Socioeconomic factors and concomitant diseases are related to the risk for venous thromboembolism during long time follow-up

Baseline socioeconomic status predicting post-COVID-19 symptoms: Results from Isfahan COVID Cohort (ICC) study

Objectives

Patients experience complications following their recovery from COVID-19, known as post-COVID-19. This study aimed to investigate the association between baseline socioeconomic status (SES) and post-COVID-19 symptoms among hospitalized and non-hospitalized patients.

Methods

In the study, we used data from the Isfahan COVID Cohort (ICC) study, a 5-year longitudinal cohort study started from March 10, 2020. SES was measured using short form of SES questionnaire (SES-SQ), consisting of employment status, house room number, the number of trips taken, and using notebooks, laptop, or tablet in the house. Cox proportional hazard analysis was used to examine the association between baseline SES and post-COVID-19 symptoms including general, cardiovascular and respiratory systems, adjusting for potential confounders.

Results

Out of the 3912 patients included in the study, 66.4 % reported post-COVID-19 symptoms. There was an association between low SES and increased risk of post-COVID-19 cardiovascular symptoms in the whole population (HR = 1.15; 95 CI, 1.01-1.31, p = 0.039). Considering the hospitalization status revealed that hospitalized patients with low SES had a higher risk of experiencing post-COVID-19 cardiovascular symptoms (HR = 1.96; 95 CI, 1.23-3.12, p = 0.004), while in non-hospitalized, low SES patients a lower risk was observed (HR = 0.82; 95 CI, 0.70-0.97, p = 0.017). No significant association was found between SES and other post-COVID-19 symptoms including general and respiratory symptoms.

Conclusions

We concluded an association between higher SES and increased post-COVID-19 cardiovascular symptoms. Low SES was associated with higher risk of post-COVID-19 cardiovascular symptoms in hospitalized patients, while in non-hospitalized, it was associated with a lower risk.

Association between diabetes and venous thromboembolism: A systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM) plays a vital role in the development of cardiovascular disease. However, its association with venous thromboembolism (VTE) remains unclear, for the published study results are conflicting. We performed a meta-analysis of published cohort studies and case-control studies to assess the role of DM in the formation and prognosis of VTE.

METHODS

PubMed and EMBASE databases were searched for articles from the database's establishment until September 15, 2022. Of the 15,754 publications retrieved, 50 studies were identified that met the selection criteria. The New castle-Ottawa Scale was used to evaluate the quality of the literature. Pooled odds ratios (ORs) and 95% confidence intervals were calculated using fixed- or random-effect models.

RESULTS

We combined OR using a random-effects or fixed-effects model: patients with DM had an increased risk of VTE (OR 1.27, 95% confidence interval [CI]: 1.15-1.41), which still showed a partial association in studies adjusted by confounding factors (OR 1.20, 95% CI: 1.07-1.35). DM was not significantly associated with VTE when analyzed in studies adjusted by body mass index (OR 1.04, 95% CI: 0.94-1.15). VTE patients with DM had a higher risk of short-term and long-term mortality than those without DM (OR 1.58 [95% CI: 1.26-1.99] for long-term mortality and OR 1.20 [95% CI: 1.19-1.21] for short-term mortality).

CONCLUSION

There was no significant association between DM and VTE risk, and body mass index may be a significant confounding factor between DM and VTE risk. However, DM can still lead to an increased risk of long-term and short-term mortality in patients with VTE.

Perspectives: on Precision Nutrition Research in Heart, Lung, and Blood Diseases and Sleep Disorders

