Heart failure in patients with deep vein thrombosis

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.

Giant Left Ventricular Thrombus Rapidly Developing in an Extremely Short Period of Time in a Patient With Severe Systolic Dysfunction

Although left ventricular thrombi (LVTs) are closely related to the prognosis of patients with systolic dysfunction, anticoagulation therapy is not recommended for the primary prevention of LVTs in patients with sinus rhythm heart failure. We report a case of a patient with systolic dysfunction who developed a giant LVT in an extremely short period of time (one month) after an infection. The LVT led to acute limb ischemia, gangrene, and death. Additionally, we incidentally detected pulmonary thrombosis in this patient.

Effectiveness, Safety, and Costs of Thromboprophylaxis with Enoxaparin or Unfractionated Heparin Among Medical Inpatients With Chronic Obstructive Pulmonary Disease or Heart Failure

Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are risk factors for venous thromboembolism (VTE). Enoxaparin and unfractionated heparin (UFH) help prevent hospital-associated VTE, but few studies have compared them in COPD or HF. Objectives: To compare effectiveness, safety, and costs of enoxaparin vs UFH thromboprophylaxis in medical inpatients with COPD or HF. Methods: This retrospective cohort study included adults with COPD or HF from the Premier PINC AI Healthcare Database. Included patients received prophylactic-dose enoxaparin or UFH during a >6-day index hospitalization (the first visit/admission that met selection criteria during the study period) between January 1, 2010, and September 30, 2016. Multivariable regression models assessed independent associations between exposures and outcomes. Hospital costs were adjusted to 2017 US dollars. Patients were followed 90 days postdischarge (readmission period). Results: In the COPD cohort, 114 174 (69%) patients received enoxaparin and 51 011 (31%) received UFH. Among patients with COPD, enoxaparin recipients had 21%, 37%, and 10% lower odds of VTE, major bleeding, and in-hospital mortality during index admission, and 17% and 50% lower odds of major bleeding and heparin-induced thrombocytopenia (HIT) during the readmission period, compared with UFH recipients (all P <.006). In the HF cohort, 58 488 (58%) patients received enoxaparin and 42 726 (42%) received UFH. Enoxaparin recipients had 24% and 10% lower odds of major bleeding and in-hospital mortality during index admission, and 13%, 11%, and 51% lower odds of VTE, major bleeding, and HIT during readmission (all P <.04) compared with UFH recipients. Enoxaparin recipients also had significantly lower total hospital costs during index admission (mean reduction per patient: COPD, 1280 ; H F , 2677) and readmission (COPD, 379 ; H F , 1024). Among inpatients with COPD or HF, thromboprophylaxis with enoxaparin vs UFH was associated with significantly lower odds of bleeding, mortality, and HIT, and with lower hospital costs. Conclusions: This study suggests that thromboprophylaxis with enoxaparin is associated with better outcomes and lower costs among medical inpatients with COPD or HF based on real-world evidence. Our findings underscore the importance of assessing clinical outcomes and side effects when evaluating cost-effectiveness.

Outcomes among heart failure patients hospitalized for acute pulmonary embolism and COVID-19 infection: Insight from the National Inpatient Sample

