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Incidence and clinical impact of bleeding events in older patients with acute venous thromboembolism. Blood Adv 2022; 7:205-213. [PMID: 35381071 PMCID: PMC9841039 DOI: 10.1182/bloodadvances.2022007263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 01/21/2023] Open
Abstract
Older patients anticoagulated for venous thromboembolism (VTE) have an increased risk of bleeding compared with younger patients. Little is known about the clinical impact of anticoagulation-related bleeding in this growing patient group. To prospectively assess the incidence, clinical impact, and predictors of bleeding in older patients anticoagulated for VTE, we analyzed 981 patients aged ≥65 years with acute VTE in a prospective multicenter cohort. Eight-eight percent were anticoagulated with vitamin K antagonists. Outcomes were the occurrence of major bleeding (MB) or clinically relevant nonmajor bleeding (CRNMB) event during the initial anticoagulation period up to 36 months. We described the incidence and clinical impact of bleeding and examined the association between risk factors and time to a first bleeding using competing risk regression; 100 MB and 125 CRNMB events occurred during follow-up. The incidence of MB and CRNMB was 8.5 (95% confidence interval [CI], 7.0-10.4) and 13.4 events (95% CI, 11.4-15.7) per 100 patient-years, respectively. In patients with MB, 79% required hospitalization, 18% required surgical intervention, and 19% required permanent discontinuation of anticoagulation; 15% of MB were intracranial and 6% were fatal. After adjustment, active cancer (subhazard ratio [SHR], 1.81; 95% CI, 1.12-2.93) and low physical activity (SHR, 1.88; 95% CI, 1.19-2.98) were associated with MB and high risk of falls with CRNMB (SHR, 2.04; 95% CI, 1.39-3.00). Older patients anticoagulated for VTE had a high incidence of MB and CRNMB, and these bleeding episodes caused a great burden of disease. Physicians should carefully weigh the risks/benefits of extended anticoagulation in the older population with VTE.
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DOACs vs LMWHs in hospitalized medical patients: a systematic review and meta-analysis that informed 2018 ASH guidelines. Blood Adv 2021; 4:1512-1517. [PMID: 32289163 DOI: 10.1182/bloodadvances.2019000840] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 02/19/2020] [Indexed: 02/07/2023] Open
Abstract
Venous thromboembolism (VTE) is a relatively frequent complication in hospitalized patients, especially in those with risk factors. The benefit of using direct oral anticoagulants (DOACs) for prevention is controversial. This systematic review was performed as part of the American Society of Hematology (ASH) guidelines on VTE, developed in partnership with McMaster University. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Epistemonikos were used as data sources from date of inception to November 2019. We included randomized trials in patients hospitalized for an acute medical disease, evaluating any DOACs vs other pharmacological prophylaxis, and included 3 trials with low risk of bias. We analyzed the effects of DOACs vs low-molecular-weight heparins (LMWHs) at 2 different time points: at the end of the short-term treatment phase (both drugs given for the same period of time) and at the end of the extended prophylaxis period (extended DOACs vs a shorter course of LMWHs). We observed that the use of DOACs did not reduce the risk of pulmonary embolism or symptomatic deep venous thrombosis (DVT) in comparison with LMWHs. However, the risk of major bleeding was slightly increased. Additionally, we observed that the benefit of DOACs previously reported was largely based on the reduction of asymptomatic DVT and was not apparent when only symptomatic events were considered. The use of DOACs in hospitalized medical patients slightly increases the risk of major bleeding with no appreciable benefit over LMWHs.
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Tardy B, Picard S, Guirimand F, Chapelle C, Danel Delerue M, Celarier T, Ciais JF, Vassal P, Salas S, Filbet M, Gomas JM, Guillot A, Gaultier JB, Merah A, Richard A, Laporte S, Bertoletti L. Bleeding risk of terminally ill patients hospitalized in palliative care units: the RHESO study. J Thromb Haemost 2017; 15:420-428. [PMID: 28035750 DOI: 10.1111/jth.13606] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Indexed: 12/25/2022]
Abstract
Essentials Bleeding incidence as hemorrhagic risk factors are unknown in palliative care inpatients. We conducted a multicenter observational study (22 Palliative Care Units, 1199 patients). At three months, the cumulative incidence of clinically relevant bleeding was 9.8%. Cancer, recent bleeding, thromboprophylaxis and antiplatelet therapy were independent risk factors. SUMMARY Background The value of primary thromboprophylaxis in patients admitted to palliative care units is debatable. Moreover, the risk of bleeding in these patients is unknown. Objectives Our primary aim was to assess the bleeding risk of patients in a real-world practice setting of hospital palliative care. Our secondary aim was to determine the incidence of symptomatic deep vein thrombosis and to identify risk factors for bleeding. Patients/Methods In this prospective, observational study in 22 French palliative care units, 1199 patients (median age, 71 years; male, 45.5%), admitted for the first time to a palliative care unit for advanced cancer or pulmonary, cardiac or neurologic disease were included. The primary outcome was adjudicated clinically relevant bleeding (i.e. a composite of major and clinically relevant non-major bleeding) at 3 months. The secondary outcome was symptomatic deep vein thrombosis. Results The most common reason for palliative care was cancer (90.7%). By 3 months, 1087 patients (91.3%) had died and 116 patients had presented at least one episode of clinically relevant bleeding (fatal in 23 patients). Taking into account the competing risk of death, the cumulative incidence of clinically relevant bleeding was 9.8% (95% confidence interval [CI], 8.3-11.6). Deep vein thrombosis occurred in six patients (cumulative incidence, 0.5%; 95% CI, 0.2-1.1). Cancer, recent bleeding, antithrombotic prophylaxis and antiplatelet therapy were independently associated with clinically relevant bleeding at 3 months. Conclusions Decisions regarding the use of thromboprophylaxis in palliative care patients should take into account the high risk of bleeding in these patients.
