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Couturaud F, Meneveau N, Sevestre MA, Morange PE, Jimenez D. Duration of anticoagulation of venous thromboembolism. Presse Med 2024:104245. [PMID: 39244021 DOI: 10.1016/j.lpm.2024.104245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2024] Open
Abstract
Venous thromboembolism (VTE) is a common, serious condition that requires anticoagulation for at least three months to prevent recurrence and long-term complications. After this initial period, the decision to continue or stop anticoagulation depends on the balance between the risk of recurrent VTE and the risk of bleeding. Established guidelines suggest short-term anticoagulation for VTE caused by transient factors and indefinite anticoagulation for recurrent or cancer-associated VTE. However, for a first unprovoked VTE, decision-making remains challenging. Current predictive scores for recurrence and bleeding are not sufficiently reliable, and the safety and efficacy of reduced-dose anticoagulation remain unclear. In the future, precision and patient-centred medicine may improve treatment decisions in this area.
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Affiliation(s)
- Francis Couturaud
- CHU Brest, Département de Médecine Interne et Pneumologie, Brest, France; Univ_Brest, INSERM U1304-GETBO, CIC INSERM 1412, F29609 Brest; FCRIN INNOVTE network, Saint-Etienne, France.
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besançon, France;; EA3920, University of Franche-Comté, 25000 Besançon, France
| | | | - Pierre-Emmanuel Morange
- Aix-Marseille University, INSERM, INRAE, Centre de Recherche en CardioVasculaire et Nutrition, Laboratory of Haematology, CRB Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - David Jimenez
- Respiratory Department, Ramón y Cajal Hospital (IRICYS), Madrid, Spain; Medicine Department, Universidad de Alcalá (IRICYS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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2
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Kimmerle AR, Noflatscher M, Raggam RB. Optimal long-term anticoagulation after acute pulmonary embolism: current state of the art and a look into the near future. Curr Opin Pulm Med 2024; 30:421-428. [PMID: 38989794 DOI: 10.1097/mcp.0000000000001106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize the current state of the art and future directions in optimal long-term anticoagulation following acute pulmonary embolism (PE). RECENT FINDINGS Actual studies and guidelines underscore the preference for direct oral anticoagulants (DOAC) in standard therapeutic doses for maintenance therapy post-PE, while considering patient-specific factors and dose-reduction criteria. Risk stratification should always include the assessment of concomitant trigger- or risk factors regarding their strength and persistence. The use of tools like specific scores can facilitate the identification of optimal candidates for long-term therapy, emphasizing once more personalized approaches and strategies. Special patient groups, such as cancer associated thrombosis, chronic thromboembolic pulmonary hypertension or antiphospholipid syndrome require even more tailored therapy approaches. SUMMARY Optimal long-term anticoagulation post-PE should be guided by straightforward and individual risk assessment strategies. The array of indications for DOACs has gotten wider in last years, also within special patient groups. Still, chronic thromboembolic pulmonary hypertension and antiphospholipid syndrome remains domain of vitamin K agonists.
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Affiliation(s)
| | - Maria Noflatscher
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Reinhard Bernd Raggam
- Department of Internal Medicine, Division of Angiology, Medical University of Graz, Graz
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Sartori M, Iotti M, Camporese G, Siragusa S, Imberti D, Bucherini E, Corradini S, Ageno W, Prandoni P, Ghirarduzzi A. Six-week low-molecular-weight heparin versus 12-week warfarin for calf deep vein thrombosis: A randomized, prospective, open-label study. Am J Hematol 2024; 99:854-861. [PMID: 38375893 DOI: 10.1002/ajh.27255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/24/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024]
Abstract
Current guidelines suggest a 3-month anticoagulant treatment course for isolated distal deep vein thrombosis (IDDVT), but shorter durations of treatment are frequently prescribed in clinical practice. We investigated whether a 6-week treatment with low-molecular-weight heparin (LMWH) at intermediate dosage can be an effective and safe alternative to vitamin K antagonists (VKA) in patients with IDDVT (non-inferiority trial). In a multicenter, open-label, randomized trial, 260 outpatients with symptomatic IDDVT were randomly assigned to receive either LMWH followed by VKA for 12 weeks or LMWH 1 mg/kg subcutaneously twice a day for 2 weeks followed by 1 mg/kg subcutaneously once a day for 4 weeks. The follow-up was 6 months and the primary endpoint was the composite measure of recurrent venous thromboembolism (VTE) defined as: recurrence or extension of IDDVT, proximal DVT, and pulmonary embolism (PE). The study was stopped prematurely due to slow recruiting rates. The primary efficacy outcome occurred in 14 patients receiving LMWH (10.8%) and in five patients receiving VKA (3.8%); risk difference was 0.069 (95% CI: 0.006-0.132), hazard ratio 2.8 (95% CI: 1.04-7.55). There was one PE in the VKA group and one proximal DVT in the LMWH group. IDDVT recurrence was 10.0% in the LMWH group versus 3.1% in the VKA group (p = .024). Two patients had clinically relevant bleedings (1.6%) in the LMWH group versus one (0.8%) in VKA group (p = .56). In conclusion, VKA for 12 weeks seems superior to LMWH for 6 weeks in reducing the risk of VTE recurrences in our cohort of outpatients with IDDVT.
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Affiliation(s)
- Michelangelo Sartori
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Iotti
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Giuseppe Camporese
- General Medicine Unit, Thrombotic and Haemorrhagic Disorders Unit, Department of Internal Medicine, University Hospital of Padua, Padua, Italy
| | - Sergio Siragusa
- Haematology Unit, Thrombosis and Haemostasis Reference Regional Center, University of Palermo, Palermo, Italy
| | - Davide Imberti
- Haemostasis and Thrombosis Center, Department of Internal Medicine, Hospital of Piacenza, Piacenza, Italy
| | | | - Sara Corradini
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Donmez I, Muduroglu A. Systemic immune-inflammation index as a novel hematological marker for predicting the recurrence of deep venous thrombosis. Vascular 2024:17085381241237146. [PMID: 38433463 DOI: 10.1177/17085381241237146] [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: 03/05/2024]
Abstract
OBJECTIVE To determine whether there was a possible predictive relationship between systemic immune-inflammation index (SII) and recurrence of deep venous thrombosis (DVT). METHODS A total of 231 patients with DVT who met the study criteria and whose data could be accessed were enrolled to this retrospective single-centered cross-sectional study. Of them 26 patients with DVT recurrence consisted of the study group (Group 1) while remaining 205 cases without recurrence were considered as the control population (Group 2). The patients' basic clinical features and laboratory results from the complete blood count (CBC) test were recorded and compared between groups. Following univariate analyses, a multivariate logistic regression analysis was performed to identify the independent predictors of the recurrence of DVT. Additionally, a receiver-operating characteristic (ROC) curve analysis was performed to detect the cut-off values of the predictors with sensitivity and specificity rates. RESULTS There were no significant differences between the groups for basic clinical features, except for diabetes mellitus, pulmonary embolism, and atrial fibrillation. Although the univariate analysis revealed that the median values of NLR, PLR, and SII were significantly higher in the DVT recurrence group, only SII was determined to be a significant and independent predictor of DVT recurrence in the multivariate logistic regression analysis. According to ROC curve analysis, SII of 1685 × 103/mm3 constituted the cut-off value for predicting DVT recurrence with 61.5% sensitivity and 76.6% specificity (AUC = 0.686, p = .001). CONCLUSION The present study demonstrated for the first time in the literature that SII significantly predicted the recurrence of DVT.
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Affiliation(s)
- Ibrahim Donmez
- Department of Cardiology, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey
| | - Ayhan Muduroglu
- Department of Cardiovascular Surgery, Bursa City Hospital, Bursa, Turkey
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Hashimoto H, Imai S, Yamashita R, Kiyomi A, Sugiura M. Association of Antipsychotic Drugs with the Risk of Recurrent Venous Thromboembolism: A Retrospective Study of Data from a Japanese Inpatient Database. Drugs Real World Outcomes 2024; 11:109-116. [PMID: 38015358 DOI: 10.1007/s40801-023-00401-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Approximately a decade has passed since the addition of venous thromboembolism to the list of significant adverse reactions of antipsychotic drugs. However, only a few studies have investigated the relationship between antipsychotic use and venous thromboembolism in the Japanese population. PURPOSE We aimed to evaluate the risk of recurrent venous thromboembolism in users of antipsychotic drugs and update the evidence on venous thromboembolism in the Japanese population. METHODS A cross-sectional retrospective analysis of data from a large Japanese claims database, managed by Medical Data Vision Co. Ltd., was conducted. Adult patients who experienced venous thromboembolism between October 2014 and September 2018 in acute care hospitals were identified. The risk of recurrent venous thromboembolism was evaluated with logistic regression using demographic variables. The data of patients using antipsychotic drugs within specific therapeutic classes were also evaluated. RESULTS We included 8960 patients (mean age, 69 years; 59.2% female). Recurrent venous thromboembolism was observed in 686 patients (7.7%). The risk of recurrent venous thromboembolism was significantly higher in younger patients [< 65 years: reference; 65-74 years: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.66-0.99, p = 0.04; ≥ 75 years: OR 0.77, 95% CI 0.64-0.94, p = 0.01], those with history of surgery (OR 1.39, 95% CI 1.18-1.65, p = 0.01), and anticoagulant users (OR 2.25, 95% CI 1.46-3.48, p = 0.01) and was significantly lower in the presence of comorbidities (OR 0.68, 95% CI 0.58-0.81, p< 0.01) and fractures (OR 0.49, 95% CI 0.26-0.94, p = 0.03). Long-term antipsychotic drug prescriptions (> 14 days) were associated with a higher risk of venous thromboembolism than short-term prescriptions (≤ 14 days) (OR 1.56, 95% CI 1.04-2.34, p = 0.03). CONCLUSIONS In patients with a history of venous thromboembolism, particular attention should be paid to recurrence in younger patients. If antipsychotic drugs are prescribed for > 14 days to patients with a history of venous thromboembolism, they should be administered carefully, guided by reported findings. Further evaluations using different databases or populations are required to generalize the findings of this study.
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Affiliation(s)
- Hiroyuki Hashimoto
- Department of Drug Safety and Risk Management, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1, Horinouchi, Hachioji, Tokyo, 192-0392, Japan
| | - Shinobu Imai
- Division of Pharmacoepidemiology, Department of Healthcare and Regulatory Sciences, Showa University School of Pharmacy, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Ryoka Yamashita
- Department of Drug Safety and Risk Management, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1, Horinouchi, Hachioji, Tokyo, 192-0392, Japan
| | - Anna Kiyomi
- Department of Drug Safety and Risk Management, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1, Horinouchi, Hachioji, Tokyo, 192-0392, Japan
| | - Munetoshi Sugiura
- Department of Drug Safety and Risk Management, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1, Horinouchi, Hachioji, Tokyo, 192-0392, Japan.
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Nakamura M, Tamaru S, Hirooka S, Hirayama A, Tsuji A, Hirata M, Munemasa M, Nakagawa I, Toshima M, Shimokawa H, Nishimura Y, Ogura T, Yamamoto T, Satokawa H, Obayashi T, Yamada N. Efficacy and Safety of Warfarin for the Treatment of Venous Thromboembolism - A Multicenter Prospective Observational Cohort Study in Japan (AKAFUJI Study). Circ J 2024; 88:359-368. [PMID: 37394573 DOI: 10.1253/circj.cj-23-0158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
BACKGROUND A large-scale prospective study of the efficacy and safety of warfarin for the treatment of venous thromboembolism (VTE) has not been conducted in Japan. Therefore, we conducted a real-world prospective multicenter observational cohort study (AKAFUJI Study; UMIN000014132) to investigate the efficacy and safety of warfarin for VTE. METHODS AND RESULTS Between May 2014 and March 2017, 352 patients (mean [±SD] age 67.7±14.8 years; 57% female) with acute symptomatic/asymptomatic VTE were enrolled; 284 were treated with warfarin. The cumulative incidence of recurrent symptomatic VTE was higher in patients without warfarin than in those treated with warfarin (8.7 vs. 2.2 per 100 person-years, respectively; P=0.018). The cumulative incidence of bleeding complications was not significantly different between the 2 groups. The mean prothrombin time-international normalized ratio (PT-INR) during warfarin on-treatment was <1.5 in 180 patients, 1.5-2.5 in 97 patients, and >2.5 in 6 patients. The incidence of bleeding complications was significantly higher in patients with PT-INR >2.5, whereas the incidence of recurrent VTE was not significantly different between the 3 PT-INR groups. The cumulative incidence of recurrent VTE and bleeding complications did not differ significantly among those in whom VTE was provoked by a transient risk factor, was unprovoked, or was associated with cancer. CONCLUSIONS Warfarin therapy with an appropriate PT-INR according to Japanese guidelines is effective without increasing bleeding complications, regardless of patient characteristics.
