Sex differences in risk of incident venous thromboembolism in heart failure patients

Incidence and characteristic of deep venous thrombosis in hospitalized chronic heart failure patients

BACKGROUND

This study was conducted to investigate the incidence of deep venous thrombosis (DVT), outcomes and its characteristics in patients with chronic heart failure (CHF) in a retrospective setting.

OUTCOMES

Patients died of cardiac shock or acute exacerbation of heart failure (HF), admitted to intensive care unit (ICU) due to acute exacerbation of HF, patients decided to withdraw treatment and return home due to acute exacerbation of HF.

METHODS

From January 2015 to June 2022, we admitted 359 patients diagnosed with CHF, and lower limb ultrasonography was performed for the examination of DVT after admission. The incidence of DVT was recorded and patients with known risk factors of VTE were identified and excluded after incidence of DVT was calculated. Patients' clinical data were then collected.

RESULTS

The occurrence of DVT was 10.0% (36/359), as calf intramuscular vein thrombosis was the main constitution (n  =  28, 75%). DVT patients with other factors (carcinoma, surgery, stroke, previous history of DVT) constituted a considerable part (33.3%, 12/36). Age, history of Diabetes Mellitus (DM), levels of DDi (D-Dimer), levels of alanine transferase (ALT) and left ventricular end-diastolic diameter (LVEDd) were independent predictors or risk factors of DVT in CHF patients, while chronic kidney disease (CKD) stage 1-4, white blood cell (WBC) and direct oral anticoagulant (DOAC) were protective factors. Incidence of DVT was correlated with a poor outcome of CHF patients (Pearson Chi-Square test, Value 19.612, P  <  0.001).

CONCLUSIONS

In this retrospective study, incidence of DVT was found to be relatively high among hospitalized CHF patients, while patients with DVT was associated with a poor prognosis.

Inconsistency in UK Biobank Event Definitions From Different Data Sources and Its Impact on Bias and Generalizability: A Case Study of Venous Thromboembolism

The UK Biobank study contains several sources of diagnostic data, including hospital inpatient data and data on self-reported conditions for approximately 500,000 participants and primary-care data for approximately 177,000 participants (35%). Epidemiologic investigations require a primary disease definition, but whether to combine data sources to maximize statistical power or focus on only 1 source to ensure a consistent outcome is not clear. The consistency of disease definitions was investigated for venous thromboembolism (VTE) by evaluating overlap when defining cases from 3 sources: hospital inpatient data, primary-care reports, and self-reported questionnaires. VTE cases showed little overlap between data sources, with only 6% of reported events for persons with primary-care data being identified by all 3 sources (hospital, primary-care, and self-reports), while 71% appeared in only 1 source. Deep vein thrombosis-only events represented 68% of self-reported VTE cases and 36% of hospital-reported VTE cases, while pulmonary embolism-only events represented 20% of self-reported VTE cases and 50% of hospital-reported VTE cases. Additionally, different distributions of sociodemographic characteristics were observed; for example, patients in 46% of hospital-reported VTE cases were female, compared with 58% of self-reported VTE cases. These results illustrate how seemingly neutral decisions taken to improve data quality can affect the representativeness of a data set.

Thrombin-activatable fibrinolysis inhibitor and sex modulate thrombus stability and pulmonary embolism burden in a murine model

BACKGROUND

Thrombin-activatable fibrinolysis inhibitor (TAFI) levels are positively correlated with the risk of thrombosis. The mechanism of how TAFI affects venous thromboembolism (VTE) remains uncertain. In addition, the role of sex on the risk of VTE has also been studied. However, their association also remains unclear.

OBJECTIVES

To investigate how TAFI and/or sex affect venous thrombus stability and consequent pulmonary embolism (PE).

