Pulmonary embolism and deep vein thrombosis—comorbidities and temporary provoking factors in a register‐based study of 1.48 million people

The Association between Obstructive Sleep Apnea and Venous Thromboembolism: A Bidirectional Two-Sample Mendelian Randomization Study

BACKGROUND

 Despite previous observational studies linking obstructive sleep apnea (OSA) to venous thromboembolism (VTE), these findings remain controversial. This study aimed to explore the association between OSA and VTE, including pulmonary embolism (PE) and deep vein thrombosis (DVT), at a genetic level using a bidirectional two-sample Mendelian randomization (MR) analysis.

METHODS

 Utilizing summary-level data from large-scale genome-wide association studies in European individuals, we designed a bidirectional two-sample MR analysis to comprehensively assess the genetic association between OSA and VTE. The inverse variance weighted was used as the primary method for MR analysis. In addition, MR-Egger, weighted median, and MR pleiotropy residual sum and outlier (MR-PRESSO) were used for complementary analyses. Furthermore, a series of sensitivity analyses were performed to ensure the validity and robustness of the results.

RESULTS

 The initial and validation MR analyses indicated that genetically predicted OSA had no effects on the risk of VTE (including PE and DVT). Likewise, the reverse MR analysis did not find substantial support for a significant association between VTE (including PE and DVT) and OSA. Supplementary MR methods and sensitivity analyses provided additional confirmation of the reliability of the MR results.

CONCLUSION

 Our bidirectional two-sample MR analysis did not find genetic evidence supporting a significant association between OSA and VTE in either direction.

Venous thromboembolism: diagnostic advances and unaddressed challenges in management

PURPOSE OF REVIEW

This review summarizes recent advances in developing targeted diagnostics for venous thromboembolism (VTE) and unaddressed knowledge gaps in patient management. Without addressing these critical data needs, the morbidity in VTE patients will persist.

RECENT FINDINGS

Recent studies investigating plasma protein profiles in VTE patients have identified key diagnostic targets to address the currently unmet need for low-cost, confirmatory, point-of-care VTE diagnostics. These studies and a growing body of evidence from animal model studies have revealed the importance of inflammatory and vascular pathology in driving VTE, which are currently unaddressed targets for VTE therapy. To enhance the translation of preclinical animal studies, clinical quantification of thrombus burden and comparative component analyses between modeled VTE and clinical VTE are necessary.

SUMMARY

Lead candidates from protein profiling of VTE patients' plasma offer a promising outlook in developing low cost, confirmatory, point-of-care testing for VTE. Additionally, addressing the critical knowledge gap of quantitatively measuring clinical thrombi will allow for an array of benefits in VTE management and informing the translatability of experimental therapeutics.

Association of type of oral anticoagulation with risk of bleeding in 45,114 patients with venous thromboembolism during initial and extended treatment-A nationwide register-based study

BACKGROUND

Safety data for different anticoagulant medications in venous thromboembolism (VTE) are scarce, in particular for extended treatment.

OBJECTIVES

To compare major bleeding rates depending on the choice of anticoagulation during initial (first 6 months) and extended treatment (6 months up to 5 years).

METHODS

A nationwide register-based study including cancer-free patients with a first-time VTE between 2014 and 2020. Cox proportional hazards models were used to compare bleeding rates.

RESULTS

We included 6558 patients on warfarin, 18,196 on rivaroxaban, and 19,498 on apixaban. At 6 months, 4750 (72.4%) remained on warfarin, 11,366 (62.5%) on rivaroxaban, and 11,940 (61.2%) on apixaban. During initial treatment, major bleeding rates were 3.86 (95% CI 3.14-4.58), 2.93 (2.55-3.31), and 1.95 (1.65-2.25) per 100 patient-years for warfarin, rivaroxaban, and apixaban, respectively, yielding adjusted hazard ratios (aHRs) of 0.89 (95% CI 0.71-1.12) for rivaroxaban versus warfarin, 0.55 (0.43-0.71) for apixaban versus warfarin, and 0.62 (0.50-0.76) for apixaban versus rivaroxaban. During extended treatment, major bleeding rates were 1.55 (1.19-1.91), 1.05 (0.85-1.26), and 0.96 (0.78-1.15) per 100 patient-years for warfarin, rivaroxaban, and apixaban, respectively, with aHRs of 0.72 (0.53-0.99) for rivaroxaban versus warfarin, 0.60 (0.44-0.82) for apixaban versus warfarin, and 0.85 (0.64-1.12) for apixaban versus rivaroxaban. Previous bleeding and increasing age were risk factors for bleeding both during initial and extended treatment.