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Affiliation(s)
| | - Satoshi Tamaru
- Clinical Research Support Center, Mie University Hospital
| | - Shigeki Hirooka
- Department of Cardiovascular Surgery, Yamagata Saisei Hospital
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Akihiro Tsuji
- Department of Cardiology, Division of Pulmonary Circulation, National Cerebral and Cardiovascular Center
| | - Mitsuhiro Hirata
- Department of Cardiovascular Surgery, Kitasato University Hospital
| | | | | | | | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Yuki Nishimura
- Clinical Research Support Center, Mie University Hospital
| | - Toru Ogura
- Clinical Research Support Center, Mie University Hospital
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Hirono Satokawa
- Department of Cardiovascular Surgery, Fukushima Medical University Hospital
| | - Toru Obayashi
- Department of Cardiology, Musashino Red Cross Hospital
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Sugimura K. Resolving the Gap in Evidence on the Role of Warfarin in Venous Thromboembolism Management in Japan. Circ J 2024; 88:369-370. [PMID: 37673639 DOI: 10.1253/circj.cj-23-0582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Affiliation(s)
- Koichiro Sugimura
- Department of Cardiology, International University of Health and Welfare Narita Hospital
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Yamashita Y, Morimoto T, Muraoka N, Oyakawa T, Umetsu M, Akamatsu D, Nishimoto Y, Sato Y, Takada T, Jujo K, Minami Y, Ogihara Y, Dohi K, Fujita M, Nishikawa T, Ikeda N, Hashimoto G, Otsui K, Mori K, Sueta D, Tsubata Y, Shoji M, Shikama A, Hosoi Y, Tanabe Y, Chatani R, Tsukahara K, Nakanishi N, Kim K, Ikeda S, Mo M, Yoshikawa Y, Kimura T. Edoxaban for 12 Months Versus 3 Months in Patients With Cancer With Isolated Distal Deep Vein Thrombosis (ONCO DVT Study): An Open-Label, Multicenter, Randomized Clinical Trial. Circulation 2023; 148:1665-1676. [PMID: 37638968 DOI: 10.1161/circulationaha.123.066360] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND The optimal duration of anticoagulation therapy for isolated distal deep vein thrombosis in patients with cancer is clinically relevant, but the evidence is lacking. The prolonged anticoagulation therapy could have a potential benefit for prevention of thrombotic events; however, it could also increase the risk of bleeding. METHODS In a multicenter, open-label, adjudicator-blinded, randomized clinical trial at 60 institutions in Japan, we randomly assigned patients with cancer with isolated distal deep vein thrombosis, in a 1-to-1 ratio, to receive either a 12-month or 3-month edoxaban treatment. The primary end point was a composite of a symptomatic recurrent venous thromboembolism (VTE) or VTE-related death at 12 months. The major secondary end point was major bleeding at 12 months, according to the criteria of the International Society on Thrombosis and Haemostasis. The primary hypothesis was that a 12-month edoxaban treatment was superior to a 3-month edoxaban treatment with respect to the primary end point. RESULTS From April 2019 through June 2022, 604 patients were randomized, and after excluding 3 patients who withdrew consent, 601 patients were included in the intention-to-treat population: 296 patients in the 12-month edoxaban group and 305 patients in the 3-month edoxaban group. The mean age was 70.8 years, 28% of the patients were men, and 20% of the patients had symptoms of deep vein thrombosis at baseline. The primary end point of a symptomatic recurrent VTE event or VTE-related death occurred in 3 of the 296 patients (1.0%) in the 12-month edoxaban group and in 22 of the 305 patients (7.2%) in the 3-month edoxaban group (odds ratio, 0.13; 95% CI, 0.03-0.44). The major secondary end point of major bleeding occurred in 28 of the 296 patients (9.5%) in the 12-month edoxaban group and in 22 of the 305 patients (7.2%) in the 3-month edoxaban group (odds ratio, 1.34; 95% CI, 0.75-2.41). The prespecified subgroups did not affect the estimates on the primary end point. CONCLUSIONS In patients with cancer with isolated distal deep vein thrombosis, 12 months was superior to 3 months for an edoxaban treatment with respect to the composite outcome of a symptomatic recurrent VTE or VTE-related death. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03895502.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Yamashita, Y. Yoshikawa)
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan (T.M.)
| | - Nao Muraoka
- Division of Cardiology, Shizuoka Cancer Center, Japan (N.M., T.O.)
| | - Takuya Oyakawa
- Division of Cardiology, Shizuoka Cancer Center, Japan (N.M., T.O.)
| | - Michihisa Umetsu
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan (M.U., D.A.)
| | - Daijirou Akamatsu
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan (M.U., D.A.)
| | - Yuji Nishimoto
- Division of Cardiology, Osaka General Medical Center, Japan (Y.N.)
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Japan (Y.S.)
| | - Takuma Takada
- Department of Cardiology, Tokyo Women's Medical University, Japan (T.T., K.J., Y.M.)
| | - Kentaro Jujo
- Department of Cardiology, Tokyo Women's Medical University, Japan (T.T., K.J., Y.M.)
| | - Yuichiro Minami
- Department of Cardiology, Tokyo Women's Medical University, Japan (T.T., K.J., Y.M.)
| | - Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y.O., K.D.)
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y.O., K.D.)
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute, Japan (M.F., T.N.)
| | - Tatsuya Nishikawa
- Department of Onco-Cardiology, Osaka International Cancer Institute, Japan (M.F., T.N.)
| | - Nobutaka Ikeda
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan (N.I., G.H.)
| | - Go Hashimoto
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan (N.I., G.H.)
| | - Kazunori Otsui
- Department of General Internal Medicine, Kobe University Graduate School of Medicine, Japan (K.O., K.M.)
| | - Kenta Mori
- Department of General Internal Medicine, Kobe University Graduate School of Medicine, Japan (K.O., K.M.)
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (D.S.)
| | - Yukari Tsubata
- Department of Internal Medicine, Division of Medical Oncology and Respiratory Medicine, Shimane University Faculty of Medicine, Izumo, Japan (Y. Tsubata)
| | - Masaaki Shoji
- Department of Cardiovascular Medicine, National Cancer Center Hospital, Tokyo, Japan (M.S.)
| | - Ayumi Shikama
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Japan (A.S.)
| | - Yutaka Hosoi
- Department of Cardiovascular Surgery, Kyorin University Faculty of Medicine, Tokyo, Japan (Y.H.)
| | - Yasuhiro Tanabe
- Department of Cardiology, St Marianna University School of Medicine, Kawasaki, Japan (Y. Tanabe)
| | - Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Japan (R.C.)
| | - Kengo Tsukahara
- Division of Cardiology, Fujisawa City Hospital, Japan (K.T.)
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan (N.N.)
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Japan (K.K.)
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan (S.I.)
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Japan (M.M.)
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Yamashita, Y. Yoshikawa)
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Japan (T.K.)
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9
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Vrotniakaite-Bajerciene K, Rütsche S, Calzavarini S, Quarroz C, Stalder O, Mean M, Righini M, Staub D, Beer JH, Frauchiger B, Osterwalder J, Kucher N, Matter CM, Husmann M, Banyai M, Aschwanden M, Mazzolai L, Hugli O, Rodondi N, Aujesky D, Angelillo-Scherrer A. Thrombin Generation Is Associated with Venous Thromboembolism Recurrence, but Not with Major Bleeding and Death in the Elderly: A Prospective Multicenter Cohort Study. J Clin Med 2023; 12:6050. [PMID: 37762997 PMCID: PMC10531633 DOI: 10.3390/jcm12186050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
It is currently unknown whether thrombin generation is associated with venous thromboembolism (VTE) recurrence, major bleeding, or mortality in the elderly. Therefore, our aim was to prospectively study the association between thrombin generation and VTE recurrence, major bleeding, and mortality in elderly patients with acute VTE. Consecutive patients aged ≥65 years with acute VTE were followed for 2 years, starting from 1 year after the index VTE. Primary outcomes were VTE recurrence, major bleeding, and mortality. Thrombin generation was assessed in 551 patients 1 year after the index VTE. At this time, 59% of the patients were still anticoagulated. Thrombin generation was discriminatory for VTE recurrence, but not for major bleeding and mortality in non-anticoagulated patients. Moreover, peak ratio (adjusted subhazard ratio 4.09, 95% CI, 1.12-14.92) and normalized peak ratio (adjusted subhazard ratio 2.18, 95% CI, 1.28-3.73) in the presence/absence of thrombomodulin were associated with VTE recurrence, but not with major bleeding and mortality after adjustment for potential confounding factors. In elderly patients, thrombin generation was associated with VTE recurrence, but not with major bleeding and/or mortality. Therefore, our study suggests the potential usefulness of thrombin generation measurement after anticoagulation completion for VTE to help identify among elderly patients those at higher risk of VTE recurrence.
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Affiliation(s)
- Kristina Vrotniakaite-Bajerciene
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Sereina Rütsche
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Sara Calzavarini
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Claudia Quarroz
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Odile Stalder
- Clinical Trials Unit (CTU) Bern, University of Bern, 3010 Bern, Switzerland;
| | - Marie Mean
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.M.); (N.R.); (D.A.)
- Department of Medicine, Lausanne University Hospital, Lausanne University, 1005 Lausanne, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital, 1205 Geneva, Switzerland;
| | - Daniel Staub
- Division of Angiology, Basel University Hospital, 4031 Basel, Switzerland; (D.S.); (M.A.)
| | - Juerg H. Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, 5404 Baden, Switzerland;
| | - Beat Frauchiger
- Department of Internal Medicine, Cantonal Hospital of Frauenfeld, 8501 Frauenfeld, Switzerland;
| | | | - Nils Kucher
- Clinic of Angiology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Christian M. Matter
- Department of Cardiology, University Heart Center, University Hospital Zurich, 8091 Zurich, Switzerland;
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, Zurich University Hospital and University of Zurich, 8091 Zurich, Switzerland
| | - Marc Husmann
- Center for Vascular Diseases, Zurich-Stadelhofen, Stadelhoferstrasse 8, 8001 Zurich, Switzerland;
| | - Martin Banyai
- Gefässpraxis Luzern Swiss AG, Pilatusstrasse 34, 6003 Lucerne, Switzerland;
| | - Markus Aschwanden
- Division of Angiology, Basel University Hospital, 4031 Basel, Switzerland; (D.S.); (M.A.)
| | - Lucia Mazzolai
- Service of Angiology, Lausanne University Hospital, Lausanne University, 1005 Lausanne, Switzerland;
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne University, 1005 Lausanne, Switzerland;
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.M.); (N.R.); (D.A.)
- Institute of Primary Health Care (BIHAM), University of Bern, 3010 Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.M.); (N.R.); (D.A.)
| | - Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
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10
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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11
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Soler-Espejo E, Esteve-Pastor MA, Rivera-Caravaca JM, Roldan V, Marín F. Reducing bleeding risk in patients on oral anticoagulation therapy. Expert Rev Cardiovasc Ther 2023; 21:923-936. [PMID: 37905915 DOI: 10.1080/14779072.2023.2275662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/23/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION Oral anticoagulation (OAC) significantly mitigates thromboembolism risks in atrial fibrillation (AF) and venous thromboembolism (VTE) patients yet concern about major bleeding events persist. In fact, clinically relevant hemorrhages can be life-threatening. Bleeding risk is dynamic and influenced by factors such as age, new comorbidities, and drug therapies, and should not be assessed solely based on static baseline factors. AREAS COVERED We comprehensively review the bleeding risk associated with OAC therapy. Emphasizing the importance of assessing both thromboembolic and bleeding risks, we present clinical tools for estimating stroke and systemic embolism (SSE) and bleeding risk in AF and VTE patients. We also address overlapping risk factors and the dynamic nature of bleeding risk. EXPERT OPINION The OAC management is undergoing constant transformation, motivated by the primary objective of mitigating thromboembolism and bleeding hazards, thereby amplifying patient safety throughout the course of treatment. The future of OAC embraces personalized approaches and innovative therapies, driven by advanced pathophysiological insights and technological progress. This holds promise for improving patient outcomes and revolutionizing anticoagulation practices.
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Affiliation(s)
- Eva Soler-Espejo
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Faculty of Nursing, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - Vanessa Roldan
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
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12
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Rinde FB, Jørgensen CT, Pettersen HH, Hansen JB, Ghanima W, Braekkan SK. Low D-dimer levels at diagnosis of venous thromboembolism are associated with reduced risk of recurrence: data from the TROLL registry. J Thromb Haemost 2023; 21:1861-1868. [PMID: 37004791 DOI: 10.1016/j.jtha.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/14/2023] [Accepted: 03/19/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a frequent disease with a high risk of recurrence. It has been suggested that the D-dimer level at the time of VTE diagnosis can be used to identify patients at a low risk of recurrence. OBJECTIVES We aimed to investigate the impact of D-dimer levels measured at the time of VTE diagnosis on the risk of recurrence in a large cohort of patients with a first-time VTE. METHODS The study included 2585 patients with first symptomatic non-cancer-associated VTE from the Venous Thrombosis Registry in Østfold Hospital (TROLL) (2005-2020). All recurrent events during the follow-up were recorded, and cumulative incidences of recurrence were estimated according to D-dimer levels of ≤1900 ng/mL (≤25th percentile) and >1900 ng/mL. RESULTS During a median follow-up of 3.3 years, 395 patients experienced a recurrent VTE. The 1- and 5-year cumulative incidences of recurrence were 2.9% (95% CI: 1.8-4.6) and 11.4% (95% CI: 8.7-14.8), respectively, in those with a D-dimer concentration of ≤1900 ng/mL and 5.0% (95% CI, 4.0-6.1) and 18.3% (95% CI: 16.2-20.6), respectively, in those with a D-dimer concentration of >1900 ng/mL, respectively. In patients with unprovoked VTE, the 5-year cumulative incidence was 14.3% (95% CI: 10.3-19.7) in the ≤1900-ng/mL category, and 20.2% (95% CI: 17.3-23.5) in the >1900-ng/mL category. CONCLUSIONS D-dimer levels within the lowest quartile, measured at the time of VTE diagnosis, were associated with lower recurrence risk. Our findings imply that D-dimer levels measured at the time of diagnosis may be used to identify patients with VTE at a low risk of recurrent VTE.
