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Palareti G, Santagata D, De Ponti C, Ageno W, Prandoni P. Anticoagulation and compression therapy for proximal acute deep vein thrombosis. VASA 2024. [PMID: 39017921 DOI: 10.1024/0301-1526/a001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
The treatment of proximal deep vein thrombosis (DVT) of the lower limbs includes an initial management phase, covering the first 1 to 3 weeks, a primary treatment phase, lasting a minimum of 3 months, and a secondary treatment phase for those patients requiring continuing anticoagulation beyond the first 3 to 6 months. During the initial phase most patients with DVT can be managed as outpatients. Exclusion criteria for home treatment include high risk of bleeding, limb threatening DVT or other conditions requiring hospitalisation. Anticoagulant drugs represent the mainstay of treatment and include parenteral drugs such as unfractionated heparin or low molecular weight heparin, and oral drugs such as the vitamin K antagonists and the direct oral anticoagulants (DOACs). DOACs are currently recommended as the first line of treatment for proximal DVT of the lower limbs, with no preference for one DOAC over another. Factors to consider when choosing the anticoagulant strategy include, among others, renal and liver function, underlying diseases such as cancer or the antiphospholipid syndrome, and patient preferences. Indefinite duration of anticoagulation beyond the first 3 to 6 months is recommended for patients with unprovoked DVT and patients with permanent, chronic risk factors. Two DOACs, namely apixaban and rivaroxaban, can be administered at low doses for the secondary prevention of DVT. Elastic compression stockings (ECS) have been used for decades in patients with proximal DVT with the aim of counteracting the venous hypertension generated by the vascular disorder and reducing leg edema and to prevent the post-thrombotic syndrome.
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Affiliation(s)
| | - Davide Santagata
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
| | - Chiara De Ponti
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
| | - Walter Ageno
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
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2
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Salvi A, Nitti C, Fabbri A, Groff P, Ruggiero EG, Agnelli G. Diagnosis and Treatment of Deep Vein Thrombosis in the Emergency Department: Results of an Italian Nominal Group Technique Study. Clin Appl Thromb Hemost 2021; 26:1076029620959720. [PMID: 33112649 PMCID: PMC7791439 DOI: 10.1177/1076029620959720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Early diagnosis and treatment of deep vein thrombosis (DVT) is a main issue in
the Emergency setting. With the aim of assisting clinicians in the diagnosis and
the subsequent management of DVT in the Emergency Departments, a Nominal Group
Technique (NGT) study was conducted. A panel of 5 Italian experts developed 21
consensus statements based on available evidence and their clinical experience.
The agreed consensus statements may assist clinicians in applying the results of
clinical studies and clinical experience to routine care settings, providing
guidance on all aspects of the risk assessment, prophylaxis, early diagnosis and
appropriate treatment of DVT in the EDs.
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Affiliation(s)
- Aldo Salvi
- Emergency Department, 18494"Ospedali Riuniti Ancona", Ancona, Italy
| | - Cinzia Nitti
- Emergency Department, 18494"Ospedali Riuniti Ancona", Ancona, Italy
| | - Andrea Fabbri
- Emergency Department, "Presidio ospedaliero Morgagni-Pierantoni", Forlì, Italy
| | - Paolo Groff
- Emergency Department, 18633"Azienda ospedaliera di Perugia", Perugia, Italy
| | | | - Giancarlo Agnelli
- Internal and Vascular Medicine-Stroke Unit, 9309University of Perugia, Perugia, Italy
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3
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Wan T, Rahmani A, Hanakova M, Wong HY, Caragata G, Ross ES, Akinyemi O. Reducing emergency department visits in patients with deep vein thrombosis: introducing a standardised outpatient treatment pathway. BMJ Open Qual 2021; 10:bmjoq-2020-001123. [PMID: 34117006 PMCID: PMC8202109 DOI: 10.1136/bmjoq-2020-001123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 06/02/2021] [Indexed: 11/17/2022] Open
Abstract
Deep vein thrombosis (DVT) is an acute medical condition that requires urgent diagnosis and treatment to prevent significant morbidity and mortality. Patients with DVT frequently present to the emergency department (ED) because the necessary diagnostic investigations and medical treatment for successful outpatient management are not readily accessible in the outpatient clinics. A collaborative quality improvement project was undertaken to implement and evaluate a standardised outpatient treatment pathway designed to direct patients with a newly diagnosed DVT from the ultrasound department to the thrombosis clinic, where guideline-based management for DVT can be accomplished without ED visits. During the baseline period (1 February 2017 to 31 January 2019), the number of ED visits for DVT was 383 with an average of 16 visits per month. During the intervention period (1 February 2019 to 31 January 2020), the number of ED visits for DVT was 106 with an average of 8.8 visits per month. This represents almost a 50% reduction in the average ED visits during the intervention period. A standardised outpatient treatment pathway can significantly reduce the number of ED visits in patients with DVT, potentially improving patient care and reducing ED overcrowding.
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Affiliation(s)
- Tony Wan
- Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Anna Rahmani
- Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Michaela Hanakova
- Emergency Department, Providence Health Care, Vancouver, British Columbia, Canada
| | - Hing Yi Wong
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Glenyth Caragata
- Gerontology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Emily S Ross
- Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
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4
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Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Cuker A, Hutten BA, Jaff MR, Manja V, Schulman S, Thurston C, Vedantham S, Verhamme P, Witt DM, D Florez I, Izcovich A, Nieuwlaat R, Ross S, J Schünemann H, Wiercioch W, Zhang Y, Zhang Y. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv 2020; 4:4693-4738. [PMID: 33007077 PMCID: PMC7556153 DOI: 10.1182/bloodadvances.2020001830] [Citation(s) in RCA: 604] [Impact Index Per Article: 151.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000 each year, corresponding to ∼300 000 to 600 000 events in the United States annually. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 28 recommendations for the initial management of VTE, primary treatment, secondary prevention, and treatment of recurrent VTE events. CONCLUSIONS Strong recommendations include the use of thrombolytic therapy for patients with PE and hemodynamic compromise, use of an international normalized ratio (INR) range of 2.0 to 3.0 over a lower INR range for patients with VTE who use a vitamin K antagonist (VKA) for secondary prevention, and use of indefinite anticoagulation for patients with recurrent unprovoked VTE. Conditional recommendations include the preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications and a preference for direct oral anticoagulants over VKA for primary treatment of VTE.
