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Jiménez S, Miró Ò, Llorens P, Martín-Sánchez FJ, Burillo-Putze G, Piñera P, Martín A, Alquézar A, García-Lamberechts EJ, Jacob J, Grima ML, Millán J, Molina F, Albero PB, Cardozo C, Mòdol JM, Aguirre A, Gaya R, Adroher M, Llauger L, Díaz JJL, González NC, Aragües PL, Gómez AP, del Castillo JG. Incidence, risk factors, clinical characteristics and outcomes of deep venous thrombosis in patients with COVID-19 attending the Emergency Department: results of the UMC-19-S8. Eur J Emerg Med 2021; 28:218-226. [PMID: 33904528 PMCID: PMC8082992 DOI: 10.1097/mej.0000000000000783] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND IMPORTANCE A higher incidence of venous thromboembolism [both pulmonary embolism and deep vein thrombosis (DVT)] in patients with coronavirus disease 2019 (COVID-19) has been described. But little is known about the true frequency of DVT in patients who attend emergency department (ED) and are diagnosed with COVID-19. OBJECTIVE We investigated the incidence, risk factors, clinical characteristics and outcomes of DVT in patients with COVID-19 attending the ED before hospitalization. METHODS We retrospectively reviewed all COVID patients diagnosed with DVT in 62 Spanish EDs (20% of Spanish EDs, case group) during the first 2 months of the COVID-19 outbreak. We compared DVT-COVID-19 patients with COVID-19 without DVT patients (control group). Relative frequencies of DVT were estimated in COVID and non-COVID patients visiting the ED and annual standardized incidences were estimated for both populations. Sixty-three patient characteristics and four outcomes were compared between cases and controls. RESULTS We identified 112 DVT in 74 814 patients with COVID-19 attending the ED [1.50‰; 95% confidence interval (CI), 1.23-1.80‰]. This relative frequency was similar than that observed in non-COVID patients [2109/1 388 879; 1.52‰; 95% CI, 1.45-1.69‰; odds ratio (OR) = 0.98 [0.82-1.19]. Standardized incidence of DVT was higher in COVID patients (98,38 versus 42,93/100,000/year; OR, 2.20; 95% CI, 2.03-2.38). In COVID patients, the clinical characteristics associated with a higher risk of presenting DVT were older age and having a history of venous thromboembolism, recent surgery/immobilization and hypertension; chest pain and desaturation at ED arrival and some analytical disturbances were also more frequently seen, d-dimer >5000 ng/mL being the strongest. After adjustment for age and sex, hospitalization, ICU admission and prolonged hospitalization were more frequent in cases than controls, whereas mortality was similar (OR, 1.37; 95% CI, 0.77-2.45). CONCLUSIONS DVT was an unusual form of COVID presentation in COVID patients but was associated with a worse prognosis.
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Affiliation(s)
- Sònia Jiménez
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia
| | - Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia
| | - Pere Llorens
- Emergency Department, Hospital General de Alicante, University Miguel Hernández, Elche, Alicante
| | | | | | - Pascual Piñera
- Emergency Department, Hospital General Universitario Reina Sofia, Murcia
| | - Alfonso Martín
- Servicio de Urgencias, Hospital Universitario de Móstoles, Móstoles, Madrid
| | - Aitor Alquézar
- Emergency Department, Hospital de la Santa Creu I Sant Pau
| | | | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Catalonia
| | - María L.L. Grima
- Emergency Department, Hospital Universitario Doctor Peset Aleixandre
| | - Javier Millán
- Emergency Department, Hospital Universitario y Politécnico La Fe, Valencia
| | - Francisca Molina
- Emergency Department, Hospital Universitario General de Alicante
| | - Patricia B. Albero
- Emergency Department, Hospital Virgen de los Lirios, Alcoy, Alicante, Spain
| | - Carlos Cardozo
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia
- Emergency Department, Hospital Austral, Buenos Aires, Argentina
| | - Josep M. Mòdol
- Emergency Department, Hospital Universitari Germans Trias i Pujol, Badalona
| | | | - Ruth Gaya
- Emergency Department, Hospital Universitari Joan XXIII, Tarragona
| | - María Adroher
- Emergency Department, Hospital Universitari de Girona Dr. Josep Trueta, Girona
| | - Lluís Llauger
- Emergency Department, Hospital Universitari de Vic, Barcelona, Catalonia
| | - Juan J. L. Díaz
- Emergency Department, Hospital Universitario Lucus Augusti, Lugo
| | - Nayra C. González
- Emergency Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria
| | - Paula L. Aragües
- Emergency Department, Hospital General Universitario Reina Sofia, Murcia
| | - Ana P. Gómez
- Emergency Department, Hospital de Lliria, Valencia, Spain
| | - Juan G. del Castillo
- Emergency Department, Hospital Clínico San Carlos, IDISSC, Universidad Complutense, Madrid
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Thrombosis at hospital presentation in patients with and without coronavirus disease 2019. J Vasc Surg Venous Lymphat Disord 2020; 9:845-852. [PMID: 33186750 PMCID: PMC7655032 DOI: 10.1016/j.jvsv.2020.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/01/2020] [Indexed: 01/27/2023]
Abstract
Objective In the present study, we sought to better characterize the patients with coronavirus disease 2019 (COVID-19) most at risk of severe, outpatient thrombosis by defining the patients hospitalized with COVID-19 with arterial or venous thrombosis diagnosed at admission. Methods We conducted a single-center, retrospective analysis of COVID-19 patients. We found a shift in the proportions of thrombosis subtypes from 2019 to 2020, with declines in ST-segment myocardial infarction (from 22.0% to 10.1% of thrombotic events) and stroke (from 48.6% to 37.2%) and an increase in venous thromboembolism (from 29.4% to 52.7%). The patients with COVID-19–associated thrombosis were younger (age, 58 years vs 64 years; P = .043) and were less frequently women (31.3% vs 43.9%; P = .16). However, no differences were found in the body mass index or major comorbidities between those with and without COVID-19. COVID-19–associated thrombosis correlated with greater mortality (15.2% vs 4.3%; P = .016). The biometric profile of patients admitted with COVID-19–associated thrombosis compared with regular thrombosis showed significant changes in the complete blood count, liver function test results, D-dimer levels, C-reactive protein, ferritin, and coagulation panels. Conclusions Outpatients with COVID-19 who developed thrombosis requiring hospitalization had increased mortality compared with outpatients without COVID-19 who developed thrombosis requiring hospitalization. Given the significantly higher inflammatory marker levels, it is possible this is related to different mechanisms of thrombotic disease in these patients. The inflammation could be a therapeutic target to reduce the risk, or aid in the treatment, of thrombosis. We call for more studies elucidating the role that immunothrombosis might be playing in patients with COVID-19.