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Affiliation(s)
- Fridtjof B Rinde
- Thrombosis Research Center (TREC), Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.
| | - Camilla T Jørgensen
- Internal Medicine Clinic, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - John-Bjarne Hansen
- Thrombosis Research Center (TREC), Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Waleed Ghanima
- Internal Medicine Clinic, Østfold Hospital, Kalnes, Norway; Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Sigrid K Braekkan
- Thrombosis Research Center (TREC), Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
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13
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Berry J, Patell R, Zwicker JI. The bridging conundrum: perioperative management of direct oral anticoagulants for venous thromboembolism. J Thromb Haemost 2023; 21:780-786. [PMID: 36709100 PMCID: PMC11000626 DOI: 10.1016/j.jtha.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/19/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023]
Abstract
Most patients diagnosed with venous thromboembolism (VTE) are currently treated with direct oral anticoagulants (DOACs). Before an invasive procedure or surgery, clinicians face the challenging decision of how to best manage DOACs. Should the DOAC be held, for how long, and are there instances where bridging with other anticoagulants should be considered? Although clinical trials indicate that most patients taking DOACs for atrial fibrillation do not require bridging anticoagulation, the optimal strategy for patients with a history of VTE is undefined. In this review, we present a case-based discussion for DOAC interruption perioperatively in patients receiving anticoagulation for management of VTE.
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Affiliation(s)
- Jonathan Berry
- Division of Hematology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/jlberrymd
| | - Rushad Patell
- Division of Hematology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/rushadpatell
| | - Jeffrey I Zwicker
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.
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14
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Schenker C, Stalder O, Méan M, Tritschler T, Righini M, Rodondi N, Aujesky D. Bleeding Risk in Elderly Patients with Venous Thromboembolism Who Would Have Been Excluded from Anticoagulation Trials. Thromb Haemost 2023; 123:427-437. [PMID: 36649737 DOI: 10.1055/s-0042-1760365] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Older patients with venous thromboembolism (VTE) are underrepresented in clinical anticoagulation trials. We examined to which extent elderly patients with VTE would be excluded from such trials and compared the bleeding risk between hypothetically excluded and enrolled patients. We studied 991 patients aged ≥65 years with acute VTE in a prospective multicenter cohort. We identified 12 landmark VTE oral anticoagulation trials from the eighth and updated ninth American College of Chest Physician Guidelines. For each trial, we abstracted the exclusion criteria and calculated the proportion of our study patients who would have been excluded from trial participation. We examined the association between five common exclusion criteria (hemodynamic instability, high bleeding risk, comorbidity, co-medication, and invasive treatments) and major bleeding (MB) within 36 months using competing risk regression, adjusting for age, sex, and periods of anticoagulation. A median of 31% (range: 20-52%) of our patients would have been excluded from participation in the landmark trials. Hemodynamic instability (sub-hazard ratio [SHR]: 2.2, 95% CI: 1.1-4.7), comorbidity (SHR: 1.5, 95% CI: 1.1-2.2), and co-medication (SHR: 1.5, 95% CI: 1.0-2.3) were associated with MB. Compared to eligible patients, those with ≥2 exclusion criteria had a twofold (SHR: 2.16, 95% CI: 1.38-3.39) increased risk of MB. Overall, about one-third of older patients would not be eligible for participation in guideline-defining VTE anticoagulation trials. The bleeding risk increases significantly with the number of exclusion criteria present. Thus, results from such trials may not be generalizable to older, multimorbid, and co-medicated patients.
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Affiliation(s)
- Carla Schenker
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Marie Méan
- Division of Internal Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, 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
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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15
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Knueppel P, Bang SH, Troyer C, Barriga A, Shin J, Cadiz CL, Abdo C, McCart T, Huynh B, Stevens C, Zhou C, Yang NT, Wilson M, Pon T. Evaluation of standard versus reduced dose apixaban for the treatment of venous thromboembolism in patients with severe renal disease (ESRD-VTE). Thromb Res 2022; 220:91-96. [PMID: 36306678 PMCID: PMC9850596 DOI: 10.1016/j.thromres.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/10/2022] [Accepted: 10/21/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND There are no clear dosing recommendations when using apixaban for venous thromboembolism (VTE) treatment in patients with severe or end-stage renal disease; clinical trials excluded patients with a creatinine clearance (CrCl) <25 mL/min or on dialysis. This study compares bleeding rates in patients with severe or end-stage renal disease taking standard versus reduced dose apixaban for VTE treatment. MATERIALS AND METHODS This was a multicenter, retrospective cohort study using electronic medical records between January 1, 2013, and August 31, 2021. This study included patients 18 years or older who had severe or end-stage renal disease when prescribed apixaban for VTE treatment. Severe or end-stage renal disease was defined as at least one of the following: CrCl <25 mL/min, SCr >2.5 mg/dL, CKD stage 4 or 5, or on dialysis. The primary endpoint was rate of clinically relevant bleeding within six months of starting apixaban. Secondary endpoints were VTE recurrence within six months of starting apixaban, time to clinically relevant bleed, and time to VTE recurrence. RESULTS A total of 203 patients were included in the final analysis (n = 125 on 5 mg; n = 78 on 2.5 mg). Clinically relevant bleeding rate was significantly higher in the standard dose group (14.4 % vs 3.8 %, p = 0.02). Rates of VTE recurrence appear similar (6.4 % vs 7.7 %, p = 0.21). CONCLUSIONS A reduced dose of apixaban may be considered when treating VTE in patients with severe or end-stage renal disease.
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Affiliation(s)
- Parker Knueppel
- University of California, Davis Health, 2420 Stockton Blvd, Ste 2000, Sacramento, CA 95817, USA.
| | - Seo Hyoun Bang
- University of California, San Diego Health, 200 W Arbor Dr, San Diego, CA 92103, USA.
| | - Camille Troyer
- University of California, San Francisco Health, 521 Parnassus Ave, Rm 3304, San Francisco, CA 94143, USA.
| | - Alyssa Barriga
- University of California, Irvine School of Pharmacy & Pharmaceutical Sciences, 515 Bison Modular 147C, Irvine, CA 92697, USA.
| | - Jaekyu Shin
- University of California, San Francisco Health, 521 Parnassus Ave, Rm 3304, San Francisco, CA 94143, USA.
| | - Christine L Cadiz
- University of California, Irvine School of Pharmacy & Pharmaceutical Sciences, 515 Bison Modular 147C, Irvine, CA 92697, USA.
| | - Connie Abdo
- University of California, Irvine School of Pharmacy & Pharmaceutical Sciences, 515 Bison Modular 147C, Irvine, CA 92697, USA.
| | - Taylor McCart
- University of California, San Francisco Health, 521 Parnassus Ave, Rm 3304, San Francisco, CA 94143, USA.
| | - Brittany Huynh
- University of California, San Francisco Health, 521 Parnassus Ave, Rm 3304, San Francisco, CA 94143, USA.
| | - Craig Stevens
- University of California, San Diego Health, 200 W Arbor Dr, San Diego, CA 92103, USA.
| | - Crystal Zhou
- University of California, San Francisco Health, 521 Parnassus Ave, Rm 3304, San Francisco, CA 94143, USA.
| | - Nuen Tsang Yang
- University of California, Davis Health, 2420 Stockton Blvd, Ste 2000, Sacramento, CA 95817, USA.
| | - Machelle Wilson
- University of California, Davis Health, 2420 Stockton Blvd, Ste 2000, Sacramento, CA 95817, USA.
| | - Tiffany Pon
- University of California, Davis Health, 2420 Stockton Blvd, Ste 2000, Sacramento, CA 95817, USA; University of California, San Francisco Health, 521 Parnassus Ave, Rm 3304, San Francisco, CA 94143, USA.
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16
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Ageno W, Bertù L, Bucherini E, Camporese G, Dentali F, Iotti M, Lessiani G, Parisi R, Prandoni P, Sartori M, Visonà A, Bigagli E, Palareti G. Rivaroxaban treatment for six weeks versus three months in patients with symptomatic isolated distal deep vein thrombosis: randomised controlled trial. BMJ 2022; 379:e072623. [PMID: 36520715 PMCID: PMC9682494 DOI: 10.1136/bmj-2022-072623] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare two different treatment durations of rivaroxaban in patients with symptomatic isolated distal deep vein thrombosis (DVT). DESIGN Randomised, double blind, placebo controlled clinical trial. SETTING 28 outpatient clinics specialising in venous thromboembolism. PARTICIPANTS 402 adults (≥18 years) with symptomatic isolated distal DVT. INTERVENTIONS After receiving standard dose rivaroxaban for six weeks, participants were randomly assigned to receive rivaroxaban 20 mg or placebo once daily for an additional six weeks. Follow-up was for 24 months from study inclusion. MAIN OUTCOMES MEASURES The primary efficacy outcome was recurrent venous thromboembolism during follow-up after randomisation, defined as the composite of progression of isolated distal DVT, recurrent isolated distal DVT, proximal DVT, symptomatic pulmonary embolism, or fatal pulmonary embolism. The primary safety outcome was major bleeding after randomisation until two days from the last dose of rivaroxaban or placebo. An independent committee adjudicated the outcomes. RESULTS 200 adults were randomised to receive additional rivaroxaban treatment and 202 to receive placebo. Isolated distal DVT was unprovoked in 81 (40%) and 86 (43%) patients, respectively. The primary efficacy outcome occurred in 23 (11%) patients in the rivaroxaban arm and 39 (19%) in the placebo arm (relative risk 0.59, 95% confidence interval 0.36 to 0.95; P=0.03, number needed to treat 13, 95% confidence interval 7 to 126). Recurrent isolated distal DVT occurred in 16 (8%) patients in the rivaroxaban arm and 31 (15%) in the placebo arm (P=0.02). Proximal DVT or pulmonary embolism occurred in seven (3%) patients in the rivaroxaban arm and eight (4%) in the placebo arm (P=0.80). No major bleeding events occurred. CONCLUSIONS Rivaroxaban administered for six additional weeks in patients with isolated distal DVT who had an uneventful six week treatment course reduces the risk of recurrent venous thromboembolism, mainly recurrent isolated distal DVT, over a two year follow-up without increasing the risk of haemorrhage. TRIAL REGISTRATION EudraCT 2016-000958-36; ClinicalTrials.gov NCT02722447.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Lorenza Bertù
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | | | - Giuseppe Camporese
- Unit of Angiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Matteo Iotti
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Gianfranco Lessiani
- Angiology Unit, Department of Internal Medicine, Villa Serena Hospital, Città Sant'Angelo, Italy
| | - Roberto Parisi
- Department of Medicine, SS Giovanni e Paolo Hospital, Venice, Italy
| | | | - Michelangelo Sartori
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Adriana Visonà
- Angiology Unit, Azienda ULSS 2 Marca Trevigiana, Castelfranco Veneto, Italy
| | - Elisabetta Bigagli
- Department of Neuroscience, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
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17
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Jolobe OMP. Palla's sign and the challenge of optimizing the imaging strategy in patients with high pretest probability of pulmonary embolism. QJM 2022; 115:775-777. [PMID: 34918170 DOI: 10.1093/qjmed/hcab322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- O M P Jolobe
- From the British Medical Association, BMA House, Tavistock Square, London WC1H 9JP, UK
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18
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AlEidan FAS, AlManea RK, AlMoneef AT, Shalash NA, AlRajhi NA, AlMousa SF, Al Raizah A, Abuelgasim KA. Incidence and Predictors of Recurrence and Mortality Following First Venous Thromboembolism Among the Saudi Population: Single-Center Cohort Study. Int J Gen Med 2022; 15:7559-7568. [PMID: 36199587 PMCID: PMC9527814 DOI: 10.2147/ijgm.s359893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Little is written about recurrence and mortality rates after a first episode of venous thromboembolism (VTE) among Saudi population. Aim Determine incidence rates and assess predictors of recurrence and mortality following the first VTE event. Patients and Methods A total of 1124 patients aged ≥18 years with symptomatic VTE confirmed by imaging tests were evaluated. The incidence of VTE recurrence and mortality were assessed. The association between patient characteristics, and VTE recurrence and mortality was explored by estimating the hazard ratio (HR) and 95% confidence interval (CI). The difference between cancer-related, provoked and unprovoked VTE in terms of recurrence and mortality was explored using Kaplan–Meier curves. Results The annual incidence rate of the first VTE was 1.7 per 1000 patients. Of 1124 patients with first VTE, 214 (19%) developed recurrent VTE, and 192 (17%) died with overall incidence rates of 15.8 per 100 person-years (95% CI, 13.8–18.0) and 10.0 per 100 person-years (95% CI, 8.7–11.5). Intensive care unit (ICU) admission (HR, 2.15; 95% CI, 1.67–3.10), presence of active cancer (HR, 2.97; 95% CI, 1.87–3.95), immobilization (HR, 2.52; 95% CI, 1.79–3.67), infection (HR, 2.32; 95% CI, 1.94–3.45), and pulmonary embolism ± deep venous thrombosis (HR, 2.22; 95% CI, 1.56–3.16) were found to be independent predictors of recurrent VTE. Recurrence carries a high hazard of mortality (HR, 5.21; 95% CI, 3.61–7.51). The estimated median time to VTE recurrence was lower in cancer-related VTE (18.7 months) compared with provoked (29.0 months) and unprovoked VTE (28.4 months). The estimated survival median time was lower in cancer-related VTE (21.8 months) compared with provoked (30.5 months) and unprovoked VTE (29.8 months). Conclusion Immobilization and presence of active cancer, infection, and PE ± DVT were significant predictors of recurrent VTE. Patients who developed recurrent VTE had a 5.2-fold higher hazard of mortality compared with patients with no VTE recurrence.
