Socioeconomic and occupational risk factors for venous thromboembolism in Sweden: A nationwide epidemiological study

Baseline socioeconomic status predicting post-COVID-19 symptoms: Results from Isfahan COVID Cohort (ICC) study

Objectives

Patients experience complications following their recovery from COVID-19, known as post-COVID-19. This study aimed to investigate the association between baseline socioeconomic status (SES) and post-COVID-19 symptoms among hospitalized and non-hospitalized patients.

Methods

In the study, we used data from the Isfahan COVID Cohort (ICC) study, a 5-year longitudinal cohort study started from March 10, 2020. SES was measured using short form of SES questionnaire (SES-SQ), consisting of employment status, house room number, the number of trips taken, and using notebooks, laptop, or tablet in the house. Cox proportional hazard analysis was used to examine the association between baseline SES and post-COVID-19 symptoms including general, cardiovascular and respiratory systems, adjusting for potential confounders.

Results

Out of the 3912 patients included in the study, 66.4 % reported post-COVID-19 symptoms. There was an association between low SES and increased risk of post-COVID-19 cardiovascular symptoms in the whole population (HR = 1.15; 95 CI, 1.01-1.31, p = 0.039). Considering the hospitalization status revealed that hospitalized patients with low SES had a higher risk of experiencing post-COVID-19 cardiovascular symptoms (HR = 1.96; 95 CI, 1.23-3.12, p = 0.004), while in non-hospitalized, low SES patients a lower risk was observed (HR = 0.82; 95 CI, 0.70-0.97, p = 0.017). No significant association was found between SES and other post-COVID-19 symptoms including general and respiratory symptoms.

Conclusions

We concluded an association between higher SES and increased post-COVID-19 cardiovascular symptoms. Low SES was associated with higher risk of post-COVID-19 cardiovascular symptoms in hospitalized patients, while in non-hospitalized, it was associated with a lower risk.

Increased risk of venous thromboembolism in young and middle-aged individuals with hereditary angioedema: a family study

ABSTRACT

Hereditary angioedema (HAE), caused by C1 inhibitor protein deficiency, was recently shown to be associated with an increased risk for venous thromboembolism (VTE). To our knowledge, this is the first national family study of HAE, which aimed to determine the familial risk of VTE. The Swedish Multi-Generation Register was linked to the Swedish National Patient Register for the period of 1964 to 2018. Only patients with HAE with a validated diagnosis were included in the study and were linked to their family members. Hazard ratios (HRs) and 95% confidence intervals (CIs) for VTE were calculated for patients with HAE in comparison with relatives without HAE. Among 2006 individuals (from 276 pedigrees of 365 patients with HAE), 103 individuals were affected by VTE. In total, 35 (9.6%) patients with HAE were affected by VTE, whereas 68 (4.1%) non-HAE relatives were affected (P < .001). The adjusted HR for VTE among patients with HAE was 2.51 (95% CI, 1.67-3.77). Patients with HAE were younger at the first VTE than their non-HAE relatives (mean age, 51 years vs 63 years; P < .001). Before the age of 70 years, the HR for VTE among patients with HAE was 3.62 (95% CI, 2.26-5.80). The HR for VTE for patients with HAE born after 1964 was 8.29 (95% CI, 2.90-23.71). The HR for VTE for patients with HAE who were born in 1964 or earlier was 1.82 (95% CI, 1.14-2.91). HAE is associated with VTE among young and middle-aged individuals in Swedish families with HAE. The effect size of the association is in the order of other thrombophilias. We suggest that HAE may be considered a new rare thrombophilia.

Causal association between major depressive disorder and venous thromboembolism: a bidirectional mendelian randomization study

Purpose

Major depressive disorder (MDD) and venous thromboembolism (VTE) may be linked in observational studies. However, the causal association remains ambiguous. Therefore, this study investigates the causal associations between them.

Methods

We performed a two-sample univariable and multivariable bidirectional Mendelian randomization (MR) analysis to evaluate the associations between MDD and VTE. The summary genetic associations of MDD statistics were obtained from the Psychiatric Genomics Consortium and UK Biobank. Information on VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE) were obtained from the FinnGen Biobank. Inverse-variance weighting was used as the main analysis method. Other methods include weighted median, MR-Egger, Simple mode, and Weighted mode.

Results

Univariable MR analysis revealed no significant associations between MDD and VTE risk (odds ratio (OR): 0.936, 95% confidence interval (CI): 0.736-1.190, p = 0.590); however, after adjusting the potential relevant polymorphisms of body mass index and education, the multivariable MR analysis showed suggestive evidence of association between them (OR: 1.163, 95% CI: 1.004-1.346, p = 0.044). Univariable MR analysis also revealed significant associations between MDD and PE risk (OR: 1.310, 95% CI: 1.073-1.598, p = 0.008), but the association between them was no longer significant in MVMR analysis (p = 0.072). We found no significant causal effects between MDD and DVT risk in univariable or multivariable MR analyses. There was also no clear evidence showing the causal effects between VTE, PE, or DVT and MDD risk.

Conclusion

We provide suggestive genetic evidence to support the causal association between MDD and VTE risk. No causal associations were observed between VTE, PE, or DVT and MDD risk. Further validation of these associations and investigations of potential mechanisms are required.

Evidence for causal effects of neuropsychiatric conditions on risk of venous thromboembolism: A univariable and multivariable Mendelian randomization study

BACKGROUND

Substantial observational evidence suggests an association between neuropsychiatric conditions and venous thromboembolism (VTE). However, the causal relationship between these two conditions requires further investigation. Therefore, we used a two-sample Mendelian randomization (MR) approach to assess the bidirectional causal effects between four neuropsychiatric conditions and VTE, deep vein thrombosis, and pulmonary embolism (PE).

METHODS

Genetic variants associated with four neuropsychiatric conditions (ie, schizophrenia, major depressive disorder [MDD], bipolar disorder, and epilepsy) and VTE, deep vein thrombosis, and PE were selected. Bidirectional univariable and multivariable MR methods were applied to evaluate the causal relationships among these conditions. The primary causal estimates were obtained using the inverse variance weighted method with multiplicative random effects, supplemented by MR Egger regression, weighted median, simple mode, and weighted mode. Sensitivity analysis was conducted using the MR pleiotropy residual sum, funnel plots, and outlier (MR pleiotropy and residual sum and outlier) method.

