Venous thromboembolism in COPD hospitalized patients

Effects of simvastatin on tissue factor pathway of blood coagulation in STATCOPE (Simvastatin in the prevention of COPD exacerbations) trial

BACKGROUND

Statins are widely used to lower lipids and reduce cardiovascular events. In vitro studies and small studies in patients with hyperlipidemias show statins inhibit tissue factor (TF) and blood coagulation mechanisms. We assessed the effects of simvastatin on TF and coagulation biomarkers in patients entered in STATCOPE, a multicenter, randomized, placebo-controlled trial of simvastatin (40 mg daily) versus placebo on exacerbation rates in patients with chronic obstructive pulmonary disease (COPD).

METHODS

In 227 patients (114 simvastatin, 113 placebo; mean [± standard error of the mean] age 62 ± 0.53 years, 44.5% women) we measured (baseline, and 6 and 12 months): whole blood membrane TF-procoagulant activity (TF-PCA) and plasma factors VIIa, VII, VIII, fibrinogen, TF antigen, tissue factor pathway inhibitor (TFPI), thrombin-antithrombin complexes (TAT), and D-dimer. We excluded patients with diabetes, cardiovascular disease, and those taking or requiring a statin.

RESULTS

In the statin group, there was a small increase in TF-PCA (from 25.18 ± 1.08 to 30.36 ± 1.10 U/ml; p = .03) over 12 months; factors VIIa and VIII, fibrinogen, TAT, and D-dimer did not change. Plasma TFPI (from 52.4 ± 1.75 to 44.7 ± 1.78 ng/ml; p < .0001) and FVIIC (1.23 ± 0.04 to 1.15 ± 0.03 U/ml; p = .03) decreased and correlated with total cholesterol levels. No changes in biomarkers were observed with placebo.

CONCLUSIONS

In contrast to previous studies on statins, in COPD patients without diabetes, cardiovascular disease, or requiring a statin treatment, simvastatin (40 mg per day) did not decrease TF or factors VIIa and VIII, fibrinogen, TAT, or D-dimer. The decreases in TFPI and factor VII reflect the decrease in serum lipids.

Efficacy and safety of low-dose urokinase for the treatment of hemodynamically stable AECOPD patients with acute pulmonary thromboembolism

PURPOSE

The aim of this study was to assess the incidence of pulmonary thromboembolism (PTE) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD),and to evaluate the efficacy and safety of low-dose urokinase (UK) thrombolysis therapy when treating hemodynamically stable AECOPD patients with acute PTE (AECOPD-PTE).

METHODS

A total of 419 AECOPD patients, including 96 AECOPD-PTE, were enrolled. A total of 30 AECOPD-PTE patients were collected retrospectively, and 66 AECOPD-PTE patients were prospectively divided into anticoagulation-only, low-dose UK and standard-dose UK groups. Follow-up 1 year, we evaluated the efficacy and safety of low-dose UK therapy for hemodynamically stable AECOPD-PTE patients.

RESULTS

The incidence of PTE in AECOPD patients was 22.9% (96/419), which increased with COPD severity degree ranging from 3.5% (2/57) in mild, 13.6% (19/140) in moderate and 33.8% (75/222) in severe subgroups (P < .05). In the prospective study, the total effective rate of low-dose UK group 97.2% (35/36) was higher than that in anticoagulation 75.0% (12/16) and standard-dose UK group 78.6% (11/14) respectively (P < .05). In the follow-up, the adverse events rate in low-dose UK group 8.3% (3/36) was significantly lower than that in anticoagulation group 25.0% (4/16) and standard-dose UK group 71.4% (10/14) respectively (P < .05). In addition, the mean PTE recurrence time of low-dose UK group (9.0 ± 0) months was longer than anticoagulation group (2.0 ± 1.41) months (P < .05). AECOPD relapse time in anticoagulation, low-dose UK and standard-dose UK groups corresponding to (8.5 ± 2.12), (9.0 ± 0) and (8.8 ± 3.40) months were compared with no significant difference (P > .05).

CONCLUSIONS

The incidence of PTE in AECOPD patients was 22.9%, especially with higher occurrence rate in severe COPD. Compared with anticoagulation-only therapy, low-dose UK treatment (500 000 IU/day for 5-7 days) could obtain a better efficacy and safety in hemodynamically stable AECOPD patients with acute PTE, corresponding with a higher effective rate (97.2%) and lower adverse events rate (8.3%) respectively.

Is diabetes mellitus a risk factor for venous thromboembolism? A systematic review and meta-analysis of case-control and cohort studies

OBJECTIVE

Diabetes mellitus is a well-established risk factor for atherosclerotic disease, but its role in the occurrence of venous thromboembolism (VTE) has not been elucidated. We conducted a meta-analysis of published cohort and case-control studies to assess whether diabetes mellitus is a risk factor for VTE.

RESEARCH DESIGN AND METHODS

We systematically searched MEDLINE and EMBASE for case-control and prospective cohort studies assessing association between the risk of venous thromboembolism and diabetes. Odds ratios (OR) from case-control studies were combined while for prospective studies hazard ratios (HR) were combined. Models with random effects were used. Meta-analyses were conducted separately for raw and adjusted measures of association.