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Affiliation(s)
- Fahad A S AlEidan
- King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Correspondence: Fahad A S AlEidan, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia, Tel +966118011111, Email
| | - Reem K AlManea
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Alyah T AlMoneef
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nada A Shalash
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Norah A AlRajhi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sarah F AlMousa
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman Al Raizah
- King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Khadega A Abuelgasim
- King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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19
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Kang HR, Lo-Ciganic WH, DeRemer CE, Dietrich EA, Huang PL, Park H. Effectiveness and Safety of Extended Oral Anticoagulant Therapy in Patients with Venous Thromboembolism: A Retrospective Cohort Study. Clin Pharmacol Ther 2022; 112:133-145. [PMID: 35420702 DOI: 10.1002/cpt.2611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/11/2022] [Indexed: 11/12/2022]
Abstract
Limited real-world evidence exists for effectiveness and safety of extended oral anticoagulation beyond 6 months of initial treatment in prevention of recurrent venous thromboembolism (VTE) and adverse major bleeding events among patients with VTE. Using MarketScan Commercial and Medicare Supplemental databases (2013-2019), we conducted a retrospective cohort study to compare the risk of recurrent VTE and major bleeding events during extended treatment among patients with VTE who completed the 6-month initial treatment and received extended oral anticoagulant treatment with apixaban, warfarin, or no extended treatment. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using Cox proportional hazards modeling with inverse probability treatment weighting. We identified 14,818 patients with extended treatment of apixaban (n = 4,338), warfarin (n = 5,298), or no extended treatment (n = 5,182). Compared with no extended treatment, apixaban use was associated with decreased risk of recurrent VTE (HR: 0.10, 95% CI: 0.04-0.26) without increased risk of major bleeding events (HR: 1.06, 95% CI: 0.52-2.17); warfarin use was associated with decreased risk of recurrent VTE (HR: 0.23, 95% CI: 0.12-0.44) but with increased risk of major bleeding events (HR: 2.64, 95% CI: 1.51-4.59). Compared with warfarin, apixaban use was associated with decreased risk of major bleeding events (HR: 0.42, 95% CI: 0.22-0.80) but no difference in risk of recurrent VTE (HR: 0.46, 95% CI: 0.15-1.36). In a real-world clinical setting, extended anticoagulation with apixaban or warfarin was associated with decreased risk of recurrent VTE compared with no extended treatment, and apixaban had a better safety profile with fewer major bleeding events compared with warfarin among commercially insured patients with VTE.
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Affiliation(s)
- Hye-Rim Kang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
| | - Christina E DeRemer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Eric A Dietrich
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Pei-Lin Huang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
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20
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Goldenberg NA, Kittelson JM, Abshire TC, Bonaca M, Casella JF, Dale RA, Halperin JL, Hamblin F, Kessler CM, Manco-Johnson MJ, Sidonio RF, Spyropoulos AC, Steg PG, Turpie AGG, Schulman S. Effect of Anticoagulant Therapy for 6 Weeks vs 3 Months on Recurrence and Bleeding Events in Patients Younger Than 21 Years of Age With Provoked Venous Thromboembolism: The Kids-DOTT Randomized Clinical Trial. JAMA 2022; 327:129-137. [PMID: 35015038 PMCID: PMC8753509 DOI: 10.1001/jama.2021.23182] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/08/2021] [Indexed: 12/11/2022]
Abstract
Importance Among patients younger than 21 years of age, the optimal duration of anticoagulant therapy for venous thromboembolism is unknown. Objective To test the hypothesis that a 6-week duration of anticoagulant therapy for provoked venous thromboembolism is noninferior to a conventional 3-month therapy duration in patients younger than 21 years of age. Design, Setting, and Participants Randomized clinical trial involving 417 patients younger than 21 years of age with acute, provoked venous thromboembolism enrolled at 42 centers in 5 countries from 2008-2021. The main exclusions were severe anticoagulant deficiencies or prior venous thromboembolism. Patients without persistent antiphospholipid antibodies and whose thrombi were resolved or not completely occlusive upon repeat imaging at 6 weeks after diagnosis underwent randomization. The final visit for the primary end points occurred in January 2021. Interventions Total duration for anticoagulant therapy of 6 weeks (n = 207) vs 3 months (n = 210) for provoked venous thromboembolism. Main Outcomes and Measures The primary efficacy and safety end points were centrally adjudicated symptomatic recurrent venous thromboembolism and clinically relevant bleeding events within 1 year blinded to treatment group. The primary analysis was noninferiority in the per-protocol population. The noninferiority boundary incorporated a bivariate trade-off that included an absolute increase of 0% in symptomatic recurrent venous thromboembolism with an absolute risk reduction of 4% in clinically relevant bleeding events (1 of 3 points on the bivariate noninferiority boundary curve). Results Among 417 randomized patients, 297 (median age, 8.3 [range, 0.04-20.9] years; 49% female) met criteria for the primary per-protocol population analysis. The Kaplan-Meier estimate for the 1-year cumulative incidence of the primary efficacy outcome was 0.66% (95% CI, 0%-1.95%) in the 6-week anticoagulant therapy group and 0.70% (95% CI, 0%-2.07%) in the 3-month anticoagulant therapy group, and for the primary safety outcome, the incidence was 0.65% (95% CI, 0%-1.91%) and 0.70% (95% CI, 0%-2.06%). Based on absolute risk differences in recurrent venous thromboembolism and clinically relevant bleeding events between groups, noninferiority was demonstrated. Adverse events occurred in 26% of patients in the 6-week anticoagulant therapy group and in 32% of patients in the 3-month anticoagulant therapy group; the most common adverse event was fever (1.9% and 3.4%, respectively). Conclusions and Relevance Among patients younger than 21 years of age with provoked venous thromboembolism, anticoagulant therapy for 6 weeks compared with 3 months met noninferiority criteria based on the trade-off between recurrent venous thromboembolism risk and bleeding risk. Trial Registration ClinicalTrials.gov Identifier: NCT00687882.
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Affiliation(s)
- Neil A. Goldenberg
- Institute for Clinical and Translational Research, Cancer and Blood Disorder Institute, and Heart Institute, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - John M. Kittelson
- Department of Biostatistics, School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
- CPC Clinical Research, Aurora, Colorado
| | - Thomas C. Abshire
- Versiti Blood Research Institute and Department of Pediatrics and Medicine and Clinical and Translational Science Institute, Medical College of Wisconsin, Milwaukee
| | - Marc Bonaca
- CPC Clinical Research, Aurora, Colorado
- Division of Cardiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - James F. Casella
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Jonathan L. Halperin
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Frances Hamblin
- Institute for Clinical and Translational Research, Cancer and Blood Disorder Institute, and Heart Institute, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Craig M. Kessler
- Lombardi Cancer Center, Department of Medicine, School of Medicine, Georgetown University, Washington, DC
| | - Marilyn J. Manco-Johnson
- Department of Pediatrics, School of Medicine, Children’s Hospital of Colorado, Hemophilia and Thrombosis Center, University of Colorado Anschutz Medical Campus, Aurora
| | - Robert F. Sidonio
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Alex C. Spyropoulos
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell and Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - P. Gabriel Steg
- Université de Paris, AP-HP, Hôpital Bichat, French Alliance for Cardiovascular Trials and INSERM 1148, Paris, France
| | - Alexander G. G. Turpie
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
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21
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Alexander P, Visagan S, Issa R, Gorantla VR, Thomas SE. Current Trends in the Duration of Anticoagulant Therapy for Venous Thromboembolism: A Systematic Review. Cureus 2021; 13:e18992. [PMID: 34853735 PMCID: PMC8608253 DOI: 10.7759/cureus.18992] [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] [Accepted: 10/23/2021] [Indexed: 01/15/2023] Open
Abstract
Anticoagulation therapy is the first line and drug of choice for both the treatment and prophylaxis of venous thromboembolism (deep vein thrombosis and/or pulmonary embolism). Anticoagulation drugs, ranging from different preparations of heparin, warfarin, and newer direct oral drugs such as rivaroxaban and dabigatran, work mainly by inhibiting important factors and enzymes in the coagulation cascade by preventing fibrin formation, platelet aggregation, and clot assembly. With recurrent thrombosis and embolisms being a feared complication for many physicians treating such cases, anticoagulation is often extended beyond the initial three- to six-month acute phase after an incident of venous thromboembolism. For some groups of patients, anticoagulation needs to be offered indefinitely to decrease the risk of a recurrent thrombosis. However, this concomitantly increases obvious and dangerous adverse effects such as increased risk of hemorrhage, as the ability to clot is hindered. This tradeoff between recurrent venous thromboembolism and bleeding is what underscores the controversy of the clinical question: for how long should anticoagulation be administered for venous thromboembolism? This review analyzes the use of anticoagulants in different types of venous thromboembolism and remarks on current consensus and trends on the length of anticoagulation treatment. We are doing so while acknowledging that venous thromboembolism management is an active area of research that is rapidly evolving. A literature search was performed looking at recent studies on anticoagulant administration for the treatment of venous thromboembolism with a focus on varying durations and patient populations. Factors that affect clinical decisions of duration are also elucidated. The most clinically relevant anticoagulants were discussed and their effects on the risk of recurrent thrombosis and embolism, and the risk of bleeding in relation to other drugs were analyzed. Ultimately, this article discussed patterns of anticoagulant treatments duration and which patient groups are likely to benefit the most from certain durations, shedding light on the ambiguity in how physicians should approach administering anticoagulation therapy over time for a broad range of presentations of venous thromboembolism.
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Affiliation(s)
- Peter Alexander
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Shakthi Visagan
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Reem Issa
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | | | - Sneha E Thomas
- Internal Medicine, University of Maryland Medical Center, Baltimore, USA
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22
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Outcomes of isolated distal thrombosis managed with serial compression ultrasonography. Thromb Res 2021; 208:66-70. [PMID: 34717132 DOI: 10.1016/j.thromres.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/27/2021] [Accepted: 10/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Isolated distal deep vein thrombosis (IDDVT) is a common subtype of deep vein thrombosis (DVT). Consensus guidelines provide conflicting recommendations for IDDVT management; some recommend anticoagulant treatment, while others suggest serial compression ultrasonography (CUS) monitoring for patients not at "high risk" of proximal extension. The purpose of this study was to describe outcomes of serial CUS-monitored IDDVT and identify risk factors for proximal thrombus extension or anticoagulant treatment initiation. METHODS A retrospective descriptive study was conducted using electronic data from University of Utah Health. Adult subjects with objectively confirmed, serial CUS-monitored IDDVT were included. Subjects were followed for 30 days for occurrence of a composite outcome of proximal thrombus extension or anticoagulant treatment initiation. Descriptive statistics were used to summarize characteristics of the study population. Characteristics were compared across outcome groups using inferential statistics. RESULTS A total of 182 subjects were included, with 53 subjects (29.1%) experiencing the composite outcome. Of these, 12 (22.6%) experienced proximal thrombus extension and 41 (77.4%) initiated anticoagulant treatment. A prior history of venous thromboembolism (VTE) was significantly higher in those who experienced the composite outcome than in those who did not. CONCLUSIONS Our results suggest that 70% of patients with serial CUS-monitored IDDVT did not experience thrombus extension or require anticoagulant treatment within 30 days of diagnosis, regardless of risk factors for proximal extension. Serial CUS monitoring may be a useful management strategy for IDDVT. A history of VTE may identify patients more likely to experience proximal thrombus extension or require anticoagulation.
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23
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Makedonov I, Galanaud JP, Kahn SR. Significance and management of isolated distal deep vein thrombosis. Curr Opin Hematol 2021; 28:331-338. [PMID: 34267078 DOI: 10.1097/moh.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Management of isolated distal deep vein thrombosis (IDDVT) remains controversial. We summarize recent studies regarding the natural history of IDDVT as well as pertinent therapeutic trials. We also provide our management approach. RECENT FINDINGS IDDVT is more commonly associated with transient risk factors and less often associated with permanent, unmodifiable risk factors than proximal DVT. IDDVT has a significantly lower risk of proximal extension and recurrence than proximal DVT. Cancer-associated IDDVT has a similar natural history to cancer-associated proximal DVT, with substantially less favourable outcomes than noncancer-associated IDDVT. Anticoagulant treatment reduces the risk of proximal extension and recurrence in IDDVT at the cost of increased bleeding risk. Intermediate dosing of anticoagulation may be effective for treating noncancer-associated IDDVT in patients without prior DVT. SUMMARY IDDVT with a transient risk factor can be treated for 6 weeks in patients without a prior DVT. Unprovoked IDDVT in patients without malignancy can be treated for 3 months. Outpatients without malignancy or a prior DVT can be left untreated and undergo surveillance compression ultrasound in one week to detect proximal extension, but few patients opt for this in practice. Cancer-associated IDDVT should be treated analogously to cancer-associated proximal DVT.
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Affiliation(s)
- Ilia Makedonov
- Department of Medicine, Division of General Internal Medicine, Sunnybrook Health Sciences Center
| | - Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - Susan R Kahn
- Center for Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute; Division of Internal Medicine, Department of Medicine, McGill University, Montreal, Québec, Canada
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24
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Management and Outcomes of Isolated Distal Deep Vein Thromboses: A Questionable Trend toward Long-Lasting Anticoagulation Treatment. Results from the START-Register. TH OPEN 2021; 5:e239-e250. [PMID: 34263110 PMCID: PMC8266420 DOI: 10.1055/s-0041-1730038] [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] [Received: 02/05/2021] [Accepted: 04/12/2021] [Indexed: 12/18/2022] Open
Abstract
Background
Isolated distal deep vein thromboses (IDDVT) are frequently diagnosed; however, their natural history and real risk of complications are still uncertain. Though treatment is still not well standardized, international guidelines recommend no more than 3 months of anticoagulation therapy. We investigated how Italian clinicians treat IDDVT patients in their real life in our country.
