blood donors were evaluated as control subjects. Serum miRNAs (MiRNA 126, 155, 17.92, 195), inflammatory cytokines (IL-6, tumor necrosis factor-α, IL-8), and lymphocyte subsets were evaluated in patients at enrolment (T0) and in controls. In VTE patients, clinical and instrumental follow-up were performed assessing residual vein obstruction, miRNA and ILs evaluation at 3 months' follow-up (T1). At T0, IL-8, activated T lymphocytes, Treg lymphocytes, and monocytes were higher in patients compared with healthy controls, as were miRNA 126 levels. Moreover, miRNA 126 and IL-6 were significantly increased at T0 compared with T1 evaluation in VTE patients. Higher levels of MiR126 at T0 correlated with a significant overall thrombotic residual at follow-up. In recent years an increasing number of studies (case-control studies, in vivo studies in animal models, in vitro studies) have suggested the potential role of miRNAs in modulating the cellular and biohumoral responses involved in VTE. In the frame of epidemiological evidence, this pilot study with a novel observational approach supports the notion that miRNA can be diagnostic biomarkers of VTE and first identifies miRNA 126 as a predictor of outcome, being associated with poor early recanalization.
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Affiliation(s)
- Pietro Rossetti
- Department of Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
| | - Matteo Goldoni
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Vittorio Pengo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Rosanna Vescovini
- Department of Clinical and Experimental Medicine, University Hospital of Parma, Parma, Italy
| | - Paola Mozzoni
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Maria Ilaria Tassoni
- Department of Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
| | - Maria Lombardi
- Department of Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
| | - Pasquale Rubino
- Department of Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
| | - Gino Bernuzzi
- Immunohematology and Transfusion Center, University Hospital of Parma, Parma, Italy
| | - Ignazio Verzicco
- Department of Clinical and Experimental Medicine, University Hospital of Parma, Parma, Italy
| | - Cesare Manotti
- Department of Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
| | - Roberto Quintavalla
- Department of Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
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Kemp MT, Obi AT, Henke PK, Wakefield TW. A narrative review on the epidemiology, prevention, and treatment of venous thromboembolic events in the context of chronic venous disease. J Vasc Surg Venous Lymphat Disord 2021; 9:1557-1567. [PMID: 33866055 DOI: 10.1016/j.jvsv.2021.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/28/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Chronic venous disease (CVD) describes a spectrum of conditions associated with venous hypertension. The association between various CVD etiologies and the subsequent risk of venous thromboembolism (VTE), such as deep vein thrombosis or pulmonary embolism, is a topic of considerable clinical interest. The aims of the present review were to characterize the risk of VTE according to the CVD etiology and to determine the optimal anticoagulation strategy for the treatment or prevention of VTE in patients with CVD. METHODS An extensive search of the available surgical and medical data was conducted in PubMed and Google Scholar. We searched for the following terms and other related terms to identify relevant studies: CVD, chronic venous insufficiency, varicose veins, post-thrombotic syndrome (PTS), anticoagulation, venous thromboembolism, and venous disease scoring systems (eg, CEAP [clinical, etiology, anatomic, pathophysiology], Villalta, Ginsberg, venous clinical severity score). The identified studies included randomized control trials, retrospective and prospective observational studies, narrative and systematic reviews, case reports, and case series that contributed to the proposed aims. The ClinicalTrials.gov database was also queried to identify any relevant ongoing clinical trials. RESULTS Congenital CVD carries a heightened risk of VTE, although few higher level studies are available to inform on this topic or on the appropriate anticoagulation strategies for these patients. Noncongenital CVD seems to carry a heightened risk of VTE, although few studies have adequately differentiated between primary and secondary etiologies. Varicose veins are a risk factor for primary VTE but might not be associated with an increased risk of recurrent VTE. In the hospital setting, patients with varicosities should be provided thromboprophylaxis. In the setting of varicose vein intervention, high-risk patients should be identified using risk assessment models and receive thromboprophylaxis. The risk of recurrent VTE in the setting of PTS is unclear but indefinite anticoagulation is not currently indicated. For patients with PTS, residual vein thrombosis might be an indicator of when anticoagulation can be safely stopped, although practical limitations to its application exist. CONCLUSIONS CVD is associated with an increased risk of VTE. Few studies have differentiated between classes of CVD using a standardized method and have assessed the efficacy of anticoagulation prophylaxis against or treatment of VTE. Additional studies are needed to determine the optimal therapy for preventing and treating VTE in patients with active concurrent CVD.