METHODS

Ferric chloride-induced thrombi were formed within the femoral veins of male and female wild-type (WT) or TAFI-knockout (Cpb2-/-) mice. Thrombi were imaged over 2 hours using intravital videomicroscopy to quantify embolization and thrombus size over time. Lungs were examined by immunohistochemistry to quantify (a) emboli and (b) fibrin composition of these emboli.

RESULTS

Embolization events in female mice were higher than in males (7.9-fold in WT and 3.1-fold in Cpb2-/- mice). Although the maximal thrombus sizes were not different across groups, Cpb2-/- mice had thrombi that were, on average, 24% smaller at the end of the 2-hour experiment than WT mice. Loss of TAFI led to a 4.0- and 2.8-fold increase in PE burden in males and females, respectively, while sex had no influence. Pulmonary emboli in Cpb2-/- mice had higher fibrin composition compared with WT mice.

CONCLUSION

Female mice had less stable venous thrombi than male mice, suggesting a higher risk of PE in females with deep vein thrombosis. Mice lacking TAFI had more thrombus degradation and higher PE burden than WT mice. These results confirm the role of TAFI in venous thrombosis.

Incidence and risk factors of admission deep venous thrombosis in nonagenarians and centenarians with intertrochanteric fracture: a retrospective study

PURPOSE

The objective of this study was to identify the risk factors for admission deep venous thrombosis (aDVT) and proximal aDVT in nonagenarians and centenarians with intertrochanteric fracture (IF).

METHODS

We collected statistics on nonagenarians and centenarians with IF admitting from January 2010 to October 2022. Patients with aDVT were considered as the aDVT group and those without aDVT as the non-aDVT group. Additionally, we also conducted a subgroup analysis based on the location of aDVT to investigate the predictors of proximal aDVT. The demographics, comorbidities and admission laboratory examinations of patients were computed by univariate analysis, logistic regression analysis, and receiver operating characteristic (ROC) curve analysis.

RESULTS

In our study, the rate of aDVT (109 of 318) was 34.3%, and 5.7% (18 of 318) of patients had proximal aDVT. Logistic regression analysis showed that female patients and a high level of D-dimer were risk factors for aDVT. Similarly, hypoproteinemia and a high level of D-dimer were found to be risk factors for proximal aDVT. ROC curve analysis indicated the cut-off values of D-dimer to predict the aDVT and proximal aDVT were 1.28 mg/L and 1.485 mg/L, respectively.

CONCLUSIONS

Our findings investigated the risk factors of aDVT and proximal aDVT in nonagenarians and centenarians with IF and identified the cut-off values of D-dimer, helping us assess the risk of aDVT and proximal aDVT to manage early targeted interventions.

LEVEL OF EVIDENCE III

Predictors of preoperative deep vein thrombosis in hip fractures: A systematic review and meta-analysis

BACKGROUND

The predictors of preoperative deep vein thrombosis (DVT) in patients with hip fractures remain unclear. Therefore, this study describes the results of a systematic review and meta-analysis of relevant peer-reviewed literature on this topic.

METHODS

We searched PubMed, Google Scholar, Cochrane Library, Web of Science, and MEDLINE for articles published in English on the predictors of preoperative DVT in hip fractures. We calculated pooled odds ratios (OR) or mean differences (MD) for the DVT groups as compared with the non-DVT groups for each variable, including gender, age, body mass index, injury side, current smoking status, time from injury to admission, time from injury to surgery, fracture type, hypertension, arrhythmia, coronary artery disease, diabetes, stroke, kidney disease, liver disease, lung disease, malignancy, rheumatoid arthritis, D-dimer, fibrinogen, activated partial thromboplastin time, prothrombin time, thrombin time, hemoglobin, albumin, total cholesterol, and triglycerides.