CONCLUSION

Apixaban had a lower bleeding risk than warfarin or rivaroxaban during initial treatment. During extended treatment, bleeding risk was similar for apixaban and rivaroxaban, and higher with warfarin.

Risk factors for pulmonary embolism in lung cancer patients with lower limb deep venous thrombosis: a case-control study

Background

There is growing evidence that misdiagnosis contributes to the high mortality rate in lung cancer patients complicated with pulmonary embolism (PE). This current study analyzed predictors of PE in lung cancer patients with lower extremity deep venous thrombosis (DVT) with the aim of personalizing the treatment and management of patients with PE.

Methods

This retrospective case-control study included lung cancer patients with DVT at the emergency department of Shanghai Chest Hospital from January 2018 to December 2019. Patients were classified as having DVT with or without PE. The following characteristics were examined, including age, gender, smoking, hypertension, surgical trauma, hyperlipidemia, long-term bedridden status, calf swelling, coronary heart disease, chronic pulmonary disease, DVT location, DVT type, prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen, and D-dimer, and univariate and multivariate analyses were performed.

Results

A total of 90 patients with lung cancer and DVT were analyzed, of whom 60% (54/90) had PE. Those variables independently associated to PE were hypertension [odds ratio (OR): 7.883, 95% confidence interval (CI): 2.038-30.495, P=0.003], long-term bedridden status (OR: 4.166, 95% CI: 1.236-14.044, P=0.021), and D-dimer levels (OR: 2.123, 95% CI: 1.476-3.053, P=0.000) were identified as independent risk factors for PE. The cut-off value of the receiver operating characteristic (ROC) curve for predicting PE by presented scoring system according to the risk factors was 1.5 and the area under the curve (AUC) was 0.84 (P<0.001).

Conclusions

Hypertension, being bedridden for an extended period, and elevated serum D-dimer levels were independent risk factors of PE in lung cancer patients with lower extremity DVT. Novel strategies for patient management should be developed to decrease the risk of PE.

Pulmonary embolism and deep venous thrombosis after COVID-19: long-term risk in a population-based cohort study

Background

Venous thromboembolism (VTE) (pulmonary embolism (PE) or deep venous thrombosis (DVT)) is common during acute COVID-19. Long-term excess risk has not yet been established.

Objective

To study long-term VTE risk after COVID-19.

Methods

Swedish citizens aged 18-84 years, hospitalized and/or testing positive for COVID-19 between January 1, 2020, and September 11, 2021 (exposed), stratified by initial hospitalization, were compared to matched (1:5) non-exposed population-derived subjects without COVID-19. Outcomes were incident VTE, PE or DVT recorded within 60, 60-<180, and ≥180 days. Cox regression was used for evaluation and a model adjusted for age, sex, comorbidities and socioeconomic markers developed to control for confounders.

Results

Among exposed patients, 48,861 were hospitalized for COVID-19 (mean age 60.6 years) and 894,121 were without hospitalization (mean age 41.4 years). Among patients hospitalized for COVID-19, fully adjusted hazard ratios (HRs) during 60-<180 days were 6.05 (95% confidence interval (CI) 4.80─7.62) for PE and 3.97 (CI 2.96─5.33) for DVT, compared to non-exposed with corresponding estimates among COVID-19 without hospitalization 1.17 (CI 1.01─1.35) and 0.99 (CI 0.86─1.15), based on 475 and 2,311 VTE events, respectively. Long-term (≥180 days) HRs in patients hospitalized for COVID-19 were 2.01 (CI 1.51─2.68) for PE and 1.46 (CI 1.05─2.01) for DVT while non-hospitalized had similar risk to non-exposed, based on 467 and 2,030 VTE events, respectively.

Conclusions

Patients hospitalized for COVID-19 retained an elevated excess risk of VTE, mainly PE, after 180 days, while long-term risk of VTE in individuals with COVID-19 without hospitalization was similar to the non-exposed.