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Montes Santiago J, Argibay Filgueira AB. Home treatment of venous thromboembolism disease. Rev Clin Esp 2020; 220:S0014-2565(20)30130-2. [PMID: 32560918 DOI: 10.1016/j.rce.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/08/2020] [Accepted: 03/24/2020] [Indexed: 11/30/2022]
Abstract
Despite the potential benefits of outpatient care, most patients with pulmonary embolisms are treated in hospitals for fear of possible adverse events. However, there is a wealth of scientific evidence from studies covering more than 4000 outpatients, which has led the current clinical practice guidelines to recommend early discharge or outpatient treatment when a low risk of death or complications has been confirmed, when there are no comorbidities or aggravating processes present to warrant hospitalisation and when appropriate monitoring and treatment are observed. This approach minimises the complications that can arise in hospitals and represents considerable cost savings. When selecting these patients, the use of prognostic tools such as the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI) and the Hestia Criteria are of paramount importance. Using these tools, the short-term outcomes (30-90days) show low mortality (in general <3%) and a low incidence of other complications (rate of recurrence and major bleeding <2%). Based on the available evidence, outpatient treatment can be considered the most appropriate strategy at this time for most hemodynamically stable patients with pulmonary embolisms.
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Affiliation(s)
- J Montes Santiago
- Departamento de Medicina Interna, Complejo Hospital Universitario, Vigo, Pontevedra, España.
| | - A B Argibay Filgueira
- Departamento de Medicina Interna, Complejo Hospital Universitario, Vigo, Pontevedra, España
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Pandor A, Horner D, Davis S, Goodacre S, Stevens JW, Clowes M, Hunt BJ, Nokes T, Keenan J, de Wit K. Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation. Health Technol Assess 2019; 23:1-190. [PMID: 31851608 PMCID: PMC6936165 DOI: 10.3310/hta23630] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Thromboprophylaxis can reduce the risk of venous thromboembolism (VTE) during lower-limb immobilisation, but it is unclear whether or not this translates into meaningful health benefit, justifies the risk of bleeding or is cost-effective. Risk assessment models (RAMs) could select higher-risk individuals for thromboprophylaxis. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of different strategies for providing thromboprophylaxis to people with lower-limb immobilisation caused by injury and to identify priorities for future research. DATA SOURCES Ten electronic databases and research registers (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, the Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluation Database, Science Citation Index Expanded, ClinicalTrials.gov and the International Clinical Trials Registry Platform) were searched from inception to May 2017, and this was supplemented by hand-searching reference lists and contacting experts in the field. REVIEW METHODS Systematic reviews were undertaken to determine the effectiveness of pharmacological thromboprophylaxis in lower-limb immobilisation and to identify any study of risk factors or RAMs for VTE in lower-limb immobilisation. Study quality was assessed using appropriate tools. A network meta-analysis was undertaken for each outcome in the effectiveness review and the results of risk-prediction studies were presented descriptively. A modified Delphi survey was undertaken to identify risk predictors supported by expert consensus. Decision-analytic modelling was used to estimate the incremental cost per quality-adjusted life-year (QALY) gained of different thromboprophylaxis strategies from the perspectives of the NHS and Personal Social Services. RESULTS Data from 6857 participants across 13 trials were included in the meta-analysis. Thromboprophylaxis with low-molecular-weight heparin reduced the risk of any VTE [odds ratio (OR) 0.52, 95% credible interval (CrI) 0.37 to 0.71], clinically detected deep-vein thrombosis (DVT) (OR 0.40, 95% CrI 0.12 to 0.99) and pulmonary embolism (PE) (OR 0.17, 95% CrI 0.01 to 0.88). Thromboprophylaxis with fondaparinux (Arixtra®, Aspen Pharma Trading Ltd, Dublin, Ireland) reduced the risk of any VTE (OR 0.13, 95% CrI 0.05 to 0.30) and clinically detected DVT (OR 0.10, 95% CrI 0.01 to 0.94), but the effect on PE was inconclusive (OR 0.47, 95% CrI 0.01 to 9.54). Estimates of the risk of major bleeding with thromboprophylaxis were inconclusive owing to the small numbers of events. Fifteen studies of risk factors were identified, but only age (ORs 1.05 to 3.48), and injury type were consistently associated with VTE. Six studies of RAMs were identified, but only two reported prognostic accuracy data for VTE, based on small numbers of patients. Expert consensus was achieved for 13 risk predictors in lower-limb immobilisation due to injury. Modelling showed that thromboprophylaxis for all is effective (0.015 QALY gain, 95% CrI 0.004 to 0.029 QALYs) with a cost-effectiveness of £13,524 per QALY, compared with thromboprophylaxis for none. If risk-based strategies are included, it is potentially more cost-effective to limit thromboprophylaxis to patients with a Leiden thrombosis risk in plaster (cast) [L-TRiP(cast)] score of ≥ 9 (£20,000 per QALY threshold) or ≥ 8 (£30,000 per QALY threshold). An optimal threshold on the L-TRiP(cast) receiver operating characteristic curve would have sensitivity of 84-89% and specificity of 46-55%. LIMITATIONS Estimates of RAM prognostic accuracy are based on weak evidence. People at risk of bleeding were excluded from trials and, by implication, from modelling. CONCLUSIONS Thromboprophylaxis for lower-limb immobilisation due to injury is clinically effective and cost-effective compared with no thromboprophylaxis. Risk-based thromboprophylaxis is potentially optimal but the prognostic accuracy of existing RAMs is uncertain. FUTURE WORK Research is required to determine whether or not an appropriate RAM can accurately select higher-risk patients for thromboprophylaxis. STUDY REGISTRATION This study is registered as PROSPERO CRD42017058688. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John W Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Beverley J Hunt