There is paucity of data regarding the outcomes of hospitalized acute pulmonary embolism (PE) patients with heart failure (HF) and Coronavirus Disease 2019 (COVID-19) infection. We utilized the 2020 National Inpatient Sample (NIS) Database in conducting a retrospective cohort study to investigate the outcomes of hospitalized acute PE patients with HF and COVID-19, looking at its impact on in-hospital mortality, thrombolysis, and thrombectomy utilization as well as hospital length of stay (LOS). A total of 23,413 hospitalized acute PE patients with HF were identified in our study, of which 1.26% (n = 295/23,413) had COVID-19 infection. Utilizing a stepwise survey multivariable logistic regression model that adjusted for confounders, COVID-19 infection among acute PE patients with HF was found to be an independent predictor of overall in-hospital mortality (adjusted odds ratio [aOR]: 2.77; 95% confidence interval [CI], 1.15-6.67; p = 0.023) and thrombolysis utilization (aOR: 5.52; 95% CI, 2.57-11.84; p ≤ 0.001) compared to those without COVID-19. However, there were comparable rates of thrombectomy utilization and LOS among acute PE patients with HF regardless of the COVID-19 infection status. On subgroup analysis, patients with HF with reduced ejection fraction was found to be associated with increased risk for in-hospital mortality (aOR: 3.89; 95% CI, 1.33-11.39; p = 0.013) and thrombectomy utilization (aOR: 4.58; 95% CI, 1.08-19.41; p = 0.042), whereas both HF subtypes were associated with increased thrombolysis utilization. COVID-19 infection among acute PE patients with HF was associated with higher over-all in-hospital mortality and increased thrombolysis utilization but had comparable hospital LOS as well as thrombectomy utilization.

The effect of intermittent pneumatic compression on deep-vein thrombosis and ventilation-free days in critically ill patients with heart failure

There are contradictory data regarding the effect of intermittent pneumatic compression (IPC) on the incidence of deep-vein thrombosis (DVT) and heart failure (HF) decompensation in critically ill patients. This study evaluated the effect of adjunctive use of IPC on the rate of incident DVT and ventilation-free days among critically ill patients with HF. In this pre-specified secondary analysis of the PREVENT trial (N = 2003), we compared the effect of adjunctive IPC added to pharmacologic thromboprophylaxis (IPC group), with pharmacologic thromboprophylaxis alone (control group) in critically ill patients with HF. The presence of HF was determined by the treating teams according to local practices. Patients were stratified according to preserved (≥ 40%) versus reduced (< 40%) left ventricular ejection fraction, and by the New York Heart Association (NYHA) classification. The primary outcome was incident proximal lower-limb DVT, determined with twice weekly venous Doppler ultrasonography. As a co-primary outcome, we evaluated ventilation-free days as a surrogate for clinically important HF decompensation. Among 275 patients with HF, 18 (6.5%) patients had prevalent proximal lower-limb DVT (detected on trial day 1 to 3). Of 257 patients with no prevalent DVT, 11/125 (8.8%) patients in the IPC group developed incident proximal lower-limb DVT compared to 6/132 (4.5%) patients in the control group (relative risk, 1.94; 95% confidence interval, 0.74–5.08, p = 0.17). There was no significant difference in ventilator-free days between the IPC and control groups (median 21 days versus 25 days respectively, p = 0.17). The incidence of DVT with IPC versus control was not different across NYHA classes (p value for interaction = 0.18), nor across patients with reduced and preserved ejection fraction (p value for interaction = 0.15). Ventilator-free days with IPC versus control were also not different across NYHA classes nor across patients with reduced or preserved ejection fraction. In conclsuion, the use of adjunctive IPC compared with control was associated with similar rate of incident proximal lower-limb DVT and ventilator-free days in critically ill patients with HF.

Trial registration: The PREVENT trial is registered at ClinicalTrials.gov, ID: NCT02040103 (registered on 3 November 2013, https://clinicaltrials.gov/ct2/show/study/NCT02040103) and Current controlled trials, ID: ISRCTN44653506 (registered on 30 October 2013).