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Affiliation(s)
- Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University, Durham NC
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insurbria, Varese, Italy
| | - Rebecca Beyth
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation Service, Kaiser Permanente, Aurora, CO
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Veena Manja
- University of California Davis, Sacramento, CA
- Veterans Affairs Northern California Health Care System, Mather, CA
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Suresh Vedantham
- Division of Diagnostic Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Peter Verhamme
- KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Ivan D Florez
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ariel Izcovich
- Internal Medicine Department, German Hospital, Buenos Aires, Argentina; and
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Stephanie Ross
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Kline J, Adler D, Alanis N, Bledsoe J, Courtney D, D'Etienne J, B Diercks D, Garrett J, Jones AE, MacKenzie D, Madsen T, Matuskowitz A, Mumma B, Nordenholz K, Pagenhardt J, Runyon M, Stubblefield W, Willoughby C. Study protocol for a multicentre implementation trial of monotherapy anticoagulation to expedite home treatment of patients diagnosed with venous thromboembolism in the emergency department. BMJ Open 2020; 10:e038078. [PMID: 33004396 PMCID: PMC7534683 DOI: 10.1136/bmjopen-2020-038078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION In the USA, many emergency departments (EDs) have established protocols to treat patients with newly diagnosed deep vein thrombosis (DVT) as outpatients. Similar treatment of patients with pulmonary embolism (PE) has been proposed, but no large-scale study has been published to evaluate a comprehensive, integrated protocol that employs monotherapy anticoagulation to treat patients diagnosed with DVT and PE in the ED. METHODS AND ANALYSIS This protocol describes the implementation of the Monotherapy Anticoagulation To expedite Home treatment of Venous ThromboEmbolism (MATH-VTE) study at 33 hospitals in the USA. The study was designed and executed to meet the requirements for the Standards for Reporting Implementation Studies guideline. The study was funded by investigator-initiated awards from industry, with Indiana University as the sponsor. The study principal investigator and study associates travelled to each site to provide on-site training. The protocol identically screens patients with both DVT or PE to determine low risk of death using either the modified Hestia criteria or physician judgement plus a negative result from the simplified PE severity index. Patients must be discharged from the ED within 24 hours of triage and treated with either apixaban or rivaroxaban. Overall effectiveness is based upon the primary efficacy and safety outcomes of recurrent VTE and bleeding requiring hospitalisation respectively. Target enrolment of 1300 patients was estimated with efficacy success defined as the upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0%. Thirty-three hospitals in 17 states were initiated in 2016-2017. ETHICS AND DISSEMINATION All sites had Institutional Review Board approval. We anticipate completion of enrolment in June 2020; study data will be available after peer-reviewed publication. MATH-VTE will provide information from a large multicentre sample of US patients about the efficacy and safety of home treatment of VTE with monotherapy anticoagulation.
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Affiliation(s)
- Jeffrey Kline
- Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - David Adler
- Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Naomi Alanis
- Emergency Medicine, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Joseph Bledsoe
- Emergency Medicine, Intermountain Health Care Inc, Salt Lake City, Utah, USA
| | - Daniel Courtney
- Emergency Medicine, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - James D'Etienne
- Emergency Medicine, John Peter Smith Hospital, Fort Worth, Texas, USA
| | - Deborah B Diercks
- Emergency Medicine, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - John Garrett
- Emergency Medicine, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Alan E Jones
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - David MacKenzie
- Emergency Medicine, Maine Medical Center, Portland, Maine, USA
| | - Troy Madsen
- Emergency Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Andrew Matuskowitz
- Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bryn Mumma
- Emergency Medicine, University of California Davis, Davis, California, USA
| | - Kristen Nordenholz
- Emergency Medicine, University of Colorado Denver, Denver, Colorado, USA
| | - Justine Pagenhardt
- Emergency Medicine, West Virginia University - Health Sciences Campus, Morgantown, West Virginia, USA
| | - Michael Runyon
- Emergency Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - William Stubblefield
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Thukral S, Vedantham S. Catheter-Based Therapies and Other Management Strategies for Deep Vein Thrombosis and Post-Thrombotic Syndrome. J Clin Med 2020; 9:E1439. [PMID: 32408611 PMCID: PMC7290684 DOI: 10.3390/jcm9051439] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/07/2020] [Indexed: 02/07/2023] Open
Abstract
Acute deep vein thrombosis (DVT) causes substantial short-term and long-term patient morbidity. Medical, lifestyle, and compressive therapies have been investigated for the prevention of pulmonary embolism (PE) and recurrence of venous thromboembolism (VTE). However, patient-centered outcomes such as resolution of presenting DVT symptoms and late occurrence of post-thrombotic syndrome (PTS) have not been prioritized to the same degree. Imaging-guided, catheter-based endovascular therapy has been used in selected patients to alleviate these sequelae, but important questions remain about their optimal use. In this article, we review the available evidence and summarize the rationale for use of catheter-based therapy in specific patient groups.
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Affiliation(s)
- Siddhant Thukral
- School of Medicine, University of Missouri—Kansas City, Kansas City, MO 64108, USA;
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO 63110, USA
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Pfaundler N, Limacher A, Stalder O, Méan M, Rodondi N, Baumgartner C, Aujesky D. Prognosis in patients with cancer-associated venous thromboembolism: Comparison of the RIETE-VTE and modified Ottawa score. J Thromb Haemost 2020; 18:1154-1161. [PMID: 32124545 DOI: 10.1111/jth.14783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/31/2020] [Accepted: 02/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The RIETE-VTE score was derived to risk-stratify patients with cancer-associated venous thromboembolism (CAT). OBJECTIVES To externally validate the RIETE-VTE score and to compare its prognostic performance with the modified Ottawa score. PATIENTS/METHODS We studied 178 elderly patients with CAT in a prospective multicenter cohort and assessed 30-day all-cause mortality, 90-day overall complications (mortality, major bleeding, or venous thromboembolism [VTE] recurrence), and 6-month VTE recurrence. Patients were stratified into RIETE-VTE and modified Ottawa score risk classes (low, intermediate, high). We compared the discriminative power (area under the receiver operating characteristic [ROC] curve) to predict mortality, overall complications, and VTE recurrence. RESULTS Fifteen patients (8.4%) died within 30 days, 42 (23.6%) experienced an overall complication by day 90, and 6 (3.4%) had recurrent VTE within 6 months. The RIETE-VTE and the modified Ottawa score classified similar proportions of patients as low risk (35.4% versus 31.5%; P = .37). No low-risk patient died within 30 days. Low-risk patients identified by the RIETE-VTE and modified Ottawa score had similar rates of overall complications (7.9% versus 8.9%) and VTE recurrence (1.6% versus 1.8%). The modified Ottawa score and the RIETE-VTE score had similar areas under the ROC curve for predicting all-cause mortality (0.84 versus 0.75; P = .21), overall complications (0.74 versus 0.68; P = .26), and VTE recurrence (0.67 versus 0.64; P = .78). CONCLUSIONS Both the RIETE-VTE and modified Ottawa score accurately identified elderly patients with CAT who are at low risk for short-term mortality and who are potential candidates for outpatient care.