- Haemostasis Research Unit, King's College London, London, UK
| | - Tim Nokes
- Department of Haematology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jonathan Keenan
- Department of Haematology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Kerstin de Wit
- Department of Medicine, Hamilton General Hospital, Hamilton, ON, Canada
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Haas S, Ageno W, Weitz JI, Goldhaber SZ, Turpie AGG, Goto S, Angchaisuksiri P, Dalsgaard Nielsen J, Kayani G, Zaghdoun A, Farjat AE, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Anticoagulation therapy patterns for acute treatment of venous thromboembolism in GARFIELD-VTE patients. J Thromb Haemost 2019; 17:1694-1706. [PMID: 31220403 DOI: 10.1111/jth.14548] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 06/13/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Parenteral anticoagulants and vitamin K antagonists (VKAs) have constituted the cornerstone of venous thromboembolism (VTE) treatment. Meanwhile, direct oral anticoagulants (DOACs) provide physicians with an alternative. The Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE observes real-world treatment practices. OBJECTIVES Describe initial anticoagulation (AC) treatment patterns in VTE patients who received parenteral AC, VKAs, and/or DOACs within ±30 days of diagnosis. METHODS VTE patients were categorized into parenteral AC only, parenteral AC with transition to VKA, VKA only, parenteral AC with transition to DOAC, and DOAC only. RESULTS A total of 9647 patients were initiated on AC treatment alone. 4781 (49.6%) patients received DOACs ± parenteral ACs; 3187 (33.0%), VKA ± parenteral ACs; and 1679 (17.4%) parenteral ACs alone. Rivaroxaban was the most frequently used DOAC (79.4%). DOACs were more frequently used in North America/Australia (58.1%), Europe (52.2%), and Asia (47.6%) than in Latin America (29.7%) and the Middle East/South Africa (32.5%). In patients with suspected VTE, most received parenteral AC monotherapy (67.7%). Patients with deep vein thrombosis were more likely to receive DOACs alone than those with pulmonary embolism with or without deep vein thrombosis (36.2% vs 25.9%). Active cancer patients received parenteral AC alone (58.9%), with 25.5% receiving DOAC ± parenteral AC and 12.8% parenteral AC and VKA. A total of 46.5% of pregnant patients received parenteral AC monotherapy, 34.0% were treated with VKA ± parenteral AC, and 19.5% received a DOAC (± parenteral AC). CONCLUSION AC treatment patterns vary by patient population, geographic region and site of VTE. Guidelines for AC therapy are not always adhered to.
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Affiliation(s)
- Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | | | | | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
| | | | | | | | | | | | | | - Henri Bounameaux
- Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland
| | | | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, UK
- University College London, London, UK
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Ageno W, Haas S, Weitz JI, Goldhaber SZ, Turpie AGG, Goto S, Angchaisuksiri P, Nielsen JD, Kayani G, Pieper KS, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Characteristics and Management of Patients with Venous Thromboembolism: The GARFIELD-VTE Registry. Thromb Haemost 2018; 119:319-327. [PMID: 30593086 DOI: 10.1055/s-0038-1676611] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Management of venous thromboembolism (VTE), encompassing both deep vein thrombosis (DVT) and pulmonary embolism (PE), varies worldwide. METHODS The Global Anticoagulant Registry in the FIELD - Venous Thromboembolism (GARFIELD-VTE) is a prospective, observational study of 10,685 patients with objectively diagnosed VTE recruited from May 2014 to January 2017 at 417 sites in 28 countries. All patients are followed for at least 3 years. We describe the baseline characteristics of the study population and their management within 30 days of diagnosis. RESULTS The median age was 60.2 years; 50.4% were male; 61.7% had DVT and 38.3% had PE ± DVT; and 32.3% were obese (body mass index ≥ 30 kg/m2). The most common risk factors were surgery (12.5%), hospitalization (12.0%) and trauma to the lower limbs (7.8%). At the time of VTE diagnosis, 10.1% had active cancer and 5.7% were chronically immobilized. Treatment for VTE was anticoagulant (AC) therapy alone in 90.9% of patients; 5.1% received thrombolytic and/or surgical/mechanical therapy ± AC and 4.0% received no therapy. Pre-diagnosis, 12.8% received AC therapy alone and 0.2% received thrombolytic and/or surgical/mechanical therapy ± AC. After diagnosis, parenteral AC therapy alone was administered in 17.6% of patients, and it was followed by a direct oral AC (DOAC) in 16.4% or a vitamin K antagonist (VKA) in 26.8%. DOACs alone were prescribed to 32.3% of patients, while 5.9% received VKA alone. CONCLUSION The initial findings from this global registry highlight the heterogeneity in characteristics and management of VTE patients. Prospective follow-up will reveal the impact of this heterogeneity on outcomes.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sylvia Haas