The Renin-Angiotensin System: A Key Role in SARS-CoV-2-Induced COVID-19

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), was first identified in Eastern Asia (Wuhan, China) in December 2019. The virus then spread to Europe and across all continents where it has led to higher mortality and morbidity, and was declared as a pandemic by the World Health Organization (WHO) in March 2020. Recently, different vaccines have been produced and seem to be more or less effective in protecting from COVID-19. The renin-angiotensin system (RAS), an essential enzymatic cascade involved in maintaining blood pressure and electrolyte balance, is involved in the pathogenicity of COVID-19, since the angiotensin-converting enzyme II (ACE2) acts as the cellular receptor for SARS-CoV-2 in many human tissues and organs. In fact, the viral entrance promotes a downregulation of ACE2 followed by RAS balance dysregulation and an overactivation of the angiotensin II (Ang II)-angiotensin II type I receptor (AT1R) axis, which is characterized by a strong vasoconstriction and the induction of the profibrotic, proapoptotic and proinflammatory signalizations in the lungs and other organs. This mechanism features a massive cytokine storm, hypercoagulation, an acute respiratory distress syndrome (ARDS) and subsequent multiple organ damage. While all individuals are vulnerable to SARS-CoV-2, the disease outcome and severity differ among people and countries and depend on a dual interaction between the virus and the affected host. Many studies have already pointed out the importance of host genetic polymorphisms (especially in the RAS) as well as other related factors such age, gender, lifestyle and habits and underlying pathologies or comorbidities (diabetes and cardiovascular diseases) that could render individuals at higher risk of infection and pathogenicity. In this review, we explore the correlation between all these risk factors as well as how and why they could account for severe post-COVID-19 complications.

Novel Hyp-Gly-containing antiplatelet peptides from collagen hydrolysate after simulated gastrointestinal digestion and intestinal absorption

Bioactive components causing the antiplatelet activity upon collagen hydrolysate (CH) ingestion have not been clarified yet. This study aimed to identify antiplatelet peptides from CH after simulated gastrointestinal digestion and intestinal absorption. Four antiplatelet peptides containing the Hyp-Gly (OG) sequence including OG, Hyp-Gly-Glu (OGE), Pro-Gly-Glu-Hyp-Gly (PGEOG) and Val-Gly-Pro-Hyp-Gly-Pro-Ala (VGPOGPA) were successfully identified. All four peptides exhibited antiplatelet activity, but OGE and PGEOG exerted stronger activity than OG and VGPOGPA. The IC50 value of OGE and PGEOG was 1.076 mM and 1.167 mM, respectively. These four antiplatelet peptides could survive simulated gastrointestinal digestion and be absorbed intact by Caco-2 cells. Furthermore, plasma stability experiments showed that OG and OGE showed a good stability in human plasma, but PGEOG and VGPOGPA showed a relatively poor stability. In vivo studies indicated that OG and OGE were present in blood after the oral administration of CH. Meanwhile, OGE exerted significant in vivo anti-thrombotic activity after its ingestion. The present study clarifies the antiplatelet components causing the CH activity and highlights the potential application of CH or these four peptides as functional foods to combat thrombosis by inhibiting platelet aggregation.

Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association

Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.

New score including daily life independence levels with dementia is associated with the onset of deep vein thrombosis in frail older adults

AIM

The detailed risk factors of deep vein thrombosis (DVT) remain unknown, and no efficient tool to assess the risk of the development of DVT among older adults has been established. This study aimed to clarify the risk factors, including the level of daily life independence, and develop an assessment score for DVT in older patients.

METHODS

We recruited 252 patients aged ≧65 years with suspected deep vein thrombosis. Risk factors for deep vein thrombosis, cognitive impairment, laboratory data and level of daily life independence were analyzed to calculate the odds ratios for the onset of DVT with logistic regressions. The Himi score was generated with factors significantly related to DVT by adjusting the respective odds ratios. The discrimination accuracy of the Himi score associated with the onset of DVT was compared with those of conventional scores (Wells score, Padua score) based on the area under the receiver operating characteristic curve.

RESULTS

Low levels of daily life independence, D-dimer level >3.0 μg/mL, anticoagulant use, cancer and immobilization or symptoms of the lower limbs were associated with the onset of DVT. The discrimination accuracy of Himi scores composed of these related factors was significantly higher than those of the Wells and Padua scores.