RESULTS

Univariable MR results showed that genetic susceptibility to MDD increases the risk of VTE and PE (VTE: odds ratio [OR], 1.25; 95% confidence interval [CI], 1.08-1.46; P = .004; PE: OR, 1.36; 95% CI, 1.09-1.69; P = .006) and that PE has an adverse causal effect on MDD (OR, 1.02; 95% CI, 1.00-1.04; P = .026). Adjustment for confounders such as obesity, sleep duration, smoking, physical activity, and alcohol consumption revealed that increased genetic susceptibility to MDD is also associated with VTE and PE.

CONCLUSIONS

Our results suggest that genetic susceptibility to MDD might have an adverse causal effect on the risk of VTE and PE and that PE has a reverse causal effect on MDD. Prevention and early diagnosis of depression are crucial in the management of VTE and PE.

Retrospective cross-sectional analysis of concurrent VTE diagnosis in hospitalised socially excluded individuals in Ireland

OBJECTIVE

Social exclusion (such as that experienced by people who are homeless, incarcerated or use drugs) increases morbidity across a range of diseases but is poorly captured in routine data sets. The aim of this study was to use a novel composite variable in a national-level hospital usage dataset to identify social exclusion and to determine whether social exclusion is associated with concurrent venous thromboembolism (VTE) in hospitalised patients in Ireland. Identifying and characterising this association in people who are socially excluded will inform VTE prevention and treatment strategies.

DESIGN

Retrospective cross-sectional study.

SETTING

Irish Hospital Inpatient Enquiry (HIPE) system, which collects diagnostic information by International Classification of Diseases Tenth Revision code on all hospital admission episodes in the Ireland.

PARTICIPANTS

All hospital admission episodes involving a VTE diagnosis (in a primary 'Dx 1' or secondary 'Dx 2-30' coding position) during a 12-month period in the Ireland were identified from consolidated, national-level datasets derived from the Irish HIPE system. Social exclusion was defined as the presence of one or more indicators of homelessness, drug use, incarceration, health hazards due to socioeconomic status or episodes of healthcare terminated prematurely.

RESULTS

Of 5701 admission episodes involving a VTE diagnosis (in a primary or secondary position) during the study period, 271 (4.8%) related to an individual affected by social exclusion. Among hospitalised individuals identified as being socially excluded based on the novel composite variable, the likelihood of having a concurrent VTE diagnosis was over twofold greater than that observed in the general population (OR 2.14, 95% CI 1.79 to 2.26; p<0.001).

CONCLUSION

These data suggest that VTE (primary and secondary) is over-represented in hospitalised socially excluded persons in Ireland and that the development of strategies to address this potentially life-threatening accompanying condition in this vulnerable patient group must be prioritised.

Race, sex, and socioeconomic disparities affect the clinical stage of patients presenting for treatment of superficial venous disease

OBJECTIVE

Superficial venous disease has a U.S. prevalence of nearly 30%, with advanced disease contributing to a significant healthcare burden. Although the risk factors for venous disease are well known, the correlation between race, sex, socioeconomic status, and disease severity on presentation is not well established. The area deprivation index (ADI) is a validated metric with respect to regional geography, social determinants of health, and degree of socioeconomic disadvantage. In the present study, we aimed to identify the disparities and the effect that the ADI, in addition to race and sex, has among patients associated with an advanced venous disease presentation.

METHODS

A retrospective review between 2012 and 2022 was performed at four tertiary U.S. institutions to identify patients who underwent endovenous closure of their saphenous veins. Patient demographics, state ADI, comorbidities, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, and periprocedural outcomes were included. Pearson's correlation was performed between the CEAP classification and ADI. Poisson regression analysis was performed to identify factors predicting for an increasing CEAP classification at presentation. Variables with P < .05 were deemed significant.

RESULTS

A total of 2346 patients underwent endovenous saphenous vein closure during the study period, of whom 7 were excluded because of a lack of follow-up data. The mean age was 60.4 ± 14.9 years, 65.9% were women, and 55.4% were White. Of the 2339 patients, 73.3% presented with an advanced CEAP class (≥3). The mean state ADI for the entire cohort was 4.9 ± 3.1. The percent change in the CEAP classification is an increase of 2% and 1% for every level increase in the state ADI for unadjusted (incidence rate ratio [IRR] = 1.02; P < .001) and adjusted (IRR = 1.01; P < .001) models, respectively. Black race has a 12% increased risk of a higher CEAP class on presentation compared with White race (IRR = 1.12; P = .005). Female sex had a 16% lower risk of a higher CEAP presentation compared with male sex (IRR = 0.84; P < .01).

CONCLUSIONS

Low socioeconomic status, Black race, and male sex are predictive of an advanced CEAP classification on initial presentation. These findings highlight the opportunity for improved mechanisms for identification of venous disease and at-risk patients before advanced disease progression in known disadvantaged patient populations.

Rural-urban differences in characteristics, postoperative outcomes, and costs for patients undergoing knee arthroplasty: a national retrospective propensity score matched cohort study

BACKGROUND

The rural-urban disparities in postoperative complications and costs among patients undergoing knee arthroplasty (KA) have not been thoroughly explored. This study aimed to determine whether such differences exist in this patient population.

MATERIAL AND METHODS

The study was conducted using data from the national Hospital Quality Monitoring System of China. Hospitalized patients undergoing KA from 2013 to 2019 were enrolled. Patient and hospital characteristics were compared between rural and urban patients, and differences in postoperative complications, readmissions, and hospitalization costs were analyzed using propensity score matching.

RESULTS

Of the 146 877 KA cases analyzed, 71.4% (104 920) were urban patients and 28.6% (41 957) were rural patients. Rural patients tended to be younger (64.4±7.7 years vs. 68.0±8.0 years; P <0.001) and had fewer comorbidities. In the matched cohort of 36 482 participants per group, rural patients were found to be more likely to experience deep vein thrombosis (OR: 1.31, 95% CI: 1.17-1.46; P <0.001) and require red blood cell (RBC) transfusion (OR: 1.38, 95% CI: 1.31-1.46; P <0.001). However, they had a lower incidence of readmission within 30 days (OR: 0.65, 95% CI: 0.59-0.72; P <0.001) and readmission within 90 days (OR: 0.61, 95% CI: 0.57-0.66; P <0.001) than their urban counterparts. In addition, rural patients incurred lower hospitalization costs than urban patients (57 396.2 Chinese Yuan vs. 60 844.3 Chinese Yuan; P <0.001).

CONCLUSION

Rural KA patients had different clinical characteristics compared with urban patients. While they had a higher likelihood of deep vein thrombosis and RBC transfusion following KA than urban patients, they had fewer readmissions and lower hospitalization costs. Targeted clinical management strategies are needed for rural patients.