- Technical University of Munich, Munich, Germany
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | | | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Tokai University, Tokai, Japan
| | | | - Joern Dalsgaard Nielsen
- Department of Cardiology, Copenhagen University Hospital, Copenhagen University, Copenhagen, Denmark
| | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Karen S Pieper
- Department of Statistical Research Science, Duke Clinical Research Institute, Durham, North Carolina, United States
| | | | - Henri Bounameaux
- Faculty of Medicine, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
| | | | | | - Ajay K Kakkar
- Thrombosis Research Institute, University College London, London, United Kingdom
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Jimenez S, Ruiz-Artacho P, Merlo M, Suero C, Antolin A, Casal JR, Sanchez M, Ortega-Duarte A, Genis M, Piñera P. Risk profile, management, and outcomes of patients with venous thromboembolism attended in Spanish Emergency Departments: The ESPHERIA registry. Medicine (Baltimore) 2017; 96:e8796. [PMID: 29310357 PMCID: PMC5728758 DOI: 10.1097/md.0000000000008796] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The objective of this study was to determine the clinical profile of and diagnostic and therapeutic approach to patients with venous thromboembolism (VTE) in Spanish Emergency Departments (EDs). Risk factors, adherence to clinical practice guidelines, and outcomes were also evaluated.Patients with VTE diagnosed in 53 Spanish EDs were prospectively and consecutively included. Demographic data, comorbidities, risk factors for VTE, index event characteristics, hemorrhagic risk, and mortality were evaluated. Adherence to clinical practice guidelines was assessed based on clinical probability scales, requests for determination of D-dimer, use of anticoagulant treatment before confirmation of diagnosis, and assessment of bleeding and prognostic risk. Recurrence, bleeding, and death during admission and at 30, 90, and 180 days after diagnosis in the EDs were recorded.From 549,840 ED visits made over a mean period of 40 days, 905 patients were diagnosed with VTE (incidence 1.6 diagnoses per 1000 visits). The final analysis included 801 patients, of whom 49.8% had pulmonary embolism. The most frequent risk factors for VTE were age (≥70 years), obesity, and new immobility. Clinical probability, prognosis, and bleeding risk scales were recorded in only 7.6%, 7.5%, and 1% of cases, respectively. D-dimer was determined in 87.2% of patients with a high clinical probability of VTE, and treatment was initiated before confirmation in only 35.9% of these patients. In patients with pulmonary embolism, 31.3% had a low risk of VTE. Overall, 98.7% of patients with pulmonary embolism and 50.2% of patients with deep venous thrombosis were admitted. During follow-up, total bleeding was more frequent than recurrences: the rates of any bleeding event were 4.4%, 3.9%, 5.3%, and 3.5% at admission and at 30 and 90, and 180 days, respectively; the rates of VTE recurrence were 2.3%, 1.3%, 1.7%, and 0.6%, respectively. Mortality rates were 3.4%, 3.1%, 4.1%, and 2.6% during hospitalization and at 30, 90, and 180 days, respectively.VTE had a substantial impact on Spanish EDs. The clinical presentation and risk profile for the development of VTE in patients diagnosed in the EDs was similar to that recorded in previous studies. During follow-up, bleeding (overall) was more frequent than recurrences. Adherence to clinical practice guidelines could improve significantly.
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Affiliation(s)
- Sonia Jimenez
- Hospital Clínic, Grupo UPP, Área 1 IDIBAPS, Barcelona
| | | | | | | | | | | | | | | | - Mar Genis
- Departamento Médico, Bayer Hispania, Barcelona
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Rowswell HR, Nokes TJC. Significant reduction in hospital-acquired thrombosis: impact of national risk assessment and real-time feedback. Open Heart 2017; 4:e000653. [PMID: 29071090 PMCID: PMC5640138 DOI: 10.1136/openhrt-2017-000653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 09/01/2017] [Accepted: 09/12/2017] [Indexed: 11/29/2022] Open
Abstract
Objective Since 2010, National Health Service hospitals in England have been incentivised to risk assess for Venous Thromboembolism (VTE) in all adult patients admitted, using a national tool. We studied the impact of this, together with local real-time reporting of VTE events to senior clinicians, on cases of hospital-acquired thrombosis (HAT) diagnosed, since 2010. Methods This was an observational cohort study reviewing all cases of VTE diagnosed between January 2010 and December 2016 in a single teaching hospital. These were matched against the number of patients admitted to produce crude incidence rates per thousand admissions. Similarly, all cases associated with inadequate thromboprophylaxis (TP) measures were documented over the same period. Results By the end of 2010, with 70% compliance with VTE risk assessment, improving to 90% (the national target) early in 2011, there were 217 HAT events from 103 845 admissions. In 2016, there were 176 HAT events from 119 128 admissions, being a significant reduction, relative risk (RR) 0.718 (95% CI 0.589 to 0.875; p=0.001). In 2010, there were 50 of 217 HAT events associated with inadequate TP, falling to 7 of 176 in 2016, also a significant reduction, RR 0.140 (95% CI 0.065 to 0.300; p=0.0001). Conclusions National guidance on VTE prevention and mandatory risk assessment linked to local real-time reporting of VTE events are associated with significant reductions both in total HAT events and those associated with inadequate TP.
