Secular Trends in Incidence and Mortality of Acute Venous Thromboembolism: The AB-VTE Population-Based Study

Epidemiology of deep vein thrombosis

Deep vein thrombosis (DVT) is a cause of considerable morbidity worldwide. It is a common clinical disease in the daily practice of several medical disciplines including general medicine, angiology, and internal medicine, as well as of interest to public health because of its preventability and its sensitivity to secular changes in the distribution of population risk factors. In this review we present a comprehensive overview of the epidemiological features of DVT, including incidence and risk factors. Additionally, we give an overview of the burden that DVT poses on modern health care systems.

Sex differences in Chronic Thromboembolic Pulmonary Hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed sequela of acute pulmonary embolism with varied clinical presentation causing significant morbidity among the affected population. There exist important differences in the occurrence, clinical features and diagnosis of CTEPH between men and women, with women carrying a greater predisposition for the disease. Ongoing studies have also pointed out variations among men and women, in the treatment offered and long-term outcomes including mortality. This focused review article highlights important sex-associated differences in multiple aspects of CTEPH including its epidemiology, clinical features, diagnosis, treatment and outcomes as reported in current literature and highlights the need for future research to facilitate a clearer understanding of these differences.

Machine-learning-based models assist the prediction of pulmonary embolism in autoimmune diseases: A retrospective, multicenter study

BACKGROUND

Pulmonary embolism (PE) is a severe and acute cardiovascular syndrome with high mortality among patients with autoimmune inflammatory rheumatic diseases (AIIRDs). Accurate prediction and timely intervention play a pivotal role in enhancing survival rates. However, there is a notable scarcity of practical early prediction and risk assessment systems of PE in patients with AIIRD.

METHODS

In the training cohort, 60 AIIRD with PE cases and 180 age-, gender-, and disease-matched AIIRD non-PE cases were identified from 7254 AIIRD cases in Tongji Hospital from 2014 to 2022. Univariable logistic regression (LR) and least absolute shrinkage and selection operator (LASSO) were used to select the clinical features for further training with machine learning (ML) methods, including random forest (RF), support vector machines (SVM), neural network (NN), logistic regression (LR), gradient boosted decision tree (GBDT), classification and regression trees (CART), and C5.0 models. The performances of these models were subsequently validated using a multicenter validation cohort.

RESULTS

In the training cohort, 24 and 13 clinical features were selected by univariable LR and LASSO strategies, respectively. The five ML models (RF, SVM, NN, LR, and GBDT) showed promising performances, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.962-1.000 in the training cohort and 0.969-0.999 in the validation cohort. CART and C5.0 models achieved AUCs of 0.850 and 0.932, respectively, in the training cohort. Using D-dimer as a pre-screening index, the refined C5.0 model achieved an AUC exceeding 0.948 in the training cohort and an AUC above 0.925 in the validation cohort. These results markedly outperformed the use of D-dimer levels alone.

CONCLUSION

ML-based models are proven to be precise for predicting the onset of PE in patients with AIIRD exhibiting clinical suspicion of PE.

TRIAL REGISTRATION

Chictr.org.cn : ChiCTR2200059599.

Cannula-Associated Deep Vein Thrombosis Following Extracorporeal Membrane Oxygenation Decannulation: Incidence and Risk Factors

Thrombotic complications during and after extracorporeal membrane oxygenation (ECMO) are commonly observed clinically. The incidences of cannula-associated deep vein thrombosis (CaDVT) post-ECMO support have predominantly focused on Caucasian demographics. This study aims to determine the incidence and risk factors for CaDVT in Vietnamese patients following ECMO decannulation. The retrospective study from January 2019 to February 2020 observed ECMO weaning patients and screened for CaDVT using Doppler ultrasonography. Data were collected on patient demographics, ECMO parameters, and transfusion and coagulation profiles during ECMO support. Of the 82 patients successfully weaned ECMO, 89% were assessed for CaDVT. We observed a CaDVT incidence of 24.7%, and only one patient (5.6%) had a pulmonary embolism in the CaDVT group. Noteworthy is that the anticoagulation goals, transfusion during ECMO, and hospital mortality showed no significant difference between the CaDVT and non-CaDVT groups. The findings showed that the duration of ECMO support is a risk factor for CaDVT. The incidence of CaDVT following ECMO decannulation was 24.7%, and the diagnosis of CaDVT can be underestimated. Therefore, we suggest routine screening for CaDVT after cannula removal.

Pulmonary Embolism in Donor Lungs-Incidence and Management

In efforts to decrease the mortality on the waiting list for lung transplantation, alternatives to increase the donor pool have been explored. Caution must be used when accepting donor lungs with pulmonary embolism (PE), as prior evidence has shown mixed results after transplantation of donor lungs with PE. However, the mere diagnosis of PE on imaging should not be the sole reason for the exclusion of these donors for transplant, and they should be reviewed as any other donor. A comprehensive evaluation should be performed for every donor, with a special focus on abnormalities of gas exchange and gross pathologic characteristics during procurement.

Anticoagulation in the Management of Acute Pulmonary Embolism-A Review

Venous thromboembolism (VTE) is a very frequent cardiovascular entity that encompasses deep vein thrombosis and pulmonary embolism (PE). This last entity represents a major cause of cardiovascular morbidity and mortality. The incidence of PE and the rate of PE-related morbidity significantly increase with age, race, and underlying medical conditions, such as malignancy. Given the recent advances in diagnostic strategies and algorithms, patients can be risk assessed and treated promptly to avoid disease progression. Anticoagulation is the mainstay of treatment for acute PE that is not hemodynamically unstable. Direct oral anticoagulants, such as apixaban, rivaroxaban, or edoxaban, are currently the preferred agents for the treatment of patients who present with acute PE or for long-term treatment. Treatment duration should be continued for at least 3 months, and all patients should be assessed for extended duration of therapy based on the precipitating factors that led to the development of the VTE. Novel anticoagulant agents targeting factor XI/XIa are currently being investigated in phases 2 and 3 clinical trials, representing an attractive option in anticoagulation therapies in patients with VTE. For hemodynamically unstable patients, systemic thrombolysis is the treatment of choice, and it may also be of benefit-in reduced dose-for patients with intermediate to high risk who are at risk of hemodynamic collapse.

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.

Persistent Peril: Recurrent Deep Vein Thrombosis and Pulmonary Embolism in a Patient With Protein S Deficiency Despite Optimal Anticoagulation Therapies

The clotting system has evolved as an adaptive mechanism to prevent blood loss during vascular damage. However, the intricate nature of the clotting cascade and the complexities of human life can sometimes lead to the unnatural activation of this delicate cascade. This can result in blood clot formation within the cardiovascular system, contributing to a wide range of pathological conditions. Abnormal intravascular coagulation most commonly occurs in the deep veins of the lower extremities, and can emboli to other organs, hence, it is termed "venous thromboembolism" (VTE). In this report, we introduce a challenging case of VTE that poses a dilemma for current medical management. The patient with possible protein S deficiency underwent various guideline-directed medical treatments, yet experienced recurrent VTE episodes, including deep vein thrombosis (DVT) and pulmonary embolism (PE), leading to hospital readmissions. This case report sheds light on our challenges in effectively treating VTE.

An epidemiologic study comparing cancer- and noncancer-associated venous thromboembolism in a racially diverse Southeastern United States county

Background

Cancer-associated venous thromboembolism (CA-VTE) represents a major cause of morbidity and mortality in patients with cancer. Despite poor outcomes, there is an ongoing knowledge gap in epidemiologic data related to this association.

Objectives

To compare venous thromboembolism (VTE) characteristics, risk factors, and outcomes between patients with and without active cancer in a racially diverse population.

Methods

Our surveillance project occurred at the 3 hospitals in Durham County, North Carolina, from April 2012 through March 2014. Electronic and manual methods were used to identify unique Durham County residents with VTE.