Methods
Baseline characteristics and clinical history of the patients enrolled in the prospective, observational, multicenter START-Register for a first IDDVT or proximal DVT (PDVT) were analyzed.
Results
Overall, 412 IDDVT patients were significantly younger, with better renal function, and more frequent major transient risk factors, when compared with 1,173 PDVT patients. The anticoagulation duration was >180 days in 52.7% of IDDVT patients (70.7% in PDVT). During treatment, bleeding occurred in 5.6 and 2.8% patient-years in IDDVT and PDVT, respectively (
p
= 0082). Bleeding was more frequent in IDDVT than PDVT patients treated with warfarin (6.8 vs. 3.2 patient-years,
p
= 0.0228, respectively). Thrombotic complications occurred in 1.1 and 2.4% patient-years in IDDVT and PDVT patients, respectively. Analyzing together the two groups, 66.1% of bleeds and 86.1% thrombotic complications occurred after 90 days anticoagulation treatment.
Conclusion
The large majority of IDDVT patients received anticoagulation for more than 3 months. Most bleeding and thrombotic complications occurred after the first 90 days of anticoagulation therapy. These results indicate that an extended anticoagulation beyond 90 days in IDDVT patients is associated with increased risk of complications. Whether an extended treatment may lower recurrences after anticoagulation withdrawal should be assessed by specifically designed studies.
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25
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Yamashita Y, Amano H, Morimoto T, Kadota K, Hata R, Matsushita K, Osakada K, Sano A, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Inoko M, Tada T, Chen PM, Murata K, Tsuyuki Y, Nishimoto Y, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Kato T, Ono K, Kimura T. Risk factors of thrombotic recurrence and major bleeding in patients with intermediate-risk for recurrence of venous thromboembolism. J Thromb Thrombolysis 2021; 53:182-190. [PMID: 34228248 DOI: 10.1007/s11239-021-02520-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 02/02/2023]
Abstract
Prolonged anticoagulation therapy is recommended for patients with intermediate-risk for recurrence of venous thromboembolism (VTE). The current study aimed to identify risk factors of VTE recurrence and major bleeding in intermediate-risk patients. The COMMAND VTE Registry is a multicenter registry enrolled consecutive 3027 patients with acute symptomatic VTE among 29 centers in Japan. The current study population consisted of 1703 patients with intermediate-risk for recurrence. The primary outcome measure was recurrent VTE during the entire follow-up period, and the secondary outcome measures were recurrent VTE and major bleeding during anticoagulation therapy. In the multivariable Cox regression model for recurrent VTE incorporating the status of anticoagulation therapy as a time-updated covariate, off-anticoagulation therapy was strongly associated with an increased risk for recurrent VTE (HR 9.42, 95% CI 5.97-14.86). During anticoagulation therapy, the independent risk factor for recurrent VTE was thrombophilia (HR 3.58, 95% CI 1.56-7.50), while the independent risk factors for major bleeding were age ≥ 75 years (HR 2.04, 95% CI 1.36-3.07), men (HR 1.52, 95% CI 1.02-2.27), history of major bleeding (HR 3.48, 95% CI 1.82-6.14) and thrombocytopenia (HR 3.73, 95% CI 2.04-6.37). Among VTE patients with intermediate-risk for recurrence, discontinuation of anticoagulation therapy was a very strong independent risk factor of recurrence during the entire follow-up period. The independent risk factors of recurrent VTE and those of major bleeding during anticoagulation therapy were different: thrombophilia for recurrent VTE, and advanced age, men, history of major bleeding, and thrombocytopenia for major bleeding. CLINICAL TRIAL REGISTRATION: Unique identifier: UMIN000021132. COMMAND VTE Registry: http://www.umin.ac.jp/ctr/index.htm .
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hidewo Amano
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Reo Hata
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazuki Matsushita
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kohei Osakada
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Arata Sano
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Moriaki Inoko
- Cardiovascular Center, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Faculty of Medicine, Kinki University, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
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Zhuang Y, Dai LF, Chen MQ. Efficacy and safety of non-vitamin K antagonist oral anticoagulants for venous thromboembolism: a meta-analysis. JRSM Open 2021; 12:20542704211010686. [PMID: 34178359 PMCID: PMC8207293 DOI: 10.1177/20542704211010686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective Several trials had compared the efficacy and safety between non-vitamin K antagonist oral anticoagulants and warfarin for acute venous thromboembolism, but the results were incomplete. This updated review comprehensively assessed the efficacy and safety of non-vitamin K antagonist oral anticoagulants for venous thromboembolism. Design Meta-analysis of randomised control trials. Six databases were searched from January 2000 to December 2018. Setting Adult patients had got non-vitamin K antagonist oral anticoagulants or warfarin for venous thromboembolism. Participants Randomised control trials that compared the efficacy and safety between non-vitamin K antagonist oral anticoagulants and warfarin. Main outcome measures The efficacy and safety of non-vitamin K antagonist oral anticoagulants . Results Seven studies involving 29,879 cases were included, among which 14,943 cases were assigned to non-vitamin K antagonist oral anticoagulants group and 14,936 cases to warfarin group. Meta-analysis showed that compared with warfarin, recurrent venous thromboembolism (odds ratio 0.94 [95% confidence interval 0.81 to 1.11]), death related to venous thromboembolism or fatal pulmonary embolism (odds ratio 1.00 [95% confidence interval 0.63 to 1.60]), symptomatic deep-vein thrombosis (odds ratio 0.88 [95% confidence interval 0.72 to 1.09]), symptomatic nonfatal pulmonary embolism (odds ratio 1.03 [(95% confidence interval 0.82 to 1.30]) and all deaths (odds ratio 0.92 [95% confidence interval 0.76 to 1.12]) are similar in non-vitamin K antagonist oral anticoagulants group, but major bleeding event (odds ratio 0.61 [95% confidence interval 0.50 to 0.75]) and clinically relevant non-major bleeding event (odds ratio [95% confidence interval 0.53 to 0.85]) are less in non-vitamin K antagonist oral anticoagulants group. . Conclusions For the treatment of venous thromboembolism, non-vitamin K antagonist oral anticoagulants is as effective as warfarin, and has a better safety profile than warfarin.
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Affiliation(s)
- Yan Zhuang
- Department of Critical Care Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029 China
| | - Lin-Feng Dai
- Department of Critical Care Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029 China
| | - Ming-Qi Chen
- Department of Critical Care Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029 China
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27
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Hodeib H, Youssef A, Allam AA, Selim A, Tawfik MA, Abosamak MF, Esam A, Abd Elghafar MS, Samir S, ELshora OA. Genetic Risk Profiling Associated with Recurrent Unprovoked Venous Thromboembolism. Genes (Basel) 2021; 12:874. [PMID: 34200207 PMCID: PMC8230078 DOI: 10.3390/genes12060874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and/or pulmonary embolism (PE), is a common, acute, multifactorial disease with a five-years cumulative incidence of recurrence of approximately 25%. Actually, no single genetic defect can predict the risk of recurrence of VTE. Therefore, individual genetic risk profiling could be useful for the prediction of VTE recurrence. AIM OF THE STUDY To assess the combined effect of the common prothrombotic genotypes on the risk of recurrence of VTE in recently diagnosed unprovoked VTE patients. PATIENTS AND METHODS This population based, prospective follow-up study was carried out from January 2015 to December 2020 in (internal medicine, cardiovascular medicine and anesthesia and ICU departments, Tanta University Hospital, Egypt) on 224 recently diagnosed unprovoked VTE patients. Whole blood was collected by standard venipuncture at the time of admission prior to the beginning of anticoagulant therapy. Genomic DNA was extracted and was genotyped for the 5-SNPs Genetic risk score (GRS), previously validated for first venous thrombosis (FVL rs6025, PTM rs1799963, ABO rs8176719, FGG rs2066865 and FXI rs2036914). RESULTS The main important finding in the present study was that patients having ≥3 risk alleles were associated with higher risk of VTE recurrence compared to those having ≤2 risk alleles (the reference group) (HR 2.5, 95% CI 1.48-4.21) (p = 0.001). Patients with GRS ≥ 3 had a significantly shorter time recurrence free survival (43.07 months) compared to the low risk group of patients with GRS (0-2) (p < 0.001). CONCLUSION GRS model could be an effective and useful model in risk stratification of VTE patients, and genetic risk profiling of VTE patients could be used for the prediction of recurrence of VTE.
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Affiliation(s)
- Hossam Hodeib
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (H.H.); (A.Y.); (O.A.E.)
| | - Amira Youssef
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (H.H.); (A.Y.); (O.A.E.)
| | - Alzahraa A. Allam
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (A.A.A.); (A.S.)
| | - Amal Selim
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (A.A.A.); (A.S.)
| | - Mohamed A. Tawfik
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (A.A.A.); (A.S.)
| | - Mohammed F. Abosamak
- Anesthesia/ICU Department, Faculty of Medicine, Tanta University Hospital, Tanta 31512, Egypt; (M.F.A.); (A.E.); (M.S.A.E.)
| | - Ahmed Esam
- Anesthesia/ICU Department, Faculty of Medicine, Tanta University Hospital, Tanta 31512, Egypt; (M.F.A.); (A.E.); (M.S.A.E.)
| | - Mohamed S. Abd Elghafar
- Anesthesia/ICU Department, Faculty of Medicine, Tanta University Hospital, Tanta 31512, Egypt; (M.F.A.); (A.E.); (M.S.A.E.)
| | - Sameh Samir
- Cardiovascular Medicine Department, Faculty of Medicine, Tanta University, Tanta 31511, Egypt;
| | - Ola A. ELshora
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (H.H.); (A.Y.); (O.A.E.)
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2116] [Impact Index Per Article: 705.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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de Moreuil C, Le Mao R, Le Moigne E, Pan-Petesch B, Tromeur C, Hoffmann C, Salaun PY, Nonent M, Danguy des Déserts M, Savary X, Guegan M, Poulhazan E, Leroyer C, Lacut K, Couturaud F. Long-term recurrence risk after a first venous thromboembolism in men and women under 50 years old: A French prospective cohort. Eur J Intern Med 2021; 84:24-31. [PMID: 33214024 DOI: 10.1016/j.ejim.2020.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/23/2020] [Accepted: 10/15/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Data on long-term venous thromboembolism (VTE) recurrence risk according to gender are conflicting. OBJECTIVE To evaluate long-term VTE recurrence risk after a first VTE in men and women under 50 years old. METHODS Since May 2000, 875 consecutive patients (315 men, 560 women) with a first symptomatic VTE under 50 years old were enrolled in a French prospective multicentre cohort study and were followed up as long as possible. The primary outcome was symptomatic recurrent VTE during follow-up. RESULTS At baseline, men were older and had more comorbidities than women. First VTE was mainly unprovoked in men (80.6%) and hormone-related in women (84.3%). During a median follow-up of 7.0 years (inter-quartile range, 5.0-11.0), recurrent VTE occurred in 97 men (30.8%) and in 72 women (12.9%) (annual incidence rates of recurrent VTE of 4.8% versus 1.8%-person-years, P<0.001). However, there was no difference according to gender in subgroups of patients with a first unprovoked VTE (5.8% versus 3.8%-person-years, P = 0.09). In women, duration of hormonal treatment before first VTE did not influence recurrence risk. In multivariable analysis, unprovoked VTE and family history of VTE were independently associated with recurrence (hazard ratio of 2.50 (95% confidence interval, 1.61 to 3.85) and 1.52 (1.11 to 2.09) respectively). LIMITATIONS Number of women with unprovoked VTE was low. CONCLUSIONS In patients with a first VTE under 50 years old, a first unprovoked episode and a family history of VTE, but not gender, were associated with a high risk of long-term recurrence.