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Affiliation(s)
- B Tardy
- Inserm, CIC 1408, FCRIN-INNOVTE, Saint-Etienne, France
- UMR1059 SAINBIOSE, Université Jean Monnet, PRES de Lyon, Saint-Etienne, France
- Service de Soins Intensifs Médicaux, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - S Picard
- Unité de Soins Palliatifs, Hôpital les Diaconesses, Paris, France
| | - F Guirimand
- Pôle Recherche SPES "soins palliatifs en société", Maison Médicale Jeanne Garnier, Paris, France
| | - C Chapelle
- Inserm, CIC 1408, FCRIN-INNOVTE, Saint-Etienne, France
- UMR1059 SAINBIOSE, Université Jean Monnet, PRES de Lyon, Saint-Etienne, France
| | - M Danel Delerue
- Unité de Soins Palliatifs, Centre Hospitalier Saint Vincent de Paul, Lille, France
| | - T Celarier
- Fédération de Soins Palliatifs, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - J-F Ciais
- Unité de Soins Palliatifs, Centre Hospitalo-Universitaire de Nice, Nice, France
| | - P Vassal
- Fédération de Soins Palliatifs, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - S Salas
- Service d'Oncologie Médicale, Assistance Publique des Hôpitaux de Marseille, Marseille, France
- CRO2, Aix Marseille Université, Marseille, France
- INSERM U911, Marseille, France
| | - M Filbet
- Centre de Soins Palliatifs, Centre Hospitalier Lyon Sud, Hospices Civiles de Lyon, Pierre-Bénite, France
| | - J-M Gomas
- Unité de Soins Palliatifs, Hôpital Sainte Perine, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - A Guillot
- Service d'Oncologie Médicale, Institut de Cancérologie Lucien Neuwirth, Saint Priest en Jarez, France
| | - J-B Gaultier
- Service de Médecine Interne, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - A Merah
- Inserm, CIC 1408, FCRIN-INNOVTE, Saint-Etienne, France
| | - A Richard
- Fédération de Soins Palliatifs, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - S Laporte
- UMR1059 SAINBIOSE, Université Jean Monnet, PRES de Lyon, Saint-Etienne, France
- Unité de Recherche Clinique, Innovation et Pharmacologie, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - L Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
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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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Tang L, Wu YY, Lip GYH, Yin P, Hu Y. Heart failure and risk of venous thromboembolism: a systematic review and meta-analysis. LANCET HAEMATOLOGY 2015; 3:e30-44. [PMID: 26765646 DOI: 10.1016/s2352-3026(15)00228-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 10/20/2015] [Accepted: 10/21/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Venous thromboembolism is a major global health problem that is often secondary to other clinical situations. Many studies have investigated the association between venous thromboembolism and heart failure, but have yielded inconsistent findings. We aimed to quantify the absolute and relative risks (RR) for venous thromboembolism in patients with heart failure after hospital admission. We also assessed rates of venous thromboembolism in patients in different settings. METHODS In this systematic review and meta-analysis, we searched for studies investigating the risk of venous thromboembolism in patients in hospital with heart failure. We searched for studies published between Jan 1, 1955, and March 31, 2015, in PubMed, Embase, Evidence-Based Medicine Reviews, Allied and Complementary Medicine Database, Ovid HealthSTAR, Global Health, Ovid Nursing Database, Web of Science, CINAHL Plus, ProQuest Central, Conference Papers Index, BIOSIS Previews, and ClinicalTrials.gov. All cohort studies and subgroup analyses of randomised controlled trials (RCTs) were eligible for inclusion if they reported venous thromboembolism rates (number of events per follow-up period) or RR estimates. We extracted data from published reports and contacted the corresponding authors of records with insufficient quantitative data. RRs and 95% CIs were pooled using a random-effects model. This study is registered with PROSPERO, number CRD42014015504. FINDINGS Of 8673 records identified, we included 71 studies with data from 88 cohorts in our analysis, with 59 cohorts included in the assessment of venous thromboembolism rates and 46 cohorts included in the meta-analysis of heart failure and risk of venous thromboembolism. Venous thromboembolism rates varied widely in patients in hospital with heart failure from different settings. The overall median symptomatic venous thromboembolism rate was 2·48% (IQR 0·84-5·61); rates was were 3·73% (1·05-7·31) for patients who did not receive thromboprophylaxis and 1·47% (0·64-3·54) for those who did. Overall, patients with heart failure in hospital had an RR of 1·51 (1·36-1·68) for venous thromboembolism. The overall I(2) statistic was 96·1% and there was no evidence of publication bias (Egger's test, p=0·46). INTERPRETATION Heart failure is a common independent risk factor for venous thromboembolism. Thromoboprophylaxis should be considered in clinical practice for high-risk patients. FUNDING National Natural Science Foundation.