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Affiliation(s)
- Nubio Pfaundler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Limacher
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Odile Stalder
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Marie Méan
- Department of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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8
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Khatib R, Ross S, Kennedy SA, Florez ID, Ortel TL, Nieuwlaat R, Neumann I, Witt DM, Schulman S, Manja V, Beyth R, Clark NP, Wiercioch W, Schünemann HJ, Zhang Y. Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis. Blood Adv 2020; 4:500-513. [PMID: 32040553 PMCID: PMC7013254 DOI: 10.1182/bloodadvances.2019001223] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 12/20/2019] [Indexed: 12/22/2022] Open
Abstract
Increasing evidence supports the safety and effectiveness of managing low-risk deep vein thrombosis (DVT) or pulmonary embolism (PE) in outpatient settings. We performed a systematic review to assess safety and effectiveness of managing patients with DVT or PE at home compared with the hospital. Medline, Embase, and Cochrane databases were searched up to July 2019 for relevant randomized clinical trials (RCTs), and prospective cohort studies. Two investigators independently screened titles and abstracts of identified citations and extracted data from relevant full-text papers. Risk ratios (RRs) were calculated, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Seven RCTs (1922 patients) were included in meta-analyses on managing patients with DVT. Pooled estimates indicated decreased risk of PE (RR = 0.64; 95% confidence interval [CI], 0.44-0.93) and recurrent DVT (RR = 0.61; 95% CI, 0.42-0.90) for home management, both with moderate certainty of the evidence. Reductions in mortality and major bleeding were not significant, both with low certainty of the evidence. Two RCTs (445 patients) were included in meta-analyses on home management of low-risk patients with PE. Pooled estimates indicated no significant difference in all-cause mortality, recurrent PE, and major bleeding, all with low certainty of the evidence. Results of pooled estimates from 3 prospective cohort studies (234 patients) on home management of PE showed similar results. Our findings indicate that low-risk DVT patients had similar or lower risk of patient-important outcomes with home treatment compared with hospital treatment. In patients with low-risk PE, there was important uncertainty about a difference between home and hospital treatment.
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Affiliation(s)
- Rasha Khatib
- Advocate Research Institute, Advocate Health Care, Downers Grove, IL
| | - Stephanie Ross
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sean Alexander Kennedy
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ivan D Florez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
| | - Thomas L Ortel
- Division of Hematology, Medicine and Pathology, Duke University Medical Center, Durham, NC
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynecology, The First I. M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Veena Manja
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Rebecca Beyth
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation Service, Kaiser Permanente Colorado, Aurora, CO; and
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Guang' anmen Hospital, China Academy of Chinese Medical Science, Xicheng District, Beijing, China
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9
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Bauersachs R, Debus S, Nehler M, Huelsebeck M, Balradj J, Bowrin K, Briere JB. A Targeted Literature Review of the Disease Burden in Patients With Symptomatic Peripheral Artery Disease. Angiology 2019; 71:303-314. [DOI: 10.1177/0003319719896477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patients with peripheral artery disease (PAD) have an increased risk of cardiovascular (CV) and limb events, but the disease is frequently underdiagnosed and treatment options are limited. This review examines the disease burden of symptomatic PAD as well as key guideline recommendations. Publications were identified using the ProQuest portal to access the Medline, Medline In-Process, and Embase databases. Search terms for symptomatic PAD were combined with terms relevant to epidemiology, burden, treatment practice, and physiopathology. Articles in English published between January 2001 and September 2016 were screened according to the population, interventions, comparator, outcomes, and study design criteria. Relevant publications (n = 200) were identified. The reported incidence and prevalence of PAD varied depending on the definitions used and the study populations. Patients generally had a poor prognosis, with an increased risk of mortality, CV, and limb events and decreased quality of life. Guideline recommendations included ankle–brachial index measurements, exercise testing, and angiography for diagnosis and risk factor modification, antiplatelets, cilostazol, exercise therapy, or surgical interventions for treatment, depending on the patient profile. The clinical, humanistic, and economic burden of disease in patients with symptomatic PAD is substantial and needs to be reduced through improved PAD management.
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Affiliation(s)
- Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmBH, Darmstadt, Germany
| | - Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery, Angiology, Endovascular Interventions, University of Hamburg-Eppendorf, Hamburg Germany
| | - Mark Nehler
- Vascular Surgery and Endovascular Therapy Faculty, University of Colorado and CPC Research, Denver, CO, USA
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10
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Musco SE, Smallwood SM, Gossard J. Development and Evaluation of a Pharmacist-Driven Screening Tool to Identify Patients Presenting to the Emergency Department Who Are Eligible for Outpatient Treatment of Deep Vein Thrombosis. J Pharm Pract 2019; 34:378-385. [PMID: 33969771 DOI: 10.1177/0897190019872582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is a critical and costly health issue. Treatment in the outpatient setting is preferred compared to the inpatient setting. However, there is a lack of evidence regarding how best to identify patients who are ideal for outpatient DVT treatment. OBJECTIVE To design and evaluate a pharmacist-driven screening tool for the identification of patients presenting to the emergency department (ED) at a community hospital with DVT who are appropriate for outpatient treatment. METHODS This study was conducted in sequential phases: compilation and vetting of screening criteria, descriptive evaluation of criteria through retrospective chart review, and quantification of potential cost savings by avoiding admissions. Criteria were collected via literature search and assembled into a screening tool, which was applied retroactively to a cohort of ED patients admitted with DVT diagnosis. RESULTS A screening tool was developed with multidisciplinary input and consisted of 5 categories with individual patient and disease state criteria. The majority (91%) of patients reviewed would not have qualified for outpatient DVT treatment based on the retrospective application of the screening tool. The most common disqualification criteria category was high risk of bleeding/clotting (n = 81), and the most frequently represented parameter within that category was antithrombotic therapy prior to admission (n = 53). CONCLUSION A screening tool may not be the most efficient method for health-care practitioners such as pharmacists to identify ED patients appropriate for outpatient management of DVT. Other avenues should be explored for improving the cost-effective management of these patients.