Results

We identified 987 patients with VTE during the surveillance period. Of these, 189 patients had active cancer at the time of their VTE event. Patients with CA-VTE were older (median age: 69 years vs 60 years, P < .0001) and had a lower body mass index (median body mass index: 26.0 kg/m2 vs 28.4 kg/m2, P = .0001) than noncancer patients. The most common cancers in our cohort were gastrointestinal, breast, genitourinary, and lung. The proportion of VTE cases with pulmonary embolism (PE) was greater in the cancer cohort compared with that in the noncancer cohort (58.2% vs 44.0%, P = .0004). Overall survival was lower in the CA-VTE group than in patients without cancer (P < .0001). Black patients with CA-VTE had lower proportion of PE (52.3% vs 67.1%, P = .05) but had decreased survival (P < .0003) in comparison with White patients.

Conclusion

Future studies may be needed to continue to evaluate local and national VTE data to improve VTE prevention strategies and CA-VTE outcomes.

An overview of systematic reviews on imaging tests for diagnosis of pulmonary embolism applying different network meta-analytic methods

PURPOSE

This study aimed to apply different methods of diagnostic test accuracy network meta-analysis (DTA-NMA) for studies reporting results of five imaging tests for the diagnosis of suspected pulmonary embolism (PE): pulmonary angiography (PA), computed tomography angiography (CTPA), magnetic resonance angiography (MRA), planar ventilation/perfusion (V/Q) scintigraphy and single-photon emission computed tomography ventilation/perfusion (SPECT V/Q).

METHODS

We searched four databases (MEDLINE [via PubMed], Cochrane CENTRAL, Scopus, and Epistemonikos) from inception until June 2, 2022 to identify systematic reviews (SRs) describing diagnostic accuracy of PA, CTPA, MRA, V/Q scan and SPECT V/Q for suspected PE. Study-level data were extracted and pooled using a hierarchical summary receiver operating characteristic (HSROC) meta-regression approach and two DTA-NMA models to compare accuracy estimates of different imaging tests. Risk of bias was assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool and certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.

RESULTS

We identified 13 SRs, synthesizing data from 33 primary studies and for four imaging tests (PA, CTPA, MRA and V/Q scan). The HSROC meta-regression model using PA as the reference standard showed that MRA had the best overall diagnostic performance with sensitivity of 0.93 (95% confidence interval [CI]: 0.76, 1.00) and specificity of 0.94 (95% CI: 0.84, 0.99). However, DTA-NMA models indicated that V/Q scan had the highest sensitivity, while CTPA was most specific.

CONCLUSION

Selecting a different DTA-NMA method to assess multiple diagnostic tests can affect estimates of diagnostic accuracy. There is no established method, but the choice depends on the data and familiarity with Bayesian statistics.

Risk factors for venous thromboembolism following knee arthroscopy: A systematic review and meta-analysis of observational studies

Objectives

To evaluate the risk factors for increased risk of venous thrombosis after arthroscopic knee surgery.

Methods

PubMed, EMBASE and Cochrane Library were searched from their inception to April 4, 2023. Observational studies investigated venous thrombosis following arthroscopic knee surgery were included. The Newcastle Ottawa Scale (NOS) was used to evaluate the methodological quality of included studies. The odd ratios (ORs) and 95% confidence intervals (CIs) pertaining to each risk factor were synthesized through a random effects model by STATA 14 software.

Results

The protocol this meta-analysis has been registered on PROSPERO (CRD42023410283). A total of 22 observational studies were included in the systematic review, all of which were of moderate or high methodological quality. The results of the meta-analysis revealed that several factors were significantly associated with an elevated risk of venous thrombosis following arthroscopic knee surgery. These factors included age (mean age ≥30 years) [OR = 1.08, 95%CI (1.04, 1.13), P = 0.001], overweight or obesity [OR = 1.31, 95%CI (1.13, 1.52), P＜0.001], oral contraceptive use [OR = 1.90, 95%CI (1.52, 2.37), P＜0.001], and smoking history [OR = 1.35, 95%CI (1.06, 1.71), P = 0.014]. Furthermore, the subgroup analysis indicated that patients with an average age over 50 years [OR = 3.18, 95%CI (1.17, 8.66), P = 0.001] and those who underwent surgery with a tourniquet for ≥90 min [OR = 4.79, 95%CI (1.55, 14.81), P = 0.007] were at a significantly increased risk of venous thrombosis after knee arthroscopy.

Conclusion

Age, obesity, oral contraceptives, smoking history, and prolonged tourniquet use may increase the risk of venous thrombosis after arthroscopic knee surgery. The incidence of venous thrombosis after knee arthroscopy is on a downward trend, but due to its severity, increasing awareness of risk factors and implementing effective prophylaxis are important tasks for clinicians to prevent the risk of venous thrombosis after knee arthroscopy.

Mortality, Recurrent Thromboembolism and Major Bleeding in Cancer-Associated and Non-Cancer Pulmonary Embolism Patients Treated With Direct Oral Anticoagulants

BACKGROUND

Pulmonary embolism (PE) is a potentially fatal form of venous thromboembolism (VTE). This study compares the mortality, incidence of recurrent VTE, and incidence of major bleeding between non-cancer and cancer-associated PE patients treated with direct oral anticoagulants (DOACs).

METHODS AND RESULTS

This was a retrospective, observational, single-center study involving 130 consecutive patients (87 with active cancer; 43 without cancer) who received DOAC treatment for PE between January 2016 and December 2019. Kaplan-Meier analysis showed significantly higher mortality in cancer-associated PE patients than in non-cancer patients (35/87 [40%] vs. 1/43 [2%], P<0.001, log-rank test, HR 18.6 [95% CI: 2.5-136.0]). In contrast, the cumulative incidences of recurrent VTE and major bleeding were comparable between the 2 groups. Among the cancer-associated PE patients, the incidence for the composite outcome of recurrent VTE or major bleeding was significantly higher in patients undergoing chemotherapy than in those not undergoing chemotherapy (9/37 [24%] vs. 2/50 [4%], P=0.004, log-rank test, HR 6.9 [95% CI: 1.5-32.0]).

CONCLUSIONS

Although cancer-associated PE patients treated with DOACs showed higher mortality compared with non-cancer patients, presumably because of the presence of cancer, the risk of recurrent VTE or major bleeding was comparable between the 2 groups. Thus, DOAC is an important treatment option for cancer-associated PE, although underlying cancer-related risks (e.g., chemotherapy) remain.

Development and validation of a clinical prediction model for 90-day venous thromboembolism risk following total hip and total knee arthroplasty: a multinational study

BACKGROUND

The risk of venous thromboembolism (VTE) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is 1.0% to 1.5%, despite uniform thromboprophylaxis.

OBJECTIVES

To develop and validate a prediction model for 90-day VTE risk.

METHODS

A multinational cohort study was performed. For model development, records were used from the Oxford Royal College of General Practitioners Research and Surveillance Centre linked to Hospital Episode Statistics and Office of National Statistics UK routine data. For external validation, data were used from the Danish Hip and Knee Arthroplasty Registry, the National Patient Registry, and the National Prescription Registry. Binary multivariable logistic regression techniques were used for development.

RESULTS

In the UK data set, 64 032 THA/TKA procedures were performed and 1.4% developed VTE. The prediction model consisted of age, body mass index, sex, cystitis within 1 year before surgery, history of phlebitis, history of VTE, presence of varicose veins, presence of asthma, history of transient ischemic attack, history of myocardial infarction, presence of hypertension and THA or TKA. The area under the curve of the model was 0.65 (95% CI, 0.63-0.67). Furthermore, 36 169 procedures were performed in the Danish cohort, of whom 1.0% developed VTE. Here, the area under the curve was 0.64 (95% CI, 0.61-0.67). The calibration slope was 0.92 in the validation study and 1.00 in the development study.

CONCLUSION

This clinical prediction model for 90-day VTE risk following THA and TKA performed well in both development and validation data. This model can be used to estimate an individual's risk for VTE following THA/TKA.

Modern Treatment of Pulmonary Embolism (USCDT vs MT): Results From a Real-World, Big Data Analysis (REAL-PE)

Background

Advanced therapies are increasingly utilized to treat pulmonary embolism (PE). A unique data platform allows access to electronic health record data for comparison of the safety of PE therapies.

