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Lafaie L, Poenou G, Hanon O, López-Jiménez L, Nieto JA, Lorenzo A, Porras JA, Lumbierres M, Bertoletti L, Monreal M. Anticoagulation and venous thromboembolism in patients aged 90 years and older: Data from the RIETE registry. J Am Geriatr Soc 2024; 72:113-125. [PMID: 37814983 DOI: 10.1111/jgs.18626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/23/2023] [Accepted: 09/16/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Age is a major risk factor for venous thromboembolism (VTE), yet patients aged ≥90 years are under-represented in clinical trials of anticoagulant therapy. The objectives were to describe and compare patient clinical characteristics, treatments, and outcomes (VTE recurrence, bleeding, and mortality) during the first 3 months of anticoagulation between VTE patients aged ≥90 years and those aged <90 years. METHODS We analyzed data from the Registro Informatizado Enfermedad TromboEmbὀlica (RIETE), an ongoing global observational registry of patients with objectively confirmed acute VTE. RESULTS From January 2001 to October 2022, 96,701 patients were registered in RIETE, of whom 3262 (3.4%) were aged ≥90 years. Patients aged ≥90 years were less likely to be men, and to have experienced cancer or recent surgery, but more likely to manifest immobility, chronic heart failure, anemia, renal insufficiency, or dementia than those aged <90 years. Most (99.6%) patients aged ≥90 years were receiving anticoagulant therapy. During the first 3 months, 26 patients aged ≥90 years developed VTE recurrences, 116 experienced major bleeding, and 564 died. Among patients initially presenting with pulmonary embolism (PE), deaths due to PE exceeded those due to fatal bleeding (76 vs. 19). Among those initially presenting with isolated deep-vein thrombosis (DVT), it was the reverse (2 vs. 11 deaths). CONCLUSIONS In patients aged ≥90 years, the difference in the outcome of anticoagulant treatment depending on the initial presentation of VTE could suggest a need for different management approaches. Clinical trials evaluating the optimal duration of anticoagulation according to initial VTE presentation are warranted to limit excess deaths in this particular population.
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Affiliation(s)
- Ludovic Lafaie
- Département de Gérontologie Clinique, CHU de Saint-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
| | - Géraldine Poenou
- Service de Médecine Vasculaire et Thérapeutique, CHU de Saint-Etienne, Saint-Etienne, France
| | - Olivier Hanon
- Hôpital Broca, Service de Gérontologie, Assistance Publique - Hôpitaux de Paris and EA 4468, Université de Paris Cité, Paris, France
| | - Luciano López-Jiménez
- Department of Internal Medicine, Hospital Universitario, Reina Sofía, Córdoba, Spain
| | - José Antonio Nieto
- Department of Internal Medicine, Hospital General Virgen de la Luz, Cuenca, Spain
| | - Alicia Lorenzo
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - José Antonio Porras
- Department of Internal Medicine, Hospital Universitario Joan XXIII de Tarragona, Tarragona, Spain
| | - Marina Lumbierres
- Respiratory Department, Arnau de Vilanova-Santa María University Hospital, IRB Lleida, Lleida, Catalonia, Spain
| | - Laurent Bertoletti
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- Service de Médecine Vasculaire et Thérapeutique, CHU de Saint-Etienne, Saint-Etienne, France
- INSERM, CIC1408, CHU de Saint-Etienne, Saint-Etienne, France
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitario Germans Trias i Pujol de Badalona, Universidad Católica de Murcia, Murcia, Spain
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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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Lafaie L, Célarier T, Monreal M, Mismetti P, Delavenne X, Bertoletti L. The impact of advanced age on anticoagulant therapy for acute venous thromboembolism. Expert Opin Drug Metab Toxicol 2022; 18:27-37. [PMID: 35195483 DOI: 10.1080/17425255.2022.2045273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Management of venous thromboembolic events (VTE) has been completely changed after the introduction of direct oral anticoagulants (DOAC). VTE is common in the geriatric population, but the management of DOACs remains complex because of the lack of specific data in this polymedicated fragile population.An exhaustive search of anticoagulants in the indication of VTE was performed on PubMed, including data from clinical trials, observational studies, real-world data, drug-drug interaction studies, as well as various guidelines from scientific societies. AREAS COVERED The present review aims to summarize our current knowledge on the era of DOACs in the management of VTE in the elderly. This involves learning the pharmacokinetics/pharmacodynamics of drugs specific to geriatrics, the problem of drug-drug interactions, and the main randomized clinical trials validating the use of DOACs. EXPERT OPINION DOACs have become an essential part of the management of VTE in the elderly, both for their efficacy and safety. However, we are faced with a list of unmet needs, such as the relevance of DOACs in the very elderly, cancer patients, and those with renal impairment. Clinicians and pharmacists must remain cautious about comedications, as well as about the patient's comorbidities.