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Affiliation(s)
- Shaina E Musco
- 465018High Point University Fred Wilson School of Pharmacy, One University Parkway, High Point, NC, USA
| | | | - Jill Gossard
- Pharmacy Department, Community Howard Regional Hospital, Kokomo, IN, USA
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11
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Coscia C, Jaureguizar A, Quezada CA, Muriel A, Monreal M, Villén T, Barbero E, Chiluiza D, Yusen RD, Jimenez D. Comparison of All-Cause Mortality Following VTE Treatment Between Propensity Score-Adjusted Observational Studies and Matched Randomized Controlled Trials: Meta-Epidemiologic Study. Chest 2019; 155:689-698. [PMID: 30961834 PMCID: PMC6743207 DOI: 10.1016/j.chest.2018.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/08/2018] [Accepted: 10/02/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND It is unknown whether propensity score-adjusted observational studies produce results comparable to those of randomized controlled trials (RCTs) that address similar VTE treatment issues. METHODS The PubMed and Web of Science databases were systematically searched for propensity score-adjusted observational studies, RCTs, and meta-analyses of RCTs that estimated all-cause mortality following VTE treatment. After identifying distinct clinical treatment issues evaluated in the eligible observational studies, a standardized algorithm was used to identify and match at least one RCT or RCT meta-analysis publication for paired study design analyses. Meta-analyses were used to summarize groups of studies. Treatment efficacy statistics (relative ORs) were compared between the paired observational and RCT studies, and the summary relative ORs for all study design pairs were also calculated. RESULTS The observational and RCT study pairs assessed seven clinical treatment issues. Overall, the observational study-RCT pairs did not exhibit significantly different mortality estimates (summary relative OR, 0.89; 95% CI, 0.32-1.46; I2 = 23%). However, two of the seven treatment issue study pairs (thrombolysis vs anticoagulation for pulmonary embolism; once- vs twice-daily enoxaparin for VTE) exhibited a significantly different treatment effect direction, and there was a substantial (nonsignificant) difference in the magnitude of the effect in another two of the study pairs (rivaroxaban vs vitamin K antagonists for VTE; home treatment vs hospitalization for DVT). CONCLUSIONS This systematic comparison across seven VTE treatment topics suggests that propensity score-adjusted observational studies and RCTs often exhibit similar all-cause mortality, although differences in the direction or the magnitude of estimated treatment effects may occasionally occur. TRIAL REGISTRY PROSPERO; CRD42018087819; URL: http://www.crd.york.ac.uk/PROSPERO.
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Affiliation(s)
- Claudia Coscia
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | - Ana Jaureguizar
- Respiratory Department, Hospital Ramón y Cajal, Medicine Department, Universidad de Alcala (IRYCIS), Madrid, Spain
| | - Carlos Andres Quezada
- Respiratory Department, Hospital Ramón y Cajal, Medicine Department, Universidad de Alcala (IRYCIS), Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain.
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Universidad Católica de Murcia, Murcia, Spain
| | - Tomas Villén
- Emergency Department, Hospital Universitario La Paz, Madrid, Spain
| | - Esther Barbero
- Respiratory Department, Hospital Ramón y Cajal, Medicine Department, Universidad de Alcala (IRYCIS), Madrid, Spain
| | - Diana Chiluiza
- Respiratory Department, Hospital Ramón y Cajal, Medicine Department, Universidad de Alcala (IRYCIS), Madrid, Spain
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal, Medicine Department, Universidad de Alcala (IRYCIS), Madrid, Spain
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Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018; 71:e59-e109. [PMID: 29681319 DOI: 10.1016/j.annemergmed.2018.03.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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13
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Weeda ER, Butt S. Systematic Review of Real-World Studies Evaluating Characteristics Associated With or Programs Designed to Facilitate Outpatient Management of Deep Vein Thrombosis. Clin Appl Thromb Hemost 2018; 24:301S-313S. [PMID: 30428693 PMCID: PMC6714833 DOI: 10.1177/1076029618811082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Select patients with acute deep vein thrombosis (DVT) can be managed as outpatients. We sought to conduct a systematic review of real-world studies describing either (1) the clinical characteristics associated with outpatient DVT treatment in all-comers or (2) emergency department (ED) programs designed to facilitate outpatient DVT treatment. MEDLINE and SCOPUS were searched (January 1, 2012, to May 1, 2018) to identify citations meeting the aforementioned criteria. Twenty-one real-world studies were included. The proportion of all-comer patients with DVT managed as outpatients was ≤50% in 11 of 15 studies. With the exception of younger age, no characteristics were consistently associated with outpatient treatment across the 13 studies reporting these characteristics. We identified 8 studies describing ED programs aimed at facilitating DVT outpatient treatment, all of which provided education and included measures to encourage early outpatient follow-up after ED discharge. In conclusion, the proportion of patients with DVT managed as outpatients across real-world studies was low. Several ED programs aimed at facilitating this treatment have been described. It is possible that programs similar to these will increase the proportion of patients with DVT that can be safely managed as outpatients.
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Affiliation(s)
- Erin R Weeda
- Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - Sofia Butt
- Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
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Abstract
IMPORTANCE Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common and potentially fatal disease. OBJECTIVE To summarize the advances in diagnosis and treatment of VTE of the past 5 years. EVIDENCE REVIEW A systematic search was conducted in EMBASE Classic, EMBASE, Ovid MEDLINE, and other nonindexed citations using broad terms for diagnosis and treatment of VTE to find systematic reviews and meta-analyses, randomized trials, and prospective cohort studies published between January 1, 2013, and July 31, 2018. The 10th edition of the American College of Chest Physicians Antithrombotic Therapy Guidelines was screened to identify additional studies. Screening of titles, abstracts, and, subsequently, full-text articles was performed in duplicate, as well as data extraction and risk-of-bias assessment of the included articles. FINDINGS Thirty-two articles were included in this review. The application of an age-adjusted D-dimer threshold in patients with suspected PE has increased the number of patients in whom imaging can be withheld. The Pulmonary Embolism Rule-Out Criteria safely exclude PE when the pretest probability is low. The introduction of direct oral anticoagulants has allowed for a simplified treatment of VTE with a lower risk of bleeding regardless of etiology or extent of the VTE (except for massive PE) and has made extended secondary prevention more acceptable. Thrombolysis is best reserved for patients with massive PE or those with DVT and threatened limb loss. Insertion of inferior vena cava filters should be avoided unless anticoagulation is absolutely contraindicated in patients with recent acute VTE. Graduated compression stockings are no longer recommended to treat DVT but may be used when acute or chronic symptoms are present. Anticoagulation may no longer be indicated for patients with isolated distal DVT at low risk of recurrence. CONCLUSIONS AND RELEVANCE Over the past 5 years, substantial progress has been made in VTE management, allowing for diagnostic and therapeutic strategies tailored to individual patient characteristics, preferences, and values.
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Affiliation(s)
- Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Grégoire Le Gal
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Philip S Wells
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Ioannou P, Tsagkaraki E, Andrianaki AM, Papadakis JA. Unnecessary hospitalizations for DVT in the era of NOACs. Eur J Intern Med 2017; 44:e40-e41. [PMID: 28739351 DOI: 10.1016/j.ejim.2017.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 07/17/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Petros Ioannou
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece.
| | - Emmanouela Tsagkaraki
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece.
| | - Aggeliki M Andrianaki
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece.
| | - John A Papadakis
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece.