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Affiliation(s)
- Michael T Kemp
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
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Napolitano M, Mansueto MF, Raso S, Siragusa S. Quality of Life in Patients With Cancer Under Prolonged Anticoagulation for High-Risk Deep Vein Thrombosis: a Long-Term Follow-Up. Clin Appl Thromb Hemost 2021; 26:1076029620918290. [PMID: 32271622 PMCID: PMC7288837 DOI: 10.1177/1076029620918290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Current guidelines recommend to prolong anticoagulant treatment in patients with cancer with venous thromboembolism (VTE); only few studies evaluated other parameters than cancer itself for selecting patients at higher risk of recurrent VTE. Long-term management of VTE is thus challenged by several controversies mainly for patients compliance. We here report results of a long-term follow-up in patients with deep vein thrombosis under anticoagulant treatment with low-molecular-weight heparin (LMWH) for residual vein thrombosis (RVT) detected at compression ultrasonography (CUS), 6 months after standard anticoagulant treatment. Patients with RVT were deemed at high risk of recurrences and included in the current observational study. They continued LMWH (reduced at 75% standard dose) for further additional 2 years after enrolment or until death. Patients were followed up every 3 months or earlier, if needed. Among ancillary study end points, there was the assessment of patients’ quality of life during daily treatment with subcutaneous injections. Quality of life was determined by the EORTC-C30 questionnaire, administered by a skilled psychologist at enrolment and every 6 months follow-up visits. Overall, 128 patients were evaluated during follow-up. Mean global EORTC-C30 score at enrollment and at 6, 12 and 24 months follow-up were 52.1, 51.4, 50.8 and 50.1, respectively. There were no statistically significant differences between scores at enrolment and at the last available follow-up (P = .1). Long-term treatment with LMWH resulted, effective and safe, it was globally well tolerated and exempt of negative impact on quality of life of the enrolled patients. Reported results support long-term anticoagulant treatment with LMWH in cancer patients at risk of recurrent VTE.
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Affiliation(s)
- Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), Haematology Unit, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Italy
| | - Maria Francesca Mansueto
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), Haematology Unit, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Italy
| | - Simona Raso
- Division of Haematology, Department of Surgical, Oncological and Stomatological Disciplines, (Di.Chir.On.S.), AOUP Paolo Giaccone, Palermo, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), Haematology Unit, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Italy
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Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2020; 61:9-82. [PMID: 33334670 DOI: 10.1016/j.ejvs.2020.09.023] [Citation(s) in RCA: 298] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Wu CT, Yang TH, Chen MC, Chung YP, Guan SS, Long LH, Liu SH, Chen CM. Low Intensity Pulsed Ultrasound Prevents Recurrent Ischemic Stroke in a Cerebral Ischemia/Reperfusion Injury Mouse Model via Brain-derived Neurotrophic Factor Induction. Int J Mol Sci 2019; 20:ijms20205169. [PMID: 31635269 PMCID: PMC6834125 DOI: 10.3390/ijms20205169] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/13/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023] Open
Abstract
The incidence of stroke recurrence is still higher despite the advanced progression of therapeutic treatment and medical technology. Low intensity pulsed ultrasound (LIPUS) has been demonstrated to possess therapeutic effects on neuronal diseases and stroke via brain-derived neurotrophic factor (BDNF) induction. In this study, we hypothesized that LIPUS treatment possessed therapeutic benefits for the improvement of stroke recurrence. Adult male C57BL/6J mice were subjected to a middle cerebral artery occlusion (MCAO) surgery and then followed to secondary MCAO surgery as a stroke recurrence occurred after nine days from the first MCAO. LIPUS was administered continuously for nine days before secondary MCAO. LIPUS treatment not only decreased the mortality but also significantly moderated neuronal function injury including neurological score, motor activity, and brain pathological score in the recurrent stroke mice. Furthermore, the administration of LIPUS attenuated the apoptotic neuronal cells and increased Bax/Bcl-2 protein expression ratio and accelerated the expression of BDNF in the brain of the recurrent stroke mice. Taken together, these results demonstrate for the first time that LIPUS treatment arouses the expression of BDNF and possesses a therapeutic benefit for the improvement of stroke recurrence in a mouse model. The neuroprotective potential of LIPUS may provide a useful strategy for the prevention of a recurrent stroke.
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Affiliation(s)
- Cheng-Tien Wu
- Department of Nutrition, China Medical University, Taichung 40402, Taiwan.
- Master Program of Food and Drug Safety, China Medical University, Taichung 40402, Taiwan.
| | - Ting-Hua Yang
- Department of Otolaryngology, College of Medicine and Hospital, National Taiwan University, Taipei 10051, Taiwan.
| | - Man-Chih Chen
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan.
| | - Yao-Pang Chung
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan.
| | - Siao-Syun Guan
- Institute of Nuclear Energy Research, Atomic Energy Council, Taoyuan 32546, Taiwan.
| | - Lin-Hwa Long
- Division of Neurosurgery, Department of Surgery, College of Medicine and Hospital, National Taiwan University, Taipei 10051, Taiwan.
| | - Shing-Hwa Liu
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan.
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 40402, Taiwan.
