Excluding deep venous thrombosis in symptomatic outpatients: is fibrin monomer aid to D-dimer analysis?

Preoperative Lower Extremity Motor Weakness Affects Deep Vein Thrombosis During the Perioperative Period of Lumbar Surgery

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim of this study was to assess preoperative factors in the development/exacerbation of deep vein thrombosis (DVT) in lumbar surgery and selectively perform lower-extremity venous ultrasonography (US) in patients at risk of perioperative deep vein thrombosis (DVT).

SUMMARY OF BACKGROUND DATA

DVT is often present before lumbar surgery and also can develop or is exacerbated postoperatively. An elevated d-dimer level is predictive of DVT but not in all patients or during every operative period. The level of the thrombogenic marker soluble fibrin monomer complex (SFMC) peaks early postoperatively.

METHODS

The study enrolled 698 patients (396 males; 12- 91 years [346 patients aged ≥70 years] at surgery) undergoing surgery for lumbar degenerative diseases. Patients with d-dimer levels ≥0.5 μg/mL or with a lower-extremity manual muscle test (MMT) < grade 3 underwent preoperative US. All preoperative DVT-positive patients and patients with SFMC levels ≥20 μg/mL on postoperative day 1 (POD1) underwent US. Patients with pre- and postoperative femoral-vein DVT underwent screening for pulmonary embolism (PE).

RESULTS

There were 251 patients with preoperative d-dimer levels ≥ 0.5 μg/mL, including 226 with MMT ≥ grade 3, 38 (16.8%) of whom were DVT-positive on US. In 48 patients with MMT

CONCLUSION

Preoperative DVT screening by US is advisable for patients with elevated d-dimer levels, lower extremities with MMT < grade 3, or DVT positivity. Postoperative US is advisable for patients with elevated SFMC levels on POD1.Level of Evidence: 3.

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MESH Headings

• Humans
• Lower Extremity/diagnostic imaging
• Male
• Perioperative Period
• Postoperative Complications/diagnosis
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Prospective Studies
• Pulmonary Embolism
• Venous Thrombosis/diagnostic imaging
• Venous Thrombosis/epidemiology

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Affiliation(s)

Takashi Imuro Department of Orthopedic Surgery, Atsugi City Hospital, Kana-gawa, Japan
Mitsuru Saito Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan

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Soluble fibrin monomer complex is associated with cardio- and cerebrovascular events in patients with heart failure

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The soluble fibrin monomer complex (SFMC), is a marker of fibrin formation.

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SFMC is abnormally elevated in a variety of clinical situations of hypercoagulability.

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SFMC is an independent predictor of adverse prognosis in patients with heart failure.

Background

A biomarker of fibrin formation, the soluble fibrin monomer complex (SFMC), is abnormally elevated in a variety of clinical situations of hypercoagulability. The aim of the present study was to examine the prognostic impact of SFMC, with regard to increased risk of major cardio- and cerebrovascular events (MACCE) and all-cause mortality, on patients with heart failure (HF).

Methods and Results

We conducted a prospective observational study where we analyzed data of 723 hospitalized patients with decompensated HF who were discharged alive and whose SFMC had been measured in a stable condition prior to discharge. The patients were divided into tertiles based on SFMC levels: the first (SFMC < 1.7 μg/ml, n = 250), second (≤1.8 SFMC < 2.9 μg/ml, n = 233), and third (3.0 μg/ml ≤ SFMC, n = 240) tertiles. The prevalence of chronic kidney disease and anemia was significantly higher in the third tertile than in the first and second tertiles. In contrast, age, sex, CHADS₂-Vasc score, left ventricular ejection fraction, and prevalence of hypertension, diabetes and atrial fibrillation did not differ among the tertiles. In the Kaplan-Meier analysis, accumulated event rates of both MACCE and all-cause mortality progressively increased from the first to third tertiles (log-rank P < 0.05, respectively). In the multivariate Cox proportional hazard analysis, the third tertile was found to be an independent predictor of MACCE (HR 2.014, P = 0.046) and all-cause mortality (HR 1.792, P = 0.036).

Conclusion

SFMC is an independent predictor of adverse prognosis in patients with HF.

Concentration of fibrin monomer in pregnancy and during the postpartum period

Background

D-dimer increases during pregnancy and is problematic to use in the diagnosis of venous thromboembolism. Fibrin monomer represents an alternative biomarker for venous thromboembolism. However, to be useful in pregnancy, the fibrin monomer concentration should be stable throughout pregnancy and during postpartum.

Methods

To describe the course of fibrin monomer concentration during pregnancy and the postpartum period in healthy pregnant women and to compare their within-subject biological variation (CVI) with non-pregnant women. Blood samples were obtained every fourth week during pregnancy and three samples after delivery in 20 healthy women and every fourth week during a 40-week period in 19 healthy non-pregnant women. Fibrin monomer (STA Liatest FM, Stago) was analysed in duplicates for all samples. Concentrations of fibrin monomer in pregnant and non-pregnant women were compared and the CVI for fibrin monomer was calculated.