Methods

All data from Truveta (Truveta, Inc) were analyzed (16 systems, 83,612,413 patients, 535,567 with PE). All patients treated with ultrasound-assisted catheter-directed thrombolysis (USCDT) (Boston Scientific) or mechanical thrombectomy (MT) (Inari Medical) for PE were identified. The primary analysis was based on index procedures performed from January 2009 to May 2023, and contemporary analysis on those performed from January 2018 to May 2023. Bleeding was assessed via direct laboratory analysis and transfusion administration documentation. International Society for Thrombosis and Hemostasis (ISTH) and Bleeding Academic Research Consortium (BARC) 3b definitions were recreated. Multiple logistic regression analysis of major bleeding was performed. In-hospital death and median length of stay were measured.

Results

For the primary analysis, 2259 patients (N = 1577 USCDT, N = 682 MT) and for the contemporary analysis 1798 patients (N = 1137 USCDT, N = 661 MT) met the criteria. Incidence of hemoglobin reduction (>2 and >5 g/dL) and transfusions received were significantly higher among MT-treated patients in both analyses, as was ISTH and BARC 3b major bleeding (primary: ISTH MT 17.3% vs USCDT 12.4% P = .002; BARC 3b MT 15.4% vs USCDT 11.8% P = .019) (contemporary: ISTH MT 17.2% vs USCDT 11.0% P = .0002; BARC 3b MT 15.4% vs USCDT 10.6% P = .002). Regression analysis demonstrated that MT is associated with major bleeding. Median length of stay, all-cause 30-day readmission and in-hospital mortality were similar between groups. Intracranial hemorrhage was more common with MT.

Conclusions

Major bleeding derived from direct laboratory and transfusion data occurred more frequently with MT vs USCDT. Intracranial hemorrhage was more common among MT-treated patients. In the absence of randomized data, these results provide guidance regarding the bleeding risk and safety of strategies for advanced PE therapy.

Diagnostic trends of preoperative venous thromboembolism and its clinical implications in patients who underwent surgery for degenerative spinal diseases

BACKGROUND CONTEXT

Although the risk of postoperative venous thromboembolism (VTE) in patients who undergo surgery for degenerative spinal disease has received attention, patients experiencing prolonged pain and disability while awaiting or considering surgery have not received adequate attention regarding the risk of VTE.

PURPOSE

To investigate the epidemiology of preoperative VTE in patients undergoing surgery for degenerative spinal disease.

DESIGN

Retrospective cohort study using a nationwide database.

PATIENT SAMPLE

Patients who underwent surgery for degenerative spinal disease.

OUTCOME MEASURES

Preoperative occurrence of VTE.

METHODS

Data from 2014 to 2018 were obtained from the Korean National Health Insurance claims database. The occurrence of preoperative VTE within a 1-year period divided into 12 time intervals of 30 days each was investigated. The patients were categorized into two groups based on the presence of preoperative VTE. Multivariable logistic regression analysis was conducted to identify the factors associated with preoperative VTE. To validate the relationship between degenerative spinal disease and preoperative VTE, the diagnostic trends of preoperative VTE were analyzed in accordance with the identified risk factors.

RESULTS

The overall incidence of preoperative VTE was 50 per 10,000 individuals. Multivariable analysis revealed that VTE occurred more frequently in older patients with specific medical comorbidities, particularly in those with a lumbar spinal lesion accompanied by arthritis of the hip, knee, or shoulder. We also found that the incidence rates of preoperative VTE, as well as the gradient of their increase, began to rise approximately 2 to 3 months prior to the index surgery, peaking just before the index surgery. This diagnostic trend was consistently observed in all patients irrespective of the presence of other risk factors.

CONCLUSIONS

The incidence of preoperative VTE in patients with degenerative spinal disease exhibited a sharp increase immediately before surgery, with similar rates to those of postoperative VTE. Clinicians managing patients with degenerative spinal disease should be vigilant for preoperative as well as postoperative VTE.

Immune cell-mediated venous thrombus resolution

Herein, we review the current processes that govern experimental deep vein thrombus (DVT) resolution. How the human DVT resolves at the molecular and cellular level is not well known due to limited specimen availability. Experimentally, the thrombus resolution resembles wound healing, with early neutrophil-mediated actions followed by monocyte/macrophage-mediated events, including neovascularization, fibrinolysis, and eventually collagen replacement. Potential therapeutic targets are described, and coupling with site-directed approaches to mitigate off-target effects is the long-term goal. Similarly, timing of adjunctive agents to accelerate DVT resolution is an area that is only starting to be considered. There is much critical research that is needed in this area.

Risk of Venous Thromboembolism With Gout Flares

OBJECTIVE

Previous studies demonstrated that the risk of venous thromboembolism (VTE) is increased in patients with gout, but not whether there was a temporal association between gout flare and VTE. This study was undertaken to evaluate potential temporal associations between gout flare and VTE.

METHODS

Data were obtained from electronic primary-care records from the UK's Clinical Practice Research Datalink, which links data from hospitalization and mortality registers. Using self-controlled case series analysis adjusted for season and age, we evaluated the temporal association between gout flare and VTE. The 90 days after primary-care consultation or hospitalization for gout flare was designated the exposed period. This was divided into three 30-day intervals. The baseline period was up to 2 years before the start of and up to 2 years after the end of the exposed period. The association between gout flare and VTE was measured using adjusted incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs).

RESULTS

In total, 314 patients met the inclusion criteria (age ≥18 years, incident gout, no presence of VTE or use of a primary-care anticoagulant prescription before the start of the pre-exposure period). Among the 314 patients, VTE incidence was significantly higher in the exposed period than in the baseline period (adjusted IRR 1.83, 95% CI 1.30-2.59). The adjusted IRR of VTE during the first 30 days after gout flare was 2.31 (95% CI 1.39-3.82) relative to the baseline period. No increase in the adjusted IRRs was observed in days 31-60 (adjusted IRR 1.49, 95% CI 0.79-2.81) and days 61-90 (adjusted IRR 1.67, 95% CI 0.91-3.06) relative to baseline. Results were consistent across sensitivity analyses.

CONCLUSION

Among patients with gout, there was a transient increase in the rate of VTE within 30 days after primary-care consultation or hospitalization for gout flare.

Echocardiographic Evaluation of Pulmonary Embolism: A Review

Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States. Appropriate risk stratification is an important component of the initial evaluation for acute management of these patients. Echocardiography plays a crucial role in the risk stratification of patients with PE. In this literature review, we describe the current strategies in risk stratification of patients with PE using echocardiography and the role of echocardiography in the diagnosis of PE.

Venous thromboembolism prophylaxis for hospitalized adult patients: a survey of US health care providers on attitudes and practices

Background

Venous thromboembolism (VTE) is a leading cause of preventable mortality among hospitalized patients, but appropriate risk assessment and thromboprophylaxis remain underutilized or misapplied.

Objectives

We conducted an electronic survey of US health care providers to explore attitudes, practices, and barriers related to thromboprophylaxis in adult hospitalized patients and at discharge.

Results

A total of 607 US respondents completed the survey: 63.1% reported working in an academic hospital, 70.7% identified as physicians, and hospital medicine was the most frequent specialty (52.1%). The majority of respondents agreed that VTE prophylaxis is important (98.8%; 95% CI: 97.6%-99.5%) and that current measures are safe (92.6%; 95% CI: 90.2%-94.5%) and effective (93.8%; 95% CI: 91.6%-95.6%), but only half (52.0%; 95% CI: 47.9%-56.0%) believed that hospitalized patients at their institution are on appropriate VTE prophylaxis almost all the time. One-third (35.4%) reported using a risk assessment model (RAM) to determine VTE prophylaxis need; 44.9% reported unfamiliarity with RAMs. The most common recommendation for improving rates of appropriate thromboprophylaxis was to leverage technology. A majority of respondents (84.5%) do not reassess a patient's need for VTE prophylaxis at discharge, and a minority educates patients about the risk (16.2%) or symptoms (18.9%) of VTE at discharge.

Conclusion

Despite guideline recommendations to use RAMs, the majority of providers in our survey do not use them. A majority of respondents believed that technology could help improve VTE prophylaxis rates. A majority of respondents do not reassess the risk of VTE at discharge or educate patients about this risk of VTE at discharge.

Subsegmental pulmonary embolism and anticoagulant therapy: the impact of clinical context

BACKGROUND

Anticoagulation for subsegmental pulmonary embolism (SSPE) is controversial.

AIM

To assess the impact of clinical context on anticoagulation and outcomes of SSPE.