- Department of Pediatrics, College of Medicine and Hospital, National Taiwan University, Taipei 10051, Taiwan.
| | - Chang-Mu Chen
- Division of Neurosurgery, Department of Surgery, College of Medicine and Hospital, National Taiwan University, Taipei 10051, Taiwan.
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Metabolic and Vascular Effect of the Mediterranean Diet. Int J Mol Sci 2019; 20:ijms20194716. [PMID: 31547615 PMCID: PMC6801699 DOI: 10.3390/ijms20194716] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 09/18/2019] [Accepted: 09/21/2019] [Indexed: 12/17/2022] Open
Abstract
Several studies indicated how dietary patterns that were obtained from nutritional cluster analysis can predict disease risk or mortality. Low-grade chronic inflammation represents a background pathogenetic mechanism linking metabolic risk factors to increased risk of chronic degenerative diseases. A Mediterranean diet (MeDi) style has been reported as associated with a lower degree of inflammation biomarkers and with a protective role on cardiovascular and cerebrovascular events. There is heterogeneity in defining the MedDiet, and it can, owing to its complexity, be considered as an exposome with thousands of nutrients and phytochemicals. Recently, it has been reported a novel positive association between baseline plasma ceramide concentrations and cardiovascular events and how adherence to a Mediterranean Diet-style may influence the potential negative relationship between elevated plasma ceramide concentrations and cardiovascular diseases (CVD). Several randomized controlled trials (RCTs) showed the positive effects of the MeDi diet style on several cardiovascular risk factors, such as body mass index, waist circumference, blood lipids, blood pressure, inflammatory markers and adhesion molecules, and diabetes and how these advantages of the MeDi are maintained in comparison of a low-fat diet. Some studies reported a positive effect of adherence to a Mediterranean Diet and heart failure incidence, whereas some recent studies, such as the PREDIMED study, showed that the incidence of major cardiovascular events was lower among those assigned to MeDi supplemented with extra-virgin olive oil or nuts than among those assigned to a reduced-fat diet. New studies are needed to better understand the molecular mechanisms, whereby the MedDiet may exercise its effects. Here, we present recent advances in understanding the molecular basis of MedDiet effects, mainly focusing on cardiovascular diseases, but also discussing other related diseases. We review MedDiet composition and assessment as well as the latest advances in the genomic, epigenomic (DNA methylation, histone modifications, microRNAs, and other emerging regulators), transcriptomic (selected genes and whole transcriptome), and metabolomic and metagenomic aspects of the MedDiet effects (as a whole and for its most typical food components). We also present a review of the clinical effects of this dietary style underlying the biochemical and molecular effects of the Mediterranean diet. Our purpose is to review the main features of the Mediterranean diet in particular its benefits on human health, underling the anti-inflammatory, anti-oxidant and anti-atherosclerotic effects to which new knowledge about epigenetic and gut-microbiota relationship is recently added.
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Mediterranean diet adherence and congestive heart failure: Relationship with clinical severity and ischemic pathogenesis. Nutrition 2019; 70:110584. [PMID: 31759318 DOI: 10.1016/j.nut.2019.110584] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 06/24/2019] [Accepted: 08/27/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To our knowledge, no study has addressed the relationship between adherence to a Mediterranean diet style and severity of heart failure. The aim of this retrospective study was to evaluate the relationship between adherence to the Mediterranean diet assessed using the calculation of Mediterranean diet score and congestive heart failure (CHF), its severity, and pathogenesis. METHODS We analyzed charts and collected data of all consecutive patients with a diagnosis of CHF at admission to our Internal Medicine Ward from 2008 to 2014. RESULTS We analyzed 209 patients with CHF and 200 controls. Patients with CHF showed a significantly lower mean MeDi score than controls. At receiver operating characteristic curve analysis, we found a good sensitivity and specificity of mean MeDi score to predict CHF. We also observed a significant positive correlation between MeDi score and ischemic pathogenesis of CHF, a positive relationship between New York Heart Association (NYHA) class and ischemic heart disease, and a significant negative relationship between NYHA class and MeDi score. CONCLUSION The beneficial effects of adherence to the Mediterranean diet suggest a possible answer to the question of the biochemical bases of our data, which should be seen as the direct consequence of the anti-inflammatory, antioxidant, and anti-remodeling effects linked to the diet.