A review of the current literature of ethnic, gender, and socioeconomic disparities in venous disease

Venous disease is prevalent, undertreated, and frequently unrecognized. During the past two decades, new treatment modalities have changed how venous disease is approached. Some of these treatment modalities are only available in certain centers or locations and access to care could be inequitable. Although venous disease affects millions in the United States, we have little understanding of the gender, socioeconomic, and ethnic disparities in both superficial and deep venous disease presentation. In an effort to better understand the treatment of male and female patients from different gender, ethnic, and socioeconomic backgrounds, literature searches were conducted to investigate how these patients were evaluated and treated. PubMed was used to search literature using the terms "venous insufficiency," "superficial venous disease," "venous thromboembolism," "deep vein thrombosis," "DVT," "May-Thurner," and "pulmonary embolism," with gender, sex, racial, and socioeconomic disparities and differences within the keywords. In addition, once articles were discovered, the "similar articles" function was used to expand the search. The included studies were restricted to those reported from 1995 to the present. Given the paucity of data, no study was excluded. It is readily apparent that there is not enough data to make decisions that would modify treatment to affect the outcomes of patients with differing backgrounds and gender. Studies currently are limited to evaluating patients by sex assigned at birth without interrogation of their identified gender. It is imperative that consideration is given to evaluating gender and ethnic differences, because treatment options might need to be tailored accordingly. Outreach and education for underserved patient populations with improvement in access to care must also be incorporated into the healthcare system. Additional work in this area is required. Further data collection and research related to demographic disparities among patients with venous disease is necessary to better understand the differences that could change treatment algorithms tailored to specific groups.

Epidemiology and prevention of venous thromboembolism

Venous thromboembolism, that consists of the interrelated conditions deep-vein thrombosis and pulmonary embolism, is an under-appreciated vascular disease. In Western regions, approximately 1 in 12 individuals will be diagnosed with venous thromboembolism in their lifetime. Rates of venous thromboembolism are lower in Asia, but data from other regions are sparse. Numerous risk factors for venous thromboembolism have been identified, which can be classified as acute or subacute triggers (provoking factors that increase the risk of venous thromboembolism) and basal or acquired risk factors (which can be modifiable or static). Approximately 20% of individuals who have a venous thromboembolism event die within 1 year (although often from the provoking condition), and complications are common among survivors. Fortunately, opportunities exist for primordial prevention (prevention of the development of underlying risk factors), primary prevention (management of risk factors among individuals at high risk of the condition) and secondary prevention (prevention of recurrent events) of venous thromboembolism. In this Review, we describe the epidemiology of venous thromboembolism, including the incidence, risk factors, outcomes and opportunities for prevention. Meaningful health disparities exist in both the incidence and outcomes of venous thromboembolism. We also discuss these disparities as well as opportunities to reduce them.

Influence of rosuvastatin on apolipoproteins and coagulation factor levels: Results from the STAtin Reduce Thrombophilia trial

Background

The STAtins Reduce Thrombophilia trial showed that, in patients with prior venous thrombosis, rosuvastatin decreased various coagulation factor levels.

Objectives

Here, we investigated the hypothesis that statins decrease coagulation factor levels through shared mechanisms of synthesis or regulatory pathways with apolipoproteins.

Methods

We measured the levels of apolipoprotein (Apo)A-I, A-II, A-IV, (a), B-100, B-total, C-I, C-II, C-III, and E in patients (n = 126) randomized to 28 days of rosuvastatin use. We assessed the association between apolipoproteins and coagulation factors at baseline using linear regression. The mean difference in apolipoprotein levels between baseline and after 28 days of rosuvastatin use was determined through linear regression, adjusting for age, sex, and body mass index. Coagulation factors were added to this model to determine if the lowering of apolipoproteins by rosuvastatin was linked with coagulation factor levels.

Results

At baseline, levels of all apolipoproteins, except Apo(a), were positively associated with FVII, FIX, and FXI. Apolipoproteins levels, except for ApoA-I, A-IV, and Apo(a), were decreased after 28 days of rosuvastatin. ApoB-100 showed the largest mean decrease of -0.43 g/L (95% CI = -0.46 to -0.40). The decrease in ApoC-I and C-III levels was associated with a decrease in FVII, whereas the decrease in apoA-II, B-100, and B-total was associated with a decrease in FXI. The decrease in apolipoproteins was neither associated with FVIII or vWF decrease nor with endogenous thrombin potential changes.

Conclusions

Rosuvastatin decreases the level of several apolipoproteins, but this decrease was associated only with a decrease in FVII and XI and not with FVIII/vWF.

Associations among Health Status, Occupation, and Occupational Injuries or Diseases: A Multi-Level Analysis

PURPOSE

The present study used a hierarchical generalized linear model to explore the effects of physical and mental health and occupational categories on occupational injuries and diseases.

METHODS

The data were obtained from the Registry for Beneficiaries of the 2002-2013 National Health Insurance Research Database. The benefit categories involved adults with occupational injuries and diseases. Six major occupational categories and 28 subcategories were used. The main analysis methods were binary logistic regression (BLR) and hierarchical generalized linear model (HGLM).

RESULTS

After adjustment for relevant factors, the three major occupation subcategories most likely to develop occupational injuries and diseases were Subcategory 12 "employees with fixed employers" of Category 1 "civil servants, employees in public or private schools, laborers, and self-employed workers"; Subcategory 2 "employees in private organizations" of Category 1; and "sangha and religionists" of Category 6 "other citizens." Conditions such as mental disorders and obesity increased the risk of occupational injuries and diseases.

CONCLUSION

A portion of the occupational categories had a higher risk of occupational injuries and diseases. Physical and mental health issues were significantly correlated with occupational injuries and diseases. To the authors' knowledge, this is the first study to use HGLM to analyze differences in occupational categories in Taiwan.

Socioeconomic status and risk of incident venous thromboembolism

BACKGROUND

Although venous thromboembolism (VTE) is a leading cause of morbidity and mortality, and socioeconomic status (SES) affects human health and health behavior, few studies have examined the association between SES and VTE.

OBJECTIVES

We aimed to investigate the association between SES, assessed individually and in a composite score by levels of education, income, and employment status, and incident VTE.

METHODS

We used Danish national registries to identify 51 350 persons aged 25-65 years with incident VTE during 1995-2016. For each case, we used incidence density sampling to select five age-, sex-, and index-year-matched controls from the general Danish population (n = 256 750). SES indicators, including education, income, and employment status, were assessed 1 and 5 years before the VTE. We used conditional logistic regression to compute odds ratios (ORs) with 95% confidence intervals (CIs) for VTE according to individual SES indicators and a composite SES score in analyses adjusted for age, sex, and comorbidities.