CONCLUSIONS

Achieving a better performance than did the Wells and Padua scores, the Himi score could be used to assess the risk of DVT in frail older adults. Geriatr Gerontol Int 2020; 20: 414-421.

Risk factors for venous thromboembolism in individuals undergoing coronary artery bypass grafting

OBJECTIVE

Venous thromboembolism (VTE) can easily occur after coronary artery bypass grafting (CABG). We assessed the proportion of patients with a diagnosis of VTE after CABG and determined the associated risk factors and complications in these patients.

METHODS

We assessed all the patients included in the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2015 who had undergone CABG. The demographic characteristics, surgical parameters, and complications were analyzed using single-factor and binary logistic regression analyses to identify the risk factors for VTE after CABG.

RESULTS

Overall, 8956 patients were identified. Postoperative VTE was found in 1.75% of these patients, with pulmonary embolism and deep vein thrombosis accounting for 0.61% and 1.28%, respectively; 0.15% of the patients had both conditions. The patients who had developed VTE had greater odds of being white and having an American Society of Anesthesiologists classification of ≥5. Multivariate analysis showed that a history of bleeding disorders, congestive heart failure, and operative time of ≥310 minutes were risk factors for the development of postoperative VTE. Patients with VTE had worse outcomes, including greater odds of returning to the operating room, hospitalization, unplanned reoperation, and readmission. The occurrence of VTE was associated with several postoperative complications, including emergency intubation, ventilator time >48 hours, pneumonia, urinary tract infection, peri- and postoperative transfusions, gradual kidney function reduction, acute kidney failure, cardiac arrest necessitating cardiopulmonary resuscitation, myocardial infarction, and septic shock.

CONCLUSIONS

The overall VTE rate after CABG has been low. However, the condition has been associated with worse 30-day postoperative outcomes and complications. The independent predictors of VTE development included a history of bleeding disorders, congestive heart failure in the 30 days before surgery, and operative time of ≥310 minutes. Understanding these risk factors should aid physicians in the decisions regarding prophylaxis and treatment.

Learning bundled care opportunities from electronic medical records

OBJECTIVE

The traditional fee-for-service approach to healthcare can lead to the management of a patient's conditions in a siloed manner, inducing various negative consequences. It has been recognized that a bundled approach to healthcare - one that manages a collection of health conditions together - may enable greater efficacy and cost savings. However, it is not always evident which sets of conditions should be managed in a bundled manner. In this study, we investigate if a data-driven approach can automatically learn potential bundles.

METHODS

We designed a framework to infer health condition collections (HCCs) based on the similarity of their clinical workflows, according to electronic medical record (EMR) utilization. We evaluated the framework with data from over 16,500 inpatient stays from Northwestern Memorial Hospital in Chicago, Illinois. The plausibility of the inferred HCCs for bundled care was assessed through an online survey of a panel of five experts, whose responses were analyzed via an analysis of variance (ANOVA) at a 95% confidence level. We further assessed the face validity of the HCCs using evidence in the published literature.

RESULTS

The framework inferred four HCCs, indicative of (1) fetal abnormalities, (2) late pregnancies, (3) prostate problems, and (4) chronic diseases, with congestive heart failure featuring prominently. Each HCC was substantiated with evidence in the literature and was deemed plausible for bundled care by the experts at a statistically significant level.

CONCLUSIONS

The findings suggest that an automated EMR data-driven framework conducted can provide a basis for discovering bundled care opportunities. Still, translating such findings into actual care management will require further refinement, implementation, and evaluation.