RESULTS

24 studies were identified including 10 cohort studies (274,501 patients) and 14 case-control studies (1,157,086 patients). Meta-analysis of the prospective cohort studies demonstrated a significant association between diabetes and VTE (HR 1.60; 95% CI 1.35 to 1.89). This association was no longer present after analysis of multi-adjusted HRs (HR 1.10; 95% CI 0.77 to 1.56). Meta-analysis of case-control studies showed a significant association between diabetes and VTE (OR 1.57; 95%CI 1.17 to 2.12), but this association was no longer present when adjusted ORs were used (OR 1.18; 95%CI 0.89 to 1.56).

CONCLUSIONS

The increased risk of VTE associated with diabetes mainly results from confounders rather than an intrinsic effect of diabetes on venous thrombotic risk. Therefore, no specific recommendations should apply for the management of diabetic patients at risk for VTE.

History of deep vein thrombosis is a discriminator for concomitant atrial fibrillation in pulmonary embolism

BACKGROUND

Pulmonary embolism (PE) is the consequence of deep vein thrombosis (DVT) in 70% of all cases. Although, PE and DVT are commonly related to risk factors of Virchow's triad, both entities are linked to cardiovascular risk factors, but risk factors seem differently important in both entities.

OBJECTIVES

We aimed to investigate clinical profile and outcome of patients with PE history stratified by concomitant DVT.

PATIENTS/METHODS

Data from the observational multi-center thrombEVAL-study were analyzed.

RESULTS

The sample (N=2,318) comprised 295 PE patients, of whom 69.2% (N=204) had DVT. Individuals without DVT were older and had higher prevalence of concomitant atrial fibrillation (AF), chronic lung diseases, coronary artery disease, heart failure and hypertension. Multivariable regression revealed an independent association of AF (Odds Ratio (OR) 3.17, 95% CI 1.63-6.18, P<0.001) and coronary artery disease (OR 2.31, 95% CI 1.15-4.66, P=0.019) with PE without DVT. There was higher frequency of permanent AF in individuals without DVT, whereas paroxysmal AF was more prevalent in individuals with DVT. All AF subtypes were independently associated with PE without DVT with increasing ORs from paroxysmal to permanent AF. PE patients with and without DVT did not differ in survival (P=0.32) and cost-relevant clinical outcome (P=0.26) during follow-up. AF in PE patients was associated with cost-relevant clinical outcome (Hazard Ratio (HR) 1.78, 95% CI 1.03-3.09, P=0.040), but no significant difference in survival (HR 0.93, 95% CI 0.35-2.50, P=0.88) was observed.

CONCLUSIONS

History of DVT is a significant discriminator for clinical profile of PE patients. Individuals without DVT had more often cardiac and pulmonary disease with strongest association with AF. Data advocate a potential link between AF and PE.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov, Unique identifier NCT01809015.

Risk Factors for Venous Thromboembolism Among Reproductive Age Women

BACKGROUND

Venous thromboembolism (VTE) is rare among young women and is often presumed to occur in the setting of a genetic predisposition or during the use of estrogen-containing combined hormonal contraceptive or to have an unknown cause. This study aims to describe the distribution of VTE risk factors among women with a confirmed VTE.

METHODS

We identified all women aged 15-46 years with a VTE diagnosis at Columbia University Medical Center from 2005 to 2012 using medical center databases. We then reviewed all electronic medical records to validate the diagnoses and identify risk factors associated with each confirmed case.

RESULTS

We identified 315 cases and confirmed 186 (59%). The proportion of unconfirmed cases increased over time. Forty percent of confirmed cases were associated with hormonal contraceptives or pregnancy. Ninety-five percent of confirmed cases had identifiable major risk factors including a personal history, family history, malignancy or other predisposing illness, recent long-haul travel, trauma, hospitalization, and obesity; many had multiple simultaneous risk factors. None of the confirmed cases was associated with a previously known genetic predisposition, but in 10 confirmed cases a genetic predisposition was identified during evaluation. In only 10 of the 186 confirmed cases could we not identify any acquired risk factor, and only 2 of those 10 women had a genetic predisposition.

CONCLUSIONS

Many reproductive age women experiencing a VTE have risk factors unique to this group, and most have multiple risk factors, confirming that this is a multifactorial disease. The large proportion of unconfirmed cases suggests the need for great caution in using administrative databases for research due to poor diagnostic specificity and due to lack of information about additional risk factors.

Factors related to venous ulceration: a cross-sectional study

The aim of the study was to determine the factors related to venous ulceration. Patients with venous ulceration (278 patients) were compared with 1401 patients in other categories of clinical classification of venous disease (clinical, etiologic, anatomic, and pathophysiological [CEAP]). Demographic, anthropometric, and clinical data were collected. Univariate and multivariate logistic regression analyses were used. According to multivariate analyses, risk factors for venous ulceration were age, male sex, personal history of superficial and deep venous thrombosis, diabetes, high blood pressure, skeletal or joint disease in the legs and emphysema or chronic obstructive pulmonary disease, higher body mass index and physical inactivity, parental history of ankle ulcer as well as reflux in deep and perforator veins, deep obstruction, and combination of reflux and obstruction. It seems reasonable to pay special attention to patients in whom the postulated risk factors for venous ulceration are present.