RESULTS

Compared with low levels, high educational level (OR 0.74; 95% CI 0.71-0.77), high income (OR 0.70; 95% CI 0.68-0.72), and high employment status (OR 0.66; 95% CI 0.64-0.68) were associated with decreased risk of VTE, even after adjusting for comorbidities. A composite SES score was superior to the individual indicators in assessing VTE risk (OR for high vs. low score: 0.61; 95% CI 0.59-0.63). In sensitivity analysis with SES indicators measured 5 years before the VTE, the risk estimates remained essentially the same.

CONCLUSION

High levels of both individual SES indicators and a composite SES score were associated with decreased VTE risk.

Incidence of and risk factors for thromboembolism during pregnancy and postpartum: A 10-year nationwide population-based study

OBJECTIVE

Knowledge of the incidence of pregnancy-related thromboembolism and its risk factors is clinically important because thromboembolism is the leading cause of maternal death. However, there are insufficient large population-based studies on this topic. The purpose of this study was to estimate the incidence of and identify the risk factors for thromboembolism during pregnancy and puerperium.

MATERIALS AND METHODS

We analyzed data from 2007 to 2016 using the Health Insurance Review and Assessment Service (HIRA) database. Women who gave birth in the Republic of Korea were identified. Thromboembolism was defined as the simultaneous presence of both the diagnostic and test codes. Risk factors for thromboembolism were identified using logistic regression.

RESULTS

A total of 1,188 delivery episodes with thromboembolism were extracted from 4,243,393 delivery episodes. The incidence of thromboembolism was 0.28 per 1,000 deliveries, and it increased over the 10-year period. The incidence of antepartum thromboembolism was 0.1 per 1,000 deliveries (418 cases), and the incidence of postpartum thromboembolism was 0.18 per 1,000 deliveries (770 cases). Thromboembolism was associated with ovarian hyperstimulation syndrome, low socioeconomic status, multiple birth, cesarean birth, preeclampsia, postpartum hemorrhage, placenta previa, advanced maternal age, hyperemesis and primiparity. The factors associated with mortality from thromboembolism were cesarean birth and preterm premature rupture of membranes.

CONCLUSION

The incidence of pregnancy-related thromboembolism increased over the 10-year study period. Low socioeconomic status, ovarian hyperstimulation syndrome, cesarean delivery and premature rupture of membranes were high-risk factors. This study provides an important reference for thromboprophylaxis for pregnancy-related thromboembolism.

Antithrombotic Preventive Medication Prescription Redemption and Socioeconomic Status in Hungary in 2016: A Cross-Sectional Study

This work was designed to investigate antithrombotic drug utilization and its link with the socioeconomic characteristics of specific population groups in Hungary by a comparative analysis of data for prescriptions by general practitioners and the redeemed prescriptions for antithrombotic drugs. Risk analysis capabilities were applied to estimate the relationships between socioeconomic status, which was characterized by quintiles of a multidimensional composite indicator (deprivation index), and mortality due to thromboembolic diseases as well as antithrombotic medications for the year 2016 at the district level in Hungary. According to our findings, although deprivation is a significant determinant of mortality due to thromboembolic diseases, clusters can be identified that represent exemptions to this rule: an eastern part of Hungary, consisting of two highly deprived counties, had significantly lower mortality than the country average; by contrast, the least-deprived northwestern part of the country, consisting of five counties, had significantly higher mortality than the country average. The fact that low socioeconomic status in general and poor adherence to antithrombotic drugs irrespective of socioeconomic status were associated with increased mortality indicates the importance of more efficient control of preventive medication and access to healthcare in all districts of the country to reduce mortality due to thromboembolic diseases.

Lower limb venous and arterial peripheral diseases and work conditions: systematic review

OBJECTIVES

The individual peripheral vascular disease risk factors are well documented, but the role of work conditions remains equivocal. This systematic review aims to assess relationships between lower limb peripheral venous diseases (lower limb varicose veins (LLVV), venous thromboembolism (VTE) comprising deep vein thrombosis and pulmonary embolism), peripheral arterial disease (intermittent claudication, aortic dissection, aortic aneurysm) and occupational constraints among working adults.

METHODS

Several databases were systematically searched until February 2019 for observational studies and clinical trials. Preferred Reporting Items for Systematic Reviews and Meta-Analyses method was used for article selection. Quality assessment and risk of bias were evaluated using Strengthening the Reporting of Observational Studies in Epidemiology and Newcastle-Ottawa scales.

RESULTS

Among the 720 screened articles, 37 remained after full-text evaluation. Among the 21 studies on LLVV, prolonged standing was significantly associated to a higher risk of varicose veins with a threshold probably around >3 to 4 hours/day but exposure duration in years was not sufficiently considered. Seated immobility was often observed in workers, with no sufficient evidence to prove that prolonged sitting at work is related to VTE. Carrying heavy loads, stress at work and exposure to high temperatures have emerged more recently notably in relation to varicose veins but need to be better explored. Only three studies discussed the potential role of work on peripheral arterial disease development.

CONCLUSIONS

Although some observational studies showed that prolonged standing can be related to varicose veins and that seated immobility at work could be linked to VTE, very little is known about peripheral arterial disease and occupational constraints. Clinical trials to determine preventive strategies at work are needed.

PROSPERO REGISTRATION NUMBER

CRD42019127652.

Psychotic, Mood, and Anxiety Disorders and Venous Thromboembolism: A Systematic Review and Meta-Analysis

OBJECTIVE

Several studies have shown that psychiatric disorders can be associated with venous thromboembolism (VTE) risk, that is, pulmonary embolism (PE) and/or deep vein thrombosis (DVT). In this study, we provide a systematic review and meta-analyses of the studies addressing this issue.

METHODS

All studies addressing the risk of VTE phenomena (whole VTE, PE, DVT, fatal VTE) in individuals with psychotic, mood, and anxiety disorders published between 1998 and 2019 were reviewed and included in the meta-analyses. Main characteristics of the studies and data concerning VTE risk were extracted. The methodological qualities of the studies were also analyzed. A random-effects meta-analysis model was used. A meta-analysis was conducted separately for each disorder, as well as separately for unadjusted and adjusted studies. Meta-analyses were repeated considering only good-quality studies. Heterogeneity was assessed.