METHODS

We electronically searched computed tomography pulmonary angiogram reports to identify SSPE. We extracted demographic, risk factor, investigations and outcome data from the electronic medical record. We stratified patients according to anticoagulation and no anticoagulation.

RESULTS

From 1 January 2017 to 31 December 2019, we identified 166 patients with SSPE in 5827 pulmonary angiogram reports. Of these, 123 (74%) received anticoagulation. Compared with non-anticoagulated patients, such patients had a different clinical context: higher rates of previous venous thromboembolism (11% vs 0%; P = 0.019), more recent surgery (26% vs 9%; P = 0.015), more elevated serum D-dimer (22% vs 5%; P = 0.004), more lung parenchymal abnormalities (76% vs 61%; P = 0.037) and were almost twice as likely to require inpatient care (76% vs 42%; P < 0.001). Such patients also had twice the all-cause mortality at 1 year (32% vs 16%).

CONCLUSIONS

SSPE is diagnosed in almost 3% of pulmonary angiograms and is associated with high mortality, regardless of anticoagulation, due to coexistent disease processes rather than SSPE. Anticoagulation appears dominant but markedly affected by the clinical context of risk factors, alternative indications and illness severity. Thus, the controversy is partly artificial because anticoagulation after SSPE is clinically contextual with SSPE as only one of several factors.

Clinical presentations of acute pulmonary embolism: A retrospective cohort study

We aimed to investigate whether the unusual clinical presentation of pulmonary embolism (PE) varies by the type of provocation. In this retrospective cohort study, we examined the electronic health records (EHR) records of all patients diagnosed with PE (upon presentation or during hospitalization) presented to our tertiary hospital during 2014 to 2019. Inclusion criteria were the diagnosis of acute PE and age above 18 years. Excluded were all patients to whom complete EHR were not available. The primary outcome was the main presenting symptom, categorized by a multidisciplinary consensus expert committee as either typical or atypical of PE. Comorbidities, vital signs, medications and laboratory results on presentations were recorded. 591 patients were included in the final analysis. Dyspnea was significantly less common and hemoptysis and chest pain more common in the unprovoked PE group (35%, 5%, and 25%, respectively) compared with nonmalignant (42.6%, 0%, and 16.3%) and malignancy-associated (47.7%, 0.9%, and 8.2%) PE (Pv = 0.02, 0.002 and 0.001, respectively). No recorded symptoms were the third most common presentation overall, accounting for a significantly (Pv < 0.001) higher proportion of PE patients with malignancy (19%) whereas atypical presentation was the hallmark of patients with nonmalignant provokation (19.7%) (Pv = 0.005). Accounting for multiple potential confounders, the risk of atypical or asymptomatic presentation was higher with lower heart rates (RR = 0.974 95%C.I. [0.957-0.990]) and higher pulse oximetry saturation (RR = 1.114 95%CI [1.034-1.201]). The clinical presentation of PE varies with different types of provoking factors, with atypical presentation most common in nonmalignant provocation and asymptomatic presentation most prevalent in patients with underlying malignancy. Further studies are needed to determine the effect of said variance on long term clinical outcomes.

Unmet Needs and Future Direction for Pulmonary Embolism Interventions

Venous thromboembolism (VTE) usually develops in the deep veins of the extremities. Pulmonary embolism (PE) is a type of VTE that is most commonly (∼90%) caused by a thrombus that originates from the deep veins of the lower extremities. PE is the third most common cause of death after myocardial infarction and stroke. In this review, the authors investigate and discuss the risk stratification and definitions of the aforementioned categories of PE and further explore the management of acute PE along with the types of catheter-based treatment options and their efficacy.

Pulmonary embolism in United States emergency departments, 2010-2018

Little is known about pulmonary embolism (PE) in the United States emergency department (ED). This study aimed to describe the disease burden (visit rate and hospitalization) of PE in the ED and to investigate factors associated with its burden. Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2010 to 2018. Adult ED visits with PE were identified using the International Classification of Diseases codes. Analyses used descriptive statistics and multivariable logistic regression accounting for the NHAMCS's complex survey design. Over the 9-year study period, there were an estimated 1,500,000 ED visits for PE, and the proportion of PE visits in the entire ED population increased from 0.1% in 2010-2012 to 0.2% in 2017-2018 (P for trend = 0.002). The mean age was 57 years, and 40% were men. Older age, obesity, history of cancer, and history of venous thromboembolism were independently associated with a higher proportion of PE, whereas the Midwest region was associated with a lower proportion of PE. The utilization of chest computed tomography (CT) scan appeared stable, which was performed in approximately 43% of the visits. About 66% of PE visits were hospitalized, and the trend remained stable. Male sex, arrival during the morning shift, and higher triage levels were independently associated with a higher hospitalization rate, whereas the fall and winter months were independently associated with a lower hospitalization rate. Approximately 8.8% of PE patients were discharged with direct-acting oral anticoagulants. The ED visits for PE continued to increase despite the stable trend in CT use, suggesting a combination of prevalent and incident PE cases in the ED. Hospitalization for PE remains common practice. Some patients are disproportionately affected by PE, and certain patient and hospital factors are associated with hospitalization decisions.

Updated Renal Dosage Recommendations for Rivaroxaban in Patients Experiencing or at Risk of Thromboembolic Disease

Patients with chronic kidney disease are at an increased risk of venous thromboembolism (VTE). The factor Xa inhibitor rivaroxaban has been shown to provide similar efficacy and a lower risk of bleeding compared with vitamin K antagonists for the treatment and prevention of VTE. Rivaroxaban has been studied in patients with varying degrees of renal impairment, and this review summarizes current knowledge supporting its use in patients with severe renal impairment (creatinine clearance [CrCl] of 15 to < 30 mL/min) for the prevention, treatment, or prophylaxis of VTE. Clinical pharmacology studies have demonstrated an increase in rivaroxaban systemic exposure, factor Xa inhibition, and prothrombin time with decreasing renal function. These changes reach a plateau with comparable increases in exposure among individuals with moderate or severe renal impairment and end-stage renal disease. The clinical development program for the treatment and prevention of VTE as well as prophylaxis of deep vein thrombosis (DVT) following orthopedic surgery excluded patients with CrCl < 30 mL/min; however, a limited number of patients with severe renal impairment were enrolled. Efficacy outcomes in these patients with severe renal impairment were not meaningfully different from those of patients with higher levels of renal function. There was also no increase in the incidence of major bleeding with rivaroxaban in patients with CrCl < 30 mL/min. Taken together, these pharmacological and clinical data suggest that in patients with severe renal impairment, the approved dosages of rivaroxaban can be used in the treatment and prevention of VTE and for prophylaxis of DVT after hip or knee replacement surgery.

Endovascular Venous Interventions - A State-of-the-Art Review

Venous vascular diseases are an important clinical entity estimated to affect several million people worldwide. Deep vein thrombosis (DVT) is a common venous disease with a population variable prevalence of 122 to 160 persons per 100,000 per year, whereas pulmonary embolism (PE) affects up to 60 to 70 per 100 000 and carries much higher mortality. Chronic venous diseases, which cause symptoms like leg swelling, heaviness, pain, and discomfort, are most prevalent in the elderly and significantly impact their quality of life. Some estimate that chronic vascular diseases account for up to 2% of healthcare budgets in Western countries. Treating venous vascular disease includes using systemic anticoagulation and interventional therapies in some patient subsets. In this comprehensive review, we discuss endovascular treatment modalities in the management of venous vascular diseases.

Venous thromboembolism: Why is it still a significant health problem?

BACKGROUND

Venous thromboembolism (VTE) remains the third leading cause of acute cardiovascular syndrome following myocardial infarction and ischemic stroke. The global burden of disease worldwide is high and shows a steady upward trend in recent years with an incidence of 1-2 per 1000 adults per year. The overarching goal of the initial management of VTE is to prevent early and late adverse outcomes. Rapid evaluation and therapeutic intervention is vital to improving prognosis.

METHODS

We searched PubMed, Science Direct and Scopus databases for articles published in the last 10 years. Additionally, some earlier articles were analyzed.