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Affiliation(s)
- Claire de Moreuil
- Département de médecine vasculaire, médecine interne et pneumologie, CHU Brest, Univ Brest, Brest, France; EA3878, GETBO, Univ Brest, Brest, France
| | - Raphael Le Mao
- Département de médecine vasculaire, médecine interne et pneumologie, CHU Brest, Univ Brest, Brest, France; EA3878, GETBO, Univ Brest, Brest, France; CIC INSERM1412, CHU Brest, Univ Brest, Brest, France
| | - Emmanuelle Le Moigne
- Département de médecine vasculaire, médecine interne et pneumologie, CHU Brest, Univ Brest, Brest, France; EA3878, GETBO, Univ Brest, Brest, France
| | - Brigitte Pan-Petesch
- EA3878, GETBO, Univ Brest, Brest, France; Service d'hématologie, CHU Brest, Univ Brest, Brest, France
| | - Cécile Tromeur
- Département de médecine vasculaire, médecine interne et pneumologie, CHU Brest, Univ Brest, Brest, France; EA3878, GETBO, Univ Brest, Brest, France
| | - Clément Hoffmann
- Département de médecine vasculaire, médecine interne et pneumologie, CHU Brest, Univ Brest, Brest, France; EA3878, GETBO, Univ Brest, Brest, France
| | - Pierre-Yves Salaun
- EA3878, GETBO, Univ Brest, Brest, France; Service de médecine nucléaire, CHU Brest, Univ Brest, Brest, France
| | - Michel Nonent
- EA3878, GETBO, Univ Brest, Brest, France; Service de radiologie, CHU Brest, Univ Brest, Brest, France
| | - Marc Danguy des Déserts
- EA3878, GETBO, Univ Brest, Brest, France; Service d'anesthésie réanimation, HIA, Brest, France
| | - Xavier Savary
- Département de médecine vasculaire, médecine interne et pneumologie, CHU Brest, Univ Brest, Brest, France; EA3878, GETBO, Univ Brest, Brest, France
| | - Marie Guegan
- EA3878, GETBO, Univ Brest, Brest, France; CIC INSERM1412, CHU Brest, Univ Brest, Brest, France
| | | | - Christophe Leroyer
- Département de médecine vasculaire, médecine interne et pneumologie, CHU Brest, Univ Brest, Brest, France; EA3878, GETBO, Univ Brest, Brest, France; CIC INSERM1412, CHU Brest, Univ Brest, Brest, France
| | - Karine Lacut
- Département de médecine vasculaire, médecine interne et pneumologie, CHU Brest, Univ Brest, Brest, France; EA3878, GETBO, Univ Brest, Brest, France; CIC INSERM1412, CHU Brest, Univ Brest, Brest, France.
| | - Francis Couturaud
- Département de médecine vasculaire, médecine interne et pneumologie, CHU Brest, Univ Brest, Brest, France; EA3878, GETBO, Univ Brest, Brest, France; CIC INSERM1412, CHU Brest, Univ Brest, Brest, France
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Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2020; 61:9-82. [PMID: 33334670 DOI: 10.1016/j.ejvs.2020.09.023] [Citation(s) in RCA: 298] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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31
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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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Mortality risk associated with venous thromboembolism: a systematic review and Bayesian meta-analysis. LANCET HAEMATOLOGY 2020; 7:e583-e593. [PMID: 32735837 DOI: 10.1016/s2352-3026(20)30211-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Venous thromboembolism is associated with increased mortality risk in some populations, but how frequently it is a direct cause of death is unclear. We used data from venous thromboembolism prevention trials to evaluate the causal effect of venous thromboembolism reduction on mortality. METHODS We did a systematic review and meta-analysis of randomised controlled trials (RCTs) evaluating venous thromboembolism prevention. We searched MEDLINE, Embase, PubMed, and Web of Science starting from Jan 1, 1993, to March 19, 2018. We included studies of patients who were at elevated risk of venous thromboembolism and were randomly assigned to either anticoagulant or antiplatelet therapy versus placebo or no treatment. We excluded studies with an active control agent (which might mitigate the lethality of venous thromboembolism) and those for which mortality data were unavailable. We modelled heterogeneity in a Bayesian framework, taking overall mortality as a primary endpoint, and pulmonary embolism, fatal pulmonary embolism, and major bleeding as secondary endpoints. We focused our analyses on studies reporting statistically significant effects of prevention on venous thromboembolism endpoints. We report treatment effects as median risk ratios (RRs), wherein a null effect equals 1, with 95% credible intervals (CrIs). This meta-analysis was registered with PROSPERO, CRD42018089697. FINDINGS From 4229 studies screened, we identified 86 eligible RCTs; 52, with data from over 70 000 patients, were positive, with significantly increased venous thromboembolism risk in patients in control groups versus treatment groups (RR 2·74, 95% CrI 2·32-3·31, p<0·0001). The meta-analysis established that the causal effect of venous thromboembolism prevention on mortality was null (control group mortality was 3391 [9·8%] of 34 537 patients; treatment group mortality was 3498 [9·8%] of 35 795 patients [RR 1·01, 95% CrI 0·97-1·06; p=0·58]) with low heterogeneity (τ 0·02, 95% CrI 0·00-0·07, p=0·89). Patients in control groups had more pulmonary embolism (RR 2·22, 95% CrI 1·78-2·89, p<0·0001) and fatal pulmonary embolism (1·58, 1·14-2·19, p=0·01), but less major bleeding (0·60, 0·47-0·75, p<0·0001) than those in treatment groups. A meta-analysis with the additional 34 negative studies yielded similar results for all endpoints except fatal pulmonary embolism, where evidence of an effect was weaker (1·42, 1·05-1·91, p=0·02). INTERPRETATION The perception that venous thromboembolism is a common cause of mortality should be revised considering the null effect of venous thromboembolism prevention on mortality. Our findings call into question the use of composite endpoints in venous thromboembolism-prevention trials and provide rationale for de-escalation trials. FUNDING None.
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Torii Y, Kusunose K, Zheng R, Yamada H, Amano R, Matsumoto R, Hirata Y, Nishio S, Yamada N, Ise T, Yamaguchi K, Tobiume T, Fukuda D, Yagi S, Soeki T, Wakatsuki T, Okayama Y, Sata M. Association between Sarcopenia/Lower Muscle Mass and Short-Term Regression of Deep Vein Thrombosis Using Direct Oral Anticoagulants. Int Heart J 2020; 61:787-794. [PMID: 32684602 DOI: 10.1536/ihj.20-032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Advanced age, obesity, and muscle weakness are independent factors in the onset of deep vein thrombosis (DVT). Recently, an association between sarcopenia and DVT has been reported. We hypothesized that sarcopenia related factors, observed by ultrasonography, are associated with the regression effect on the thrombus following anticoagulation therapy. The present study focused on gastrocnemius muscle (GCM) thickness and the GCM's internal echogenic brightness. We examined the association with DVT regression following direct oral anticoagulants (DOACs) treatment.The prospective cohort study period was between October 2017 and August 2018. We enrolled 46 patients diagnosed with DVT by ultrasonography, who were aged >60 years old and treated with DOACs. Sarcopenia was evaluated using the Asian Working Group for Sarcopenia flowchart. The average DOACs treatment period was 94 days, and 29 patients exhibited thrombus regression. On univariate logistic regression analysis, sarcopenia, average GCM diameter index, and gastrocnemius integrated backscatter index were significantly associated with thrombus regression. In a multivariate model, only the average GCM diameter index correlated with thrombus regression.The average GCM diameter index is associated with DVT regression treated with DOACs. Considering the GCM diameter during DVT treatment can be a marker to make a decision for the treatment of DVT.
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Affiliation(s)
- Yuta Torii
- Ultrasound Examination Center, Tokushima University Hospital
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Robert Zheng
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Hirotsugu Yamada
- Department of Community Medicine for Cardiology, Tokushima University Graduate School of Biomedical Sciences
| | - Rie Amano
- Ultrasound Examination Center, Tokushima University Hospital
| | | | - Yukina Hirata
- Ultrasound Examination Center, Tokushima University Hospital
| | - Susumu Nishio
- Ultrasound Examination Center, Tokushima University Hospital
| | - Nao Yamada
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Takeshi Tobiume
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Takeshi Soeki
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Tetsuzo Wakatsuki
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Yoshihiro Okayama
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital
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Becattini C, Cimini LA. Long term use of anticoagulant therapy for patients with pulmonary embolism. Expert Rev Hematol 2020; 13:709-718. [DOI: 10.1080/17474086.2020.1770589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
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35
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Notten P, van Laanen JHH, Eijgenraam P, de Wolf MAF, Kurstjens RLM, ten Cate H, ten Cate‐Hoek AJ. Quality of anticoagulant therapy and the incidence of in-stent thrombosis after venous stenting. Res Pract Thromb Haemost 2020; 4:594-603. [PMID: 32548558 PMCID: PMC7292674 DOI: 10.1002/rth2.12330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/08/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In patients with a venous outflow obstruction following iliofemoral deep vein thrombosis stenting of the venous tract to prevent or alleviate postthrombotic syndrome is applied with increasing frequency. The impact of the quality of anticoagulant therapy with vitamin K antagonists (VKAs) on the development of in-stent thrombosis is currently unknown. OBJECTIVES To determine the association between the quality of postinterventional VKA treatment and the occurrence of in-stent thrombosis. METHODS Seventy-nine patients with iliofemoral and/or caval venous stent placement for obstruction of the venous outflow were included in this study. All patients received postinterventional VKA. The quality of VKA anticoagulant therapy was expressed as the time within therapeutic range (TTR) calculated using the linear interpolation method and as the proportion of International Normalized Ratio (INR) values < 2.0. In-stent thrombosis was assessed by the use of duplex ultrasound. Survival analysis (Kaplan-Meier curves, Cox regression) was used to analyze the data. RESULTS In-stent thrombosis developed in 16 patients (20.3%). The total population had a mean TTR of 64.0% (±19.0) and a mean proportion of INR values < 2.0 of 11.6% (±12.0). Overall, a TTR < 49.9% was associated with an increased risk of in-stent thrombosis. The multivariable adjusted analysis showed a hazard ratio (HR) of 0.96 (95% confidence interval [CI], 0.92-0.99; P = .02) per 1% increase in TTR. The proportion of INR values < 2.0 had no significant association with the occurrence of in-stent thrombosis: HR 0.98 (95% CI, 0.91-1.06; P = .66). CONCLUSIONS We conclude that the quality of anticoagulant treatment reflected in the TTR following a venous stenting procedure is an important independent determinant for the risk of in-stent thrombosis. The role of anticoagulant treatment for the prevention of in-stent thrombosis following stenting procedures therefore merits further research.
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Affiliation(s)
- Pascale Notten
- Department of Vascular SurgeryMaastricht University Medical CentreMaastrichtthe Netherlands
- CARIMSchool for Cardiovascular DiseasesCardiovascular Research Institute MaastrichtMaastricht University Medical CentreMaastrichtthe Netherlands
| | | | - Pieter Eijgenraam
- Laboratory for Clinical Thrombosis and HemostasisMaastricht UniversityMaastrichtthe Netherlands
| | - Mark A. F. de Wolf
- Department of Vascular SurgeryMaastricht University Medical CentreMaastrichtthe Netherlands
- CARIMSchool for Cardiovascular DiseasesCardiovascular Research Institute MaastrichtMaastricht University Medical CentreMaastrichtthe Netherlands
- Department of RadiologyMaasstad HospitalRotterdamthe Netherlands
- Department of RadiologyErasmus Medical CentreRotterdamthe Netherlands
| | - Ralph L. M. Kurstjens
- Department of Vascular SurgeryMaastricht University Medical CentreMaastrichtthe Netherlands
- CARIMSchool for Cardiovascular DiseasesCardiovascular Research Institute MaastrichtMaastricht University Medical CentreMaastrichtthe Netherlands
- Department of Obstetrics and GynaecologyLeiden University Medical CentreLeidenthe Netherlands
| | - Hugo ten Cate
- CARIMSchool for Cardiovascular DiseasesCardiovascular Research Institute MaastrichtMaastricht University Medical CentreMaastrichtthe Netherlands
- Laboratory for Clinical Thrombosis and HemostasisMaastricht UniversityMaastrichtthe Netherlands
- Heart + Vascular Centre and Thrombosis Expertise CentreMaastricht University Medical CentreMaastrichtthe Netherlands
| | - Arina J. ten Cate‐Hoek
- CARIMSchool for Cardiovascular DiseasesCardiovascular Research Institute MaastrichtMaastricht University Medical CentreMaastrichtthe Netherlands
- Laboratory for Clinical Thrombosis and HemostasisMaastricht UniversityMaastrichtthe Netherlands
- Heart + Vascular Centre and Thrombosis Expertise CentreMaastricht University Medical CentreMaastrichtthe Netherlands
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Albertsen IE, Piazza G, Søgaard M, Nielsen PB, Larsen TB. Extended oral anticoagulation after incident venous thromboembolism – a paradigm shift? Expert Rev Cardiovasc Ther 2020; 18:201-208. [DOI: 10.1080/14779072.2020.1755260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Ida Ehlers Albertsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, USA
| | - Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Torben Bjerregaard Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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Abstract
BACKGROUND The treatment of distal (below the knee) deep vein thrombosis (DVT) is not clearly established. Distal DVT can either be treated with anticoagulation, or monitored with close follow-up to detect progression to the proximal veins (above the knee), which requires anticoagulation. Proponents of this monitoring strategy base their decision to withhold anticoagulation on the fact that progression is rare and most people can be spared from potential bleeding and other adverse effects of anticoagulation. OBJECTIVES To assess the effects of different treatment interventions for people with distal (below the knee) deep vein thrombosis (DVT). SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 12 February 2019. We also undertook reference checking to identify additional studies. SELECTION CRITERIA Randomised controlled trials (RCTs) for the treatment of distal DVT. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials and extracted data. We resolved disagreements by discussion. Primary outcomes of interest were recurrence of venous thromboembolism (VTE), DVT and major bleeding and follow up ranged from three months to two years. We performed fixed-effect model meta-analyses with risk ratio (RRs) and 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE. MAIN RESULTS We identified eight RCTs reporting on 1239 participants. Five trials randomised participants to anticoagulation for up to three months versus no anticoagulation. Three trials compared anticoagulation treatment for different time periods. Anticoagulant compared to no intervention or placebo for distal DVT treatment Anticoagulation with a vitamin K antagonist (VKA) reduced the risk of recurrent VTE during follow-up compared with participants receiving no anticoagulation (RR 0.34, 95% CI 0.15 to 0.77; 5 studies, 496 participants; I2 = 3%; high-certainty evidence), and reduced the risk of recurrence of DVT (RR 0.25, 95% CI 0.10 to 0.67; 5 studies, 496 participants; I2 = 0%; high-certainty evidence). There was no clear effect on risk of pulmonary embolism (PE) (RR 0.81, 95% CI 0.18 to 3.59; 4 studies, 480 participants; I2 = 0%; low-certainty evidence). There was little to no difference in major bleeding with anticoagulation compared to placebo (RR 0.76, 95% CI 0.13 to 4.62; 4 studies, 480 participants; I2 = 26%; low-certainty evidence). There was an increase in clinically relevant non-major bleeding events in the group treated with anticoagulants (RR 3.34, 95% CI 1.07 to 10.46; 2 studies, 322 participants; I2 = 0%; high-certainty evidence). There was one death, not related to PE or major bleeding, in the anticoagulation group. Anticoagulation for three months or more compared to anticoagulation for six weeks for distal DVT treatment Three RCTs of 736 participants compared three or more months of anticoagulation with six weeks of anticoagulation. Anticoagulation with a VKA for three months or more reduced the incidence of recurrent VTE to 5.8% compared with 13.9% in participants treated for six weeks (RR 0.42, 95% CI 0.26 to 0.68; 3 studies, 736 participants; I2 = 50%; high-certainty evidence). The risk for recurrence of DVT was also reduced (RR 0.32, 95% CI 0.16 to 0.64; 2 studies, 389 participants; I2 = 48%; high-certainty evidence), but there was probably little or no difference in PE (RR 1.05, 95% CI 0.19 to 5.88; 2 studies, 389 participants; I2 = 0%; low-certainty evidence). There was no clear difference in major bleeding events (RR 3.42, 95% CI 0.36 to 32.35; 2 studies, 389 participants; I2 = 0%; low-certainty evidence) or clinically relevant non-major bleeding events (RR 1.76, 95% CI 0.90 to 3.42; 2 studies, 389 participants; I2 = 1%; low-certainty evidence) between three months or more of treatment and six weeks of treatment. There were no reports for overall mortality or PE and major bleeding-related deaths. AUTHORS' CONCLUSIONS Our review found a benefit for people with distal DVT treated with anticoagulation therapy using VKA with little or no difference in major bleeding events although there was an increase in clinically relevant non-major bleeding when compared to no intervention or placebo. The small number of participants in this meta-analysis and strength of evidence prompts a call for more research regarding the treatment of distal DVT. RCTs comparing different treatments and different treatment periods with placebo or compression therapy, are required.