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van der Wall SJ, van der Pol LM, Ende-Verhaar YM, Cannegieter SC, Schulman S, Prandoni P, Rodger M, Huisman MV, Klok FA. Fatal recurrent VTE after anticoagulant treatment for unprovoked VTE: a systematic review. Eur Respir Rev 2018; 27:27/150/180094. [DOI: 10.1183/16000617.0094-2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/22/2018] [Indexed: 12/23/2022] Open
Abstract
Current guidelines recommend long-term anticoagulant therapy in patients with unprovoked venous thromboembolism (VTE). The risk of fatal recurrent VTE after treatment discontinuation (versus that of fatal bleeding during anticoagulation) is of particular relevance in the decision to continue or stop anticoagulation after the first 3 months. Our primary aim was to provide a point-estimate of the yearly rate of fatal recurrent VTE and VTE case-fatality rate in patients with unprovoked VTE after anticoagulation cessation. Data were extracted from both randomised controlled trials and observational studies published before May 1, 2017. The pooled fatality rates were calculated using a random-effects model. 18 studies with low-to-moderate bias were included in the primary analysis, totalling 6758 patients with a median (range) follow-up duration of 2.2 (1–5) years. After anticoagulation cessation, the weighted pooled rate of VTE recurrence was 6.3 (95% CI 5.4–7.3) per 100 patient-years and the weighted pooled rate of fatal recurrent VTE was 0.17 (95% CI 0.047–0.33) per 100 patient-years, for a case-fatality rate of 2.6% (95% CI 0.86–5.0). These numbers are a solid benchmark for comparison to the risks associated with long-term anticoagulation treatment for the decision on the optimal duration of treatment of patients with unprovoked VTE.
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Presence and degree of residual venous obstruction on serial duplex imaging is associated with increased risk of recurrence and progression of infrainguinal lower extremity deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2018; 6:575-583.e1. [DOI: 10.1016/j.jvsv.2017.12.059] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/15/2017] [Indexed: 11/19/2022]
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Elmi G, Pizzini AM, Silingardi M. The secondary prevention of venous thromboembolism: Towards an individual therapeutic strategy. Vascular 2018; 26:670-682. [PMID: 29966487 DOI: 10.1177/1708538118776896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
After the anticoagulant withdrawal, a substantial proportion of patients with venous thromboembolism will develop recurrent events. Whether to consider an extended treatment depends on the risk of recurrence and bleeding risk. The assessment of the individual risk profile remains a difficult task. Several basal and post-basal factors modulate the risk of recurrence and may help clinicians to select patients who can benefit from the extended therapy. During the year 2017, new evidence regarding the post-basal factors was provided by the Morgagni and Scope studies. Another interesting novelty was the VTE-BLEED score, the first bleeding risk score that obtained the external validation in venous thromboembolism setting. In secondary prevention, the use of direct oral anticoagulants is growing instead of vitamin K antagonist. Even at lower doses, direct oral anticoagulants showed to be effective and safe, to reduce all-cause mortality and seemed to be superior to placebo for the composite outcome of fatal bleeding and fatal recurrence. After the recently published Einstein-Choice trial, the role of aspirin has become truly marginal as rivaroxaban 10 mg showed a bleeding risk similar to aspirin 100 mg but a greater effectiveness reducing the relative risk of recurrence by about 70%. Another option for secondary prevention could be sulodexide, with a lower protective effect than direct oral anticoagulants but an interesting safety profile. In conclusion, in our opinion, an individual strategy taking into account the risk of recurrence, bleeding risk, therapeutic options and patient preferences is the most appropriate approach to secondary prevention of venous thromboembolism.
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Affiliation(s)
- Giovanna Elmi
- Internal Medicine A Unit, Medical Department, Maggiore Hospital, Largo Nigrisoli Bologna, Italy
| | - Attilia M Pizzini
- Internal Medicine A Unit, Medical Department, Maggiore Hospital, Largo Nigrisoli Bologna, Italy
| | - Mauro Silingardi
- Internal Medicine A Unit, Medical Department, Maggiore Hospital, Largo Nigrisoli Bologna, Italy
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Ageno W, Antonucci E, Cosmi B, Kovacs MJ, Gal GL, Ockelford P, Poli D, Prandoni P, Rodger M, Saccullo G, Siragusa S, Young L, Bonzini M, Caprioli M, Dentali F, Iorio A, Douketis JD, Donadini MP. Prognostic significance of residual venous obstruction in patients with treated unprovoked deep vein thrombosis. Thromb Haemost 2017; 111:172-9. [DOI: 10.1160/th13-04-0336] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 09/12/2013] [Indexed: 12/23/2022]
Abstract
SummaryResidual venous obstruction (RVO) could improve the stratification of the risk of recurrence after unprovoked deep vein thrombosis (DVT), but results from clinical studies and study-level meta-analyses are conflicting. It was the objective of this analysis to determine if RVO is a valid predictor of recurrent venous thromboembolism (VTE) in patients with a first unprovoked DVT who had received at least three months of anticoagulant therapy. Individual patient data were obtained from the datasets of original studies, after a systematic search of electronic databases (Medline, Embase, Cochrane Library), supplemented by manual reviewing of the reference lists and contacting content experts. A multivariate, shared-frailty Cox model was used to calculate hazard ratios (HRs) for recurrent VTE, including, as covariates: RVO; age; sex; anticoagulation duration before RVO assessment; and anticoagulation continuation after RVO assessment. A total of 2,527 patients from 10 prospective studies were included. RVO was found in 1,380 patients (55.1%) after a median of six months from a first unprovoked DVT. Recurrent VTE occurred in 399 patients (15.8%) during a median follow-up of 23.3 months. After multivariate Cox analysis, RVO was independently associated with recurrent VTE (HR = 1.32, 95% confidence interval [CI]: 1.06–1.65). The association was stronger if RVO was detected early, i.e. at three months after DVT (HR = 2.17; 95% CI: 1.11–4.25), but non-significant if detected later, i.e. >6 months (HR = 1.19; 95% CI: 0.87–1.61). In conclusion, after a first unprovoked DVT, RVO is a weak overall predictor of recurrent VTE. The association is stronger if RVO is detected at an earlier time (3 months) after thrombosis.