RESULTS

Sixteen studies were reviewed and 15 included in the meta-analyses. Psychotic and bipolar disorders were significantly associated with VTE risk (VTE, DVT, PE, and fatal VTE for psychotic disorder: odds ratios [ORs] between 1.29 and 2.20; VTE, DVT, and PE for bipolar disorder: ORs between 1.22 and 2.14). Depression and anxiety disorders were associated with VTE risk only in adjusted analyses (DVT and PE for depression: ORs = 1.29; VTE and PE for anxiety disorders: ORs between 1.14 and 1.49).

CONCLUSIONS

The risk of VTE among individuals with psychiatric disorders may be explained by hypercoagulability and stasis, with both being related to, and independent of, treatment adverse effects. VTE risk should be taken into consideration in the treatment for people with psychiatric disorders.

Coagulation Status and Venous Thromboembolism Risk in African Americans: A Potential Risk Factor in COVID-19

Severe acute respiratory syndrome coronavirus 2 infection (COVID-19) is known to induce severe inflammation and activation of the coagulation system, resulting in a prothrombotic state. Although inflammatory conditions and organ-specific diseases have been shown to be strong determinants of morbidity and mortality in patients with COVID-19, it is unclear whether preexisting differences in coagulation impact the severity of COVID-19. African Americans have higher rates of COVID-19 infection and disease-related morbidity and mortality. Moreover, African Americans are known to be at a higher risk for thrombotic events due to both biological and socioeconomic factors. In this review, we explore whether differences in baseline coagulation status and medical management of coagulation play an important role in COVID-19 disease severity and contribute to racial disparity trends within COVID-19.

Association of apolipoproteins C-I, C-II, C-III and E with coagulation markers and venous thromboembolism risk

Purpose

Apolipoproteins C-I, C-II, C-III and E have been associated with risk of arterial thrombotic diseases. We investigated whether these apolipoproteins have prothrombotic properties and are associated with risk of venous thromboembolism (VTE).

Patients and methods

A total of 127 VTE patients and 299 controls were randomly selected from the Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis study (1999–2004), in the Netherlands. The apolipoproteins were quantified using mass spectrometry (LC/MS/MS), and their levels were analyzed as continuous variable (per SD increase).

Results

In controls, increases in levels of apolipoproteins were associated with increases in levels of vitamin K-dependent factors, factor XI, antithrombin and clot lysis time. Additionally, increasing apolipoproteins C-III and E levels were associated with higher factor VIII and von Willebrand factor levels. Levels of C-reactive protein were not associated with any apolipoprotein. The age- and sex-adjusted odds ratios of apolipoproteins E, C-III, CII and CI to the risk of venous thrombosis were 1.21 (95% CI, 0.98–1.49), 1.19 (95% CI, 0.99–1.44), 1.24 (95% CI, 0.95–1.61) and 1.06 (95% CI, 0.87–1.30) per SD increase, respectively. These odds ratios did not attenuate after adjustments for statin use, estrogen use, BMI, alcohol use, and self-reported diabetes.

Conclusions

Levels of apolipoproteins C-I, C-II, C-III and E are associated with those of several coagulation factors. However, whether these apolipoproteins are also associated with an increased risk of VTE remains to be established.

Depression, antidepressant use, and risk of venous thromboembolism: systematic review and meta-analysis of published observational evidence

PURPOSE

Evidence on the association between depression, antidepressant use and venous thromboembolism (VTE) risk is conflicting. We conducted a systematic review and meta-analysis of published observational studies evaluating the associations of depression and antidepressant use with VTE risk.

DESIGN

Eligible studies were identified in a literature search of MEDLINE, Embase, Web of Science and reference list of relevant studies up to April 2018. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were aggregated using random effects models.

RESULTS

Eight observational studies with data on 960 113 nonoverlapping participants and 9027 VTE cases were included. The pooled RR (95% CI) for VTE comparing antidepressant use with no antidepressant use was 1.27 (1.06-1.51). Tricyclic antidepressants, selective serotonin reuptake inhibitors and other antidepressants were each associated with an increased VTE risk; 1.16 (1.06-1.27), 1.12 (1.02-1.23), and 1.59 (1.21-2.09), respectively. In pooled analysis of three studies that compared patients with depression versus individuals without depression, the RR for VTE was 1.31 (1.13-1.53).

CONCLUSIONS

Pooled observational evidence suggests that depression and use of antidepressants are each associated with an increased VTE risk. The effect of antidepressant drugs on VTE may be a class effect. The mechanistic pathways underlying these associations deserve further evaluation. Systematic review registration: PROSPERO 2018: CRD42018095595 Key messages Emerging evidence suggests that depression and antidepressant use may be associated with venous thromboembolism (VTE) risk, but the evidence is conflicting. This first systematic review and meta-analysis of observational studies shows that depression and use of antidepressants are each associated with an increased risk of VTE. There may be a class effect of antidepressant drugs on VTE.

Relationship between neighborhood socioeconomic status and venous thromboembolism: results from a population-based study

Essentials Literature on socioeconomic status (SES) and incidence of venous thromboembolism (VTE) is scarce. We assessed neighborhood SES with VTE risk in a population of over 1.4 million inhabitants. Higher neighborhood SES was associated with lower incidence of VTE. These findings are helpful to inform policy and resource allocation in health systems.

SUMMARY

Background The association between socioeconomic status and arterial cardiovascular disease is well established. However, despite its high burden of disability-adjusted life years, little research has been carried out to determine whether socioeconomic status is associated with venous thromboembolism. Objective To determine if neighborhood socioeconomic status is associated with venous thromboembolism in a population-based study from the Netherlands. Methods We identified all patients aged 15 years and older with a first event of venous thromboembolism from inhabitants who lived in the urban districts of The Hague, Leiden and Utrecht in the Netherlands in 2008-2012. Neighborhood socioeconomic status was based on the status score, which combines educational level, income and unemployment on a four-digit postal code level. Incidence rate ratios of venous thromboembolism were calculated for different levels of neighborhood socioeconomic status, with adjustments for age and sex. Results A total of 7373 patients with a first venous thromboembolism (median age 61 years; 50% deep vein thrombosis) were identified among more than 1.4 million inhabitants. Higher neighborhood SES was associated with lower incidence of VTE. In the two highest status score groups (i.e. the 95-99th and > 99th percentile), the adjusted incidence rate ratios were 0.91 (95% confidence interval [CI], 0.84-1.00) and 0.80 (95% CI, 0.69-0.93), respectively, compared with the reference status score group (i.e. 30-70th percentile). Conclusions High neighborhood socioeconomic status is associated with a lower risk of first venous thromboembolism.