The release of the 2020-2030 Strategic Plan for NIH Nutrition Research (SPNR) and its emphasis on precision nutrition has provided an opportunity to identify future nutrition research that addresses individual variability in response to diet and nutrition across the life span-including those relevant to the Strategic Vision of the National Heart, Lung, and Blood Institute (NHLBI). The SPNR and the NHLBI's Strategic Vision were developed with extensive input from the extramural research community, and both have 4 overarching strategic goals within which are embedded several objectives for research. For the SPNR, these include 1) spur discovery science and normal biological functions (e.g., role of the microbiome in health and disease), 2) population science to understand individual differences (e.g., biomarkers including 'omics that predict disease status), 3) emerging scientific areas of investigation and their application (e.g., data science, artificial intelligence), and 4) cross-cutting themes (e.g., training the scientific workforce and minority health and health disparities). These strategic goals and objectives serve as blueprints for research and training. Nutrition remains important in the prevention and treatment of heart, lung, blood, and sleep (HLBS) disorders and diseases, and the NHLBI has played a pivotal role in supporting nutrition research. In this paper, we report important gaps in the scientific literature related to precision nutrition in HLBS diseases. Research opportunities that could stimulate precision nutrition and their alignment with the SPNR and the NHLBI Strategic Vision Objectives are provided. These opportunities include 1) exploring individual differences in response to varying dietary patterns and nutrients; 2) investigating genetic/epigenetic, biological (e.g., microbiome, biomarkers), social, psychosocial, and environmental underpinnings of individual variability in diet; 3) elucidating the role of circadian rhythm and chrononutrition; and 4) applying implementation science research methods in precision nutrition interventions relevant to HLBS diseases.

Socioeconomic status and clinical stage of patients presenting for treatment of chronic venous disease

OBJECTIVES

The association between socioeconomic status (SES) and chronic venous insufficiency has not been rigorously studied. This study aimed to determine the influence of SES on the clinical stage of patients presenting for chronic venous disease therapy.

METHODS

We performed a retrospective study of a prospectively collected data from the Vascular Quality Initiative Varicose Vein Registry at our tertiary referral center. Medical records of patients who underwent therapy for chronic venous disease between January 2015 and June 2019 were queried. SES was quantified using the neighborhood deprivation index (NDI), which summarizes 8 domains of socioeconomic deprivation and is based on census tract data derived from the patients' addresses at the time of the treatment. High NDI scores correspond with lower SES. The association between SES and severity of vein disease at presentation was assessed with bivariate analysis of variance and linear regression analysis.

RESULTS

A total of 449 patients with complete SES and clinical-etiology-anatomy-pathophysiology (CEAP) class data were included in the study. The mean age was 58 years, 67% were female, and 60% were White. CEAP classes were distributed as follows C2, 22%; C3, 50%; C4, 15%; C5, 5%; and C6, 8%. Patients with lower SES (higher NDI score) tended to have a higher CEAP class at presentation (P < 0.05). SES was not associated with history of deep venous thrombosis, use of compression therapy, or venous clinical severity score.

CONCLUSIONS

At our institution, patients with more advanced venous disease tended to belong to a lower SES group. This may reflect that patients with a lower SES have a longer time to presentation due to delay in seeking medical help for venous disease.

Socioeconomic status and risk of incident venous thromboembolism

BACKGROUND

Although venous thromboembolism (VTE) is a leading cause of morbidity and mortality, and socioeconomic status (SES) affects human health and health behavior, few studies have examined the association between SES and VTE.

OBJECTIVES

We aimed to investigate the association between SES, assessed individually and in a composite score by levels of education, income, and employment status, and incident VTE.

METHODS

We used Danish national registries to identify 51 350 persons aged 25-65 years with incident VTE during 1995-2016. For each case, we used incidence density sampling to select five age-, sex-, and index-year-matched controls from the general Danish population (n = 256 750). SES indicators, including education, income, and employment status, were assessed 1 and 5 years before the VTE. We used conditional logistic regression to compute odds ratios (ORs) with 95% confidence intervals (CIs) for VTE according to individual SES indicators and a composite SES score in analyses adjusted for age, sex, and comorbidities.

RESULTS

Compared with low levels, high educational level (OR 0.74; 95% CI 0.71-0.77), high income (OR 0.70; 95% CI 0.68-0.72), and high employment status (OR 0.66; 95% CI 0.64-0.68) were associated with decreased risk of VTE, even after adjusting for comorbidities. A composite SES score was superior to the individual indicators in assessing VTE risk (OR for high vs. low score: 0.61; 95% CI 0.59-0.63). In sensitivity analysis with SES indicators measured 5 years before the VTE, the risk estimates remained essentially the same.