RESULTS

For the purposes of this review, we discussed how understanding the epidemiology of VTE and the current knowledge of early and late complications of this disease have shaped the current approach to VTE prevention. We also analyzed the current knowledge and the most up-to-date information about VTE in COVID-19 infection. Contemporary perspective presented in this article on mortality in VTE, the incidence of recurrences, the risk of major bleeding during therapy and the chronic complications indicate why this is a major challenge for today's medicine and a current target for further research.

CONCLUSIONS

Understanding the interaction between environmental and genetic factors appears to be crucial in the diagnostic process. It can provide insight into the pathophysiology of VTE, potentially identifying options for targeted prevention and treatment. However, due to differences in clinical presentation, diagnosing pulmonary embolism may not be an easy task which perfectly illustrates the scale and complexity of the disease.

A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology

Venous thromboembolism (VTE) is the third most common cause of death worldwide. The incidence of VTE varies according to different countries, ranging from 1-2 per 1000 person-years in Western Countries, while it is lower in Eastern Countries (<1 per 1000 person-years). Many risk factors have been identified in patients developing VTE, but the relative contribution of each risk factor to thrombotic risk, as well as pathogenetic mechanisms, have not been fully described. Herewith, we provide a comprehensive review of the most common risk factors for VTE, including male sex, diabetes, obesity, smoking, Factor V Leiden, Prothrombin G20210A Gene Mutation, Plasminogen Activator Inhibitor-1, oral contraceptives and hormonal replacement, long-haul flight, residual venous thrombosis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, trauma and fractures, pregnancy, immobilization, antiphospholipid syndrome, surgery and cancer. Regarding the latter, the incidence of VTE seems highest in pancreatic, liver and non-small cells lung cancer (>70 per 1000 person-years) and lowest in breast, melanoma and prostate cancer (<20 per 1000 person-years). In this comprehensive review, we summarized the prevalence of different risk factors for VTE and the potential molecular mechanisms/pathogenetic mediators leading to VTE.

The influence of lower-leg injury and knee arthroscopy on natural anticoagulants and fibrinolysis

BACKGROUND

Patients with lower-leg injuries and those undergoing knee arthroscopy are at increased risk of developing venous thromboembolism. The mechanism is unknown, including the influence of lower-leg injury and knee arthroscopy on natural anticoagulant factors and fibrinolysis.

OBJECTIVES

To study the effect of lower-leg injury and knee arthroscopy on plasma levels of anticoagulant and fibrinolytic factors.

METHODS

We applied the following 2 designs to investigate this effect: a cross-sectional study for lower-leg trauma and a before-and-after study for knee arthroscopy. Plasma samples of POT-CAST- and POT-KAST-randomized clinical trial participants (collected shortly after lower-leg trauma or before or after arthroscopy) were analyzed for clot lysis time and levels of antithrombin, tissue factor pathway inhibitor, protein C, free protein S, plasminogen, tissue plasminogen activator, plasminogen activator inhibitor 1, antiplasmin, thrombin activatable fibrinolysis inhibitor, plasmin-antiplasmin, and D-dimer. For the effect of lower-leg injury, samples of 289 patients were compared with preoperative samples of 293 arthroscopy patients, acting as controls using linear regression and adjusting for age, sex, body mass index, comorbidities, and diurnal variation. For the effect of knee arthroscopy, mean changes were calculated for 277 patients using linear mixed models adjusted for diurnal variation. Parameters other than CLT and D-dimer were measured in smaller subsets.

RESULTS

In lower-leg injury patients, most parameters were stable, whereas D-dimer increased. After arthroscopy, most parameters decreased (especially clot lysis time, D-dimer, plasminogen, and anticoagulant factors), whereas tissue plasminogen activator and thrombin activatable fibrinolysis inhibitor slightly increased.

CONCLUSION

In contrast to lower-leg injury, knee arthroscopy was associated with decreased natural anticoagulant factor levels. Neither lower-leg injury nor knee arthroscopy affected in vivo fibrinolysis.

Impact of Time to Intervention on Catheter-Directed Therapy for Pulmonary Embolism

Cather-directed therapies (CDTs) are an evolving therapeutic option for patients with intermediate-risk pulmonary embolism (PE). Although many techniques have been studied, there is limited evidence for the impact of timing of intervention on patient outcomes. Our objective was to assess the association between time to CDT in patients presenting with PE on patient-related outcomes such as length of stay (LOS) and mortality.

DESIGN

Retrospective cohort study.

SETTING

Single academic center.

PATIENTS

We identified patients for which the PE response team had been activated from January 2014 to October 2021. Patients were split into two cohorts depending on whether they went to CDT less than 24 hours from admission (early) versus greater than 24 hours (late).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data on demographics, timing of interventions, pulmonary hemodynamics, and outcomes were collected. Sixty-four patients were included in analysis. Thirty-nine (63.8%) underwent their procedure less than 24 hours from admission, whereas 25 (36.2%) underwent the procedure after 24 hours. The time from admission to CDT was 15.9 hours (9.1-20.3 hr) in the early group versus 33.4 (27.9-41) in the late group (p ≤ 0.001). There was a greater decrease in pulmonary artery systolic pressure after intervention in the early cohort (14 mm Hg [6-20 mm Hg] vs 6 mm Hg [1-10 mm Hg]; p = 0.022). Patients who received earlier intervention were found to have shorter hospital LOS (4 vs 7 d; p = 0.038) and ICU LOS (3 vs 5 d; p = 0.004). There was no difference in inhospital mortality between the groups (17.9% vs 12%; p = 0.523).

CONCLUSIONS

Patients who underwent CDT within 24 hours of admission were more likely to have shorter hospital and ICU LOS. The magnitude of change in LOS between the two cohorts was not fully explained by the difference in time to CDT. There were modest improvements in pulmonary hemodynamics in the patients who underwent CDT earlier.

The association between iliac vein compression degree and characteristics of first diagnosed left lower extremity deep vein thrombosis

Objective

This study aimed to investigate the association between the left common iliac vein (CIV) compression degree and characteristics of first diagnosed left lower extremity deep vein thrombosis (DVT).

Patients and methods

This was a single-center retrospective observational study. Between January 2015 and June 2022, first diagnosed left lower extremity DVT patients with enhanced computed tomography of lower extremities were included. Patient demographics, comorbidities, risk factors, DVT characteristics, and CIV compression degree were collected and analyzed. Logistic regressions were performed to evaluate the odds ratio (OR) with a 95% confidence interval (CI) of iliofemoral or mixed DVT vs. compression percentage. The association between compression percentage and iliofemoral or mixed DVT was evaluated on a continuous scale with restricted cubic splines (RCS). The association between compression percentage and thrombus burden was evaluated using the Spearman test.

Results

A total of 196 (mean age, 61.8 ± 16.1 years; 86 males) patients were included. The median CIV compression percentage in iliofemoral or mixed DVT patients was significantly greater than in non-iliofemoral or non-mixed DVT, respectively (64.4 vs. 46.6%, p < 0.001; 67.8 vs. 54.8%, p = 0.004). CIV compression >50% was associated with significantly increased morbidity of iliofemoral DVT (adjusted OR, 2.96; 95% CI, 1.58-5.52; p = 0.001) or mixed DVT (adjusted OR, 2.39; 95% CI, 1.19-4.81; p = 0.014). RCS showed that a greater compression percentage was associated with a continuously increased OR of iliofemoral DVT (overall p = 0.003, non-linear p = 0.577) or mixed DVT (overall p = 0.020, non-linear p = 0.771). CIV compression percentage had a positive correlation with thrombus burden (rs = 0.284, p < 0.001).

Conclusion

A greater left CIV compression percentage may be associated with increasing likelihood of more proximal location and severe clot extent in first diagnosed left lower extremity DVT.

Applicability of the Padua scale for Chinese rheumatic in-patients with venous thromboembolism

OBJECTIVE

To investigate the risk factors for venous thromboembolism (VTE) in hospitalized patients with rheumatic diseases in China. The efficacy of the Padua scale was evaluated and an improved model for predicting VTE in hospitalized patients with rheumatic diseases was developed.

METHODS

Records of 2282 patients hospitalized in the department of rheumatology of the Sichuan Provincial People's Hospital were retrospectively reviewed. The risk factors for VTE were analyzed. The efficacy of the Padua scale was evaluated, Padua-combined prediction model and the independent risk factor-combined prediction model for predicting VTE were assessed using the receiver operating curve (ROC).