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Affiliation(s)
| | - Timothy J C Nokes
- Department of Haematology, Plymouth Hospitals NHS Trust, Plymouth, UK
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Cohen AT, Gitt AK, Bauersachs R, Fronk EM, Laeis P, Mismetti P, Monreal M, Willich SN, Bramlage P, Agnelli G, Prefer In Vte Scientific Steering Committee And The Prefer In Vte Investigators OBOT. The management of acute venous thromboembolism in clinical practice. Results from the European PREFER in VTE Registry. Thromb Haemost 2017; 117:1326-1337. [PMID: 28405675 PMCID: PMC6291854 DOI: 10.1160/th16-10-0793] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 03/22/2017] [Indexed: 01/30/2023]
Abstract
Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in Europe. Data from real-world registries are necessary, as clinical trials do not represent the full spectrum of VTE patients seen in clinical practice. We aimed to document the epidemiology, management and outcomes of VTE using data from a large, observational database. PREFER in VTE was an international, non-interventional disease registry conducted between January 2013 and July 2015 in primary and secondary care across seven European countries. Consecutive patients with acute VTE were documented and followed up over 12 months. PREFER in VTE included 3,455 patients with a mean age of 60.8 ± 17.0 years. Overall, 53.0% were male. The majority of patients were assessed in the hospital setting as inpatients or outpatients (78.5%). The diagnosis was deep-vein thrombosis (DVT) in 59.5% and pulmonary embolism (PE) in 40.5%. The most common comorbidities were the various types of cardiovascular disease (excluding hypertension; 45.5%), hypertension (42.3%) and dyslipidaemia (21.1%). Following the index VTE, a large proportion of patients received initial therapy with heparin (73.2%), almost half received a vitamin K antagonist (48.7%) and nearly a quarter received a DOAC (24.5%). Almost a quarter of all presentations were for recurrent VTE, with >80% of previous episodes having occurred more than 12 months prior to baseline. In conclusion, PREFER in VTE has provided contemporary insights into VTE patients and their real-world management, including their baseline characteristics, risk factors, disease history, symptoms and signs, initial therapy and outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Giancarlo Agnelli
- Giancarlo Agnelli, Stroke Unit and Division of Cardiovascular Medicine, Department of Internal Medicine, University of Perugia, Santa Maria della Misericordia Hospital, Via Dottori Sant' Andrea delle Fratte, 06126 Perugia, Italy, Tel.: +39 075 578 6424, Fax: +39 075 578 2346, E-mail:
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Liberman AL, Merkler AE, Gialdini G, Messé SR, Lerario MP, Murthy SB, Kamel H, Navi BB. Risk of Pulmonary Embolism After Cerebral Venous Thrombosis. Stroke 2017; 48:563-567. [PMID: 28228575 PMCID: PMC5330858 DOI: 10.1161/strokeaha.116.016316] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/06/2016] [Accepted: 12/21/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Cerebral vein thrombosis (CVT) is a type of venous thromboembolism. Whether the risk of pulmonary embolism (PE) after CVT is similar to the risk after deep venous thrombosis (DVT) is unknown. METHODS We performed a retrospective cohort study using administrative data from all emergency department visits and hospitalizations in California, New York, and Florida from 2005 to 2013. We identified patients with CVT or DVT and the outcome of PE using previously validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. Kaplan-Meier survival statistics and Cox proportional hazards models were used to compare the risk of PE after CVT versus PE after DVT. RESULTS We identified 4754 patients with CVT and 241 276 with DVT. During a mean follow-up of 3.4 (±2.4) years, 138 patients with CVT and 23 063 with DVT developed PE. CVT patients were younger, more often female, and had fewer risk factors for thromboembolism than patients with DVT. During the index hospitalization, the rate of PE was 1.4% (95% confidence interval [CI], 1.1%-1.8%) in patients with CVT and 6.6% (95% CI, 6.5%-6.7%) in patients with DVT. By 5 years, the cumulative rate of PE after CVT was 3.4% (95% CI, 2.9%-4.0%) compared with 10.9% (95% CI, 10.8%-11.0%; P<0.001) after DVT. CVT was associated with a lower adjusted hazard of PE than DVT (hazard ratio, 0.26; 95% CI, 0.22-0.31). CONCLUSION The risk of PE after CVT was significantly lower than the risk after DVT. Among patients with CVT, the greatest risk for PE was during the index hospitalization.
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Affiliation(s)
- Ava L Liberman
- From the Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (A.E.M., G.G., S.B.M., H.K., B.B.N.), and Department of Neurology, Weill Cornell Medicine (A.E.M., G.G., S.B.M., H.K., B.B.N.), New York, NY; Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); and Department of Neurology, Weill Cornell Medicine, New York-Presbyterian Queens, Flushing, NY (M.P.L.)
| | - Alexander E Merkler
- From the Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (A.E.M., G.G., S.B.M., H.K., B.B.N.), and Department of Neurology, Weill Cornell Medicine (A.E.M., G.G., S.B.M., H.K., B.B.N.), New York, NY; Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); and Department of Neurology, Weill Cornell Medicine, New York-Presbyterian Queens, Flushing, NY (M.P.L.).
| | - Gino Gialdini
- From the Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (A.E.M., G.G., S.B.M., H.K., B.B.N.), and Department of Neurology, Weill Cornell Medicine (A.E.M., G.G., S.B.M., H.K., B.B.N.), New York, NY; Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); and Department of Neurology, Weill Cornell Medicine, New York-Presbyterian Queens, Flushing, NY (M.P.L.)
| | - Steven R Messé
- From the Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (A.E.M., G.G., S.B.M., H.K., B.B.N.), and Department of Neurology, Weill Cornell Medicine (A.E.M., G.G., S.B.M., H.K., B.B.N.), New York, NY; Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); and Department of Neurology, Weill Cornell Medicine, New York-Presbyterian Queens, Flushing, NY (M.P.L.)
| | - Michael P Lerario
- From the Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (A.E.M., G.G., S.B.M., H.K., B.B.N.), and Department of Neurology, Weill Cornell Medicine (A.E.M., G.G., S.B.M., H.K., B.B.N.), New York, NY; Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); and Department of Neurology, Weill Cornell Medicine, New York-Presbyterian Queens, Flushing, NY (M.P.L.)