CONCLUSION

High levels of both individual SES indicators and a composite SES score were associated with decreased VTE risk.

Risk and Management of Venous Thromboembolism in Patients with COVID-19

BACKGROUND

One of the most pronounced and poorly understood pathological features of COVID-19 infection has been high risk for venous and arterial thromboembolic complications. An increasing number of thromboembolic events are being reported almost on a daily basis, and the medical community has struggled to predict and mitigate this risk. We aimed to review available literature on the risk and management of COVID-19 related venous thromboembolism (VTE), and provide evidence-based guidance to manage these events.

METHODS

A literature review of VTE complications in patients with COVID-19 was performed, in addition to a summary of the societal guidelines and present pathways implemented at our institution for the management of both in- and outpatient COVID-19 related VTE.

RESULTS

Although a significant VTE risk has been confirmed in patients with COVID-19, literature addressing best ways to mitigate this risk is lacking. Furthermore, there has been very limited guidance provided by societal guidelines to help prevent and manage VTE associated with the COVID-19 infection. In light of the available data, we advise that all patients admitted with suspected or confirmed COVID-19 receive pharmacological prophylaxis if bleeding risk is acceptable. For patients with COVID-19 who have been discharged from the emergency department or hospital, we suggest extended thromboprophylaxis (up to 39 days) as long as bleeding risk is low.

CONCLUSIONS

We believe that this literature summary along with our center recommendations and algorithms provide valuable guidance to providers caring for patients with COVID-19 related VTE. More research is needed to standardize prophylaxis and management protocols for these patients.

The COVID-19 Pandemic: Disproportionate Thrombotic Tendency and Management Recommendations

COVID-19 is an infectious disease caused by the SARS COV-2 virus. Patients with COVID-19 are susceptible to thrombosis due to excessive inflammation, platelet activation, endothelial dysfunction, and circulatory stasis, resulting in an increased risk of death due to associated coagulopathies. In addition, many patients receiving antithrombotic therapy for pre-existing thrombotic diseases can develop COVID-19, which can further complicate dose adjustment, choice and laboratory monitoring of antithrombotic treatment. This review summarizes the laboratory findings, the prohemostatic state, incidence of thromboembolic events and some potential therapeutic interventions of COVID-19 associated coagulopathy. We explore the roles of biomarkers of thrombosis and inflammation according to the severity of COVID-19. While therapeutic anticoagulation has been used empirically in some patients with severe COVID-19 but without thrombosis, it may be preferable to provide supportive care based on evidence-based randomized clinical trials. The likely lifting of travel restrictions will accelerate the spread of COVID-19, increasing morbidity and mortality across nations. Many individuals will continue to receive anticoagulation therapy regardless of their location, requiring on-going treatment with low-molecular weight heparin, vitamin K antagonist or direct-acting anticoagulants.

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review

Coronavirus disease-2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), may predispose patients to thrombotic disease, both in the venous and arterial circulations, because of excessive inflammation, platelet activation, endothelial dysfunction, and stasis. In addition, many patients receiving antithrombotic therapy for thrombotic disease may develop COVID-19, which can have implications for choice, dosing, and laboratory monitoring of antithrombotic therapy. Moreover, during a time with much focus on COVID-19, it is critical to consider how to optimize the available technology to care for patients without COVID-19 who have thrombotic disease. Herein, the authors review the current understanding of the pathogenesis, epidemiology, management, and outcomes of patients with COVID-19 who develop venous or arterial thrombosis, of those with pre-existing thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic.

Coagulation Status and Venous Thromboembolism Risk in African Americans: A Potential Risk Factor in COVID-19

Severe acute respiratory syndrome coronavirus 2 infection (COVID-19) is known to induce severe inflammation and activation of the coagulation system, resulting in a prothrombotic state. Although inflammatory conditions and organ-specific diseases have been shown to be strong determinants of morbidity and mortality in patients with COVID-19, it is unclear whether preexisting differences in coagulation impact the severity of COVID-19. African Americans have higher rates of COVID-19 infection and disease-related morbidity and mortality. Moreover, African Americans are known to be at a higher risk for thrombotic events due to both biological and socioeconomic factors. In this review, we explore whether differences in baseline coagulation status and medical management of coagulation play an important role in COVID-19 disease severity and contribute to racial disparity trends within COVID-19.