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Affiliation(s)
- George Kirkilesis
- University of Patras Medical SchoolDepartment of Vascular SurgeryHippocrates Ave, RioPatrasAchaiaGreece26504
| | - Stavros K Kakkos
- University of Patras Medical SchoolDepartment of Vascular SurgeryHippocrates Ave, RioPatrasAchaiaGreece26504
| | - Colin Bicknell
- Imperial College LondonDepartment of Vascular SurgeryLondonUK
| | - Safa Salim
- Imperial College Healthcare NHS TrustTransplant DepartmentLondonUK
| | - Kyriaki Kakavia
- National and Kapodistrian University of AthensDepartment of Surgery, Laiko HospitalAthensGreece
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Hirsh J, Eikelboom JW, Chan NC. Fifty years of research on antithrombotic therapy: Achievements and disappointments. Eur J Intern Med 2019; 70:1-7. [PMID: 31679885 DOI: 10.1016/j.ejim.2019.10.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/17/2019] [Indexed: 11/18/2022]
Abstract
The achievements with antithrombotic therapy over the past 50 years have been monumental and the disappointments relatively few. In this review, we will discuss, chronologically, the major developments of the two recognized classes of antithrombotics - anticoagulants and antiplatelet agents.
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Affiliation(s)
- Jack Hirsh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Noel C Chan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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Couturaud F, Girard P, Laporte S, Sanchez O. [What duration of anticoagulant treatment for PE/proximal DVT?]. Rev Mal Respir 2019; 38 Suppl 1:e99-e112. [PMID: 31711819 DOI: 10.1016/j.rmr.2019.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- F Couturaud
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; EA3878-GETBO, CIC Inserm1412, département de médecine interne et pneumologie, centre hospitalo-universitaire de Brest, université de Bretagne occidentale, 29200 Brest, France
| | - P Girard
- Institut du thorax-Curie-Montsouris, l'institut mutualiste Montsouris, 75014 Paris, France
| | - S Laporte
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; SAINBOIS U1059 équipe DVH, Unité de recherche clinique, Inserm, innovation, pharmacologie, CHU de Saint-Étienne, université Jean-Monnet, université de Lyon, hôpital du Nord, 42000 Saint-Étienne, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Service de pneumologie et soins intensifs, université de Paris, AH-HP, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Innovations thérapeutiques en hémostase, Inserm UMRS 1140, 75006 Paris, France.
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Four-factor Prothrombin Complex Concentrate for the Management of Patients Receiving Direct Oral Activated Factor X Inhibitors. Anesthesiology 2019; 131:1153-1165. [DOI: 10.1097/aln.0000000000002910] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Factor Xa inhibitors prevent thrombosis but are associated with severe or life-threatening bleeding. Here, the authors present data on four-factor prothrombin complex concentrates in management of anticoagulation-associated bleeding and restoring hemostasis, including recent results from the UPRATE study.
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Quéré I, Galanaud JP, Sanchez O. [What is the management of sub-popliteal deep venous thrombosis?]. Rev Mal Respir 2019; 38 Suppl 1:e164-e170. [PMID: 31611025 DOI: 10.1016/j.rmr.2019.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- I Quéré
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Département de médecine vasculaire, centre de référence des maladies vasculaires rares, EA2992, université de Montpellier, CHU Montpellier, hôpital Saint-Éloi, 34295 Montpellier cedex 5, France
| | - J P Galanaud
- Département de médecine vasculaire, centre de référence des maladies vasculaires rares, EA2992, université de Montpellier, CHU Montpellier, hôpital Saint-Éloi, 34295 Montpellier cedex 5, France; Department of medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - O Sanchez
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Inserm UMRS 1140, service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, Assistance publique des Hôpitaux de Paris, université Paris Descartes, Sorbonne Paris cité, 75015 Paris, France; Service de pneumologie et soins intensifs, université de Paris, AH-HP, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Innovations thérapeutiques en hémostase, Inserm UMRS 1140, 75006 Paris, France.
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Áinle FN, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Respir J 2019; 54:13993003.01647-2019. [DOI: 10.1183/13993003.01647-2019] [Citation(s) in RCA: 509] [Impact Index Per Article: 101.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Hwang HG, Choi WI, Lee B, Lee CW. Incidence and Risk Factors of Recurrent Venous Thromboembolism after Pulmonary Embolism. Tuberc Respir Dis (Seoul) 2019; 82:341-347. [PMID: 31172708 PMCID: PMC6778736 DOI: 10.4046/trd.2019.0019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/21/2019] [Accepted: 05/17/2019] [Indexed: 11/24/2022] Open
Abstract
Background Information about the epidemiology of venous thromboembolism (VTE) recurrence in Korea is lacking. The purpose of this study was to investigate VTE cumulative recurrence rates and identify risk factors for VTE recurrence among Korean adults. Methods A retrospective cohort study was conducted on adult patients (≥18 years) admitted to a university teaching hospital for pulmonary embolism (PE) from 2005 to 2013. The main outcome of interest was a recurrence of VTE. We used Cox proportional hazard regression analyses to calculate the relative risk of VTE recurrence. Results Five-year cumulative incidence of recurrent VTE events was 21.5% (95% confidence interval [CI], 17.7–25.4) in all cases of PE; 17% after provoked and 27% after unprovoked PE. Multivariate analysis showed that body mass index (BMI) of ≥25 (hazard ratio [HR], 2.02; 95% CI, 1.17–3.46; p=0.01) and longer anticoagulation therapy duration (HR, 0.90; 95% CI, 0.84–0.96; p<0.01) were independently associated with risk of VTE recurrence. Risk factors not found to be statistically significant at the <0.05 level included history of VTE (HR, 1.81; 95% CI, 0.84–3.88; p=0.12), unprovoked PE (HR, 1.70; 95% CI, 0.89–3.25; p=0.10), symptomatic deep vein thrombosis (HR, 1.62; 95% CI, 0.89–2.94; p=0.10), and female sex (HR, 1.42; 95% CI, 0.78–2.55; p=0.24). We found that age, history of cancer, and other co-morbidities did not significantly affect the risk of VTE recurrence. Conclusion Recurrence of VTE after PE is high. Patients with BMI ≥25 or reduced anticoagulation therapy duration have a higher risk of recurrent VTE.
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Affiliation(s)
- Hun Gyu Hwang
- Respiratory Division, Department of Internal Medicine, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Won Il Choi
- Department of Medicine, Keimyung University Dongsan Hospital, Daegu, Korea.
| | - Bora Lee
- Department of Biostatistic Consulting, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Choong Won Lee
- Department of Occupational and Environmental Medicine, Sungso Hospital, Andong, Korea
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Renczes J, Lindhoff-Last E. [Modern treatment of deep vein thrombosis and pulmonary embolism]. Internist (Berl) 2019; 60:644-655. [PMID: 31119310 DOI: 10.1007/s00108-019-0609-4] [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: 10/26/2022]
Abstract
Virchow's triad has been known for a 100 years. The development of therapeutic possibilities during this time was enormous. Today anticoagulant therapy is much more differentiated. Four new oral substances have replaced the traditional treatment with vitamin K antagonists in angiology. A standardized dosage is available. The monitoring of the coagulation parameters is no longer necessary, but it is important to monitor renal function. Direct oral anticoagulants are approved for the treatment of venous thrombosis and pulmonary embolism, but not during pregnancy or in children. Severe bleeding complications, especially intracerebral bleeding, are less common. The incidence of venous thromboembolism is still high. Obesity and cancer are of particular importance. The "therapeutic pact" with the patient requires that physicians master the art of "talking medicine".
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Affiliation(s)
- J Renczes
- Innere Medizin, Angiologie und Hämostaseologie, Cardioangiologisches Centrum Bethanien (CCB), Im Prüfling 23, 60389, Frankfurt am Main, Deutschland.
| | - E Lindhoff-Last
- Innere Medizin, Angiologie und Hämostaseologie, Cardioangiologisches Centrum Bethanien (CCB), Im Prüfling 23, 60389, Frankfurt am Main, Deutschland
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Abstract
Venous thromboembolism (VTE), referring to both deep vein thrombosis and pulmonary embolism, is a leading cause of death in the developed world during pregnancy. This increased risk is attributed to the Virchow triad, inherited thrombophilias, along with other standard risk factors, and continues for up to 6 to 12 weeks postpartum. During the peripartum period, women should be risk stratified and preventive measures should be initiated based on their risk. Diagnostic tests and treatment strategies commonly used in VTE differ in pregnancy. An understanding of these differences is imperative to diagnose with confidence and to treat appropriately.
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Affiliation(s)
- Christopher Deeb Dado
- Pulmonary and Critical Care Fellowship, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Andrew Tobias Levinson
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, 164 Summit Avenue, Providence, RI 02904, USA
| | - Ghada Bourjeily
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, 146 West River Street, Suite 11C, Providence, RI 02904, USA.
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Quéré I, Elias A, Maufus M, Elias M, Sevestre MA, Galanaud JP, Bosson JL, Bura-Rivière A, Jurus C, Lacroix P, Zuily S, Diard A, Wahl D, Bertoletti L, Brisot D, Frappe P, Gillet JL, Ouvry P, Pernod G. [Unresolved questions on venous thromboembolic disease. Consensus statement of the French Society for Vascular Medicine (SFMV)]. JOURNAL DE MÉDECINE VASCULAIRE 2019; 44:e1-e47. [PMID: 30770089 DOI: 10.1016/j.jdmv.2018.12.178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- I Quéré
- Service de médecine vasculaire, CHU Montpellier, 80, avenue Augustun-Fliche, 34090 Montpellier, France
| | - A Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M Maufus
- Service de médecine vasculaire, CH Pierre Oudot, 38300 Bourgoin-Jallieu, France
| | - M Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M-A Sevestre
- Service de médecine vasculaire, CHU Amiens-Picardie, Avenue Laennec, 80054 Amiens cedex 1, France
| | - J-P Galanaud
- Département de médecine, Sunnybrook Health Sciences Centre, université de Toronto, Toronto, Canada
| | - J-L Bosson
- Département de biostatistiques, CHU Grenoble-Alpes, 38043 Grenoble, France
| | - A Bura-Rivière
- Service de médecine vasculaire, CHU Rangueil, 31059 Toulouse cedex 9, France
| | - C Jurus
- Service de médecine vasculaire, clinique du Tonkin, 69100 Villeurbanne, France
| | - P Lacroix
- Service de médecine vasculaire, Hôpital Dupuytren, CHU Limoges, 87042 Limoges cedex, France
| | - S Zuily
- Service de médecine vasculaire, Hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-Les-Nancy cedex, France
| | - A Diard
- Médecine vasculaire, 25, route de Créon, 33550 Langoiran, France
| | - D Wahl
- Service de médecine vasculaire, Hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-Les-Nancy cedex, France
| | - L Bertoletti
- Service de médecine vasculaire et thérapeutique, Hôpital Nord, CHU St-Étienne, 42, avenue Albert Raimond, 42270 Saint-Priest-en-Jarez, France
| | - D Brisot
- Médecine vasculaire, 34830 Clapiers, France
| | - P Frappe
- Département de médecine générale, université Jean-Monnet, 42000 St-Étienne, France
| | - J-L Gillet
- Médecine vasculaire, 38300 Bourgoin-Jallieu, France
| | - P Ouvry
- Médecine vasculaire, 1328, avenue de la Maison Blanche, 76550 Saint-Aubin-sur-Scie, France
| | - G Pernod
- Service de médecine vasculaire, CHU Grenoble-Alpes, 38043 Grenoble, France.