RESULTS

A total of 50 patients in the VTE group and 2232 in the non-VTE group were included. Antiphospholipid syndrome (APS), VTE history, a hospital stay of over 3 days, high D-dimer (D-D), and decreased serum albumin were independent risk factors for VTE. APS was very closely associated with VTE (OR = 19.446). Padua scores in the VTE group and the non-VTE group were 3 (2, 6) and 2 (1, 2) points, respectively (p < 0.05), and the proportion of high-risk patients were 48.0% and 7.4%, respectively (p < 0.05). The incidence of VTE in the high-risk (Padua score ≥4) and low-risk (Padua score <4) groups was 12.7% and 1.2%, respectively (p < 0.05). The area under curve (AUC) of the Padua scale, Padua combined prediction model (Padua scale along with D-D and serum albumin), and the independent risk factor-combined prediction model was 0.771, 0.836, and 0.873, respectively.

CONCLUSION

The Padua scale has limited predictive efficacy of VTE in hospitalized rheumatic patients. The independent risk factor-combination prediction model was superior in predicting VTE compared to Padua scale and Padua-combined prediction model.

Cancer-associated venous thromboembolism: Incidence and features in a racially diverse population

BACKGROUND

Data on the population-based incidence of cancer-associated venous thromboembolism (VTE) from racially diverse populations are limited.

OBJECTIVE

To evaluate the incidence and burden of cancer-associated VTE, including demographic and racial subgroups in the general population of Oklahoma County-which closely mirrors the United States.

DESIGN

A population-based prospective study.

SETTING

We conducted surveillance of VTE at tertiary care facilities and outpatient clinics in Oklahoma County, Oklahoma, from 2012-2014. Surveillance included reviewing all imaging reports used to diagnose VTE and identifying VTE events from hospital discharge data and death certificates. Cancer status was determined by linkage to the Oklahoma Central Cancer Registry.

MEASUREMENTS

We used Poisson regression to calculate crude and age-adjusted incidence rates of cancer-associated VTE per 100 000 general population per year, with 95% confidence intervals (95% CI).

RESULTS

The age-adjusted incidence (95% CI) of cancer-associated VTE among adults age ≥ 18 was 70.0 (65.1-75.3). The age-adjusted incidence rates (95% CI) were 85.9 (72.7-101.6) for non-Hispanic Blacks, 79.5 (13.2-86.5) for non-Hispanic Whites, 18.8 (8.9-39.4) for Native Americans, 15.6 (7.0-34.8) for Asian/Pacific Islanders, and 15.2 (9.2-25.1) for Hispanics. Recurrent VTE up to 2 years after the initial diagnosis occurred in 38 of 304 patients (12.5%) with active cancer and in 34 of 424 patients (8.0%) with a history of cancer > 6 months previously.

CONCLUSION

Age-adjusted incidence rates of cancer-associated VTE vary substantially by race and ethnicity. The relatively high incidence rates of first VTE and of recurrence warrant further assessment of strategies to prevent VTE among cancer patients.

Sex Differences in Management and Outcomes Among Patients With High-Risk Pulmonary Embolism: A Nationwide Analysis

OBJECTIVE

To examine the sex differences in management and outcomes among patients with high-risk acute pulmonary embolism (PE).

PATIENTS AND METHODS

The Nationwide Readmissions Database was used to identify hospitalizations with high-risk PE from January 1, 2016, to December 31, 2018. Differences in use of advanced therapies, in-hospital mortality, and bleeding events were compared between men and women.

RESULTS

A total of 125,901 weighted hospitalizations with high-risk PE were identified during the study period; 46.3% were women (n=58,253). Women were older and had a higher prevalence of several comorbidities and risk factors of PE such as morbid obesity, diabetes mellitus, chronic pulmonary disease, heart failure, and metastatic cancer. Systemic thrombolysis and catheter-directed interventions were more commonly used among women; however, mechanical circulatory support was less frequently used. In-hospital mortality was higher among women in the unadjusted analysis (30.7% vs 27.8%, P<.001) and after propensity score matching (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.08 to 1.25; P<.001), whereas the rates of intracranial hemorrhage and non-intracranial hemorrhage were not different. On multivariate regression analysis, female sex (OR, 1.18; 95% CI, 1.15 to 1.21; P<.001) was independently associated with increased odds of in-hospital mortality.

CONCLUSION

In this contemporary observational cohort of patients admitted with high-risk PE, women had higher rates of in-hospital mortality despite receiving advanced therapies more frequently, whereas the rate of major bleeding events was not different from men. Efforts are needed to minimize the excess mortality observed among women.

Construction of Pulmonary Embolism Prediction, Early Warning, and Precontrol MDT Collaborative Nursing Model Based on the Smith Model

The purpose of this study was to construct a multidisciplinary collaborative nursing model for pulmonary embolism risk prediction, early warning, and precontrol based on the Smith model and evaluate the application effect and hospitalization satisfaction. 2,037 patients hospitalized in the thoracic surgery department from June 1, 2019, to May 31, 2021, were selected as the research subjects. The control group received routine pulmonary embolism prevention management, while the experimental group received safe, case-based, and programmatic multidisciplinary intervention management based on the Smith policy management model. The data were analyzed statistically. The experimental group’s extubation and hospitalization time, D-dimer value, incidence of deep vein thrombosis, and pulmonary embolism on the seventh day after surgery were lower than those in the control group, and the satisfaction of hospitalization in the experimental group was higher than that in the control group. The implementation of the multidisciplinary collaborative nursing model of pulmonary embolism risk prediction, early warning, and precontrol based on the Smith model can promote the preventive effect of pulmonary embolism risk of surgical patients in our department and effectively improve the satisfaction of hospitalization, which is worthy for further promotion.

Contemporary National Trends and Outcomes of Pulmonary Embolism in the United States

Contemporary data on the national trends in pulmonary embolism (PE) admissions and outcomes are scarce. We aimed to analyze trends in mortality and different treatment methods in acute PE. We queried the Nationwide Readmissions Database (2016 to 2019) to identify hospitalizations with acute PE using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. We described the national trends in admissions, in-hospital mortality, readmissions, and different treatment methods in acute PE. We identified 1,427,491 hospitalizations with acute PE, 2.4% of them (n = 34,446) were admissions with high-risk PE. The rate of in-hospital mortality in all PE hospitalizations was 6.5%, and it remained unchanged throughout the study period. However, the rate of in-hospital mortality in high-risk PE decreased from 48.1% in the first quarter of 2016 to 38.9% in the last quarter of 2019 (p-trend <0.001). The rate of urgent 30-day readmission was 15.2% in all PE admissions and 19.1% in high-risk PE admissions. In all PE admissions, catheter-directed interventions (CDI) were used more often (2.5%) than systemic thrombolysis (ST) (2.1%). However, in admissions with high-risk PE, ST remained the most frequently used method (ST vs CDI: 11.3% vs 6.6%). In conclusion, this study showed that the rate of in-hospital mortality in high-risk PE decreased from 2016 to 2019. ST was the most frequently used method for achieving pulmonary reperfusion in high-risk PE, whereas CDI was the most frequently used method in the entire PE cohort. In-hospital death and urgent readmissions rates remain significantly high in patients with high-risk PE.

Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand (TRAIL): A Novel Biomarker for Prognostic Assessment and Risk Stratification of Acute Pulmonary Embolism

Background: Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) is associated with poor prognosis in cardiovascular diseases. However, the predictive value of TRAIL for the short-term outcome and risk stratification of acute pulmonary embolism (PE) remains unknown. Methods: This study prospectively included 151 normotensive patients with acute PE. The study outcome was a composite of 30-day adverse events, defined as PE-related death, shock, mechanical ventilation, cardiopulmonary resuscitation, and major bleeding. Results: Overall, nine of 151 (6.0%) patients experienced 30-day adverse composite events. Multivariable logistic regression showed that TRAIL was an independent predictor of study outcome (OR 0.19 per SD; 95% CI 0.04–0.90). An ROC curve revealed that TRAIL’s area under the curve (AUC) was 0.83 (95% CI 0.76–0.88). The optimal cut-off value for TRAIL was 18 pg/mL, with a sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, and negative likelihood ratio of 89%, 69%, 99%, 15%, 2.87, and 0.16, respectively. Compared with the risk stratification algorithm outlined in the 2019 ESC guidelines, our biomarker-based risk stratification strategy (combining TRAIL and hs-cTnI) has a similar risk classification effect. Conclusion: Reduced plasma TRAIL levels predict short-term adverse events in normotensive patients with acute PE. The combination of the 2019 ESC algorithm and TRAIL aids risk stratification in normotensive patients with acute PE.