Venous Thromboembolism in Autologous Blood or Marrow Transplantation Survivors: A Report from the Blood or Marrow Transplant Survivor Study

Hemostatic complications are commonly encountered in blood or marrow transplantation (BMT) recipients, increasing their morbidity and mortality and are well described in the immediate post-transplantation period. The risk of venous thromboembolism (VTE) in long-term survivors of autologous BMT has not been studied previously. Patients who underwent autologous BMT between January 1, 1974, and December 31, 2010 for a hematologic malignancy, lived 2 years or more after transplantation, and were age ≥18 years were surveyed for long-term outcomes. The median duration of follow-up was 9.8 years (interquartile range, 6.4 to 14.3 years). We analyzed the risk of VTE in 820 autologous BMT recipients who survived for ≥2 years, compared with 644 siblings. BMT survivors were at a 2.6-fold higher risk of VTE compared with siblings (95% confidence interval [CI], 1.6 to 4.4; P =.0004), after adjusting for sociodemographic characteristics. Conditional on surviving for ≥2 years after BMT, the mean cumulative incidence of VTE was 3.9 ± .8% at 5 years and 6.1 ± 1.1% at 10 years. A diagnosis of plasma cell disorder (hazard ratio [HR], 2.37; 95% CI, 1.3 to 4.2; P = .004) and annual household income ≤$50,000 (HR, 2.02; 95% CI, 1.2 to 3.6; P = .015) were associated with increased VTE risk. Our data indicate that autologous BMT survivors are at elevated risk for developing late-occurring VTE. The development of risk prediction models to identify autologous BMT survivors at greatest risk for VTE and thromboprophylaxis may help decrease the morbidity and mortality associated with VTE.

[Estimating the incidence of venous thromboembolism (VTE) using various types of routine data of the German healthcare system]

BACKGROUND

Venous thromboembolism (VTE) mainly manifests as deep vein thrombosis (TVT) or pulmonary embolism (LE), and is the third most common cardiovascular disease worldwide. However, robust evidence on the incidence of VTE in Germany is lacking.

OBJECTIVE

Estimation and comparison of the incidence of VTE based on different routine data sources of the German healthcare system.

METHODS

Estimates and comparisons of the incidence of VTE, TVT and LE were made using two databases that both covered the inpatient and the outpatient setting; the DaTraV database comprising information of all persons subject to compulsory health insurance, and the Health Risk Institute (HRI) database derived from approximately 70 statutory health insurance funds. In addition, IMS Disease Analyzer, a medical record database comprising information from the outpatient setting, was used as a data source.

RESULTS

Patterns of age- and sex-specific VTE incidence estimates were comparable between all databases used. However, estimates based on the medical record database were comparatively high. Analyses of DaTraV data led to a VTE incidence of 0.14%. Use of HRI data yielded comparable results (0.17-0.20%). VTE incidence based on data of the IMS Disease Analyzer was comparatively high (0.32%).

DISCUSSION

Results on the VTE incidence based on DaTraV or HRI date are comparable to international evidence, whereas the use of the IMS Disease Analyzer data presumably led to an overestimation due to double-counting of VTE cases. Different types of routine healthcare data sources can therefore lead to very heterogeneous results. Thus, the selection of adequate data sources strongly depends on the study question and the quality of the dataset.

Relationship between neighborhood socioeconomic status and venous thromboembolism: results from a population-based study

Essentials Literature on socioeconomic status (SES) and incidence of venous thromboembolism (VTE) is scarce. We assessed neighborhood SES with VTE risk in a population of over 1.4 million inhabitants. Higher neighborhood SES was associated with lower incidence of VTE. These findings are helpful to inform policy and resource allocation in health systems.