Biological activities of lactobacilli relevant to cardiovascular health in skim milk

In this study, skim milk was fermented using 14 Lactobacillus strains for 16 h at 42 °C or for 48 h at 25 °C. On conclusion of fermentation, the proteolytic, angiotensin converting enzyme-inhibitory (ACE-I), and antioxidant activities as well as the inhibition of thrombin and cholesterol micellar solubility were determined. The results revealed that Lb. paracasei B-4564 exhibited the highest ACE-I activity (68.11%) under the 42 °C for 16 h condition, while Lb. rhamnosus B-1445 demonstrated the highest ACE-I activity (92.23%) under the 25 °C for 48 h condition. Lb. paracasei B-4564 exhibited the highest inhibition rate of thrombin (42.43 and 48.10%) and cholesterol (68.60 and 87.01%) under the 42 °C for 16 h and 25 °C for 48 h conditions, receptively. Lb. rhamnosus B-442 exhibited the highest DPPH radical scavenging activity of 95.63 and 62.89% under the 42 °C for 16 h and 25 °C for 48 h conditions, receptively. Lb. rhamnosus B-1445 demonstrated the highest Fe²⁺ chelating activity and reducing power under both the tested fermentation conditions.

Reduced cardiac function and risk of venous thromboembolism in Asian countries

Patients with reduced cardiac function are thought to have a higher risk of venous thromboembolism (VTE). Additionally, they are vulnerable to complications of pulmonary embolism (PE) as well as right heart failure (HF), which in return is supposed to increase the rate of mortality. Studies focusing on VTE in heart failure patients were rare in Asian countries before the 21st century. Nowadays, more and more data are becoming available in this field in Asia. It is already known that heart failure can increase the risk of VTE, but so far a consensus on this issue has not been reached for many years, not only in Asian countries but all over the world. This condition may be due to the detailed pathological advancement in Virchow’s triad and some other theories. In clinical practice, VTE, especially PE is difficult to diagnose in patients with heart failure because of overlapping symptoms (e.g. cough and chest pain) and the elevation of laboratory markers (e.g. probrain natriuretic peptide (NT-proBNP) and D-dimer in both heart failure and VTE patients). Management of VTE in heart failure patients is also controversial because heart failure patients always have complications, such as renal failure and hepatic failure, which increase the risk of bleeding. In this study, we analyzed data from China, Japan, Korea, Singapore and India mainly to get a better understanding of the research progress in VTE in patients with heart failure. The aim of this review is to discuss the risk, incidence, advancement of diagnosis, management and prevention of VTE in patients with heart failure in Asian countries.

The hypolipidemic effect and antithrombotic activity of Mucuna pruriens protein hydrolysates

Hydrolysates and peptide fractions (PF) obtained fromM. pruriensprotein concentrates with commercial and digestive enzymatic systems were studied for their hypolipidemic and antithrombotic activities.

Structure elucidation of ACE-inhibitory and antithrombotic peptides isolated from mackerel skin gelatine hydrolysates

BACKGROUND

The fish-processing industry generates significant amounts of waste and by-products that are usually discarded. This study investigated the preparation of bioactive gelatine peptides from fish skin. Gelatine was extracted from mackerel (Scomber scombrus) skin and hydrolysed by pepsin for 1, 2, 6 and 24 h. All hydrolysates were screened for antioxidant, ACE-inhibitory and antithrombotic activities.

RESULTS

Gelatine peptides obtained after 24 h of hydrolysis exhibited the highest antioxidant activity (DPPH reduction ∼80%, FRAP ∼130 µmol Trolox equivalent L(-1) ). These hydrolysates had high ACE-inhibitory activity (>70%) and were able to significantly (P < 0.05) inhibit platelet aggregation by about 30%, corresponding to moderate antithrombotic activity.

CONCLUSION

The bioactive properties were mainly due to the presence of low-molecular-weight peptides of 337 and 423 Da.

Risk Factors for DVT/PE in Patients with Stroke and Intracranial Hemorrhage

Objective:

Deep venous thrombosis (DVT) and pulmonary embolus (PE) are serious problems for patients admitted to the hospital with stroke, subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and transient ischemic attack (TIA). The purpose of this paper is to further understand the factors that place certain patients at increased risk of DVT/PE.