Lipid levels and risk of venous thrombosis: results from the MEGA-study

The relationship between lipid levels and risk of venous thrombosis is not well established. We aimed to assess the association between several lipids and risk of venous thrombosis using data from a population-based case-control study, and to evaluate the underlying mechanism, considering confounding by common risk factors and mediation via hemostatic factors and C-reactive protein. From the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA) study, 2234 patients with a first venous thrombosis and 2873 controls were included. Percentile categories of total/low-density lipoprotein/high-density lipoprotein cholesterol, triglycerides, and apolipoproteins B and A1 were established in controls (<10th, 10th-25th, 25th-75th [reference], 75th-90th, >90th percentile). In age- and sex-adjusted models, decreasing levels of apolipoproteins B and A1 were dose-dependently associated with increased thrombosis risk, with odds ratios of 1.35 (95% confidence interval 1.12-1.62) and 1.50 (95% confidence interval 1.25-1.79) for the lowest category versus the reference category, respectively. The dose-response relation remained with further adjustment for body mass index, estrogen use, statin use, and diabetes. Although apolipoproteins B and A1 were associated with several hemostatic factors and C-reactive protein, none explained the increased risk in mediation analyses. The other lipids were not associated with venous thrombosis risk. In conclusion, decreasing levels of apolipoproteins B and A1 were associated with increased risk of venous thrombosis. Our findings are consistent with experimental data on the anticoagulant properties of apolipoproteins B and A1. These findings need to be confirmed and the underlying mechanism further investigated.

Early mortality and morbidity after total hip arthroplasty in patients with femoral neck fracture

Background and purpose - Early postoperative mortality is relatively high after total hip arthroplasty (THA) that has been performed due to femoral neck fracture. However, this has rarely been investigated after adjustment for medical comorbidity and comparison with the mortality in an age-matched population. We therefore assessed early mortality in hip fracture patients treated with a THA, in the setting of a nationwide matched cohort study. Patients and methods - 24,699 patients who underwent THA due to a femoral neck fracture between 1992 and 2012 were matched with 118,518 controls. Kaplan-Meier survival analysis was used to calculate cumulative unadjusted survival, and Cox regression models were fitted to compute hazard ratios (HRs) and 95% confidence intervals (CIs), with adjustment for age, sex, comorbidity, and socioeconomic background. Results - 90-day survival was 96.3% (95% CI: 96.0-96.5) for THA cases and 98.7% (95% CI: 98.6-98.8) for control individuals, giving an adjusted HR of 2.2 (95% CI: 2.0-2.4) for THA cases compared to control individuals. Comorbidity burden increased in THA cases over time, but the adjusted risk of death within 90 days did not differ statistically significantly between the time periods investigated (1992-1998, 1999-2005, and 2006-2012). A Charlson comorbidity index of 3 or more, an American Society of Anesthesiologists (ASA) grade of 3 and above, male sex, an age of 80 years and above, an income below the first quartile, and a lower level of education were all associated with an increased risk of 90-day mortality. Interpretation - The adjusted early mortality in femoral neck fracture patients who underwent THA was about double that in a matched control population. Patients with femoral neck fracture but with no substantial comorbidity and an age of less than 80 years appear to have a low risk of early death. Patients older than 80 years and those with a Charlson comorbidity index of more than 2 have a high risk of early death, and such patients would perhaps benefit from treatment strategies other than THA, but this should be investigated further.

Educational Level, Anticoagulation Quality, and Clinical Outcomes in Elderly Patients with Acute Venous Thromboembolism: A Prospective Cohort Study

Whether the level of education is associated with anticoagulation quality and clinical outcomes in patients with acute venous thromboembolism (VTE) is uncertain. We thus aimed to investigate the association between educational level and anticoagulation quality and clinical outcomes in elderly patients with acute VTE. We studied 817 patients aged ≥65 years with acute VTE from a Swiss prospective multicenter cohort study (09/2009-12/2013). We defined three educational levels: 1) less than high school, 2) high school, and 3) post-secondary degree. The primary outcome was the anticoagulation quality, expressed as the percentage of time spent in the therapeutic INR range (TTR). Secondary outcomes were the time to a first recurrent VTE and major bleeding. We adjusted for potential confounders and periods of anticoagulation. Overall, 56% of patients had less than high school, 25% a high school degree, and 18% a post-secondary degree. The mean percentage of TTR was similar across educational levels (less than high school, 61%; high school, 64%; and post-secondary, 63%; P = 0.36). Within three years of follow-up, patients with less than high school, high school, and a post-secondary degree had a cumulative incidence of recurrent VTE of 14.2%, 12.9%, and 16.4%, and a cumulative incidence of major bleeding of 13.3%, 15.1%, and 15.4%, respectively. After adjustment, educational level was neither associated with anticoagulation quality nor with recurrent VTE or major bleeding. In elderly patients with VTE, we did not find an association between educational level and anticoagulation quality or clinical outcomes.

Long Term Effects on Risk Factors for Cardiovascular Disease after 12-Months of Aerobic Exercise Intervention - A Worksite RCT among Cleaners

Objectives

Occupational groups exposed to high occupational physical activity have an increased risk for cardiovascular disease (CVD). This may be explained by the high relative aerobic workload. Enhanced cardiorespiratory fitness reduces the relative aerobic workload. Thus, the aim was to evaluate the 12-months effects of worksite aerobic exercise on risk factors for CVD among cleaners.

Methods

One hundred and sixteen cleaners aged 18–65 years were randomized to a group performing aerobic exercise and a reference group receiving lectures. Outcomes were collected at baseline and after 12-months. A repeated measures 2×2 multi-adjusted mixed-model design was applied to compare the between-group differences using intention-to-treat analysis.

Results

Between-group differences (p<0.05) were found favouring the aerobic exercise group: cardiorespiratory fitness 2.15 (SE 1.03) mlO₂/min/kg, aerobic workload -2.15 (SE 1.06) %HRR, resting HR -5.31 (SE 1.61) beats/min, high sensitive C-reactive protein -0.65 (SE 0.24) μg/ml. The blood pressure was unaltered. Stratified analyses on relative aerobic workload at baseline revealed that those with relative aerobic workloads ≥30% of HRR seems to impose a notable adverse effect on resting and ambulatory blood pressure.

Conclusion

This long-term worksite aerobic exercise intervention among cleaners led to several beneficial effects, but also potential adverse effects among those with high relative aerobic workloads.