SUMMARY

Background The association between socioeconomic status and arterial cardiovascular disease is well established. However, despite its high burden of disability-adjusted life years, little research has been carried out to determine whether socioeconomic status is associated with venous thromboembolism. Objective To determine if neighborhood socioeconomic status is associated with venous thromboembolism in a population-based study from the Netherlands. Methods We identified all patients aged 15 years and older with a first event of venous thromboembolism from inhabitants who lived in the urban districts of The Hague, Leiden and Utrecht in the Netherlands in 2008-2012. Neighborhood socioeconomic status was based on the status score, which combines educational level, income and unemployment on a four-digit postal code level. Incidence rate ratios of venous thromboembolism were calculated for different levels of neighborhood socioeconomic status, with adjustments for age and sex. Results A total of 7373 patients with a first venous thromboembolism (median age 61 years; 50% deep vein thrombosis) were identified among more than 1.4 million inhabitants. Higher neighborhood SES was associated with lower incidence of VTE. In the two highest status score groups (i.e. the 95-99th and > 99th percentile), the adjusted incidence rate ratios were 0.91 (95% confidence interval [CI], 0.84-1.00) and 0.80 (95% CI, 0.69-0.93), respectively, compared with the reference status score group (i.e. 30-70th percentile). Conclusions High neighborhood socioeconomic status is associated with a lower risk of first venous thromboembolism.

The Association between Residence Floor Level and Cardiovascular Disease: The Health and Environment in Oslo Study

Background. Increasingly more people live in tall buildings and on higher floor levels. Factors relating to floor level may protect against or cause cardiovascular disease (CVD). Only one previous study has investigated the association between floor level and CVD. Methods. We studied associations between floor of bedroom and self-reported history of stroke, venous thromboembolism (VTE), and intermittent claudication (IC) among 12.525 inhabitants in Oslo, Norway. We fitted multivariate logistic regression models and adjusted for sociodemographic variables, socioeconomic status (SES), and health behaviors. Additionally, we investigated block apartment residents (N = 5.374) separately. Results. Trend analyses showed that disease prevalence increased by floor level, for all three outcomes. When we investigated block apartment residents alone, the trends disappeared, but one association remained: higher odds of VTE history on 6th floor or higher, compared to basement and 1st floor (OR: 1.504; 95% CI: 1.007–2.247). Conclusion. Floor level is positively associated with CVD, in Oslo. The best-supported explanation may be residual confounding by building height and SES. Another explanation, about the impact of atmospheric electricity, is also presented. The results underline a need to better understand the associations between residence floor level and CVD and multistory housing and CVD.

Educational Level, Anticoagulation Quality, and Clinical Outcomes in Elderly Patients with Acute Venous Thromboembolism: A Prospective Cohort Study

Whether the level of education is associated with anticoagulation quality and clinical outcomes in patients with acute venous thromboembolism (VTE) is uncertain. We thus aimed to investigate the association between educational level and anticoagulation quality and clinical outcomes in elderly patients with acute VTE. We studied 817 patients aged ≥65 years with acute VTE from a Swiss prospective multicenter cohort study (09/2009-12/2013). We defined three educational levels: 1) less than high school, 2) high school, and 3) post-secondary degree. The primary outcome was the anticoagulation quality, expressed as the percentage of time spent in the therapeutic INR range (TTR). Secondary outcomes were the time to a first recurrent VTE and major bleeding. We adjusted for potential confounders and periods of anticoagulation. Overall, 56% of patients had less than high school, 25% a high school degree, and 18% a post-secondary degree. The mean percentage of TTR was similar across educational levels (less than high school, 61%; high school, 64%; and post-secondary, 63%; P = 0.36). Within three years of follow-up, patients with less than high school, high school, and a post-secondary degree had a cumulative incidence of recurrent VTE of 14.2%, 12.9%, and 16.4%, and a cumulative incidence of major bleeding of 13.3%, 15.1%, and 15.4%, respectively. After adjustment, educational level was neither associated with anticoagulation quality nor with recurrent VTE or major bleeding. In elderly patients with VTE, we did not find an association between educational level and anticoagulation quality or clinical outcomes.