| | - Santosh B Murthy
- From the Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (A.E.M., G.G., S.B.M., H.K., B.B.N.), and Department of Neurology, Weill Cornell Medicine (A.E.M., G.G., S.B.M., H.K., B.B.N.), New York, NY; Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); and Department of Neurology, Weill Cornell Medicine, New York-Presbyterian Queens, Flushing, NY (M.P.L.)
| | - Hooman Kamel
- From the Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (A.E.M., G.G., S.B.M., H.K., B.B.N.), and Department of Neurology, Weill Cornell Medicine (A.E.M., G.G., S.B.M., H.K., B.B.N.), New York, NY; Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); and Department of Neurology, Weill Cornell Medicine, New York-Presbyterian Queens, Flushing, NY (M.P.L.)
| | - Babak B Navi
- From the Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (A.E.M., G.G., S.B.M., H.K., B.B.N.), and Department of Neurology, Weill Cornell Medicine (A.E.M., G.G., S.B.M., H.K., B.B.N.), New York, NY; Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); and Department of Neurology, Weill Cornell Medicine, New York-Presbyterian Queens, Flushing, NY (M.P.L.)
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Barillari G, Londero AP, Brenner B, Nauffal D, Muñoz-Torrero JFS, Del Molino F, Moustafa F, Madridano O, Martín-Martos F, Monreal M. Recurrence of venous thromboembolism in patients with recent gestational deep vein thrombosis or pulmonary embolism: Findings from the RIETE Registry. Eur J Intern Med 2016; 32:53-9. [PMID: 26972931 DOI: 10.1016/j.ejim.2016.02.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 01/21/2016] [Accepted: 02/11/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The aim of this study was to investigate the recurrence rate of venous thromboembolism (VTE) and the prevalence of major bleeding or death in patients with previous VTE in pregnancy and puerperium. Risk factors for VTE recurrence were also assessed. MATERIALS AND METHODS We evaluated a cohort of patients enrolled in the international, multicenter, prospective Registro Informatizado de la Enfermedad Trombo-Embólica (RIETE) registry with objectively confirmed VTE. RESULTS In the registry, 607 women were presenting with VTE that occurred during pregnancy or puerperium. The 2-year VTE recurrence rate was 3.3% (CI: 95 1.5-5.0%) and the recurrent VTE incidence rate was 2.28events/100 patients-year. Among the 16 cases of VTE recurrence 11 cases appeared during drug treatment while only five cases were diagnosed after therapy discontinuation. No significant difference was found in treatment duration among these two subgroups of VTE recurrence cases and women without recurrence. Furthermore, the use of thrombolytics and inferior vena cava filter in initial treatment was associated to an increased risk of VTE recurrence. CONCLUSIONS The current study provides new insights on VTE recurrence rate in patients with deep vein thrombosis (DVT) or pulmonary embolism (PE) that occurred in pregnancy or postpartum period. These findings can contribute to risk assessment of thrombotic burden, thereby allowing for better decision making regarding antithrombotic management in this clinical setting.
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Affiliation(s)
- Giovanni Barillari
- Center for Haemorrhagic and Thrombotic Disorders, Udine General and University Hospital, Udine, Italy.
| | - Ambrogio P Londero
- Clinic of Obsterics and Gynecology, DISM, University of Udine, Udine, Italy; Unit of Obstetrics and Gynecology, Saint Polo's Hospital, Monfalcone, Italy
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Israel; Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Dolores Nauffal
- Department of Pneumonology, Hospital Universitario La Fe, Valencia, Spain
| | | | - Fátima Del Molino
- Department of Internal Medicine, Hospital General de Catalunya, Department of Internal Medicine, Clínica del Vallés, Barcelona, Spain
| | - Farès Moustafa
- Department of Emergency, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Olga Madridano
- Department of Internal Medicine, Hospital Infanta Sofía, Madrid, Spain
| | | | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
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Ruiz-Artacho P, Rodríguez-López I, Pérez Peña C, González del Castillo J, Calvo E, Martín-Sánchez F. Prognostic value of a previous medical or surgical admission in outpatients with symptomatic pulmonary embolism. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2015.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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13
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Ruiz-Artacho P, Rodríguez-López I, Pérez Peña C, González del Castillo J, Calvo E, Martín-Sánchez F. Valor pronóstico de un ingreso previo médico o quirúrgico en pacientes con embolia pulmonar sintomática ambulatoria. Rev Clin Esp 2016; 216:68-73. [DOI: 10.1016/j.rce.2015.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/07/2015] [Accepted: 07/30/2015] [Indexed: 10/22/2022]
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Guijarro R, de Miguel-Diez J, Jimenez D, Trujillo-Santos J, Otero R, Barba R, Monreal M. Pulmonary embolism, acute coronary syndrome and ischemic stroke in the Spanish National Discharge Database. Eur J Intern Med 2016; 28:65-9. [PMID: 26603210 DOI: 10.1016/j.ejim.2015.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 09/23/2015] [Accepted: 10/12/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Venous and arterial thrombosis share a number of pathogenic mechanisms, but the burden of pulmonary embolism (PE) has not been consistently compared with that in other arterial diseases. METHODS We used the Spanish National Discharge Database to compare the frequency, clinical characteristics and mortality rate of all patients with PE, acute coronary syndrome (ACS) or ischemic stroke admitted from 2001 to 2010. Patients were classified as having primary diagnosis (the process leading to hospital admission) or secondary diagnosis (it appeared during hospital stay for other reasons) RESULTS During the study period, 31,949,739 patients were discharged. Of these, 165,229 (0.52%) were diagnosed with PE, 562,837 (1.76%) with ACS and 495,427 (1.55%) with ischemic stroke. Overall, 31% of patients with PE, 8.4% with ACS and 13% with ischemic stroke had secondary diagnoses. The most common reasons for admission in patients with secondary PE were: cancer (21%), acute respiratory failure (11%), acute heart failure (6.4%) and stroke (5.5%). Mean hospital stay was: 14 ± 13 days in PE patients, 9.7 ± 9.7 in those with ACS and 13 ± 14 days in those with stroke. In-hospital mortality rate was: 10.5%, 10.1% and 12.3% respectively in patients with primary diagnosis, and 36%, 34% and 29% in those with secondary diagnosis. CONCLUSIONS Patients hospitalized with PE were 3-4 times less frequent than those with ACS or stroke, but had a higher mortality. One in every 3 patients with PE (but only one in every 10 with ACS or stroke) had secondary diagnosis, and these patients had the highest mortality.