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Affiliation(s)
- Liang Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying-Ying Wu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gregory Y H Lip
- Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Ping Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Megyeri B, Christe A, Schindera ST, Horkay E, Sikula J, Cullmann JL, Kollar J, Heverhagen JT, Szucs-Farkas Z. Accuracy of computed tomography angiography in the detection of pulmonary embolism in patients with high body weight. Eur J Intern Med 2014; 25:724-30. [PMID: 25179677 DOI: 10.1016/j.ejim.2014.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 04/29/2014] [Accepted: 07/14/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND The accuracy of CT pulmonary angiography (CTPA) in detecting or excluding pulmonary embolism has not yet been assessed in patients with high body weight (BW). METHODS This retrospective study involved CTPAs of 114 patients weighing 75-99 kg and those of 123 consecutive patients weighing 100-150 kg. Three independent blinded radiologists analyzed all examinations in randomized order. Readers' data on pulmonary emboli were compared with a composite reference standard, comprising clinical probability, reference CTPA result, additional imaging when performed and 90-day follow-up. Results in both BW groups and in two body mass index (BMI) groups (BMI <30 kg/m(2) and BMI ≥ 30 kg/m(2), i.e., non-obese and obese patients) were compared. RESULTS The prevalence of pulmonary embolism was not significantly different in the BW groups (P=1.0). The reference CTPA result was positive in 23 of 114 patients in the 75-99 kg group and in 25 of 123 patients in the ≥ 100 kg group, respectively (odds ratio, 0.991; 95% confidence interval, 0.501 to 1.957; P=1.0). No pulmonary embolism-related death or venous thromboembolism occurred during follow-up. The mean accuracy of three readers was 91.5% in the 75-99 kg group and 89.9% in the ≥ 100 kg group (odds ratio, 1.207; 95% confidence interval, 0.451 to 3.255; P=0.495), and 89.9% in non-obese patients and 91.2% in obese patients (odds ratio, 0.853; 95% confidence interval, 0.317 to 2.319; P=0.816). CONCLUSION The diagnostic accuracy of CTPA in patients weighing 75-99 kg or 100-150 kg proved not to be significantly different.
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Affiliation(s)
- Boglarka Megyeri
- Department of Anaesthesiology and Intensive Care, University of Debrecen, Clinical Centre, Nagyerdei krt. 98, Debrecen H-4012, Hungary.
| | - Andreas Christe
- University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital Bern, Freiburgstrasse 10, Bern CH-3010, Switzerland
| | - Sebastian T Schindera
- Department of Radiology, University Hospital Basel, Petersgraben 4, Basel, CH-4031, Switzerland
| | - Edit Horkay
- Department of Radiology, University of Debrecen, Clinical Centre, Nagyerdei krt. 98, Debrecen H-4012, Hungary
| | - Judit Sikula
- Department of Radiology, University of Debrecen, Clinical Centre, Nagyerdei krt. 98, Debrecen H-4012, Hungary
| | - Jennifer L Cullmann
- University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital Bern, Freiburgstrasse 10, Bern CH-3010, Switzerland
| | - Jozsef Kollar
- Department of Radiology, University of Debrecen, Clinical Centre, Nagyerdei krt. 98, Debrecen H-4012, Hungary
| | - Johannes T Heverhagen
- University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital Bern, Freiburgstrasse 10, Bern CH-3010, Switzerland
| | - Zsolt Szucs-Farkas
- University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital Bern, Freiburgstrasse 10, Bern CH-3010, Switzerland; Institute of Radiology, Hospital Centre of Biel, Vogelsang 84, Biel/Bienne CH-2501, Switzerland
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