Methods:

At a 600 bed hospital, a retrospective analysis of data from 2613 patients admitted with a diagnosis of stroke, SAH, ICH or TIA in the time range 1/2008 through 3/2012 was carried out. The data was taken from the hospital’s Get with the Guidelines database and included 28 variables. These included initial NIH stroke scale, length of stay, heart failure, ambulatory by day 2 after admission, altered mental status,and renal failure among others. Multiple analyses were carried out to determine whether there were univariable or multivariable effects of any of the factors on the risk for DVT/PE.

Results:

The risk of DVT/PE was highest in patients with SAH and ICH and smallest with TIA. Multivariable analyses were performed and revealed only altered level of consciousness or heart failure as significant risks for DVT/PE. With the limited available data, administration of subcutaneous heparin or other chemoprophylaxis did not reduce the risk of DVT/PE.

Conclusion:

Although many of the variables used to describe the stroke patient are correlated, in multivariable analyses only heart failure and altered level of consciousness were important risk factors for DVT/PE. The risk of DVT/PE was 7 fold greater in patients in patients with both of these risk factors.

Venous thromboembolism in patients with diabetes mellitus

PURPOSE

The majority of epidemiological studies demonstrate an increased risk of venous thromboembolism among diabetic patients. Our aim was to compare clinical characteristics, prophylaxis, treatment, and outcomes of venous thromboembolism in patients with and without previously diagnosed diabetes.

METHODS

We studied diabetic patients in the population-based Worcester Venous Thromboembolism Study of 2488 consecutive patients with validated venous thromboembolism.

RESULTS

Of 2488 venous thromboembolism patients, 476 (19.1%) had a clinical history of diabetes. Thromboprophylaxis was omitted in more than one third of diabetic patients who had been hospitalized for non-venous-thromboembolism-related illness or had undergone major surgery within 3 months before diagnosis. Patients with diabetes were more likely than nondiabetic patients to have a complicated course after venous thromboembolism. Patients with diabetes were more likely than patients without diabetes to suffer recurrent deep vein thrombosis (14.9% vs 10.7%) and long-term major bleeding complications (16.4% vs 11.7%) (all P=.01). Diabetes was associated with a significant increase in the risk of recurrent deep vein thrombosis (adjusted odds ratio [AOR] 1.74; 95% confidence interval [CI], 1.21-2.51). Aspirin therapy at discharge (AOR 1.59; 95% CI, 1.1-2.3) and chronic kidney disease (AOR 2.19; 95% CI, 1.44-3.35) were independent predictors of long-term major bleeding.

CONCLUSION

Patients with diabetes who developed venous thromboembolism were more likely to suffer a complicated clinical course. Diabetes was an independent predictor of recurrent deep vein thrombosis. We observed a low rate of thromboprophylaxis in diabetic patients. Further studies should focus on venous thromboembolism prevention in this vulnerable population.

Venous thromboembolism in heart failure: preventable deaths during and after hospitalization

OBJECTIVE

Our aim was to compare the clinical characteristics, prophylaxis, treatment, and outcomes of patients with venous thromboembolism with and without heart failure.

METHODS

We studied patients with heart failure in the population-based Worcester Venous Thromboembolism Study of 1822 consecutive patients with validated venous thromboembolism.

RESULTS

Of the 1822 patients with venous thromboembolism, 319 (17.5%) had a history of clinical heart failure and 1503 (82.5%) did not. Patients with heart failure were older (mean age 75 vs 62 years, P<.0001) and more likely to have been immobilized (65.2% vs 46.1%, P<.0001). Thromboprophylaxis was omitted in approximately one third of patients with heart failure who had been hospitalized for non-venous thromboembolism-related illness or had undergone major surgery within the 3 months before diagnosis. Patients with heart failure had a higher frequency of in-hospital death (9.7% vs 3.3%, P<.0001) and death within 30 days of venous thromboembolism diagnosis (15.6% vs 6.4%, P<.0001). Heart failure (adjusted odds ratio [OR] 2.04; 95% confidence interval [CI], 1.15-3.62) and immobility (adjusted OR 4.37; 95% CI, 2.42-7.9) were associated with an increased risk of in-hospital death. Heart failure (adjusted OR 1.57; 95% CI, 1.01-2.43) and immobility (adjusted OR 3.05; 95% CI, 2.01-4.62) also were independent predictors of death within 30 days of venous thromboembolism diagnosis.