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Affiliation(s)
- Ricardo Guijarro
- Department of Internal Medicine, Hospital Carlos Haya, Málaga, Spain
| | - Javier de Miguel-Diez
- Pneumology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - David Jimenez
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Madrid, Spain
| | | | - Remedios Otero
- Department of Internal Medicine, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Raquel Barba
- Department of Internal Medicine, Hospital Rey Juan Carlos, Móstoles, Madrid, Spain
| | - Manuel Monreal
- Universidad Católica de Murcia, Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
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15
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Inhospital mortality among clinical and surgical inpatients recently diagnosed with venous thromboembolic disease. J Thromb Thrombolysis 2015; 40:225-30. [DOI: 10.1007/s11239-015-1234-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Rubio-Terrés C, Soria JM, Morange PE, Souto JC, Suchon P, Mateo J, Saut N, Rubio-Rodríguez D, Sala J, Gracia A, Pich S, Salas E. Economic analysis of thrombo inCode, a clinical-genetic function for assessing the risk of venous thromboembolism. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:233-242. [PMID: 25652150 PMCID: PMC4376955 DOI: 10.1007/s40258-015-0153-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Patients with venous thromboembolism (VTE) commonly have an underlying genetic predisposition. However, genetic tests nowadays in use have very low sensitivity for identifying subjects at risk of VTE. Thrombo inCode(®) is a new genetic tool that has demonstrated very good sensitivity, thanks to very good coverage of the genetic variants that modify the function of the coagulation pathway. OBJECTIVE To conduct an economic analysis of risk assessment of VTE from the perspective of the Spanish National Health System with Thrombo inCode(®) (a clinical-genetic function for assessing the risk of VTE) versus the conventional/standard method used to date (factor V Leiden and prothrombin G20210A). METHODS An economic model was created from the National Health System perspective, using a decision tree in patients aged 45 years with a life expectancy of 81 years. The predictive capacity of VTE, based on identification of thrombophilia using Thrombo inCode(®) and using the standard method, was obtained from two case-control studies conducted in two different populations (S. PAU and MARTHA; 1,451 patients in all). Although this is not always the case, patients who were identified as suffering from thrombophilia were subject to preventive treatment of VTE with warfarin, leading to a reduction in the number of VTE events and an increased risk of severe bleeding. The health state utilities (quality-adjusted life-years [QALYs]) and costs (in 2013 EUR values) were obtained from the literature and Spanish sources. RESULTS On the basis of a price of EUR 180 for Thrombo inCode(®), this would be the dominant option (more effective and with lower costs than the standard method) in both populations. The Monte Carlo probabilistic analyses indicate that the dominance would occur in 100 % of the simulations in both populations. The threshold price of Thrombo inCode(®) needed to reach the incremental cost-effectiveness ratio (ICER) generally accepted in Spain (EUR 30,000 per QALY gained) would be between EUR 3,950 (in the MARTHA population) and EUR 11,993 (in the S. PAU population). CONCLUSION According to the economic model, Thrombo inCode(®) is the dominant option in assessing the risk of VTE, compared with the standard method currently used.
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Affiliation(s)
- C. Rubio-Terrés
- Health Value, C/-Virgen de Aránzazu, 21, 5°B, 28034 Madrid, Spain
| | - J. M. Soria
- Unitat de Genòmica de Malalties Complexes, IIB-Sant Pau, Barcelona, Spain
| | - P. E. Morange
- Inserm UMR_S 1062, 13385 Marseille, France
- Aix-Marseille Université, Marseille, France
| | - J. C. Souto
- Unitat d’Hemostasia i Trombosis IIB-Sant Pau, Barcelona, Spain
| | - P. Suchon
- Inserm Unité Mixte de Recherche en Santé (UMR_S) 937, Paris, France
- ICAN Institute for Cardiometabolism and Nutrition, Université Pierre et Marie Curie Paris 6, Paris, France
| | - J. Mateo
- Unitat d’Hemostasia i Trombosis IIB-Sant Pau, Barcelona, Spain
| | - N. Saut
- Inserm Unité Mixte de Recherche en Santé (UMR_S) 937, Paris, France
- ICAN Institute for Cardiometabolism and Nutrition, Université Pierre et Marie Curie Paris 6, Paris, France
| | | | - J. Sala
- Scientific Department, Ferrer inCode, Barcelona, Spain
| | - A. Gracia
- Scientific Department, Ferrer inCode, Barcelona, Spain
| | - S. Pich
- Scientific Department, Gendiag.exe, Barcelona, Spain
| | - E. Salas
- Scientific Department, Gendiag.exe, Barcelona, Spain
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Di Micco P. Venous thromboembolism and problems related to its continuous medical surveillance. Int J Clin Pract 2015; 69:268-9. [PMID: 25727800 DOI: 10.1111/ijcp.12510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- P Di Micco
- Emergency Room, Department of Medicine, Fatebenefratelli Hospital of Naples, Naples, Italy.