Racial differences in venous thromboembolism: A surveillance program in Durham County, North Carolina

Background

Venous thromboembolism (VTE) affects approximately 1-2 individuals per 1000 annually and is associated with an increased risk for pulmonary hypertension, postthrombotic syndrome, and recurrent VTE.

Objective

To determine risk factors, incidence, treatments, and outcomes of VTE through a 2-year surveillance program initiated in Durham County, North Carolina (population approximately 280,000 at time of study).

Patients/Methods

We performed a retrospective analysis of data actively collected from three hospitals in Durham County during the surveillance period.

Results

A total of 987 patients were diagnosed with VTE, for an annual rate of 1.76 per 1000 individuals. Hospital-associated VTE occurred in 167 hospitalized patients (16.9%) and 271 outpatients who were hospitalized within 90 days of diagnosis (27.5%). Annual incidence was 1.98 per 1000 Black individuals compared to 1.25 per 1000 White individuals (p < 0.0001), and Black individuals with VTE were younger than White individuals (p < 0.0001). Common risk factors included active cancer, prolonged immobility, and obesity, and approximately half were still taking anticoagulant therapy 1 year later. A total of 224 patients died by 1 year (28.5% of patients for whom outcomes could be confirmed), and Black patients were more likely to have recurrent VTE than White patients during the first 6 months following initial presentation (9.4% vs. 4.1%, p = 0.01).

Conclusions

Ongoing surveillance provides an effective strategy to identify patients with VTE and monitor treatment and outcomes. We demonstrated that hospital-associated VTE continues to be a major contributor to the burden of VTE and confirmed the higher incidence of VTE in Black compared to White individuals.

Thromboprophylaxis after knee arthroscopy does not decrease the risk of deep vein thrombosis: a network meta-analysis

PURPOSE

The primary aim of this network meta-analysis (NMA) is to compare the incidence of venous thromboembolisms (VTE) and bleeding risk following the use of pharmacological and non-pharmacological thromboprophylaxis for arthroscopic knee surgery (AKS). This study assumed the null hypothesis which was that there will be no difference in the incidence of VTE and bleeding risk when comparing no treatment, pharmacological treatment, and non-pharmacological treatment for preventing VTE events following AKS.

METHODS

A systematic electronic search of CENTRAL, Medline, Embase, and ClinicalTrials.gov was carried out. All English language prospective randomized clinical trials published from date of database inception to November 21, 2021 were eligible for inclusion. All papers addressing arthroscopic knee surgery were eligible for inclusion regardless of timing of surgery, operation, surgical technique, or rehabilitation. Multiple random effects NMAs were conducted to compare all treatments for each outcome. The primary outcome was the incidence of pulmonary embolism (PE) and secondary outcomes consisted of overall deep vein thrombosis (DVT), symptomatic DVT, asymptomatic DVT, and all-cause mortality. Adverse outcomes consisted of major and minor bleeding, as well as adverse events.

RESULTS

A total of nine studies with 4526 patients were included for analysis. There were 1054 patients in the no treatment/placebo group (NT/Placebo), 1646 patients in the graduated compression stockings, 810 patients in the extended-duration (> 10 days) low molecular weight heparin (Ext-LMWH) group, 650 patients in the short-duration (< 10 days) LMWH group (Short-LMWH), and 356 patients in the rivaroxaban group. GCS, Ext-LMWH, Short-LMWH and rivaroxaban all demonstrated low risks of PE, symptomatic DVT, asymptomatic DVT, combined DVT and all-cause mortality. Similarly, all interventions demonstrated a low risk of major bleeding.

CONCLUSION

There is no significant difference in the risk reduction of PEs, symptomatic DVTs, major/minor bleeding, and/or all-cause mortality when using LWMH (including short or extended regimens), rivaroxaban, graduated compression stockings or no treatment following arthroscopic knee surgery. Future primary research on the efficacy of thromboprophylaxis following arthroscopic knee surgery should stratify outcomes based on key patient (i.e., age, sex, comorbidities) and surgical (i.e., major vs. minor surgery) characteristics and should include acetylsalicylic acid as an intervention.

LEVEL OF EVIDENCE

I, network meta-analysis of Level I studies.

A Young Female With Thyroid Storm and Pulmonary Embolus: A Case Study

Thyroid storm (TS) and pulmonary embolus (PE) are both dangerous conditions. We present a case of a 34-year-old woman suffering from both conditions concomitantly. She was given propranolol, propylthiouracil (PTU), potassium iodide (SSKI), hydrocortisone, and heparin, and improved gradually over the course of a 5-day hospitalization. The patient’s presentation provided difficulties in diagnosis as well as management. Based on our experience with this case, we recommend that the practitioner refrains from prematurely anchoring on one diagnosis without a full workup for the other, as these conditions can be mutually causative. Also, if the patient meets the criteria for TS, it is important to treat them as such, even in the setting of “unimpressive” thyroid study abnormalities. Finally, it is important to administer a beta blocker in the setting of TS, even in the combined setting of PE, as long as the patient has no evidence of heart strain.

Lower-leg injury and knee arthroscopy have distinct effects on coagulation

Unlike knee arthroscopy, lower-leg injury is associated with increased plasma levels of factor VIII, von Willebrand factor, and D-dimer.

In both situations, coagulation is affected differently, which suggests that there are different pathways toward venous thromboembolism.

It is unknown how lower-leg injury and knee arthroscopy, both associated with venous thromboembolism (VTE), affect coagulation. To study the effect of (1) lower-leg trauma and (2) knee arthroscopy on coagulation, plasma samples of the Prevention of Thrombosis following CAST immobilization (POT-CAST, #NCT01542762) and Prevention of Thrombosis following Knee Arthroscopy (POT-KAST, #NCT01542723) trials were used, which were collected shortly after lower-leg trauma and before/after (<4 hours) knee arthroscopy. For aim 1, 1204 lower-leg injury patients were compared with preoperative samples of 1001 controls. Mean differences/ratios (if ln-retransformed because of skewedness) were adjusted for sex, age, body mass index, comorbidity, malignancy, and oral contraceptives using linear regression. For aim 2, perioperative mean changes of 715 arthroscopy patients were calculated. Plasma levels of fibrinogen, factor (F)VIII, FIX, FXI, von Willebrand Factor (VWF), and D-dimer were measured in all individuals. Parameters of underlying mechanisms (tissue factor, interleukin-6 [IL-6], myeloperoxidase DNA, cell-free DNA) were measured in random subsets. In lower-leg injury patients, coagulation parameter levels increased, especially FVIII, VWF, and D-dimer, that is, adjusted mean differences: FVIII 26.8% (95% confidence interval [CI], 23.7-29.9), FIX 13.8% (95% CI, 11.9-15.6), FXI 5.1% (95% CI, 3.3-7.0), VWF 29.8% (95% CI, 26.0-33.6), fibrinogen 32.5 mg/dL (95% CI, 25.8-39.2), and D-dimer (mean ratio) 3.3 (95% CI, 3.1-3.6). Remaining parameters were unchanged, except for increased IL-6 levels. After arthroscopy, all parameters decreased. Lower-leg trauma is associated with increased procoagulant factor levels in contrast to knee arthroscopy. This suggests that, in both situations, different pathways are involved in development of VTE.