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Affiliation(s)
- Ludovic Lafaie
- Loire, Inserm, UMR1059, Equipe Dysfonction Vasculaire Et Hémostase, Université de Lyon Saint-Etienne, Saint-Etienne, France.,Département de Gérontologie Clinique, Chu de Saint-Etienne, Saint-Etienne, France
| | - Thomas Célarier
- Département de Gérontologie Clinique, Chu de Saint-Etienne, Saint-Etienne, France
| | - Manuel Monreal
- Department of Internal Medicine, Universidad Católica de Murcia, Hospital Universitario Germans Trias I Pujol de Badalona, Spain
| | - Patrick Mismetti
- Loire, Inserm, UMR1059, Equipe Dysfonction Vasculaire Et Hémostase, Université de Lyon Saint-Etienne, Saint-Etienne, France.,Loire, Unité de Recherche Clinique Innovation Et Pharmacologie, Chu de Saint-Etienne, Saint-Etienne, France
| | - Xavier Delavenne
- Loire, Inserm, UMR1059, Equipe Dysfonction Vasculaire Et Hémostase, Université de Lyon Saint-Etienne, Saint-Etienne, France.,Loire, Laboratoire de Pharmacologie Toxicologie, Chu de Saint-Etienne, Saint-Etienne, France
| | - Laurent Bertoletti
- Loire, Inserm, UMR1059, Equipe Dysfonction Vasculaire Et Hémostase, Université de Lyon Saint-Etienne, Saint-Etienne, France.,Loire, Service de Médecine Vasculaire Et Thérapeutique, Chu de Saint-Etienne, Saint-Etienne, France
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Galdi F, Pedone C, Antonelli Incalzi R. Thromboembolic disease: a geriatric syndrome. JOURNAL OF GERONTOLOGY AND GERIATRICS 2020. [DOI: 10.36150/2499-6564-437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Polo Friz H, Orenti A, Brambilla M, Caleffi A, Pezzetti V, Cavalieri d'Oro L, Giannattasio C, Vighi G, Cimminiello C, Boracchi P. Short and long-term mortality in elderly patients with suspected not confirmed pulmonary embolism. Eur J Intern Med 2020; 73:36-42. [PMID: 31708362 DOI: 10.1016/j.ejim.2019.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 10/14/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Most patients evaluated for suspected pulmonary embolism(PE) conclude the Emergency Department(ED) work-up with a diagnosis of PE not confirmed(PE excluded;PE-E). We aimed to investigate the clinical features, short and long-term mortality, and prognostic factors for death in elderly with PE-E, and to compare these figures with those of patients with PE confirmed(PE-C). METHODS Consecutive patients ≥65 years old evaluated in the ED for clinically suspected hemodynamically stable acute PE were included in this retrospective cohort study. RESULTS Study population: 657 patients with suspected PE, PE-C:162(24.65%). When compared with PE-C, patients with PE-E presented a higher prevalence of chronic cardiopulmonary disease (17.37% vs 8.02%, p = 0.003), a lower prevalence of pulse rate >110 (13.13% vs 25.93%; p<0.001), of arterial oxygen saturation <90% (16.16% vs. 25.93%; p = 0.007) and of hospitalized patients (52.93% vs 98.15%; p < 0.001). Thirty-day, 90-day, 1-year, 2-year and 5-year overall mortality was 8.83%, 15.98%, 23.59%, 29.68%, and 51.09%, respectively, differences between PE-E and PE-C non statistically significant. Among patients with PE-E, multivariate analysis showed that simplified Pulmonary Embolism Severity Index score>0 was associated with higher short and long-term mortality (30-day:HR:5.31,p = 0.029; 5 year:HR:2.18, p < 0.001), meanwhile comorbidity (Charlson Comorbidity Index>0) only with higher long-term mortality (30-day: HR:1.60, p = 0.342; 5 year: HR:1.41, p = 0.038). CONCLUSION In real world haemodinamically stable elderly patients evaluated in the ED for suspected PE, short and long-term mortality was markedly high regardless whether PE was confirmed or excluded. At the time to set management and follow up strategies, elderly patients with PE excluded should not be considered a low-risk population.