Association between systemic immune-inflammation index and risk of lower extremity deep venous thrombosis in hospitalized patients: a 10-year retrospective analysis

Background

The systemic immune-inflammation index (SII), as a novel inflammatory biomarker, has recently attracted attention in cardiovascular disease research. However, the relationship between SII and risk of lower extremity deep venous thrombosis (LEDVT) remains unclear to date. Thus, this study aimed to explore the association in a large sample over a 10-year period (2012-2022).

Methods

All hospitalized patients undergoing lower extremity compression ultrasonography (CUS) examination were consecutively screened by searching our hospital information system database. The receiver operating characteristic (ROC) curve analysis was used to identify the optimal cut-off value for high and low SII group. Multivariate logistic regression analyses were performed to investigate the relationship between SII and LEDVT risk. Propensity score matching (PSM), subgroup and sensitivity analyses were also conducted. Moreover, restricted cubic spline (RCS) regression and two-piecewise linear regression models were used to assess the dose-response relationship between natural log transformed SII [ln(SII)] and risk of LEDVT.

Results

A total of 16,725 consecutive hospitalized patients were included, and 1,962 LEDVT events occurred. After adjusting for confounding factors, patients in the high SII group (≥ 574.2 × 10⁹/L) showed a 1.740-fold risk of LEDVT (95% CI: 1.546-1.959, P < 0.001), and elevated ln(SII) was associated with a 36.1% increased risk of LEDVT (95% CI: 1.278-1.449, P < 0.001). PSM, subgroup and sensitivity analyses confirmed the robustness of the association. A non-linear relationship was observed (P _non-linear< 0.001), with a threshold value of 5.6 × 10⁹/L for all LEDVT events. Above the threshold, each unit increase in ln(SII) had a 1.369-fold higher risk of LEDVT (95% CI: 1.271-1.475, P < 0.001). The association also existed in both distal and proximal LEDVT.

Conclusion

Elevated SII is significantly associated with an increased risk of LEDVT in hospitalized patients. Additionally, the association is non-linear and exhibit a threshold effect.

Anatomic distribution of lower extremity deep venous thrombosis is associated with an increased risk of pulmonary embolism: A 10-year retrospective analysis

Aims

To investigate the potential relationship between anatomic distribution of lower extremity deep venous thrombosis (LEDVT) and pulmonary embolism (PE).

Methods

A retrospective case-control study was performed in patients diagnosed with LEDVT, which were confirmed by bilateral lower extremity compression ultrasonography (CUS) examination. According to the ultrasound reports, thrombus sidedness was categorized as unilateral and bilateral lower extremity, thrombus location was classified into distal and proximal LEDVT. Anatomic distributions of LEDVT were further subdivided depending on the combination of thrombus sidedness and location. Patients with PE were identified using the International Classification of Diseases-10 (ICD-10) codes (I26.0 and I26.9), and divided into PE group and Non-PE group. Univariate and multivariate logistic regression analyses were used to assess the association between anatomic distribution of LEDVT and PE. Sensitivity analyses were also conducted.

Results

A total of 2,363 consecutive patients with LEDVT were included, of whom 66.10% and 33.90% were unilateral and bilateral LEDVT, as well as 71.39% and 28.61% were isolated distal and proximal LEDVT, respectively. After the diagnosis of LEDVT, 185 patients (7.83%) developed PE. The proportions of PE ranged between the lowest (4.07%) in unilateral-distal LEDVT and highest (14.55%) in bilateral-proximal LEDVT. Multivariate logistic regression analysis showed that bilateral LEDVT (odds ratios [OR] = 2.455, 95% confidence interval [CI]: 1.803-3.344, P < 0.001) and proximal LEDVT (OR = 1.530, 95% CI: 1.105-2.118, P = 0.010) were risk factors for developing PE. Moreover, unilateral-proximal (OR = 2.129, 95% CI: 1.365-3.320, P = 0.00), bilateral-distal (OR = 3.193, 95% CI: 2.146-4.752, P < 0.001) and bilateral-proximal LEDVT(OR = 3.425, 95% CI: 2.093-5.603, P < 0.001) were significantly associated with an increased risk of PE. Sensitivity analyses also confirmed the robustness of these associations.

Conclusion

Patients with unilateral-proximal, bilateral-distal or bilateral-proximal are more likely to suffer from PE than those with unilateral-distal LEDVT.