Trial Registration

Controlled-Trials.com ISRCTN86682076

Case report: Limb-threatening femoral vein thrombosis in a healthy carpet fitter: Carpet fitter’s thrombosis

Objective

To report a case of femoral vein thrombosis in a carpet fitter and to highlight this as an occupational hazard.

Method

Case presentation and literature review.

Results

An otherwise fit 21-year-old carpet fitter with no past medical history presented with acute thrombosis of his left common femoral, superficial femoral and great saphenous veins. Attempted catheter directed thrombolysis was unsuccessful. Due to severe pain and the threat of venous gangrene he was treated by emergency surgical thrombectomy with excision of chronic venous scarring and vein-patch repair that led to resolution of his symptoms.

Conclusions

Deep vein thrombosis is typically associated with factors such as increasing age and prolonged periods of immobility; however, certain ‘active’ occupations can increase its risk. Crouched and cramped working conditions including repetitive active movement with flexed hips and knees can predispose to increased risk of venous thromboembolism.

Cognitive ability in Swedish conscripts and future risk of venous thromboembolism: A co-relative prospective national study

OBJECTIVE

Cognitive ability measured via an IQ-test (intelligence quotient) has been associated with cardiovascular (CVD) incidence. Whether cognitive ability is associated with risk of venous thromboembolism (VTE) is unknown. The present nationwide co-relative study aims to determine whether cognitive ability in male conscripts is a predictor of VTE.

METHODS

A Swedish cohort of male conscripts (n=940,964) born in 1954-1970 with no history of previous VTE were followed from enlistment (1972-1990) until 2010. Data on cognitive ability, using an IQ-test at conscription, were linked with national hospital register data to calculate future risk of VTE requiring in-patient care. Using the Swedish Multi-Generation Register, we identified all full-siblings, half-siblings and first-cousin pair discordant for IQ. This co-relative design allows for adjustment for unmeasured shared genetic or environmental factors.

RESULTS

A total of 5110 (0.54%) males were affected by VTE. IQ was associated with risk for VTE (hazard ratio=HR 0.87 95% confidence interval 0.84-0.89 per standard deviation [SD] increment). The association was highly time dependent with attenuation of effect over time and significant interaction between time and IQ. IQ was also associated with VTE in first-cousin pairs (HR=0.74, 0.69-0.79) but not when examining discordant half-sibling pairs (HR=0.94, 0.82-1.08), and only weakly in full-sibling pairs (HR=0.91, 0.84-0.98).

CONCLUSIONS

The present study suggests that familial-shared environmental factors linked to cognitive ability might be involved in the etiology of VTE. However, it is unlikely that IQ by itself causes VTE.

Aerobic exercise reduces biomarkers related to cardiovascular risk among cleaners: effects of a worksite intervention RCT

Purpose

Blue-collar workers have an increased risk of cardiovascular disease. Accordingly, elevated levels of biomarkers related to risk of cardiovascular disease, such as high-sensitive C-reactive protein, have been observed among blue-collar workers. The objective was to examine whether an aerobic exercise worksite intervention changes the level of inflammation biomarkers among cleaners.

Methods

The design was a cluster-randomized controlled trial with 4-month worksite intervention. Before the 116 cleaners aged 18–65 years were randomized, they signed an informed consent form. The reference group (n = 59) received lectures, and the aerobic exercise group (n = 57) performed worksite aerobic exercise (30 min twice a week). Levels of biomarkers (high-sensitive C-reactive protein, fibrinogen, cholesterol, low- and high-density lipoprotein cholesterol and triglyceride) were collected at baseline and after 4 months. A repeated-measure, multi-adjusted, mixed-model intention-to-treat analysis was applied to compare between-group differences. The study was registered as ISRCTN86682076.

Results

Significant (p < 0.05) between-group reductions from baseline to follow-up were found for high-sensitive C-reactive protein (−0.54 ± 0.20 µg/ml; 95 % CI −0.94, −0.14), low-density lipoprotein cholesterol (−0.32 ± 0.11 mmol/L; 95 % CI −0.54, −0.10) and the ratios of LDL/HDL (−0.30 ± 0.08; 95 % CI −0.46, −0.14), and LDL/TC cholesterol (−0.04 ± 0.02; 95 % CI −0.07, −0.01).

Conclusion

This study indicates that an aerobic exercise intervention among cleaners leads to reduced levels of high-sensitive C-reactive protein and low-density lipoprotein cholesterol, and an unaltered level of fibrinogen. The aerobic exercise seems to improve inflammatory levels and lipoprotein profile among cleaners, with no signs of cardiovascular overload.

Depression and risk of venous thromboembolism: a population-based retrospective cohort study

OBJECTIVE

This study investigated the relationship between depression and the risk of subsequent venous thromboembolism (VTE) development.

METHODS

We conducted a population-based retrospective cohort analysis by using data for the period of 2000 to 2011 from the Longitudinal Health Insurance Database 2000 of Taiwan. A depression cohort comprising 35,274 patients and a nondepression cohort comprising 70,548 patients matched according to sex, age, and index year with no history of VTE were evaluated. Cox proportional hazard regression analysis was used to assess the effects of depression and comorbidities, and the Kaplan-Meier method was applied to estimate the cumulative VTE incidence curves.

RESULTS

Compared with individuals without depression, depressed patients had a 1.38-fold greater risk (95% confidence interval = 1.09-1.73) of developing VTE. This risk was significantly higher in male and younger (≤49 years) patients. In addition, patients with comorbidities such as hypertension, diabetes, heart failure, and cancer had a higher risk of depression-associated VTE that was attenuated, although nonsignificantly, by antidepressant use.

CONCLUSIONS

The incidence of VTE in Taiwan is higher in depressed patients than in nondepressed patients. Moreover, men, people 49 years or younger, and patients with comorbidities have a significantly greater risk of VTE after depression.

Depressive symptoms as a novel risk factor for recurrent venous thromboembolism: a longitudinal observational study in patients referred for thrombophilia investigation

BACKGROUND

Increasing evidence suggests that psychosocial factors, including depression predict incident venous thromboembolism (VTE) against a background of genetic and acquired risk factors. The role of psychosocial factors for the risk of recurrent VTE has not previously been examined. We hypothesized that depressive symptoms in patients with prior VTE are associated with an increased risk of recurrent VTE.

METHODS

In this longitudinal observational study, we investigated 271 consecutive patients, aged 18 years or older, referred for thrombophilia investigation with an objectively diagnosed episode of VTE. Patients completed the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D). During the observation period, they were contacted by phone and information on recurrent VTE, anticoagulation therapy, and thromboprophylaxis in risk situations was collected.

