The influence of anemia on clinical outcomes in venous thromboembolism: Results from GARFIELD-VTE

Treating cancer-associated venous thromboembolism: A practical approach

Venous thromboembolism (VTE) is a common and potentially life-threatening complication in patients with cancer. Both cancer and its treatments increase the risk of developing VTE. Specific cancer types and individual patient comorbidities increase the risk of developing cancer-associated VTE, and the risk of bleeding is increased with anticoagulation therapies. The aims of this article are to summarize the latest evidence for treating cancer-associated VTE, discuss the practical considerations involved, and share best practices for VTE treatment in patients with cancer. The article pays particular attention to challenging contexts including patients with brain, lung, gastrointestinal, and genitourinary tumors and those with hematological malignancies. Furthermore, the article summarizes specific clinical scenarios that require additional treatment considerations, including extremes of body weight, nausea and gastrointestinal disturbances, compromised renal function, and anemia, and touches upon the relevance of drug-drug interactions. Historically, vitamin K antagonists and low-molecular-weight heparins (LMWHs) have been used as therapy for cancer-associated VTE. The development of direct oral anticoagulants has provided additional treatment options, which, in certain instances, offer advantages over LMWHs. There are numerous factors that need to be considered when treating cancer-associated VTE, and although various treatment guidelines are helpful, they do not reflect each unique scenario that may arise in clinical practice. This article provides a summary of the latest evidence and a practical approach for treating cancer-associated VTE.

Identifying prognostic factors for pulmonary embolism patients with hemodynamic decompensation admitted to the intensive care unit

We aimed to determine prognostic indicators of PE patients with hemodynamic decompensation admitted to the ICU. PE patients with hemodynamic decompensation at ICU admission from Medical Information Mart for Intensive Care IV database were included. Least absolute shrinkage and selection operator with 2 specific lambdas were performed to reduce the dimension of variables after univariate analysis. Then we conducted multivariate logistic regression analysis and 2 models were built. A total of 548 patients were included, among whom 187 died. Lactate, creatine-kinase MB, troponin-T were significantly higher in death group. Eight common factors were screened out from first model statistically mostly in consistent with second model: older age, decreased hemoglobin, elevated anion gap, elevated International Standard Ratio (INR), elevated respiratory rate, decreased temperature, decreased blood oxygen saturation (SpO2) and the onset of cardiac arrest were significantly risk factors for in-Hospital mortality. The nonlinear relationships between these indicators and mortality were showed by the restricted cubic spline and cutoff values were determined. Our study demonstrated that age, hemoglobin levels, anion gap levels, INR, respiratory rate, temperature, SpO2 levels, the onset of cardiac arrest could be applied to predict mortality of PE patients with hemodynamic decompensation at ICU admission.

Comparison of Presentation, Treatment, and Outcomes of Venous Thromboembolism in Long-Term Immobile Patients Based on Age

BACKGROUND

Chronic immobility is prevalent, especially as people age. However, little is known about venous thromboembolism (VTE) outcomes in this population.

OBJECTIVE

To compare the presentation, treatment, and outcomes in chronically immobile (>8 weeks) patients older vs. younger than 75 who presented with VTE.

DESIGN

An observational international registry of patients with VTE.

PARTICIPANTS

Patients with acute VTE from the "Registro Informatizado Enfermedad TromboEmbolica" (RIETE) registry who were chronically immobile.

MAIN MEASURES

Baseline characteristics, presenting signs and symptoms, treatment and outcomes including major bleeding, recurrent VTE, and mortality.

KEY RESULTS

Among 4612 immobile patients (mean age 75.7 years, 34% male), 2127 (46%) presented with pulmonary embolism (PE). Patients >75 years presented more often with dyspnea (44% vs. 38%) or altered mental status (23% vs. 8.1%) and less often with chest pain (13% vs. 18%). The median duration of anticoagulation was shorter in older compared with younger patients [126 vs. 169 days]. During the first 90 days of anticoagulation, major bleeding (4.0% vs. 2.2%), PE-related death (2.5% vs. 1.1%), and bleeding-related death (0.78% vs. 0.26%) occurred more frequently among older patients. In 3550 patients who received anticoagulation beyond 90 days, older patients had more major bleeding [4.23 vs. 2.21 events per 100 patient years]. After anticoagulation discontinuation, recurrent VTE and major bleeding occurred in 11.8 and 9.25 and 1.49 and 0.69 events per 100 patient years, respectively, both in similar rates in both groups. In multivariable analysis, after stopping anticoagulation, VTE recurrence was inversely associated with long-term facility residence [OR 0.51 (0.28-0.92)], anemia [OR 0.63 (0.42-0.95)], and anticoagulation duration < 90 days [OR 0.38 (0.27-0.54)].