High systemic inflammation response index level is associated with an increased risk of lower extremity deep venous thrombosis: a large retrospective study

BACKGROUND

The association between inflammation and venous thromboembolism (VTE) has attracted increasing research interest. Recently, the systemic inflammation response index (SIRI) has been proposed as a novel inflammatory biomarker, but its potential association with lower extremity deep venous thrombosis (LEDVT) has not been investigated. Thus, this study aimed to explore the association between SIRI and LEDVT risk in a large sample over a 10-year period (2012-2022).

METHODS

All hospitalized patients who underwent lower extremity compression ultrasonography (CUS) examinations were consecutively identified from our hospital information system database. Multivariate logistic regression analysis was used to investigate the association between SIRI and LEDVT risk. Sensitivity, restricted cubic spline and subgroup analyses were also performed.

RESULTS

In total, 12643 patients were included, and 1346 (10.6%) LEDVT events occurred. After full adjustment, a higher SIRI level was significantly associated with an increased risk of LEDVT (odds ratio [OR] = 1.098, 95% confidence interval [CI]: 1.068-1.128, p < 0.001), and patients in quartile 4 had a 2.563-fold higher risk of LEDVT than those in quartile 1 (95% CI: 2.064-3.182, p < 0.001). A nonlinear relationship was observed (P for nonlinearity < 0.001), with an inflection point of 4.17. Below this point, each unit increase in SIRI corresponded to a 35.3% increase in LEDVT risk (95% CI: 1.255-1.458, p < 0.001). No significant difference was found above the inflection point (OR = 1.015, 95% CI: 0.963-1.069, p = 0.582). Sensitivity and subgroup analyses confirmed the robustness of the association. This association also existed in both distal and proximal LEDVT.

CONCLUSION

A High SIRI is significantly associated with an increased risk of LEDVT in hospitalized patients. Given that the SIRI is a readily available biomarker in clinical settings, its potential clinical use deserves further exploration.

Prevalence of Cancer in Patients with Venous Thromboembolism: A Retrospective Nationwide Case-Control Study in Sweden

Cancer is a risk factor for venous thromboembolism (VTE). We aimed to define sex-specific risk of preceding cancer in patients with a first-time VTE by conducting a nationwide Swedish registry-based study including 298 172 patients with VTE and 1 185 079 matched controls. This included 44 685 patients with a diagnosis of cancer at/or within 1 year before a VTE diagnosis. Female patients with VTE had a higher multivariable adjusted odds ratios of preceding cancer than male patients with VTE (5.5 [99% confidence interval 5.4-5.7] vs 3.9 [3.8-4.0]). The highest risk of cancer in patients with VTE were found for pancreatic cancer (women: 19.6 [15.8-24.4]; men: 17.2 [13.7-21.6]) and brain cancer (women: 17.4 [12.9-23.4]; men: 17.5 [13.8-22.2]). Weak associations were seen between VTE and bladder/urothelial cancer (women: 1.31 [1.12-1.53]; men: 1.34 [1.23-1.47]), prostate cancer (men: 2.17 [2.07-2.27]), malignant melanoma (women: 2.51 [2.07-3.05]; men: 2.67 [2.23-3.18]), and kidney cancer (women: 3.20 [2.49-4.11]; men: 3.33 [2.79-4.07]). In conclusion, associations with VTE were weak for bladder/urothelial cancer and kidney cancer, and strong for pancreatic, brain, and biliary cancers.

Venous Thromboembolism Issues in Women

The lifetime risk of venous thromboembolism (VTE) is slightly higher in women than in men. There are several issues related to VTE that are unique to women. Combined hormonal contraceptives and pregnancy increase the risk of VTE in women of childbearing age, whereas hormone replacement therapy increases the VTE risk of postmenopausal women. Hereditary thrombophilia and risk factors such as older age, obesity, or smoking contribute to the risk increase. In women diagnosed with acute hormone-related VTE who are treated with oral anticoagulants, adequate contraception is mandatory to avoid unwanted pregnancies. According to current knowledge, hormonal contraception may be continued during anticoagulant therapy but must be switched to an estrogen-free contraception method at least 6 weeks before the termination of anticoagulation. VTE is also a major cause of maternal morbidity and mortality during pregnancy and the postpartum period. Currently, assisted reproduction technologies such as in vitro fertilization are widely used to treat couples affected by infertility. Complications of fertility treatment comprise VTE cases, especially in women with ovarian hyperstimulation syndrome. With this review, we intended to focus on VTE issues in women and summarize current evidence and guideline recommendations.