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Palareti G. Optimal long-term pharmacological treatment of patients with venous thromboembolism that was unprovoked or associated with weak risk factors. Expert Rev Hematol 2017; 10:921-931. [PMID: 28803491 DOI: 10.1080/17474086.2017.1366851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Unprovoked venous thromboembolism (VTE) tend to recur. Many factors, patient- or event-related, influence the individual risk of recurrence. After initial and long-term (usually for 3-6 months) anticoagulant therapy, extended anticoagulation has been recommended in patients at high risk of recurrence, provided they do not have a high risk of bleeding. Areas covered: The effect of different risk factors on the risk of recurrence is discussed, as well as risk factors for bleeding. The estimation of individual balance between these two risks is crucial to decide which can be the best treatment duration in single patients. The use of direct oral anticoagulants, with likely less risk of bleeding, may influence the balance. D-dimer assessment during and after anticoagulation is stopped is also commented for its role to help identifying the individual risk of recurrence. Expert commentary: All patients with a first VTE should be reconsidered after the initial 3-6 months of treatment. Anticoagulation can then be stopped or continued in relation to low or very high risk of recurrence, respectively. Serial D-dimer assessment during the first 2 or 3 months after anticoagulation is stopped is useful in patients with uncertain risk evaluation (especially after unprovoked events).
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Hsu N, Wang T, Friedman O, Barjaktarevic I. Medical Management of Pulmonary Embolism: Beyond Anticoagulation. Tech Vasc Interv Radiol 2017; 20:152-161. [PMID: 29029709 DOI: 10.1053/j.tvir.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pulmonary embolism (PE) is a common medical condition that carries significant morbidity and mortality. Although diagnosis, anticoagulation, and interventional clot-burden reduction strategies represent the focus of clinical research and care in PE, appropriate risk stratification and supportive care are crucial to ensure good outcomes. In this chapter, we will discuss the medical management of PE from the time of presentation to discharge, focusing on the critical care of acute right ventricular failure, anticoagulation of special patient populations, and appropriate follow-up testing after acute PE.
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Affiliation(s)
- Nancy Hsu
- Division of Pulmonary and Critical Care, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Tisha Wang
- Division of Pulmonary and Critical Care, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Oren Friedman
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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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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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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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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Zhang S, Zhai Z, Yang Y, Zhu J, Kuang T, Xie W, Yang S, Liu F, Gong J, Shen YH, Wang C. Pulmonary embolism risk stratification by European Society of Cardiology is associated with recurrent venous thromboembolism: Findings from a long-term follow-up study. Int J Cardiol 2016; 202:275-81. [DOI: 10.1016/j.ijcard.2014.09.142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 08/29/2014] [Accepted: 09/27/2014] [Indexed: 01/08/2023]
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Stephenson EJ, Liem TK. Duplex imaging of residual venous obstruction to guide duration of therapy for lower extremity deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2015; 3:326-32. [DOI: 10.1016/j.jvsv.2014.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 08/13/2014] [Indexed: 11/24/2022]
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Lang KJ, Saha P, Roberts LN, Arya R. Changing paradigms in the management of deep vein thrombosis. Br J Haematol 2015; 170:162-74. [DOI: 10.1111/bjh.13431] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kathryn J. Lang
- King's Thrombosis Centre; King's College Hospital NHS Foundation Trust; London UK
| | - Prakash Saha
- Guy's Hospital; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - Lara N. Roberts
- King's Thrombosis Centre; King's College Hospital NHS Foundation Trust; London UK
| | - Roopen Arya
- King's Thrombosis Centre; King's College Hospital NHS Foundation Trust; London UK