RESULTS

We included 9 studies involving 3,123 Asian patients with hip fractures (DVT, n = 570; non-DVT, n = 2,553). Being female (OR = 1.27; 95% confidence interval [CI] 1.04-1.56; p = 0.02), being of advanced age (MD = 1.63; 95% CI 0.80-2.47; p = 0.0001), having a longer time from injury to admission (MD = 0.80; 95% CI 0.48-1.12; p < 0.00001), having a longer time from injury to surgery (MD = 2.20; 95% CI 1.53-2.88; p < 0.00001), and the presence of kidney disease (OR = 1.76; 95% CI 1.04-2.96; p = 0.03) were correlated with a high risk of DVT. However, we found no significant differences between the two groups in the other predictors.

CONCLUSIONS

Evidence indicates that being female, being of advanced age, having a longer time from injury to admission, having a longer time from injury to surgery, and having kidney disease are significantly correlated with a high risk of preoperative DVT in Asian patients with hip fracture. Further investigations with patients of other ethnicities are required.

Pulmonary Embolism in Women: A Systematic Review of the Current Literature

Cardiovascular disease is the leading cause of death in women. Pulmonary embolism (PE) is the third most-common cause of cardiovascular death, after myocardial infarction (MI) and stroke. We aimed to evaluate the attributes and outcomes of PE specifically in women and explore sex-based differences. We conducted a systematic review of the literature using electronic databases PubMed and Embase up to 1 April 2022 to identify studies investigating PE in women. Of the studies found, 93 studies met the eligibility criteria and were included. The risk of PE in older women (especially >40 years of age) superseded that of age-matched men, although the overall age- and sex-adjusted incidence of PE was found to be lower in women. Risk factors for PE in women included age, rheumatologic disorders, hormone replacement therapy or oral contraceptive pills, pregnancy and postpartum period, recent surgery, immobilization, trauma, increased body mass index, obesity, and heart failure. Regarding pregnancy, a relatively higher incidence of PE has been observed in the immediate postpartum period compared to the antenatal period. Women with PE tended to be older, presented more often with dyspnea, and were found to have higher NT-proBNP levels compared to men. No sex-based differences in in-hospital mortality and 30-day all-cause mortality were found. However, PE-related mortality was higher in women, particularly in hemodynamically stable patients. These differences form the basis of future research and outlets for reducing the incidence, morbidity, and mortality of PE in women.

Risk factors for preoperative deep venous thrombosis in hip fracture patients: a meta-analysis

Study design

A meta-analysis.

Background

Hip fracture (HF), as common geriatric fracture, is related to increased disability and mortality. Preoperative deep vein thrombosis (DVT) is one of the most common complications in patients with hip fractures, affecting 8–34.9% of hip fracture patients. The study aimed to assess the risk factors of preoperative DVT after hip fractures by meta-analysis.

Methods

An extensive search of the literature was performed in the English databases of PubMed, Embase, and the Cochrane Library; and the Chinese databases of CNKI and WAN FANG. We collected possible predictors of preoperative DVT from included studies, and data analysis was conducted with RevMan 5.3 and STATA 12.0.

Results

A total of 26 English articles were included, and the rate of DVT was 16.6% (1627 of 9823 patients) in our study. Our findings showed that advanced age [p = 0.0003, OR = 0.13 95% CI (0.06, 0.21)], female patients [p = 0.0009, OR = 0.82 95% CI (0.72, 0.92)], high-energy injury [p = 0.009, OR = 0.58 95% CI (0.38, 0.87)], prolonged time from injury to admission [p < 0.00001, OR = 0.54 95% CI (0.44, 0.65)], prolonged time from injury to surgery [p < 0.00001, OR = 2.06, 95% CI (1.40, 2.72)], hemoglobin [p < 0.00001, OR = − 0.32 95% CI (− 0.43, − 0.21)], coronary heart disease [p = 0.006, OR = 1.25 95% CI (1.07, 1.47)], dementia [p = 0.02, OR = 1.72 95% CI (1.1, 2.67)], liver and kidney diseases [p = 0.02, OR = 1.91 95% CI (1.12, 3.25)], pulmonary disease [p = 0.02, OR = 1.55 95% CI (1.07, 2.23)], smoking [p = 0.007, OR = 1.45 95% CI (1.11, 1.89)], fibrinogen [p = 0.0005, OR = 0.20 95% CI (0.09, 0.32)], anti-platelet drug [p = 0.01, OR = 0.51 95% CI (0.30, 0.85)], C-reactive protein [p = 0.02, OR = 5.95 95% CI (1.04, 10.85)], < 35 g/l albumin [p = 0.006, OR = 1.42 95% CI (1.1, 1.82)], and thrombosis history [p < 0.00001, OR = 5.28 95% CI (2.85, 9.78)] were risk factors for preoperative DVT.