CONCLUSION

High mortality was observed among patients with heart failure and venous thromboembolism both during and after hospitalization. Heart failure and immobility are potent risk factors for in-hospital death and death within 30 days in patients with venous thromboembolism.

Importance of Biomarkers for Long-Term Mortality Prediction in Acutely Dyspneic Patients

BACKGROUND

Although numerous biomarkers may be prognostically meaningful in patients with acute dyspnea, few comparative analyses have addressed possible associations between a wide range of candidate biomarkers and clinical variables.

METHODS

Vital status was obtained for 517 acutely dyspneic patients at 4 years after emergency department presentation. A wide array of biomarkers was measured in this cohort, including natriuretic peptides, necrosis markers, inflammatory markers, hematologic markers, and renal markers. We performed statistical evaluation by using minimization of the Bayesian information criterion to evaluate predictors of 4-year mortality. Cox proportional hazards analysis was used to confirm results from the Bayesian information criterion. A final risk model was derived, and this model was then validated by applying it to patients from a separate cohort of acutely dyspneic patients.

RESULTS

By 4 years, there were 186 deaths (36%). In addition to several clinical variables, several biomarkers were significant predictors of death, including log-transformed concentrations of hemoglobin (hazard ratio=0.77; P &lt; 0.001), soluble ST2 (hazard ratio=1.38; P &lt; 0.001), and amino-terminal pro-B–type natriuretic peptide (hazard ratio=1.19; P &lt; 0.001). Risk models that used these significant variables were accurate in predicting 4-year mortality in both the training and validation sets.

CONCLUSIONS

When added to traditional clinical variables, selected biomarkers added significant value for long-term prognostication in acute dyspnea.

Risk factors for venous thromboembolism

Risk factors for venous thromboembolism (VTE) are often modifiable and overlap with risk factors for coronary artery disease. Encouraging our patients to adopt a heart-healthy lifestyle by abstaining from cigarettes, maintaining lean weight, limiting red meat intake, and controlling hypertension might lower the risk of pulmonary embolism and deep vein thrombosis (DVT), although a cause-effect relationship has not been firmly established. For hospitalized patients, guidelines have provided evidence-based strategies to identify patients at risk, such as elderly persons and those with cancer, congestive heart failure, or chronic obstructive pulmonary disease or undergoing major surgery. Most should receive pharmacological prophylaxis, which will minimize the risk of VTE. Because approximately 3 of every 4 pulmonary embolism and DVT events occur outside the hospital setting, patients should also be assessed for persistent high-risk of VTE at the time of hospital discharge.

The impact of intermittent pneumatic compression devices on deep venous flow velocity in patients with congestive heart failure

BACKGROUND

Intermittent pneumatic compression (IPC) has been used to prevent deep venous thrombosis (DVT), but the effects of IPC on the hemodynamics of popliteal and soleal veins, especially in patients with congestive heart failure (CHF) have not been evaluated. The aim of this study was to evaluate the effects of IPC on the flow velocity of deep veins in the lower extremities and to compare the efficacy of two different types of IPC in deep venous flow enhancement in patients with CHF.

METHODS

Flow velocities of popliteal and soleal veins were recorded in 19 patients with CHF and in 19 control subjects using a high-resolution linear probe. Peak and mean flow velocities were measured (1) at rest, (2) with sequential foot and calf IPC (SFC-IPC) which consists of an electrically driven air compressor and four air chambers, and (3) with impulse foot IPC (IF-IPC) which consists of a pneumatic impulse generator operated at an applied pressure of 130 mmHg.