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Affiliation(s)
- Hernan Polo Friz
- Internal Medicine, Medical Department, Vimercate Hospital, ASST di Vimercate, Vimercate, Italy; Research and Study Center of the Italian Society of Angiology and Vascular Pathology (Società Italiana di Angiologia e Patologia Vascolare, SIAPAV), Milan, Italy.
| | - Annalisa Orenti
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Epidemiology and Biometry G. A. Maccacaro, University of Milan, Milan, Italy
| | - Mattia Brambilla
- Internal Medicine, Medical Department, Vimercate Hospital, ASST di Vimercate, Vimercate, Italy
| | - Alessandro Caleffi
- Internal Medicine, Medical Department, Carate Hospital, ASST di Vimercate, Carate, Italy
| | - Valentina Pezzetti
- Internal Medicine, Medical Department, Vimercate Hospital, ASST di Vimercate, Vimercate, Italy
| | | | - Cristina Giannattasio
- School of Medicine Department, Milano-Bicocca University and Cardiologia IV, Dipartimento A. De Gasperis, Ospedale Niguarda Ca Granda, Milan, Italy
| | - Giuseppe Vighi
- Internal Medicine, Medical Department, Vimercate Hospital, ASST di Vimercate, Vimercate, Italy
| | - Claudio Cimminiello
- Research and Study Center of the Italian Society of Angiology and Vascular Pathology (Società Italiana di Angiologia e Patologia Vascolare, SIAPAV), Milan, Italy
| | - Patrizia Boracchi
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Epidemiology and Biometry G. A. Maccacaro, University of Milan, Milan, Italy
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Palareti G, Poli D. The prevention of venous thromboembolism recurrence in the elderly: a still open issue. Expert Rev Hematol 2018; 11:903-909. [PMID: 30257119 DOI: 10.1080/17474086.2018.1526667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is frequent in the elderly, with an unclear recurrence risk. After the initial and early maintenance anticoagulant treatment, the decision about its extension versus recurrences is difficult because of the high risk of bleeding in this population. Areas covered: This paper analyzes recent literature on VTE recurrence and risk of bleeding associated with extended anticoagulation in elderly patients with VTE, focusing on available data regarding efficacy and safety of old anticoagulant or recent direct oral anticoagulant (DOACs). Expert commentary: The following are clinically important and still unmet needs in elderly patients with VTE: the current real risks for recurrence or for bleeding are still uncertain; the available clinical predictive rules for recurrence are of less use; in general, the phase III trials on DOACs proved less satisfactory in the elderly than in the general population; low dose DOACs use for extended treatment seems promising and data on long periods of therapy are needed; low dose aspirin does not seem an appropriate therapeutic alternative to anticoagulants due to the high rate of bleeding in the elderly; antithrombotic drugs, with low risk of bleeding should be assessed as alternative therapeutic options for extended treatment in the elderly.
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Affiliation(s)
| | - Daniela Poli
- b Thrombosis Centre , Azienda Ospedaliero-Universitaria Careggi , Florence , Italy
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