An impact evaluation of an education bundle for patients at risk of developing venous thromboembolism

Aim: Among hospitalized patients, venous thromboembolism (VTE) is a preventable cause of morbidity and mortality. This study analyzed the effects of a large-scale adoption of a prompt response and education protocol to increase VTE prophylaxis adherence in the USA. Methods: A Markov model was developed that simulates outcomes and costs of delivering a VTE education bundle versus not, to hospitalized at-risk patients. Results: The education bundle could avert more than 134,000 VTEs, 552,000 hospital days and 19,000 deaths over 5 years. Patients could save 13 million hours in work absenteeism and travel time, valued at US$237 million. Total societal savings could amount to US$2.8 billion. In scenario analyses with assumed lower-effectiveness estimates, the bundle averts 16,000 VTEs, 67,000 hospital days and 2000 deaths. Conclusion: A nationwide rollout of an education bundle to reduce missed doses of prescribed prophylaxis could improve quality of care, resulting in a decline in VTEs and mortality.

Left Ventricle Outflow Tract Velocity-Time Index and Right Ventricle to Left Ventricle Ratio as Predictors for in Hospital Outcome in Intermediate-Risk Pulmonary Embolism

Accurate estimation of risk with both imaging and biochemical parameters in intermediate risk pulmonary embolism (PE) remains challenging. The aim of the study was to evaluate echocardiographic parameters that reflect right and left heart hemodynamic as predictors of adverse events in intermediate risk PE. This was a retrospective observational study on patients with computed tomography pulmonary angiography diagnosis of PE admitted at Cardiology department of the Clinical Emergency Hospital of Oradea, Romania between January 2018—December 2021. Echocardiographic parameters obtained at admission were studied as predictors of in hospital adverse events. The following adverse outcomes were registered: death, resuscitated cardiac arrest, hemodynamic deterioration and need of rescue thrombolysis. An adverse outcome was present in 50 patients (12.62%). PE related death was registered in 17 patients (4.3%), resuscitated cardiac arrest occurred in 6 patients (1.51%). Another 20 patients (5.05%) required escalation of therapy with thrombolysis and 7 (1.76%) patients developed haemodynamic instability. Echocardiographic independent predictors for in hospital adverse outcome were RV/LV ≥ 1 (HR = 3.599, 95% CI 1.378−9.400, p = 0.009) and VTI ≤ 15 mm (HR = 11.711, 95% CI 4.336−31.633, p < 0.001). The receiver operator curve renders an area under curve for LVOT VTI ≤ 15 mm of 0.792 (95% CI 0.719−0.864, p < 0.001) and for a RV/LV ≥ 1 of 0.746 (95% CI 0.671−0.821, p < 0.001). A combined criterion (LVOT VTI ≤ 15 and RV/LV ≥ 1) showed a positive predictive value of 75% and a negative predictive value of 95% regarding in hospital adverse outcomes. Low LVOT VTI and increased RV/LV are useful for identifying normotensive patients with PE at risk for short term adverse outcomes. Combining an LVOT VTI ≤ 15 cm with a RV/LV ≥ 1 can identify with increased accuracy PE patients with impending risk of clinical deterioration.

Incidence of Venous Thromboembolism: The 3rd Korean Nationwide Study

BACKGROUND

The incidence of venous thromboembolism (VTE) has gradually increased in the Korean population. This study aimed to evaluate the annual age- and sex-adjusted incidence rates (ASR) of VTE and anticoagulation trends between 2014 and 2018.

METHODS

Using the Korean Health Insurance Review and Assessment Service database, we retrospectively identified VTE patients between 2014 and 2018 using both diagnostic and medication anticoagulant codes assigned within 6 months of the initial index event. Anticoagulant patterns were classified as follows: direct oral anticoagulants (DOAC), parenteral anticoagulants, warfarin, and mixed anticoagulation regimens.

RESULTS

We identified 95,205 patients with VTE (female, 56.8%). The ASR for VTE per 100,000 person-years increased from 32.8 in 2014 to 53.7 cases in 2018 (relative risk of 1.63; 95% confidence interval, 1.6-1.67). The VTE incidence rates were 25 times higher in the ≥ 80 group than in the 30s group. VTE occurred 1.29 times more often in women than in men. The proportion of DOAC prescriptions increased from 40.5% to 72.8%, whereas warfarin prescriptions decreased from 27% to 5.6% in 2014 and 2018.

CONCLUSION

In Korea, the ASRs of VTE continued to increase since 2014, but the rate of increase slowed in 2018. The VTE occurred more often in the elderly and in women. Five years after the introduction of DOACs in 2013, they accounted for 73% of all anticoagulants used to treat VTE.

Effect of lower-leg trauma and knee arthroscopy on procoagulant phospholipid-dependent activity

Background

Lower-leg injury and knee arthroscopy are both associated with venous thromboembolism (VTE). The mechanism of VTE in both situations is unknown, including the role of procoagulant microparticles. This may provide useful information for individualizing thromboprophylactic treatment in both patient groups.

Objective

We aimed to study the effect of (1) lower-leg trauma and (2) knee arthroscopy on procoagulant phospholipid-dependent (PPL) activity plasma levels.

Methods

POT-(K)CAST trial participants who did not develop VTE were randomly selected for the current study. Plasma was collected shortly after lower-leg trauma or before and after knee arthroscopy. For aim 1, samples of 67 patients with lower-leg injury were compared with control samples (preoperative samples of 74 patients undergoing arthroscopy). Linear regression was used to obtain mean ratios (natural logarithm retransformed data), adjusted for age, sex, body mass index, infections, and comorbidities. For aim 2, pre- and postoperative samples of 49 patients undergoing arthroscopy were compared using paired t tests. PPL activity was measured using modified activated factor X-dependent PPL clotting assay.

Results

For aim 1, PPL activity levels were almost threefold higher in patients with lower-leg injury compared with controls, that is, mean ratio, 2.82 (95% confidence interval [CI], 1.98-4.03). For aim 2, postoperative PPL activity levels did not change significantly, that is, mean change, -0.72 mU/mL (95% CI, -2.03 to 0.59).

Conclusion

Lower-leg trauma was associated with increased plasma levels of PPL activity, in contrast to knee arthroscopy. Lower-leg trauma triggers the release of procoagulant microparticles.

Sex-specific aspects of venous thromboembolism: What is new and what is next?

Men seem to have a higher intrinsic risk of venous thromboembolism (VTE) than women, regardless of age. To date, this difference has not been explained. By integrating state-of-the-art research presented at the International Society on Thrombosis and Haemostasis Congress of 2021 with the available literature, we address potential explanations for this intriguing risk difference between men and women. We discuss the role of exogenous and endogenous sex hormones as the most important known sex-specific determinants of VTE risk. In addition, we highlight clues on the role of sex hormones and VTE risk from clinical scenarios such as pregnancy and the polycystic ovary syndrome. Furthermore, we address new potential sex-specific risk factors and unanswered research questions, which could provide more insight in the intrinsic risk difference between men and women, such as body height and differences in body fat distribution, leading to dysregulation of metabolism and inflammation.

Management of Acute Coronary Syndrome in Cancer Patients: It's High Time We Dealt with It

Cancer patients have an increased risk of cardiovascular disease and, notably, a significant prevalence of acute coronary syndrome (ACS). It has been shown that an elevated presence of cardiovascular risk factors in this setting leads to an interaction between these two conditions, influencing their therapeutic strategies and contributing to higher mortality. Nonetheless, cancer patients have generally not been evaluated in ACS trials, so that the treatment in these cases is still not fully known. We reviewed the current literature and discussed the best management for these very high-risk patients. The treatment strategy must be tailored based on the cancer type and stage, balancing thrombotic and bleeding risks. When the prognosis is longer than six months, especially if a clinical instability coexists, patients with ACS and cancer should be referred for percutaneous coronary intervention (PCI) as soon as possible. Moreover, an invasive strategy should be preferred in STEMI patients as well as in NSTEMI patients who are considered as high risk. On the contrary, in clinically stable NSTEMI patients, a conservative non-invasive strategy could be adopted, especially in cases of a poor life expectancy and/or of high risk of bleeding. Drug-Eluting-Stents (DES) should be the first choice if an invasive strategy is adopted. Conservative therapy could instead be considered in cancer patients with more stable CAD at an increased risk of major bleeding complications. However, the duration of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended, but it should be as short as possible, whereas triple antithrombotic therapy is non-advised because it significantly increases the risk of bleeding. ACS management among cancer patients should be based on an accurate evaluation of the risk of thrombosis and bleeding. Future studies focused on choosing optimal strategies in tumor patients with ACS should be performed to treat this subset of patients better.