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Quéré I, Elias A, Maufus M, Elias M, Sevestre MA, Galanaud JP, Bosson JL, Bura-Rivière A, Jurus C, Lacroix P, Zuily S, Diard A, Wahl D, Bertoletti L, Brisot D, Frappe P, Gillet JL, Ouvry P, Pernod G. Unresolved questions on venous thromboembolic disease. Consensus statement of the French Society for Vascular Medicine (SFMV). JOURNAL DE MEDECINE VASCULAIRE 2019; 44:28-70. [PMID: 30770082 DOI: 10.1016/j.jdmv.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/01/2018] [Indexed: 06/09/2023]
Affiliation(s)
- I Quéré
- Service de médecine vasculaire, CHU Montpellier, 80, avenue Augustun-Fliche, 34090 Montpellier, France
| | - A Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M Maufus
- Service de médecine vasculaire, CH Pierre Oudot, 38300 Bourgoin-Jallieu, France
| | - M Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M-A Sevestre
- Service de médecine vasculaire, CHU Amiens Picardie, avenue Laennec, 80054 Amiens cedex 1, France
| | - J-P Galanaud
- Département de médecine, Sunnybrook Health Sciences Centre, université de Toronto, Toronto, Canada
| | - J-L Bosson
- Département de biostatistiques, CHU Grenoble-Alpes, 38700 La Tronche, France
| | - A Bura-Rivière
- Service de médecine vasculaire, CHU Rangueil, 31059 Toulouse cedex 9, France
| | - C Jurus
- Service de médecine vasculaire, clinique du Tonkin, 69100 Villeurbanne, France
| | - P Lacroix
- Service de médecine vasculaire, hôpital Dupuytren, CHU Limoges, 87042 Limoges cedex, France
| | - S Zuily
- Service de médecine vasculaire, hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-les-Nancy cedex, France
| | - A Diard
- Médecine vasculaire, 25, route de Créon, 33550 Langoiran, France
| | - D Wahl
- Service de médecine vasculaire, hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-les-Nancy cedex, France
| | - L Bertoletti
- Service de médecine vasculaire et thérapeutique, hôpital Nord, CHU St.-Étienne, 42, avenue Albert-Raimond, 42270 Saint-Priest-en-Jarez, France
| | - D Brisot
- Médecine vasculaire, 34830 Clapiers, France
| | - P Frappe
- Département de médecine générale, université Jean-Monnet, 42000 St.-Étienne, France
| | - J-L Gillet
- Médecine vasculaire, 1328, avenue Maison-Blanche, 38300 Bourgoin-Jallieu, France
| | - P Ouvry
- Médecine vasculaire, 1328, avenue Maison-Blanche, 76550 Saint-Aubin-sur-Scie, France
| | - G Pernod
- Service de médecine vasculaire, CHU Grenoble-Alpes, avenue Maquis-du-Grésivaudan, 38043 Grenoble, France.
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Schnegg‐Kaufmann A, Calzavarini S, Limacher A, Mean M, Righini M, Staub D, Beer J, Frauchiger B, Osterwalder J, Kucher N, Matter CM, Husmann M, Banyai M, Aschwanden M, Mazzolai L, Hugli O, Nagler M, Daskalakis M, Rodondi N, Aujesky D, Angelillo‐Scherrer A. A high Gas6 level in plasma predicts venous thromboembolism recurrence, major bleeding and mortality in the elderly: a prospective multicenter cohort study. J Thromb Haemost 2019; 17:306-318. [PMID: 30570809 PMCID: PMC6850608 DOI: 10.1111/jth.14365] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Indexed: 12/29/2022]
Abstract
Essentials Predictive ability of pro-hemostatic Gas6 for recurrent venous thromboembolism (VTE) is unknown. We measured Gas6 levels in 864 patients with VTE over 3 years. High Gas6 (> 157%) at diagnosis is associated with VTE recurrence, major bleeding and mortality. Gas6 plasma levels measured 12 months after the index VTE are discriminatory for VTE recurrence. SUMMARY: Background Growth arrest-specific gene 6 (Gas6) is a prohemostatic protein with an unknown predictive ability for recurrent venous thromboembolism (VTE). In the elderly, VTE results in higher mortality but does not have a higher rate of recurrence than in younger patients. Consequently, anticoagulation management in the elderly is challenging. Objective To prospectively investigate the performance of Gas6 in predicting VTE recurrence, major bleeding and mortality in the elderly. Methods Consecutive patients aged ≥ 65 years with acute VTE were followed for a period of 3 years. Primary outcomes were symptomatic VTE recurrence, major bleeding, and mortality. Plasma Gas6 was measured with ELISA. Results Gas6 levels were measured in 864 patients at the time of the index VTE (T1) and, in 70% of them, also 12 months later (T2). The Gas6 level at T1 was discriminatory for VTE recurrence (C-statistic, 0.56; 95% confidence interval [CI] 0.51-0.62), major bleeding (0.60, 95% CI 0.55-0.65) and mortality (0.69, 95% CI 0.65-0.73) up to 36 months. VTE recurrence up to 24 months after T2 was discriminated by the Gas6 level at T2 (0.62, 95% CI 0.54-0.71). High Gas6 levels (> 157%) and continuous Gas6 levels at T1 were associated with VTE recurrence up to 6 months and 12 months, respectively. Conclusions In elderly patients, a high Gas6 level is associated with higher risks of VTE recurrence, major bleeding, and death. These findings support further studies to assess the performance of Gas6 in adjusting the length of anticoagulation.
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Affiliation(s)
- Annatina Schnegg‐Kaufmann
- Department of Hematology and Central Hematology Laboratory, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Sara Calzavarini
- Department of Hematology and Central Hematology Laboratory, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Andreas Limacher
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Marie Mean
- Department of General Internal Medicine, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department of MedicineLausanne University HospitalLausanneSwitzerland
| | - Marc Righini
- Division of Angiology and HemostasisGeneva University HospitalGenevaSwitzerland
| | - Daniel Staub
- Division of AngiologyBasel University HospitalBaselSwitzerland
| | - Juerg‐Hans Beer
- Department of Internal MedicineCantonal Hospital of BadenBadenSwitzerland
| | - Beat Frauchiger
- Department of Internal MedicineCantonal Hospital of FrauenfeldFrauenfeldSwitzerland
| | | | - Nils Kucher
- University Clinic of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Christian M. Matter
- Center for Molecular CardiologyUniversity of Zurich, and Clinic for CardiologyUniversity Heart CenterZurich University HospitalZurichSwitzerland
| | - Marc Husmann
- University Clinic of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Martin Banyai
- Division of AngiologyCantonal Hospital of LucerneLucerneSwitzerland
| | | | - Lucia Mazzolai
- Service of AngiologyLausanne University HospitalLausanneSwitzerland
| | - Oliver Hugli
- Emergency DepartmentLausanne University HospitalLausanneSwitzerland
| | - Michael Nagler
- Department of Hematology and Central Hematology Laboratory, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Michael Daskalakis
- Department of Hematology and Central Hematology Laboratory, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernBernSwitzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, InselspitalBern University HospitalUniversity of BernBernSwitzerland
| | - Anne Angelillo‐Scherrer
- Department of Hematology and Central Hematology Laboratory, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
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Couturaud F, Pernod G, Presles E, Duhamel E, Jego P, Provost K, Pan-Petesch B, Sollier CBD, Tromeur C, Hoffmann C, Bressollette L, Lorillon P, Girard P, Le Moigne E, Le Hir A, Guégan M, Laporte S, Mismetti P, Lacut K, Bosson JL, Bertoletti L, Sanchez O, Meyer G, Leroyer C, Mottier D. Six months versus two years of oral anticoagulation after a first episode of unprovoked deep-vein thrombosis. The PADIS-DVT randomized clinical trial. Haematologica 2019; 104:1493-1501. [PMID: 30606789 PMCID: PMC6601089 DOI: 10.3324/haematol.2018.210971] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/02/2019] [Indexed: 11/09/2022] Open
Abstract
The optimal duration of anticoagulation after a first episode of unprovoked deep-vein thrombosis is uncertain. We aimed to assess the benefits and risks of an additional 18 months of treatment with warfarin versus placebo, after an initial 6 months of anticoagulation for a first unprovoked proximal deep-vein thrombosis. We conducted a multicenter, randomized, double-blind, controlled trial comparing an additional 18 months of warfarin with placebo in patients with a unprovoked proximal deep-vein thrombosis initially treated for 6 months (treatment period: 18 months; follow up after treatment period: 24 months). The primary outcome was the composite of recurrent venous thromboembolism or major bleeding at 18 months. Secondary outcomes were the composite at 42 months, as well as each component of the composite, and death unrelated to pulmonary embolism or major bleeding, at 18 and 42 months. All outcomes were centrally adjudicated. A total of 104 patients, enrolled between July 2007 and October 2013 were analyzed on an intention-to-treat basis; no patient was lost to follow-up. During the 18-month treatment period, the primary outcome occurred in none of the 50 patients in the warfarin group and in 16 out of 54 patients (cumulative risk, 29.6%) in the placebo group (hazard ratio, 0.03; 95% confidence interval: 0.01 to 0.09; P<0.001). During the entire 42-month study period, the composite outcome occurred in 14 patients (cumulative risk, 36.8%) in the warfarin group and 17 patients (cumulative risk, 31.5%) in the placebo group (hazard ratio, 0.72; 95% confidence interval: 0.35-1.46). In conclusion, after a first unprovoked proximal deep-vein thrombosis initially treated for 6 months, an additional 18 months of warfarin therapy reduced the composite of recurrent venous thrombosis and major bleeding compared to placebo. However, this benefit was not maintained after stopping anticoagulation. Clinical registration: this trial was registered at www.clinicaltrials.gov as #NCT00740493.
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Affiliation(s)
- Francis Couturaud
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Gilles Pernod
- Département de Médecine Vasculaire, CHU de Grenoble, Université de Grenoble 1, F-CRIN INNOVTE, Grenoble
| | - Emilie Presles
- Unité de Recherche Clinique, Innovation et Pharmacologie, CHU de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, F-CRIN INNOVTE, Saint-Etienne
| | - Elisabeth Duhamel
- Service de Médecine Interne, Centre Hospitalier Général de Saint-Brieuc, F-CRIN INNOVTE, Saint-Brieuc
| | - Patrick Jego
- Service de Médecine Interne, CHU de Rennes, Université de Rennes 1, Rennes
| | - Karine Provost
- Service de Cardiologie, Centre Hospitalier Général de Lannion, Lannion
| | | | - Claire Bal Dit Sollier
- Clinique des Anticoagulants d'Ile de France (C.R.E.A.T.I.F.), CHU de Lariboisière, Paris
| | - Cécile Tromeur
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Clément Hoffmann
- Service d'Echo-Doppler Vasculaire, and EA 3878, CIC INSERM 1412, CHU de Brest, Université de Bretagne Occidentale, F-CRIN INNOVTE, Brest
| | - Luc Bressollette
- Service d'Echo-Doppler Vasculaire, and EA 3878, CIC INSERM 1412, CHU de Brest, Université de Bretagne Occidentale, F-CRIN INNOVTE, Brest
| | - Philippe Lorillon
- Pharmacie Centrale, CHU de Brest, Université de Bretagne Occidentale, Brest
| | - Philippe Girard
- Département Thoracique, Institut Mutualiste Montsouris, F-CRIN INNOVTE, Paris
| | - Emmanuelle Le Moigne
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Aurelia Le Hir
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Marie Guégan
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Silvy Laporte
- Unité de Recherche Clinique, Innovation et Pharmacologie, CHU de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, F-CRIN INNOVTE, Saint-Etienne
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Unité de Pharmacologie Clinique, CIC1408, CHU de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, F-CRIN INNOVTE, Saint-Etienne
| | - Karine Lacut
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Jean-Luc Bosson
- CIC and UMR CNRS 5525, CHU de Grenoble, Université de Grenoble 1, Grenoble, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Unité de Pharmacologie Clinique, CIC1408, CHU de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, F-CRIN INNOVTE, Saint-Etienne
| | - Oliver Sanchez
- CIC and UMR CNRS 5525, CHU de Grenoble, Université de Grenoble 1, Grenoble, France
| | - Guy Meyer
- CIC and UMR CNRS 5525, CHU de Grenoble, Université de Grenoble 1, Grenoble, France
| | - Christophe Leroyer
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Dominique Mottier
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
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van der Wall SJ, van der Pol LM, Ende-Verhaar YM, Cannegieter SC, Schulman S, Prandoni P, Rodger M, Huisman MV, Klok FA. Fatal recurrent VTE after anticoagulant treatment for unprovoked VTE: a systematic review. Eur Respir Rev 2018; 27:27/150/180094. [DOI: 10.1183/16000617.0094-2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/22/2018] [Indexed: 12/23/2022] Open
Abstract
Current guidelines recommend long-term anticoagulant therapy in patients with unprovoked venous thromboembolism (VTE). The risk of fatal recurrent VTE after treatment discontinuation (versus that of fatal bleeding during anticoagulation) is of particular relevance in the decision to continue or stop anticoagulation after the first 3 months. Our primary aim was to provide a point-estimate of the yearly rate of fatal recurrent VTE and VTE case-fatality rate in patients with unprovoked VTE after anticoagulation cessation. Data were extracted from both randomised controlled trials and observational studies published before May 1, 2017. The pooled fatality rates were calculated using a random-effects model. 18 studies with low-to-moderate bias were included in the primary analysis, totalling 6758 patients with a median (range) follow-up duration of 2.2 (1–5) years. After anticoagulation cessation, the weighted pooled rate of VTE recurrence was 6.3 (95% CI 5.4–7.3) per 100 patient-years and the weighted pooled rate of fatal recurrent VTE was 0.17 (95% CI 0.047–0.33) per 100 patient-years, for a case-fatality rate of 2.6% (95% CI 0.86–5.0). These numbers are a solid benchmark for comparison to the risks associated with long-term anticoagulation treatment for the decision on the optimal duration of treatment of patients with unprovoked VTE.
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