RESULTS

Clinically relevant depressive symptoms (HADS-D score ≥ 8) were present in 10% of patients. During a median observation period of 13 months (range 5-48), 27 (10%) patients experienced recurrent VTE. After controlling for sociodemographic and clinical factors, a 3-point increase on the HADS-D score was associated with a 44% greater risk of recurrent VTE (OR 1.44, 95% CI 1.02, 2.06). Compared to patients with lower levels of depressive symptoms (HADS-D score: range 0-2), those with higher levels (HADS-D score: range 3-16) had a 4.1-times greater risk of recurrent VTE (OR 4.07, 95% CI 1.55, 10.66).

CONCLUSIONS

The findings suggest that depressive symptoms might contribute to an increased risk of recurrent VTE independent of other prognostic factors. An increased risk might already be present at subclinical levels of depressive symptoms.

Familial Transmission of Venous Thromboembolism

Background—

Venous thromboembolism (VTE) clusters in families, but the familial risk of VTE has not been determined among adoptees. The aim was to disentangle the contributions of genetic and environmental factors to the familial transmission of VTE.

Methods and Results—

The Swedish Multi-Generation Register was used to follow all Swedish-born adoptees born from 1932 to 2004 (n=80,214) between January 1, 1964, and December 31, 2010, for VTE. The risk of VTE was estimated in adoptees with ≥1 biological parent with VTE compared with adoptees without a biological parent with VTE. The risk of VTE was also estimated in adoptees with ≥1 adoptive parent with VTE compared with adoptees without an adoptive parent with VTE. Adoptees with ≥1 biological parent with VTE (n=137) were more likely to have VTE than adoptees without a biological parent with VTE (standardized incidence ratio) 1.51 (95% confidence interval, 1.27–1.79). The standardized incidence ratio for VTE was highest for adoptees with a biological parent diagnosed with VTE before the age of 50 years (standardized incidence ratio=2.03, 1.24–3.14). In contrast, adoptees with ≥1 adoptive parent with VTE (n=156) were not at increased risk of VTE (standardized incidence ratio=1.07, 0.91–1.25).

Conclusions—

These novel findings suggest that genetic factors make a stronger contribution to the familial transmission of VTE from parents to offspring than family environmental factors.

Lifecourse social position and D-dimer; findings from the 1958 British birth cohort

The aim is to examine the association of lifecourse socioeconomic position (SEP) on circulating levels of D-dimer. Data from the 1958 British birth cohort were used, social class was determined at three stages of respondents' life: at birth, at 23 and at 42 years. A cumulative indicator score of SEP (CIS) was calculated ranging from 0 (always in the highest social class) to 9 (always in the lowest social class). In men and women, associations were observed between CIS and D-dimer (P<0.05). Thus, the respondents in more disadvantaged social classes had elevated levels of D-dimer compared to respondents in less disadvantaged social class. In multivariate analyses, the association of disadvantaged social position with D-dimer was largely explained by fibrinogen, C-reactive protein and von Willebrand Factor in women, and additionally by smoking, alcohol consumption and physical activity in men. Socioeconomic circumstances across the lifecourse at various stages also contribute independently to raised levels of D-dimer in middle age in women only. Risk exposure related to SEP accumulates across life and contributes to raised levels of D-dimer. The association of haemostatic markers and social differences in health may be mediated by inflammatory and other markers.

Familial risk of venous thromboembolism in first-, second- and third-degree relatives: a nationwide family study in Sweden

Venous thromboembolism (VTE) clusters in families, but the familial risk of VTE has only been determined in first-degree relatives. This nationwide study aimed to determine the familial risk of VTE in first-, second- and third-degree relatives of affected individuals. The Swedish Multi-Generation Register was linked to Hospital Discharge Register data for the period 1987-2009. This was a case-cohort study. Odds ratios (ORs) for VTE were calculated for individuals whose relatives were hospitalised for VTE, as determined by the International Classification of Diseases (ICD), and those whose relatives were unaffected by VTE. The familial OR for VTE was 2.49 in siblings (95% confidence interval [CI] 2.40-2.58), 2.65 in children (2.50-2.80), 2.09 in parents (2.03-2.15), 1.52 in maternal half-siblings (1.26-1.85), 2.34 in paternal half-siblings (2.00-2.73), 1.69 in nieces/nephews (1.57-1.82), 1.47 in cousins (1.33-1.64), and 1.14 in spouses of individuals diagnosed with VTE (1.09-1.18). Familial clustering was stronger at young ages. The familial transmission was slightly stronger for males compared with females but was only significant for siblings 1.13 (1.05-1.22) and parents 1.11 (1.05-1.78) of probands. The present data showing an increased VTE risk among not only first-degree relatives but also second- and third-degree relatives indicate that the genetic component of the familial clustering of VTE is strong. Family history is a potentially useful genetic surrogate marker for clinical VTE risk assessment, even in second- and third degree-relatives.

Nomograms to predict risk of in-hospital and post-discharge venous thromboembolism after abdominal and thoracic surgery: an American College of Surgeons National Surgical Quality Improvement Program analysis

BACKGROUND

Postoperative venous thromboembolism (VTE) is increasingly viewed as a quality of care metric, although risk-adjusted incident rates of postoperative VTE and VTE after hospital discharge (VTEDC) are not available. We sought to characterize the predictors of VTE and VTEDC to develop nomograms to estimate individual risk of VTE and VTEDC.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified 471,867 patients who underwent inpatient abdominal or thoracic operations between 2005 and 2010. We excluded primary vascular and spine operations. We built logistic regression models using stepwise model selection and constructed nomograms for VTE and VTEDC with statistically significant covariates.

RESULTS

The overall, unadjusted, 30-d incidence of VTE and VTEDC was 1.5% and 0.5%, respectively. Annual incidence rates remained unchanged over the study period. On multivariate analysis, age, body mass index, presence of preoperative infection, operation for cancer, procedure type (spleen highest), multivisceral resection, and non-bariatric laparoscopic surgery were significant predictors for VTE and VTEDC. Other significant predictors for VTE, but not VTEDC, included a history of chronic obstructive pulmonary disease, disseminated cancer, and emergent operation. We constructed and validated nomograms by bootstrapping. The concordance indices for VTE and VTEDC were 0.77 and 0.67, respectively.

CONCLUSIONS

Substantial variation exists in the incidence of VTE and VTEDC, depending on patient and procedural factors. We constructed nomograms to predict individual risk of 30-d VTE and VTEDC. These may allow more targeted quality improvement interventions to reduce VTE and VTEDC in high-risk general and thoracic surgery patients.