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Douce D, McClure LA, Lutsey P, Cushman M, Zakai NA. Outpatient Treatment of Deep Vein Thrombosis in the United States: The Reasons for Geographic and Racial Differences in Stroke Study. J Hosp Med 2017; 12:826-830. [PMID: 28991948 PMCID: PMC6246775 DOI: 10.12788/jhm.2831] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the uptake of outpatient DVT treatment in the United States and understand how comorbidities and socioeconomic conditions impact the decision to treat as an outpatient. DESIGN/SETTING The Reasons for Geographic and Racial Differences in Stroke cohort study recruited 30,329 participants between 2003 and 2007. DVT events were ascertained through 2011. MEASUREMENTS Multivariable logistic regression was used to determine the correlates of outpatient treatment of DVT accounting for age, sex, race, education, income, urban or rural residence, and region of residence. RESULTS Of 379 venous thromboembolism events, 141 participants had a DVT without diagnosed pulmonary embolism and that did not occur during hospitalization. Overall, 28% (39 of 141) of participants with DVT were treated as outpatients. In a multivariable model, the odds ratio for outpatient versus inpatient DVT treatment was 4.16 (95% confidence interval [CI], 1.25-13.79) for urban versus rural dwellers, 3.29 (95% CI, 1.30-8.30) for white versus black patients, 2.41 (95% CI, 1.06-5.47) for women versus men, and 1.90 (95% CI, 1.19-3.02) for every 10 years younger in age. Living outside the southeastern United States and having higher education and income were not statistically significantly associated with outpatient treatment. CONCLUSIONS Despite known safety and efficacy, only 28% of participants with DVT received outpatient treatment. This study highlights populations in which efforts could be made to reduce hospital admissions.
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Affiliation(s)
- Daniel Douce
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT
| | - Leslie A. McClure
- Department of epidemiology and biostatistics, Dornsife School of Public Health, Drexel University, Philedelphia, PA
| | - Pamela Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Mary Cushman
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT
- Department of Pathology, University of Vermont College of Medicine, Burlington VT
| | - Neil A. Zakai
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT
- Department of Pathology, University of Vermont College of Medicine, Burlington VT
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Ang DTY, Simpson JM, Stewart IC, Murchison JT, Lockman KA. Excess long-term mortality in outpatient deep venous thrombosis patients managed in an ambulatory care setting. QJM 2017; 110:149-153. [PMID: 27507017 DOI: 10.1093/qjmed/hcw133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Deep venous thrombosis (DVT) is increasingly being managed in the outpatient setting, particularly patients deemed low-risk at presentation. The long-term outcomes of these patients remain unclear. AIM To determine the long-term outcomes of patients with DVT and those with raised D-dimer without DVT managed exclusively by an ambulatory care pathway. DESIGN Retrospective cohort analysis. METHODS 828 consecutive patients assessed at the Ambulatory Care Clinic of a tertiary care university hospital between 1 January and 31 December 2008 for potential lower limb DVT were analysed. Primary and secondary outcome was all-cause mortality and new diagnosis of cancer, respectively. Median follow-up was 6.4 years. RESULTS The final cohort comprised 131 patients with DVT, 396 with raised D-dimer without DVT and 165 with normal D-dimer without DVT. Long-term survival was 72.5% for DVT, 75.3% for elevated D-dimer without thrombosis and 93.3% for those with normal D-dimer ( P < 0.0001). The risk of death with DVT remained significant after adjusting for age, gender, previous cancer, recent surgery and previous thromboembolism (HR 2.17, 95% CI [1.07, 4.38]). Cancer accounted for 44.4 and 37.8% of deaths within the first and second groups, respectively. 50% of cancers in the former group were diagnosed during follow-up vs. 95.1% in the latter. CONCLUSION The 5-year survival of patients with DVT managed via ambulatory care was worse than expected. An algorithm is urgently needed to identify predictors of adverse outcomes for both these patients as well as those with raised D-dimer without thrombosis.
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Affiliation(s)
| | | | | | - John T Murchison
- Department of Radiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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18
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Mausbach LS, Avnery O, Ellis MH. Ambulatory Versus In-Hospital Treatment of Proximal Lower-Limb Deep Vein Thrombosis in Adults: A Retrospective Cohort Study. Clin Appl Thromb Hemost 2016; 23:859-864. [PMID: 27831528 DOI: 10.1177/1076029616677801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Complications of deep vein thrombosis (DVT) are related to adequacy of initial anticoagulant therapy. In this study, we analyze consecutive patients with lower-limb proximal DVT and compare the characteristics, treatment, and clinical outcomes of patients receiving entirely ambulatory treatment versus those hospitalized for initial treatment. METHODS This was a retrospective study of consecutive patients with a first proximal lower-limb DVT during a 2-year period. Patients were followed for 90 days. Major end points were all-cause mortality, bleeding requiring hospitalization, and recurrent venous thromboembolism (VTE). Events were determined for patients who were hospitalized versus those treated on an entirely ambulatory basis. RESULTS A total of 236 patients were included in the study. Of these, 147 patients were hospitalized and 89 patients received ambulatory treatment. There were 20 fatalities-18 in-hospital and 2 in-ambulatory patients ( P = .008). By multivariable Cox regression analysis, the presence of active cancer (hazard ratio [HR] = 5.44; confidence interval [CI]: 2.16-13.7; P = .001), age (HR = 1.06; CI: 1.02-1.1; P = .001), and hospitalization (HR = 5.73; CI: 1.33-24.69; P = .019) were associated with death. Eight hospitalized and 2 ambulatory patients required readmission because of bleeding. Age was the only variable associated with bleeding (HR = 1.10; CI: 1.03-1.18; P = .004). There were no recurrent VTE events. CONCLUSION In this study of routine management of proximal DVT, we demonstrate that patients suitable for ambulatory care are adequately identified by physicians and may be treated with equal safety and efficacy to hospitalized patients.