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Napolitano M, Saccullo G, Malato A, Sprini D, Ageno W, Imberti D, Mascheroni D, Bucherini E, Gallucci P, D'Alessio A, Prantera T, Spadaro P, Rotondo S, Di Micco P, Oriana V, Urbano O, Recchia F, Ghirarduzzi A, Lo Coco L, Mancuso S, Casuccio A, Rini GB, Siragusa S. Optimal Duration of Low Molecular Weight Heparin for the Treatment of Cancer-Related Deep Vein Thrombosis: The Cancer-DACUS Study. J Clin Oncol 2014; 32:3607-3612. [DOI: 10.1200/jco.2013.51.7433] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Purpose We evaluated the role of residual vein thrombosis (RVT) to assess the optimal duration of anticoagulants in patients with cancer who have deep vein thrombosis (DVT) of the lower limbs. Patients and Methods Patients with active cancer and a first episode of DVT treated with low molecular weight heparin (LMWH) for 6 months were eligible. Patients were managed according to RVT findings: those with RVT were randomly assigned to continue LMWH for an additional 6 months (group A1) or to discontinue it (group A2), and patients without RVT stopped LMWH (group B). The primary end point was recurrent venous thromboembolism (VTE) during the 1 year after disconinuation of LMWH, and the secondary end point was major bleeding. Analyses are from the time of random assignment. Results Between October 2005 and April 2010, 347 patients were enrolled. RVT was detected in 242 patients (69.7%); recurrence occurred in 22 of the 119 patients in group A1compared with 27 of 123 patients in group A2. The adjusted hazard ratio (HR) for group A2 versus A1 was 1.37 (95% CI, 0.7 to 2.5; P = .311). Three of the 105 patients in group B developed recurrent VTE; adjusted HR for group A1 versus B was 6.0 (95% CI, 1.7 to 21.2; P = .005). Three major bleeding events occurred in group A1, and two events each occurred in groups A2 and B. The HR for major bleeding in group A1 versus group A2 was 3.78 (95% CI, 0.77 to 18.58; P = .102). Overall, 42 patients (12.1%) died during follow-up as a result of cancer progression. Conclusion In patients with cancer with a first DVT, treated for 6 months with LMWH, absence of RVT identifies a population at low risk for recurrent thrombotic events. Continuation of LMWH in patients with RVT up to 1 year did not reduce recurrent VTE.
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Affiliation(s)
- Mariasanta Napolitano
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Giorgia Saccullo
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Alessandra Malato
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Delia Sprini
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Walter Ageno
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Davide Imberti
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Doris Mascheroni
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Eugenio Bucherini
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Pina Gallucci
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Andrea D'Alessio
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Tullia Prantera
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Pietro Spadaro
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Stefano Rotondo
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Pierpaolo Di Micco
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Vincenzo Oriana
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Oreste Urbano
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Francesco Recchia
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Angelo Ghirarduzzi
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Lucio Lo Coco
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Salvatrice Mancuso
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Alessandra Casuccio
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Giovam Battista Rini
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
| | - Sergio Siragusa
- Mariasanta Napolitano, Giorgia Saccullo, Alessandra Malato, Delia Sprini, Lucio Lo Coco, Salvatrice Mancuso, Alessandra Casuccio, Giovam Battista Rini, and Sergio Siragusa, Università degli Studi di Palermo, Palermo; Walter Ageno, Università dell'Insubria, Varese; Davide Imberti, Ospedale di Piacenza, Piacenza; Doris Mascheroni, Istituto Clinico Villa Aprica, Como; Eugenio Bucherini, Ospedale di Faenza, Faenza Ravenna; Pina Gallucci, Centro Regionale Oncologico Basilicata, Rionero in Volture; Andrea
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Palareti G. How D-dimer assay can be useful in deciding the duration of anticoagulation after venous thromboembolism: a review. Expert Rev Hematol 2014; 8:79-88. [DOI: 10.1586/17474086.2015.975791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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40
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D-dimer to guide the duration of anticoagulation in patients with venous thromboembolism: a management study. Blood 2014; 124:196-203. [DOI: 10.1182/blood-2014-01-548065] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Key Points
The duration of anticoagulation after VTE is uncertain; this management study intended to identify patients with low/high recurrence risk. Patients with persistently negative D-dimers after stopping standard therapy have a low recurrence risk and can stop anticoagulation.