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Shabani F, Farrier AJ, Smith R, Venkatesan M, Thomas C, Uzoigwe CE, Isaac S, Chami G. Hip fractures sustained in hospital: comorbidities and outcome. Postgrad Med J 2014; 91:61-4. [PMID: 25550523 DOI: 10.1136/postgradmedj-2014-132674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Guidelines on the management of hip fracture in the elderly focus on fractures suffered in the community. Between 4% and 7% of hip fractures occur in hospital. Mortality is higher in those who sustain hip fracture in hospital than those who sustain a fracture in the community. However, it is not known if sustaining a nosocomial fracture is an independent risk factor for a poor outcome. OBJECTIVE To compare outcomes of hip fracture sustained in the community and sustained while in hospital for another reason. After adjusting for confounders, we sought to determine if sustaining a fracture in hospital was an independent risk factor for a poor outcome. METHODS Using the National Hip Fracture Database, we identified all patients admitted to Leicester Royal Infirmary with hip fracture between July 2009 and February 2013. We extracted demographic data, details of comorbidity, and 30-day and long-term mortality. Age, gender, American Society of Anaesthesiologists (ASA) grade, time to surgery, and survival were compared between patients with hospital-acquired and those with community-acquired hip fracture. RESULTS During the study period, 2987 patients were treated for hip fracture; 2984 were included in the study. Of these, 261 (8.7%) sustained the fracture while in hospital. Those who sustained the fracture in hospital were more commonly men (106/261 (41%)) than those with a community-acquired fracture (738/2723 (27%)) and had a worse ASA grade (III or IV, 215/230 (93%) vs 1647/2573 (64%)). Thirty-day mortality was higher in those with a hospital-acquired fracture (48/261 (18%)) than in those with a community-acquired fracture (212/2723 (7.8%)) (p<0.001). However, after adjustment for confounding variables, the association between hip fracture, in-hospital and 30-day mortality was not significant: OR 1.2 (95% CI 0.8 to 2.0), p=0.40. Longer-term mortality was associated with hip fracture in hospital after adjustment for confounding variables in multivariate proportional hazards regression: HR 1.5 (95% CI 1.2 to 1.8), p<0.001. CONCLUSIONS Patients who sustain hip fractures in hospital are unsurprisingly sicker than those who sustain hip fractures in the community. Although being in hospital is not an independent risk factor, this easily identifiable group of patients are at particular risk of a poor outcome. We suggest that it might be appropriate to consider modifying the guidelines for treatment of hip fracture for this group in an attempt to improve outcome.
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Affiliation(s)
| | - Adam J Farrier
- CT2 Orthopaedic Surgery, University Hospitals of North Tees, Stockton-on-Tees, UK
| | | | | | - Christopher Thomas
- ST3 Trauma and Orthopaedics, University Hospitals of Coventry and Warwick, Birmingham, UK
| | | | | | - George Chami
- Department of Orthopaedic and Trauma Surgery, NHS Tayside, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a well-known risk factor for venous thromboembolism (VTE). Existing guidelines for thromboprophylaxis in hospitalized patients do not extend to other clinical scenarios that may also be associated with VTE risk. Our aim was to estimate the fraction of VTE events in patients with IBD that could be prevented. METHODS A retrospective analysis assessed all patients with IBD diagnosed with VTE at a single academic medical center from 2002 to 2012. Confirmed cases were analyzed for VTE risk factors, inpatient status, the use of deep venous thrombosis prophylaxis, and when applicable the reason for omission of prophylaxis. IBD VTE cases were compared with age- and sex-matched non-IBD VTE controls with regards to risk factors and potential opportunities for VTE prevention. RESULTS There were 204 patients with IBD (108 ulcerative colitis, 96 Crohn's disease) diagnosed with VTE (110 deep venous thrombosis, 66 pulmonary embolism, 27 intra-abdominal thromboses, and 1 other). One-third of the VTE events occurred in hospitalized patients. Two-third of the medical inpatients and 44% of surgical inpatients who developed VTE did not receive prophylaxis. Importantly, 129 VTE events occurred in outpatients. The proportion of outpatients hospitalized within 4 weeks of developing venous thrombosis was higher in patients with IBD than non-IBD controls (33% versus 15%, P = 0.0003). One-third (36%) of patients were experiencing ambulatory disease flares at the time of VTE diagnosis. CONCLUSIONS A substantial portion of VTE events in patients with IBD occurred in clinical scenarios is not routinely recommended for thromboprophylaxis. Further investigation of primary prophylaxis for patients with IBD in high-risk outpatients may be warranted.
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Piran S, Le Gal G, Wells PS, Gandara E, Righini M, Rodger MA, Carrier M. Outpatient treatment of symptomatic pulmonary embolism: A systematic review and meta-analysis. Thromb Res 2013; 132:515-9. [DOI: 10.1016/j.thromres.2013.08.012] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 07/22/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022]
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Thromboprophylaxie en médecine : quelles modifications avec les nouveaux anticoagulants oraux ? Presse Med 2013; 42:1219-24. [DOI: 10.1016/j.lpm.2013.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 06/12/2013] [Indexed: 11/18/2022] Open
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[Adequation of thromboprophylaxis during former admission in patients attended in emergencies with thromboembolic disease]. Med Clin (Barc) 2013; 141:130-1. [PMID: 23433664 DOI: 10.1016/j.medcli.2012.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 12/05/2012] [Accepted: 12/13/2012] [Indexed: 11/20/2022]
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Blondon M, Righini M, Aujesky D, Le Gal G, Perrier A. Usefulness of Preemptive Anticoagulation in Patients With Suspected Pulmonary Embolism. Chest 2012; 142:697-703. [DOI: 10.1378/chest.11-2694] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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