Heart failure and risk of venous thromboembolism: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism is a major global health problem that is often secondary to other clinical situations. Many studies have investigated the association between venous thromboembolism and heart failure, but have yielded inconsistent findings. We aimed to quantify the absolute and relative risks (RR) for venous thromboembolism in patients with heart failure after hospital admission. We also assessed rates of venous thromboembolism in patients in different settings.

METHODS

In this systematic review and meta-analysis, we searched for studies investigating the risk of venous thromboembolism in patients in hospital with heart failure. We searched for studies published between Jan 1, 1955, and March 31, 2015, in PubMed, Embase, Evidence-Based Medicine Reviews, Allied and Complementary Medicine Database, Ovid HealthSTAR, Global Health, Ovid Nursing Database, Web of Science, CINAHL Plus, ProQuest Central, Conference Papers Index, BIOSIS Previews, and ClinicalTrials.gov. All cohort studies and subgroup analyses of randomised controlled trials (RCTs) were eligible for inclusion if they reported venous thromboembolism rates (number of events per follow-up period) or RR estimates. We extracted data from published reports and contacted the corresponding authors of records with insufficient quantitative data. RRs and 95% CIs were pooled using a random-effects model. This study is registered with PROSPERO, number CRD42014015504.

FINDINGS

Of 8673 records identified, we included 71 studies with data from 88 cohorts in our analysis, with 59 cohorts included in the assessment of venous thromboembolism rates and 46 cohorts included in the meta-analysis of heart failure and risk of venous thromboembolism. Venous thromboembolism rates varied widely in patients in hospital with heart failure from different settings. The overall median symptomatic venous thromboembolism rate was 2·48% (IQR 0·84-5·61); rates was were 3·73% (1·05-7·31) for patients who did not receive thromboprophylaxis and 1·47% (0·64-3·54) for those who did. Overall, patients with heart failure in hospital had an RR of 1·51 (1·36-1·68) for venous thromboembolism. The overall I(2) statistic was 96·1% and there was no evidence of publication bias (Egger's test, p=0·46).

INTERPRETATION

Heart failure is a common independent risk factor for venous thromboembolism. Thromoboprophylaxis should be considered in clinical practice for high-risk patients.

FUNDING

National Natural Science Foundation.

Residential zip code influences outcomes following hospitalization for acute pulmonary embolism in the United States

Socioeconomic status (SES) as reflected by residential zip code may adversely influence outcomes for patients with acute pulmonary embolism (PE). We sought to analyze the impact of neighborhood SES on in-hospital mortality, use of thrombolysis, implantation of inferior vena cava (IVC) filters and cost of hospitalization following acute PE. We used the 2003–2011 Nationwide Inpatient Sample (NIS) for this analysis. All hospital admissions with a principal diagnosis of acute PE were identified using ICD-9 codes. Neighborhood SES was assessed using median household income of the residential zip code for each patient. Over this 9-year period, 276,484 discharges with acute PE were analyzed. There was a progressive decrease in in-hospital mortality across the SES quartiles ( p-trend <0.001). The incidence of in-hospital mortality across quartiles 1–4 was 3.8%, 3.3%, 3.2%, and 3.1%, respectively. Despite low rates of thrombolytic utilization in this cohort, we observed a progressive increase in the rate of thrombolysis utilization across the SES quartiles (1.5%, 1.6%, 1.7%, 2.0%; p-trend <0.001). There was no significant difference in the use of IVC filters across the SES quartiles ( p-trend=0.9). The mean adjusted cost of hospitalization among quartiles 2, 3, and 4, as compared to quartile 1, was significantly higher by $1202, $1650, and $1844, respectively ( p-trend<0.001). In conclusion, patients residing in zip codes with lower SES had increased in-hospital mortality and decreased utilization of thrombolysis following acute PE compared to patients residing in higher SES zip codes. The cost of hospitalization for patients from higher SES quartiles was significantly higher than those from lower quartiles.