Conclusions

Many factors, including advanced age, female patients, high-energy injury, prolonged time from injury to admission, prolonged time from injury to surgery, patients with a history of coronary heart disease, dementia, liver and kidney diseases, pulmonary disease, smoking, and thrombosis, fibrinogen, C-reactive protein, and < 35 g/l albumin, were found to be associated with preoperative DVT. Our findings suggested that the patient with above characteristics might have preoperative DVT.

Level of evidence: Level III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10195-022-00639-6.

Systematic review of warfarin-induced skin necrosis case reports and secondary analysis of factors associated with mortality

OBJECTIVE

Warfarin-induced skin necrosis (WSN) is a rare (0.0.1%-0.1%) and severe adverse reaction. The clinical characteristics of this reaction and its mortality rate have not been explored in a large population. Therefore, we present the case of a Peruvian patient who developed WSN and perform a systematic review of case reports of WSN.

METHODS

A systematic search was performed using the Pubmed/Medline, Scopus, Web of Science and Embase databases. Patient clinical data were collected and extracted from every case report. Furthermore, we analysed the factors associated with mortality because of WSN using the Poisson regression model with robust variations, obtaining risk ratios (RR) and their respective confidence intervals (95% CI).

RESULTS

We identified 90 case reports that included a total of 111 patients with WSN (mean age 52.5 years), 20.72% of whom died of complications because of WSN. Being male (RR: 2.87; 95% CI 1.21-6.83) and having three or more affected regions (RR: 6.81; 95% CI 2.62-17.74) were associated with an increased risk of death caused by WSN.

CONCLUSION

This systematic review identified 90 case reports of WSN with three or more affected body regions. Male sex was associated with an increased risk of death. Further studies are needed to analyse and confirm these results.

The significance of heart failure in hospitalised patients with pulmonary embolism. A gender-specific analysis

BACKGROUND

Heart failure (HF) is a risk factor for the development of pulmonary embolism (PE). Few studies have examined sex differences in risk of PE among HF patients.

AIMS

(a) To examine the incidence, characteristics and in-hospital outcomes among patients hospitalised with PE according to HF status; (b) to compare the in-hospital mortality (IHM) after PE between HF and non-HF patients and (c) to identify variables associated with IHM. All analyses were stratified by sex.

METHODS

We included all adult patients hospitalised for PE from 1 January 2016 to 31 December 2018. Data were collected from the Spanish National Hospital Discharge Database. Poisson regression models were constructed to quantify the difference in the incidences between HF and non-HF populations. Propensity score matching (PSM) was used to obtain comparable subgroups by sex and HF status.

RESULTS

We identified 46,835 PE hospitalisations, 11.4% with HF. Adjusted incidence of PE was higher in HF patients than in those without HF (Incidence Rate Ratio 1.11; 95% CI 1.08-1.13). Crude and PSM adjusted IHM were significantly higher in men and women hospitalised with PE suffering HF than in men and women without HF (P < .001). Women with HF who suffered a PE had lower IHM than men with this condition (P < .001) after adjusting.

CONCLUSIONS

Adjusted incidence of PE was higher in HF patients than in those without HF. After PSM suffering, HF was associated to higher IHM in men and women. Women with PE and HF had lower IHM than men with these conditions.