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Affiliation(s)
- Lisa S Mausbach
- 1 Hematology Institute, Meir Medical Center, Kfar Saba, Israel.,2 Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orli Avnery
- 1 Hematology Institute, Meir Medical Center, Kfar Saba, Israel.,2 Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Martin H Ellis
- 1 Hematology Institute, Meir Medical Center, Kfar Saba, Israel.,2 Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rabinovich E, Bartholomew JR, Wilks ML, Tripp BL, McCrae KR, Khorana AA. Centralizing care of cancer-associated thromboembolism: The Cleveland Clinic experience. Thromb Res 2016; 147:102-103. [DOI: 10.1016/j.thromres.2016.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/29/2016] [Accepted: 10/02/2016] [Indexed: 11/27/2022]
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20
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Shimizu K, Sasaki T, Tomaru T, Noike H. Extensive deep vein thrombosis treatment using fondaparinux and edoxaban: a case report. Thromb J 2016; 14:15. [PMID: 27468257 PMCID: PMC4962499 DOI: 10.1186/s12959-016-0089-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 07/08/2016] [Indexed: 11/11/2022] Open
Abstract
Background Factor Xa inhibitor is a key drug in the coagulation cascade. Parenteral anticoagulation using low molecular weight heparin or fondaparinux is the recommended form of treatment for most patients presenting with venous thrombosis. Following the acute phase, edoxaban is recommended. We present a case of extensive deep vein thrombosis treated using fondaparinux and edoxaban. Case presentation A 63-year-old man with redness, pain, and swelling of the left leg lasting for more than 1 month was referred to our hospital. Ultrasonography revealed a thrombus in the left femoral vein. Computed tomographic angiography revealed clots in the distal right pulmonary artery. Thus, the anticoagulant treatment was initiated with subcutaneous injections of fondaparinux (7.5 mg) for 5 consecutive days, followed by once daily oral administration of edoxaban (60 mg). After 3 months of treatment, a regression of thrombotic clots was shown. Three months later, the remaining clots disappeared, leaving only mural thrombi; no bleeding complications were observed during the treatment period. Conclusion The anticoagulant treatment with subcutaneous fondaparinux and subsequently with oral edoxaban was effective for treating extensive deep vein thrombosis. Electronic supplementary material The online version of this article (doi:10.1186/s12959-016-0089-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kazuhiro Shimizu
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
| | - Takeshi Sasaki
- Department of Clinical Functional Physiology, Toho University Sakura Medical Center, Chiba, Japan
| | - Takanobu Tomaru
- Department of Clinical Functional Physiology, Toho University Sakura Medical Center, Chiba, Japan
| | - Hirofumi Noike
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
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Direct-Acting Oral Anticoagulants: Practical Considerations for Emergency Medicine Physicians. Emerg Med Int 2016; 2016:1781684. [PMID: 27293895 PMCID: PMC4884797 DOI: 10.1155/2016/1781684] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/11/2016] [Accepted: 03/29/2016] [Indexed: 01/01/2023] Open
Abstract
Nonvalvular atrial fibrillation- (NVAF-) related stroke and venous thromboembolism (VTE) are cardiovascular diseases associated with significant morbidity and economic burden. The historical standard treatment of VTE has been the administration of parenteral heparinoid until oral warfarin therapy attains a therapeutic international normalized ratio. Warfarin has been the most common medication for stroke prevention in NVAF. Warfarin use is complicated by a narrow therapeutic window, unpredictable dose response, numerous food and drug interactions, and requirements for frequent monitoring. To overcome these disadvantages, direct-acting oral anticoagulants (DOACs)—dabigatran, rivaroxaban, apixaban, and edoxaban—have been developed for the prevention of stroke or systemic embolic events (SEE) in patients with NVAF and for the treatment of VTE. Advantages of DOACs include predictable pharmacokinetics, few drug-drug interactions, and low monitoring requirements. In clinical studies, DOACs are noninferior to warfarin for the prevention of NVAF-related stroke and the treatment and prevention of VTE as well as postoperative knee and hip surgery VTE prophylaxis, with decreased bleeding risks. This review addresses the practical considerations for the emergency physician in DOAC use, including dosing recommendations, laboratory monitoring, anticoagulation reversal, and cost-effectiveness. The challenges of DOACs, such as the lack of specific laboratory measurements and antidotes, are also discussed.
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Ceresetto JM. Venous thromboembolism in Latin America: a review and guide to diagnosis and treatment for primary care. Clinics (Sao Paulo) 2016; 71:36-46. [PMID: 26872082 PMCID: PMC4732387 DOI: 10.6061/clinics/2016(01)07] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 12/31/2022] Open
Abstract
There are various region-specific challenges to the diagnosis and effective treatment of venous thromboembolism in Latin America. Clear guidance for physicians and patient education could improve adherence to existing guidelines. This review examines available information on the burden of pulmonary embolism and deep vein thrombosis in Latin America and the regional issues surrounding the diagnosis and treatment of pulmonary embolism and deep vein thrombosis. Potential barriers to appropriate care, as well as treatment options and limitations on their use, are discussed. Finally, an algorithmic approach to the diagnosis and treatment of venous thromboembolism in ambulatory patients is proposed and care pathways for patients with pulmonary embolism and deep vein thrombosis are outlined for primary care providers in Latin America.
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Rosa-Salazar V, Trujillo-Santos J, Díaz Peromingo JA, Apollonio A, Sanz O, Malý R, Muñoz-Rodriguez FJ, Serrano JC, Soler S, Monreal M. A prognostic score to identify low-risk outpatients with acute deep vein thrombosis in the upper extremity. J Thromb Haemost 2015; 13:1274-8. [PMID: 25980766 DOI: 10.1111/jth.13008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/26/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND No studies have identified which patients with upper-extremity deep vein thrombosis (DVT) are at low risk for adverse events within the first week of therapy. METHODS We used data from Registro Informatizado de la Enfermedad TromboEmbólica to explore in patients with upper-extremity DVT a prognostic score that correctly identified patients with lower limb DVT at low risk for pulmonary embolism, major bleeding, or death within the first week. RESULTS As of December 2014, 1135 outpatients with upper-extremity DVT were recruited. Of these, 515 (45%) were treated at home. During the first week, three patients (0.26%) experienced pulmonary embolism, two (0.18%) had major bleeding, and four (0.35%) died. We assigned 1 point to patients with chronic heart failure, creatinine clearance levels 30-60 mL min(-1) , recent bleeding, abnormal platelet count, recent immobility, or cancer without metastases; 2 points to those with metastatic cancer; and 3 points to those with creatinine clearance levels < 30 mL min(-1) . Overall, 759 (67%) patients scored ≤ 1 point and were considered to be at low risk. The rate of the composite outcome within the first week was 0.26% (95% confidence interval [CI] 0.004-0.87) in patients at low risk and 1.86% (95% CI 0.81-3.68) in the remaining patients. C-statistics was 0.73 (95% CI 0.57-0.88). Net reclassification improvement was 22%, and integrated discrimination improvement was 0.0055. CONCLUSIONS Using six easily available variables, we identified outpatients with upper-extremity DVT at low risk for adverse events within the first week. These data may help to safely treat more patients at home.