RESULTS

In the resting condition, popliteal venous flow velocity in the CHF group was attenuated (12.8+/-4.7 cm/s vs. 21.1+/-13.5 cm/s; p<0.05). Both SFC-IPC and IF-IPC increased venous velocity, but the increase with IF-IPC in CHF patients was lower than that in control subjects. In the soleal veins, after applying SFC-IPC, the peak and mean velocity in CHF increased to the same extent as in the control group. IF-IPC increased soleal venous velocity in control subjects, but there was no increase in CHF patients.

CONCLUSION

Two-dimensional Doppler scanning revealed a significant increase in the mean and peak velocities in the soleal and popliteal veins with SFC-IPC but not with IF-IPC in patients with CHF. These results indicate that SFC-IPC could have favorable effects in preventing DVT in patients with CHF.

Heart failure guidelines and implications for surgically treating heart failure

In 2005, the American College of Cardiology and the American Heart Association released updated guidelines for the diagnosis and management of chronic heart failure in the adult, yielding new insights into the progression and treatment of this disease. Perioperative nurses need a working knowledge of these guidelines to provide optimal care when patients require surgical interventions for heart failure. This article provides an overview of the pathophysiology, classifications, and treatments for heart failure.

Venous thromboembolic events in hospitalised medical patients

The number of acutely ill hospitalised medical patients at risk for acute venous thromboembolism (VTE) has not been well defined. Therefore, we used the 2003 United States Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample database to estimate VTE events among hospitalised medical patients. We then modeled the potential reduction in VTE with universal utilisation of appropriate pharmacological thromboprophylaxis. We calculated that 8,077,919 acutely ill hospitalised medical patients were at risk for VTE. Heart failure, respiratory failure, pneumonia, and cancer were the most common medical diagnoses. We estimated that 196,134 VTE-related events occurred in 2003, afflicting two out of every 100 acutely ill hospitalised medical patients. These VTE-related events were comprised of 122,235 symptomatic deep venous thromboses, 32,654 symptomatic episodes of pulmonary embolism, and 41,245 deaths due to VTE. In our model, rates of pharmacological thromboprophylaxis prescription were low for various acute medical illnesses, ranging from 15.3% to 49.2%. However, with universal thromboprophylaxis, 114,174 VTE-related events would have been prevented. In conclusion, acutely ill medical patients represent a large population vulnerable to the development of VTE during hospitalisation. The number of VTE-related events would be halved with universal thromboprophylaxis. Further efforts focused on improving VTE prevention strategies in hospitalised medical patients are warranted.

(3S)-N-(L-Aminoacyl)-1,2,3,4-tetrahydroisoquinolines, a class of novel antithrombotic agents: synthesis, bioassay, 3D QSAR, and ADME analysis

To increase antithrombotic activity, 3S-tetrahydroisoquinoline-3-carboxylic acid (1) was modified with natural amino acids to form 19 novel dipeptide analogs, 3S-tetrahydroisoquinoline-3-carboxyamino acids (5a-s), targeting the intestinal peptide transport system. In vitro assay of 5a-s indicated that their potencies for inhibiting adenosine diphosphate (ADP), arachidonic acid (AA), platelet-activating factor (PAF), and thrombin (TH)-induced platelet aggregations were higher than that of 1. Additionally, in vivo assay of 5a-s indicated that their potencies for inhibiting thrombogenesis in rats were also higher than that of 1. Among the candidates, 5h with Ser attachment showed the most impressive features for further development. According to molecular field analysis based Cerius(2) QSAR module, two equations (r, 0.961 and 0.988) correlating the structures with both in vitro and in vivo activities of 5a-s were established. ADMET calculations predict higher intestinal absorption for compounds 5a-s. Further investigation with 5h as a lead compound is underway.