Deep venous thrombosis in patients with neurological diseases: A multicenter, prospective study

OBJECTIVE

Patients with neurological diseases are liable to develop deep venous thrombosis (DVT) due to various factors. We investigated the prevalence, related factors, and prognosis of DVT in patients with neurological diseases.

METHODS

Patients admitted to four hospitals due to neurological diseases were prospectively recruited. Those with cerebrovascular diseases were excluded. To screen for DVT, ultrasonography was performed in patients with possible DVT risk, such as D-dimer > 1.0 µg/dL, recent surgery, active malignant diseases, recent bone fracture, decreased activity, or treatment with immunoglobulin or steroid therapy. Clinical characteristics were compared between patients with and without DVT.

RESULTS

A total of 106 patients (54 women, median 71 years old) were included. DVT was detected in 27 patients (26.0%) at the first assessment. All had DVT only in the calf; encephalopathy/meningitis (n = 4, 40.0%) had the highest prevalence of DVT among the underlying neurological diseases, followed by parkinsonian syndrome (n = 6, 37.5%). Independent predictors for DVT detection were malignant diseases (odds ratio, 11.7; 95% confidence interval, 1.0-301.4), modified Rankin Scale score ≥ 4 (5.4; 1.9-16.6), and D-dimer ≥ 2.0 µg/dL (5.7; 2.1-16.7). Ten patients were treated with anticoagulants, and no patients developed a symptomatic pulmonary embolism. No clinically evident pulmonary embolisms, systemic embolisms, or severe bleeding complications were observed in patients with DVT.

CONCLUSIONS

Asymptomatic DVT is not rare in patients with neurological diseases, especially in those with malignancy, decreased activity, or elevated D-dimer. The overall prognosis is favorable, but the potential risk of development of a pulmonary embolism should be recognized.

Viscoelastic Coagulation Monitor (VCMVet) Reference Intervals and Sex Differences in Mature Adult Mice

INTRODUCTION

Viscoelastic coagulation tests are useful to assess coagulation status in the clinical setting and to aid in understanding underlying pathophysiological mechanisms that affect coagulation status. Such tests also are useful for coagulation research. Because mouse models are widely used to study molecular mechanisms in fine detail, a simple viscoelastic coagulation test requiring small blood volumes would be convenient for such studies in mice.

METHODS

We tested viscoelastic coagulation properties of normal healthy adult mice using a novel veterinary clinical point-of-care device, Viscoelastic Coagulation Monitor (VCM Vet™; Entegrion Corp.). Fresh whole blood was collected from 63 healthy mature adult C57 black 6N mice, with ultimately 54 mice, equal numbers of male and females, used to determine reference intervals (RIs) for VCM test parameters.

RESULTS

RIs were determined for equal numbers of male and female mice: clot time: 43.0-353.0 s; clot formation time: 49.4-137.6 s; alpha angle: 54.4-62.2°; A10: 25.0-49.6 VCM units; A20: 31.0-56.5 VCM units; maximum clot firmness: 37.6-62.8 VCM units; Lysis Index 30 (Li30): 99.8-100.0%; and Li45: 99.7-100.0%. Significant differences were found between male and female subgroups, where females had higher mean A10 and A20 and median MCF values, indicating greater clot firmness in female versus male mice.

CONCLUSION

VCM Vet is a feasible viscoelastic coagulation test device for studies with mature adult mice, including studying inherent sex differences in coagulation parameters. Inherent differences in coagulability of male and female mice warrant further investigation to determine if such differences underlie greater coagulopathic, hemorrhagic, or thromboembolic risk during trauma or other pathophysiologic conditions.