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O'Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, Lurie F, Henke PK, Gloviczki ML, Eklöf BG, Stoughton J, Raju S, Shortell CK, Raffetto JD, Partsch H, Pounds LC, Cummings ME, Gillespie DL, McLafferty RB, Murad MH, Wakefield TW, Gloviczki P. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014; 60:3S-59S. [PMID: 24974070 DOI: 10.1016/j.jvs.2014.04.049] [Citation(s) in RCA: 387] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Janakiram M, Sullivan M, Shcherba M, Guo S, Billett HH. A systematic review of the utility of residual vein obstruction studies in primary and secondary venous thrombosis. THROMBOSIS 2013; 2013:247913. [PMID: 24349773 PMCID: PMC3853333 DOI: 10.1155/2013/247913] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 09/18/2013] [Accepted: 09/25/2013] [Indexed: 11/17/2022]
Abstract
Background. Residual vein obstruction (RVO), the persistence of venous thrombosis with time and often after anticoagulation, may indicate a systemic prothrombotic condition. Prior studies have shown varying efficacy in using RVO as a risk factor for future venous thromboembolic (VTE) recurrence. Methods. To assess whether positive RVO imaging predicts recurrent VTE events, we performed a meta-analysis on studies in which patients with documented VTEs, anticoagulated for a minimum of 4 weeks, had repeat sonography to assess RVO and were subsequently followed for recurrent events. Results. Thirteen studies met inclusion criteria: 3531 patient VTE events with 3474 evaluable results were analyzed. The presence of RVO was associated with recurrence in all VTE (OR 1.93; 95% CI: 1.29, 2.89) and secondary VTE (OR 2.78; 95% CI: 1.41, 5.5) but not for primary VTE (OR 1.35; 95% CI: 0.87, 2.08). When cancer patients were eliminated from the secondary VTE group, there was no longer a significant association of RVO with VTE recurrence (OR 1.73; 95% CI: 0.81, 3.67) while in the subset of cancer patients, presence of RVO was associated with an increase in VTE recurrence risk (OR 5.14; 95% CI: 1.59, 16.65, P < 0.006). Conclusions. We conclude that the presence of RVO is associated with recurrence in secondary VTE but not in primary VTE and that association may be driven by the subset with cancer.
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Affiliation(s)
- Murali Janakiram
- Division of Hematology, Montefiore Medical Center and the Albert Einstein College of Medicine, 3411 Wayne Avenue, Ground Floor, Bronx, NY 10467, USA
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, 3411 Wayne Avenue, Ground Floor, Bronx, NY 10467, USA
| | - Matthew Sullivan
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, 3411 Wayne Avenue, Ground Floor, Bronx, NY 10467, USA
| | - Marina Shcherba
- Division of Hematology, Montefiore Medical Center and the Albert Einstein College of Medicine, 3411 Wayne Avenue, Ground Floor, Bronx, NY 10467, USA
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, 3411 Wayne Avenue, Ground Floor, Bronx, NY 10467, USA
| | - Shuang Guo
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, 3411 Wayne Avenue, Ground Floor, Bronx, NY 10467, USA
| | - Henny H. Billett
- Division of Hematology, Montefiore Medical Center and the Albert Einstein College of Medicine, 3411 Wayne Avenue, Ground Floor, Bronx, NY 10467, USA
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, 3411 Wayne Avenue, Ground Floor, Bronx, NY 10467, USA
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Calvo Romero JM. [Recurrence risk in venous thromboembolic disease after anticoagulation discontinuation]. Med Clin (Barc) 2013; 140:310-3. [PMID: 22995846 DOI: 10.1016/j.medcli.2012.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 06/28/2012] [Indexed: 10/27/2022]
Abstract
To determine the risk for recurrence of venous thromboembolic disease is essential to decide the optimum duration of treatment. Clinical risk factors, elevated D-dimer after anticoagulation withdrawal and the presence of residual deep vein thrombosis should be considered. In this article the risk factors and the reported risk models are reviewed.
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Marcucci M, Iorio A, Douketis J. Management of patients with unprovoked venous thromboembolism: an evidence-based and practical approach. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:224-39. [PMID: 23344704 PMCID: PMC3608888 DOI: 10.1007/s11936-012-0225-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OPINION STATEMENT The management of patients with unprovoked venous thromboembolism is a common and challenging clinical problem. Although the initial antithrombotic management is well-established, there is uncertainty about the optimal long-term anticoagulant management, specifically whether patients should receive a short (i.e., 3- to 6-month) duration of anticoagulant therapy or indefinite anticoagulation. Factors that may be considered to estimate patients' risk for recurrent thromboembolism include the mode of initial clinical presentation, as deep vein thrombosis or pulmonary embolism, patient sex, antecedent hormonal therapy use, thrombophilia, D-dimer levels, and residual vein occlusion in patients with deep vein thrombosis. Many of these factors have been integrated into clinical prediction guides which stratify patients with unprovoked venous thromboembolism according to their risk for disease recurrence and, thereby, can assist clinicians in decisions about the duration of anticoagulation. The objective of this review is to consider the evidence relating to the clinical significance of purported risk factors and provide a practical case-based approach to guide decisions on duration of anticoagulation for patients with unprovoked venous thromboembolism.