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Affiliation(s)
- V Rosa-Salazar
- Department of Internal Medicine, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - J Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Murcia, Spain
| | - J A Díaz Peromingo
- Department of Internal Medicine, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - A Apollonio
- Department of Angiology, Ospedale Belcolle di Viterbo, Viterbo, Lazio, Italy
| | - O Sanz
- Department of Internal Medicine, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
| | - R Malý
- Department of Cardiovascular Medicine I, Charles University in Prague, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - F J Muñoz-Rodriguez
- Department of Internal Medicine, Fundación Privada Hospital de Mollet, Mollet del Vallés, Spain
| | - J C Serrano
- Department of Internal Medicine and Oncology Haematology, Hospital Dr. Patrocinio Peñuela Ruíz, Tachira, Venezuela
| | - S Soler
- Department of Internal Medicine, Hospital d'Olot I Comarcal de la Garrotxa, Garrotxa, Spain
| | - M Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universidad Católica de Murcia, Murcia, Spain
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Frank B, Ariza L, Lamparter H, Grossmann V, Prochaska JH, Ullmann A, Kindler F, Weisser G, Walter U, Lackner KJ, Espinola-Klein C, Münzel T, Konstantinides SV, Wild PS. Rationale and design of three observational, prospective cohort studies including biobanking to evaluate and improve diagnostics, management strategies and risk stratification in venous thromboembolism: the VTEval Project. BMJ Open 2015; 5:e008157. [PMID: 26133379 PMCID: PMC4499722 DOI: 10.1136/bmjopen-2015-008157] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) with its two manifestations deep vein thrombosis (DVT) and pulmonary embolism (PE) is a major public health problem. The VTEval Project aims to investigate numerous research questions on diagnosis, clinical management, treatment and prognosis of VTE, which have remained uncertain to date. METHODS AND ANALYSIS The VTEval Project consists of three observational, prospective cohort studies on VTE comprising cohorts of individuals with a clinical suspicion of acute PE (with or without DVT), with a clinical suspicion of acute DVT (without symptomatic PE) and with an incidental diagnosis of VTE (PE or DVT). The VTEval Project expects to enrol a total of approximately 2000 individuals with subsequent active and passive follow-up investigations over a time period of 5 years per participant. Time points for active follow-up investigations are at months 3, 6, 12, 24 and 36 after diagnosis (depending on the disease cohort); passive follow-up investigations via registry offices and the cancer registry are performed 48 and 60 months after diagnosis for all participants. Primary short-term outcome is defined by overall mortality (PE-related death and all other causes of death), primary long-term outcome by symptomatic VTE (PE-related death, recurrence of non-fatal PE or DVT). The VTEval Project includes three 'all-comer' studies and involves the standardised acquisition of high-quality data, covering the systematic assessment of VTE including symptoms, risk profile, psychosocial, environmental and lifestyle factors as well as clinical and subclinical disease, and it builds up a large state-of-the-art biorepository containing various materials from serial blood samplings. ETHICS AND DISSEMINATION The VTEval Project has been approved by the local data safety commissioner and the responsible ethics committee (reference no. 837.320.12 (8421-F)). Trial results will be published in peer-reviewed journals and presented at national and international scientific meetings. TRIAL REGISTRATION NUMBER NCT02156401.
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Affiliation(s)
- Bernd Frank
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Liana Ariza
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Heidrun Lamparter
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Vera Grossmann
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Jürgen H Prochaska
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Department of Medicine 2, University Medical Center Mainz, Mainz, Germany
| | - Alexander Ullmann
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Florentina Kindler
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Gerhard Weisser
- Department of Medicine 2, University Medical Center Mainz, Mainz, Germany
| | - Ulrich Walter
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Karl J Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Mainz, Germany
| | | | - Thomas Münzel
- Department of Medicine 2, University Medical Center Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), partner site RhineMain, Mainz, Germany
| | | | - Philipp S Wild
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Preventive Cardiology and Preventive Medicine, Department of Medicine 2, University Medical Center Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), partner site RhineMain, Mainz, Germany
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25
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Abstract
This issue provides a clinical overview of deep venous thrombosis, focusing on prevention, diagnosis, treatment, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.
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Liu Z, Tao X, Chen Y, Fan Z, Li Y. Bed rest versus early ambulation with standard anticoagulation in the management of deep vein thrombosis: a meta-analysis. PLoS One 2015; 10:e0121388. [PMID: 25860350 PMCID: PMC4393252 DOI: 10.1371/journal.pone.0121388] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 01/15/2015] [Indexed: 12/05/2022] Open
Abstract
Introduction Bed rest has been considered as the cornerstone of management of deep vein thrombosis (DVT) for a long time, though it is not evidence-base, and there is growing evidence favoring early ambulation. Methods Electronic databases including Medline, PubMed, Cochrane Library and three Chinese databases were searched with key words of “deep vein thrombosis”, “pulmonary embolism”, “venous thrombosis”, “bed rest”, “immobilization”, “mobilization” and “ambulation”. We considered randomized controlled trials, prospective or retrospective cohort studies that compared the outcomes of acute DVT patients managed with early ambulation versus bed rest, in addition to standard anticoagulation. Meta-analysis pertaining to the incidence of new pulmonary embolism (PE), progression of DVT, and DVT related deaths were conducted, as well as the extent of remission of pain and edema. Results 13 studies were included with a total of 3269 patients. Compared to bed rest, early ambulation was not associated with a higher incidence of new PE, progression of DVT, or DVT related deaths (RD −0.03, 95% CI −0.05∼ −0.02; Z = 1.24, p = 0.22; random effect model, Tau2 = 0.01). Moreover, if the patients suffered moderate or severe pain initially, early ambulation was related to a better outcome, with respect to remission of acute pain in the affected limb (SMD 0.42, 95%CI 0.09∼0.74; Z = 2.52, p = 0.01; random effect model, Tau2 = 0.04). Meta-analysis of alleviation of edema cannot elicit a solid conclusion because of significant heterogeneity among the few studies. Conclusions Compared to bed rest, early ambulation of acute DVT patients with anticoagulation was not associated with a higher incidence of new PE, progression of DVT, and DVT related deaths. Furthermore, for the patients suffered moderate or severe pain initially, a better outcome can be seen in early ambulation group, regarding to the remission of acute pain in the affected limb.