Crucial considerations: Sex differences in the epidemiology, diagnosis, treatment, and outcomes of acute pulmonary embolism in non-pregnant adult patients

Acute pulmonary embolism (PE) affects over 600,000 Americans per year and is a common diagnostic consideration among emergency department patients. Although there are well-documented differences in the diagnosis, treatment, and outcomes of cardiovascular conditions, such as ischemic heart disease and stroke, the influence of sex and gender on PE remains poorly understood. The overall age-adjusted incidence of PE is similar in women and men, but women have higher relative rates of PE during early and mid-adulthood (ages 20-40 years); whereas, men have higher rates of PE after age 60 years. Women are tested for PE at far higher rates than men, yet women who undergo computed tomography pulmonary angiography are ultimately diagnosed with PE 35%-55% less often than men. Among those diagnosed with PE, women are more likely to have severe clinical features, such as hypotension and signs of right ventricular dysfunction. When controlled for PE severity, women are less likely to receive reperfusion therapies, such as thrombolysis. Finally, women have more bleeding complications for all types of anticoagulation. Further investigation of possible sex-specific diagnostic and treatment algorithms is necessary in order to more accurately detect and treat acute PE in non-pregnant adults.

Anticoagulation in Patients with Heart Failure and Sinus Rhythm

The risk of thromboembolic events is significantly increased among patients with heart failure, even in those without atrial fibrillation. However, it is still unclear whether patients with heart failure and sinus rhythm can benefit from prophylactic anticoagulant therapy.This was a retrospective review of the pathophysiological mechanisms, epidemiological studies, and clinical trials on anticoagulation in patients with heart failure and sinus rhythm.Some subgroup analyses of clinical trials found that prophylactic anticoagulant therapy could reduce the incidence of stroke in patients with heart failure and sinus rhythm, and the risk of bleeding was significantly increased. Regarding the incidence of primary endpoint outcomes, all results from clinical trials were negative.Prophylactic anticoagulation did not improve the clinical outcome in patients with heart failure and sinus rhythm.

Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review

IMPORTANCE

Incidence rates for lower extremity deep vein thrombosis (DVT) range from 88 to 112 per 100 000 person-years and increase with age. Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event.

OBSERVATIONS

PubMed and Cochrane databases were searched for English-language studies published from January 2015 through June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies. Risk factors for venous thromboembolism (VTE), such as older age, malignancy (cumulative incidence of 7.4% after a median of 19 months), inflammatory disorders (VTE risk is 4.7% in patients with rheumatoid arthritis and 2.5% in those without), and inherited thrombophilia (factor V Leiden carriers with a 10-year cumulative incidence of 10.9%), are associated with higher risk of VTE. Patients with signs or symptoms of lower extremity DVT, such as swelling (71%) or a cramping or pulling discomfort in the thigh or calf (53%), should undergo assessment of pretest probability followed by D-dimer testing and imaging with venous ultrasonography. A normal D-dimer level (ie, D-dimer <500 ng/mL) excludes acute VTE when combined with a low pretest probability (ie, Wells DVT score ≤1). In patients with a high pretest probability, the negative predictive value of a D-dimer less than 500 ng/mL is 92%. Consequently, D-dimer cannot be used to exclude DVT without an assessment of pretest probability. Postthrombotic syndrome, defined as persistent symptoms, signs of chronic venous insufficiency, or both, occurs in 25% to 50% of patients 3 to 6 months after DVT diagnosis. Catheter-directed fibrinolysis with or without mechanical thrombectomy is appropriate in those with iliofemoral obstruction, severe symptoms, and a low risk of bleeding. The efficacy of direct oral anticoagulants-rivaroxaban, apixaban, dabigatran, and edoxaban-is noninferior to warfarin (absolute rate of recurrent VTE or VTE-related death, 2.0% vs 2.2%). Major bleeding occurs in 1.1% of patients treated with direct oral anticoagulants vs 1.8% treated with warfarin.

CONCLUSIONS AND RELEVANCE

Greater recognition of VTE risk factors and advances in anticoagulation have facilitated the clinical evaluation and treatment of patients with DVT. Direct oral anticoagulants are noninferior to warfarin with regard to efficacy and are associated with lower rates of bleeding, but costs limit use for some patients.