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Affiliation(s)
- Maura Marcucci
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, St. Joseph’s Healthcare, F-544, 50 Charlton Ave East, Hamilton, ON Canada L8N 4A6
| | - Alfonso Iorio
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, St. Joseph’s Healthcare, F-544, 50 Charlton Ave East, Hamilton, ON Canada L8N 4A6
| | - James Douketis
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, St. Joseph’s Healthcare, F-544, 50 Charlton Ave East, Hamilton, ON Canada L8N 4A6
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Cate-Hoek AJT, Prins MH, Wittens CHA, Cate HT. Postintervention duration of anticoagulation in venous surgery. Phlebology 2013; 28 Suppl 1:105-11. [DOI: 10.1177/0268355513476415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
For a substantial proportion of patients with deep venous thrombosis (DVT), current treatment strategies are suboptimal and new treatment options are needed. Especially for the group of patients who are at the highest risk for post-thrombotic syndrome, new treatment modalities such as catheter-directed thrombolysis and additional stenting are being investigated. With current clinical studies addressing new technical options, the medical management of patients following these interventions deserves attention. The duration of anticoagulant treatment following surgical or radiological interventions for DVT seems not to be influenced by the presence of a venous stent. According to recent ACCP 2012 guidelines the anticoagulant management in patients who have had any method of thrombus removal performed, the same intensity and duration of anticoagulant therapy as in comparable patients who do not undergo thrombosis removal is recommended (Grade 1B). In the acute phase of thrombosis, irrespective of the technique and whether or not stenting is applied, immediate anticoagulation following the procedure is pertinent to reduce the risk of recurrent thrombosis and thrombus propagation. The long-term treatment duration after venous interventions therefore may be tailored based on common risk factors for recurrent thrombosis and the individual risk for bleeding. Selected thrombophilia factors, d-dimer assessment and residual venous thrombosis provide markers for recurrent DVT. Currently, vitamin K antagonists) provide the main anticoagulants for (prolonged) anticoagulation, while the new oral anticoagulants emerge as promising alternatives. In case prolonged anticoagulation after unprovoked DVT is not indicated, cardiovascular risk management is warranted because of an increased rate of arterial thrombotic events after DVT; aspirin may be indicated as secondary prevention against recurrent thrombosis (while providing primary prevention against arterial thrombosis).
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Affiliation(s)
- A J Ten Cate-Hoek
- Departments of Internal medicine and Clinical Epidemiology, Cardiovascular Research Institute Maastricht (CARIM) and School for Public Health and Primary Care (Caphrie), Maastricht University Medical Centere, Maastricht, The Netherlands
| | | | - C H A Wittens
- Departments of Internal medicine and Clinical Epidemiology, Cardiovascular Research Institute Maastricht (CARIM) and School for Public Health and Primary Care (Caphrie), Maastricht University Medical Centere, Maastricht, The Netherlands
- Department of Vascular surgery, University Hospital, Maastricht, the Netherlands
- Department of vascular surgery, Universitäts Klinikum Aachen, Germany
| | - H Ten Cate
- Departments of Internal medicine and Clinical Epidemiology, Cardiovascular Research Institute Maastricht (CARIM) and School for Public Health and Primary Care (Caphrie), Maastricht University Medical Centere, Maastricht, The Netherlands
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Undas A, Cieśla-Dul M, Drążkiewicz T, Sadowski J. Altered fibrin clot properties are associated with residual vein obstruction: Effects of lipoprotein(a) and apolipoprotein(a) isoform. Thromb Res 2012; 130:e184-7. [DOI: 10.1016/j.thromres.2012.06.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 05/04/2012] [Accepted: 06/04/2012] [Indexed: 10/28/2022]
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Palareti G. Recurrent venous thromboembolism: what is the risk and how to prevent it. SCIENTIFICA 2012; 2012:391734. [PMID: 24278687 PMCID: PMC3820456 DOI: 10.6064/2012/391734] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 09/10/2012] [Indexed: 05/07/2023]
Abstract
Venous thromboembolism (VTE) that includes deep vein thrombosis and/or pulmonary embolism is a frequent, severe, and potentially lethal disease. After a first episode, VTE has a strong tendency to recur. While VTE is an acute disease, it may have variable outcomes in early and late phases after initial presentation. Furthermore, the incidence of late, clinically important consequences (postthrombotic syndrome and/or chronic thromboembolic pulmonary hypertension) increases in case of recurrent events. The aims of the present review are (i) to analyze the incidence and risk factors for recurrence of VTE (either those related to the type of first thrombotic event or to the patients), the risks associated with occurrence of recurrent events, and the problems linked to the diagnosis, not always easy, of recurrent events; (ii) to discuss whether or not it is possible to predict the individual risk of recurrence after a first event, by stratifying patients at high or low risk of recurrence, and how this can influence their treatment; (iii) to comment what the current guidelines and guidance suggest/recommend about anticoagulant treatment after a first VTE event and, finally, to propose practical indications on how to manage individual patients affected by VTE.
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Affiliation(s)
- Gualtiero Palareti
- Department of Angiology and Blood Coagulation, Via Albertoni 15, 40138 Bologna (BO), Italy
- *Gualtiero Palareti:
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