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Affiliation(s)
- Zhenlei Liu
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Xixi Tao
- Department of Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Yuexin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Zhongjie Fan
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Yongjun Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
- * E-mail:
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27
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Merli GJ, Hollander JE, Lefebvre P, Laliberté F, Raut MK, Olson WH, Pollack CV. Rates of hospitalization among patients with deep vein thrombosis before and after the introduction of rivaroxaban. Hosp Pract (1995) 2015; 43:85-93. [PMID: 25791984 DOI: 10.1080/21548331.2015.1021659] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Compared to warfarin, the non-vitamin K antagonist oral anticoagulant rivaroxaban may have advantages in treating patients with venous thromboembolism, because injectable bridging therapy and routine laboratory monitoring are not required. The objective of this study was to compare the rate of hospitalization in patients treated with rivaroxaban after its introduction with what it would have been before the introduction of rivaroxaban. METHODS A retrospective claims analysis was conducted using the MarketScan Hospital Drug Database from January 2011 to December 2013. Adult patients with a primary diagnosis of deep vein thrombosis (DVT) treated with rivaroxaban or low-molecular-weight heparin (LMWH) bridged to warfarin during the first day of an evaluation at a hospital were identified. Based on propensity-score methods, historical LMWH/warfarin patients (i.e., patients who received LMWH/warfarin before the approval of rivaroxaban) were matched 4:1 to rivaroxaban patients, and the rates of hospitalization were compared. RESULTS All rivaroxaban-treated patients (n = 134) in the database were well matched with four historical LMWH/warfarin-treated patients (n = 536). Among the rivaroxaban cohort, 60% of the patients were admitted to the hospital, compared to 82% of the historical patients treated with LMWH/warfarin in the matched cohort. The difference was statistically significant and corresponded to a 27% reduction in hospital admissions (rate ratio [95% confidence interval]: 0.73 [0.62-0.84]). Hospital admission rates adjusted for time-trend analyses also led to similar results. CONCLUSION The availability of rivaroxaban significantly reduced the hospitalization rate in patients with DVT treated with rivaroxaban compared to what it would have been if only LMWH/warfarin were available.
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Affiliation(s)
- Geno J Merli
- Thomas Jefferson University Hospital , Philadelphia, PA , USA
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28
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Trujillo-Santos J, Lozano F, Lorente MA, Adarraga D, Hirmerova J, Del Toro J, Mazzolai L, Barillari G, Barrón M, Monreal M, Alcalde M, Andújar V, Arcelus J, Barba R, Barrón M, Barrón-Andrés B, Bascuñana J, Blanco-Molina A, Bueso T, Casado I, Climent A, Conget F, del Molino F, del Toro J, Falgá C, Fernández-Capitán C, Font L, Gallego P, García-Bragado F, Gómez V, González J, González-Bachs E, Grau E, Guijarro R, Guil M, Gutiérrez J, Jara-Palomares L, Jaras M, Jiménez D, Jiménez R, Lecumberri R, Lobo J, López-Jiménez L, López-Montes L, López-Reyes R, López-Sáez J, Lorente M, Lorenzo A, Luque J, Madridano O, Marchena P, Martín-Antorán J, Mellado M, Monreal M, Morales M, Nauffal D, Nieto J, Núñez M, Ogea J, Otero R, Pagán B, Pedrajas J, Pérez-Rus G, Peris M, Porras J, Pons I, Riera-Mestre A, Rivas A, Rodríguez-Dávila M, Román P, Rosa V, Ruiz-Giménez N, Ruiz J, Sabio P, Samperiz A, Sánchez R, Soler S, Suriñach J, Tiberio G, Trujillo-Santos J, Uresandi F, Valero B, Valle R, Vela J, Villalobos A, Malfante P, Verhamme P, Peerlinck K, Wells P, Malý R, Hirmerova J, Kaletova M, Tomko T, Bertoletti L, Bura-Riviere A, Farès M, Grange C, Mahe I, Merah A, Quere I, Schellong S, Papadakis M, Braester A, Brenner B, Tzoran I, Zeltser D, Apollonio A, Barillari G, Ciammaichella M, Di Micco P, Duce R, Guida A, Maida R, Pace F, Pasca S, Piovella C, Pesavento R, Poggio R, Prandoni P, Rota L, Tiraferri E, Tonello D, Tufano A, Visonà A, Zalunardo B, Almeida S, Leal-Seabra F, Sousa M, Bosevski M, Alatri A, Bounameaux H, Calanca L, Mazzolai L, Serrano J. A prognostic score to identify low-risk outpatients with acute deep vein thrombosis in the lower limbs. Am J Med 2015; 128:90.e9-15. [PMID: 25242230 DOI: 10.1016/j.amjmed.2014.08.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 08/18/2014] [Accepted: 08/19/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND No prior studies have identified which patients with deep vein thrombosis in the lower limbs are at a low risk for adverse events within the first week of therapy. METHODS We used data from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) to identify patients at low risk for the composite outcome of pulmonary embolism, major bleeding, or death within the first week. We built a prognostic score and compared it with the decision to treat patients at home. RESULTS As of December 2013, 15,280 outpatients with deep vein thrombosis had been enrolled. Overall, 5164 patients (34%) were treated at home. Of these, 12 (0.23%) had pulmonary embolism, 8 (0.15%) bled, and 4 (0.08%) died. On multivariable analysis, chronic heart failure, recent immobility, recent bleeding, cancer, renal insufficiency, and abnormal platelet count independently predicted the risk for the composite outcome. Among 11,430 patients (75%) considered to be at low risk, 15 (0.13%) suffered pulmonary embolism, 22 (0.19%) bled, and 8 (0.07%) died. The C-statistic was 0.61 (95% confidence interval [CI], 0.57-0.65) for the decision to treat patients at home and 0.76 (95% CI, 0.72-0.79) for the score (P = .003). Net reclassification improvement was 41% (P < .001). Integrated discrimination improvement was 0.034 for the score and 0.015 for the clinical decision (P < .001). CONCLUSIONS Using 6 easily available variables, we identified outpatients with deep vein thrombosis at low risk for adverse events within the first week. These data may help to safely treat more patients at home. This score, however, should be validated.
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Affiliation(s)
- Javier Trujillo-Santos
- Department of Internal Medicine, Complejo Hospitalario Universitario de Cartagena, Murcia, Spain
| | - Francisco Lozano
- Department of Angiology and Vascular Surgery, Complejo Asistencial de Salamanca, Salamanca, Spain
| | - Manuel Alejandro Lorente
- Department of Internal Medicine, Hospital de la Agencia Valenciana de Salud Vega Baja, Alicante, Spain
| | - Dolores Adarraga
- Department of Internal Medicine, Hospital de Montilla, Córdoba, Spain
| | - Jana Hirmerova
- Department of Internal Medicine, University Hospital Plzen, Plzen, Czech Republic
| | - Jorge Del Toro
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lucia Mazzolai
- Department of Angiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Giovanni Barillari
- Department of Internal Medicine, Ospedale S. Maria della Misericordia, Udine, Italy
| | - Manuel Barrón
- Department of Pneumonology, Hospital San Pedro, Logroño, La Rioja, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.
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