CONCLUSIONS

Chronically immobilized patients older than 75 years presenting with VTE experience a high rate of adverse events including major bleeding and recurrent VTE. When considering treatment beyond 90 days, we should account for bleeding, recurrence risk, and associated mortality.

Antikoagulation bei Thrombose und Lungenembolie

In diesem Artikel werden aktuelle Evidenz und Leitlinienempfehlungen zur Antikoagulation (AK) bei tiefer Venenthrombose (TVT) und Lungenembolie (LE) zusammengefasst. Bei LE leitet die Stratifizierung bezüglich Frühletalität das weitere Management. Die Messung von Laktat kann hierfür hilfreich sein. Die initiale AK erfolgt intensiviert entweder parenteral oder mit erhöhter Dosis von Apixaban oder Rivaroxaban. Alle Patienten sollten eine Erhaltungstherapie von 3 – 6 Monaten erhalten, da bei AK unter 3 Monaten ein hohes Rezidivrisiko besteht. Die Dauer der anschließenden Sekundärprophylaxe richtet sich nach dem mutmaßlichen VTE-Rezidivrisiko einerseits und dem Blutungsrisiko andererseits. Bei Adipositas bis 150 kg werden Standarddosen von Rivaroxaban und Apixaban als geeignet vorgeschlagen. Bei der krebsassoziierten Thromboembolie wird die bisherige Leitlinienempfehlung für niedermolekulare Heparine (NMH) über 3 – 6 Monate ergänzt durch die Empfehlung für Xa-Inhibitoren, allerdings mit Vorsicht bei gastrointestinalen und urothelialen Tumoren oder erwarteten Wechselwirkungen. Hier und in instabilen Phasen wird NMH bevorzugt.

Safety and Efficacy of Rivaroxaban for Extended-Phase Anticoagulation of Patients with Unprovoked or Recurrent Venous Thromboembolism: Real-Life Data from the MAC Project

Venous thromboembolism (VTE) is a major cause of death in the world. After the acute-phase treatment, the optimal duration of anticoagulation is still debatable. The latest guidelines suggest maintaining long-term anticoagulation in patients with cancer-associated thrombosis (CAT) or with unprovoked VTE and a low bleeding risk. Methods: The MAC Project is an ongoing prospective-cohort, multi-center, observational study in Italy. The project aims to collect real-life clinical information in unselected patients given oral anticoagulants for VTE over a 5-year follow-up period. There were no exclusion criteria, except for life expectancy <6 months and refusal to sign the informed consent form or to attend the planned follow-up visit. All patients were followed-up prospectively with clinical controls scheduled at 3, 6, and 12 months after the index event, and then annually for up to 5 years. The primary efficacy and safety outcomes were symptomatic recurrent VTE and major bleeding. Results: We analyzed 450 consecutive patients treated with rivaroxaban and referred them to the MAC Project database for unprovoked or recurrent VTE. Of these, 267 (55%) were unprovoked VTE, and 377 (87%) were symptomatic. We followed up with the patients for a mean of 22 months (Q1 10.7; Q3 37.4 months). Recurrent VTE occurred in 12 patients on rivaroxaban treatment (IR 1.7 per 100 person-years). Males had more recurrence than women. During the follow-up period, we recorded 13 (2.9%) major bleeding, 12 (2.7%) clinically relevant non-major bleeding, 8 minor bleeding, and no fatal bleeding events. Overall, bleeding events occurred in 33 (7.3%) patients, most occurring within the first 2 years of treatment. In addition, we observed a statistically significant higher incidence of bleeding in patients with a baseline HAS-BLED score of 3 to 4 compared with those with a score of 0 to 2, with most events occurring during the first 3 months of treatment (RR 5.9). Discussion: Rivaroxaban appears to be safe and effective for the long-term treatment of patients with recurrent or unprovoked VTE. Our results match previously published data, and we are confident that the continuation of the follow-up for up to 5 years will confirm these outcomes.

Novel marker for predicting the severity and prognosis of acute pulmonary embolism: platelet-to-hemoglobin ratio

Background: We investigated the ability of the platelet-to-hemoglobin ratio (PHR) to predict mortality and disease severity in patients with acute pulmonary embolism (APE). Materials & methods: The severity of APE was classified as massive (high risk), submassive (intermediate risk) or nonmassive (low risk). PHR is defined as platelet count/hemoglobin count. Results: PHR was significantly higher in patients with massive APE, and this elevation showed a gradual increase from the nonmassive group to the massive group (p < 0.001). In-hospital and 1-month mortality were higher in patients with high PHR values. PHR was an independent risk factor for the development of massive APE (odds ratio: 1.014; 95% CI: 1.011-1.017; p = 0.009). Conclusion: PHR values predicted massive APE and were an independent predictor of mortality in APE.