Results

The median fibrin monomer concentration in pregnant women was 6.2 mg/L (2.5 and 97.5 percentiles 3.7–10.8 mg/L) and in non-pregnant women 4.8 mg/L (3.6–8.2) ( P < 0.01). The fibrin monomer concentration was relatively stable during pregnancy, although a few unexplained high fibrin monomer concentrations were found during pregnancy/postpartum. Fibrin monomer CVI in pregnancy and postpartum was 20.6% (95% CI 18.3, 23.5) and in non-pregnant 16.1% (13.7, 18.9).

Conclusions

For clinical purposes, fibrin monomer concentration can be considered stable during pregnancy, although it is slightly higher than in non-pregnant women. Pregnant and non-pregnant women have the same CVI. The suitability of fibrin monomer in venous thromboembolism diagnosis in pregnant women should be validated in further studies.

Soluble Fibrin Monomer Complex and Prediction of Cardiovascular Events in Atrial Fibrillation: The Observational Murcia Atrial Fibrillation Project

BACKGROUND

Soluble fibrin monomer complex (SFMC) is a biomarker of fibrin formation abnormally elevated in clinical situations of hypercoagulability.

OBJECTIVE

We investigated the association and predictive performance of SFMC for stroke, adverse cardiovascular events, cardiovascular mortality and all-cause mortality in a cohort of patients with atrial fibrillation (AF) receiving vitamin K antagonist (VKA) anticoagulant therapy.

DESIGN

During the second semester of 2007, we included 1226 AF outpatients stable on VKAs (INR 2.0-3.0) over a period of 6 months. SFMC levels were assessed at baseline. During 6.5 (IQR 4.4-8.0) years of follow-up, we recorded all ischemic strokes, adverse cardiovascular events (composite of stroke, acute heart failure, acute coronary syndrome and cardiovascular death), cardiovascular deaths and all-cause deaths.

PARTICIPANTS

All patients were recruited consecutively. We excluded patients with rheumatic mitral valves, prosthetic heart valves, acute coronary syndrome, stroke, hemodynamic instability, hospital admissions or surgical interventions within the preceding 6 months.

MAIN MEASURES

SFMC levels were measured in plasma by immunoturbidimetry in an automated coagulometer (STALiatestFM, Diagnostica Stago, Asnieres, France).

KEY RESULTS

We recorded 121 (1.52%/year) ischemic strokes, 257 (3.23%/year) cardiovascular events, 67 (0.84%/year) cardiovascular deaths and 486 (6.10%/year) all-cause deaths. SFMC >12 μg/mL was not associated with stroke but was associated with higher risk of cardiovascular events (HR 1.72, 95% CI 1.31-2.26), cardiovascular mortality (HR 2.16, 95% CI 1.30-3.57) and all-cause mortality (HR 1.26, 95% CI 1.03-1.55). When SFMC >12 μg/mL was added to the CHA₂DS₂-VASc, there were significant improvements in predictive performance, sensitivity and reclassification for adverse cardiovascular events (c-index: 0.645 vs. 0.660, p = 0.010; IDI = 0.013, p < 0.001; NRI = 0.121, p < 0.001) and cardiovascular mortality (c-index: 0.661 vs. 0.691, p = 0.006; IDI = 0.009, p = 0.049; NRI = 0.217, p < 0.001), but decision curves demonstrated a similar net benefit and clinical usefulness.

CONCLUSIONS

In AF patients taking VKAs, high SFMC levels were associated with the risk of adverse cardiovascular events, cardiovascular mortality and all-cause mortality. The addition of SFMC to the CHA₂DS₂-VASc score improved its predictive performance for these outcomes, but failed to show an improvement in clinical usefulness.

Economic evaluation of different screening alternatives for patients with clinically suspected acute deep vein thrombosis

INTRODUCTION

We examined the cost-effectiveness of the three different D-dimer measurements in the screening of DVT in models with and without calculation of pre-test probability (PTP) score. Moreover, we calculated the minimal cost in DVT detection.

MATERIAL AND METHODS

In the group of 192 patients with clinically suspected acute DVT, we examined the three different D-dimer measurements (Innovance D-dimer, Hemosil D-dimer HS and Vidas D-dimer Exclusion II) in combination with and without PTP assessment.

RESULTS

The diagnostic alternative employing Vidas D-dimer Exclusion II assay without and with PTP calculation gave lower incremental cost-effectiveness ratio (ICER) than the alternative employing Hemosil D-dimer HS assay (0.187 Euros vs. 0.998 Euros per one additional DVT positive patient selected for CUS in model without PTP assessment and 0.450 vs. 0.753 Euros per one DVT positive patient selected for CUS in model with PTP assessment). According to sensitivity analysis, the Hemosil D-dimer HS assay was the most cost effective alternative when one patient was admitted to the vascular ambulance per day. Vidas D-dimer Exclusion II assay was the most cost effective alternative when more than one patient were admitted to the vascular ambulance per day. Cost minimisation analysis indicated that selection of patients according to PTP score followed by D-dimer analysis decreases the cost of DVT diagnosis.

CONCLUSIONS

ICER analysis enables laboratories to choose optimal laboratory tests according to number of patients admitted to laboratory. Results support the feasibility of using PTP scoring and D-dimer measurement before CUS examination in DVT screening.