High D-dimer levels at presentation in patients with venous thromboembolism is a marker of adverse clinical outcomes

Predictors of cancer in patients with acute pulmonary embolism

BACKGROUND

Acute pulmonary embolism (PE) can occur as a manifestation of an underlying cancer and be of paraneoplastic aetiology. A previously unknown cancer is sometimes diagnosed after the acute PE diagnosis. The identification of a group of patients with elevated probability of having an occult cancer underlying PE was never performed. We aimed to determine predictors of occult cancer in acute PE. Our hypothesis was that the D-dimer levels would be a predictor of cancer.

PATIENTS AND METHODS

We retrospectively analysed a cohort of patients hospitalized with acute PE.

EXCLUSION CRITERIA

<18 years, venous embolism only of veins other than pulmonary territory or when the embolism was considered chronic, and no image confirmation of acute PE. Patients were grouped according to the timing of cancer diagnosis: 1) known concomitant active cancer, 2) cancer diagnosed during acute PE admission or in the following 2 years and, 3) no known cancer during the 2-year follow-up since PE diagnosis. Predictors of concomitant cancer were determined using a logistic regression analysis. Multivariate models were built.

RESULTS

We studied 562 patients; median age was 72 years and 219 (39.0 %) were men. In 223 (39.7 %) of the patients the PE was of central arteries and 61.4 % presented with bilateral PE. PE was considered unprovoked at time of discharge in 47.7 %. Median (interquartile range) D-dimer level was 7.98 (3.30-14.99) μg/mL. A total of 126 (22.4 %) patients were in group 1, 47 in group 2 (cancer diagnosed after the diagnosis of acute PE and up to 2 years) and 389 patients were in group 3. Elevated D-dimer levels were independently associated with already known cancer. D-dimer were independent predictors of future cancer diagnosis: OR = 1.07 ((95 % CI: 1.01-1.14) per each 5 ng/mL increase; for patients with D-dimer >15.0 μg/mL the OR of future cancer was 2.10 (1.05-4.18). If only patients with unprovoked PE upon admission (n = 307) were to be considered results were similar considering D-dimer; anaemia also predicted unknown cancer [OR = 2.13 (1.08-4.16)].

CONCLUSIONS

Patients with D-dimer >15 μg/mL presented a >2-fold higher risk of being diagnosed with a cancer condition in the upcoming 2 years. D-dimer may help clinicians in identifying which patients are at higher risk of occult cancer.

D-Dimer beyond Diagnosis of Pulmonary Embolism: Its Implication for Long-Term Prognosis in Cardio-Oncology Era

Venous thromboembolism (VTE) is a common comorbidity of cancer, often referred to as cancer-associated thrombosis (CAT). Even though its prevalence has been increasing, its clinical picture has not been thoroughly investigated. In this single-center retrospective observational study, 259 patients who were treated for pulmonary embolism (PE) between January 2015 and December 2020 were available for analysis. The patients were divided by the presence or absence of concomitant malignancy, and those with malignancy (N = 120, 46%) were further classified into active (N = 40, 15%) and inactive groups according to the treatment status of malignancy. In patients with malignancy, PE was more often diagnosed incidentally by computed tomography or D-dimer testing, and the proportion of massive PE was lower. Although D-dimer levels overall decreased after the initiation of anticoagulation therapy, concomitant malignancy was independently associated with higher D-dimer at discharge despite the lower severity of PE at onset. The patients with malignancy had a poor prognosis during post-discharge follow-up. Active malignancy was independently associated with major adverse cardiovascular events (MACE) and major bleeding. D-dimer at discharge was an independent predictor of mortality even after adjustment for malignancy. This study's findings suggest that CAT-PE patients might have hypercoagulable states, which can potentially lead to a poorer prognosis.

Autoimmunity roots of the thrombotic events after COVID-19 vaccination

Although vaccination represents the most promising way to stop or contain the coronavirus disease 2019 (COVID-19) pandemic and safety and effectiveness of available vaccines were proven, a small number of individuals who received anti-SARS-CoV-2 vaccines developed a prothrombotic syndrome. Vaccine-induced immune thrombotic thrombocytopenia (VITT) can be triggered by the adenoviral vector-based vaccine, whereas lipid nanoparticle-mRNA-based vaccines can induce rare cases of deep vein thrombosis (DVT). Although the main pathogenic mechanisms behind this rare phenomenon have not yet been identified, both host and vaccine factors might be involved, with pathology at least in part being related to the vaccine-triggered autoimmune reaction. In this review, we are considering some aspects related to pathogenesis, major risk factors, as well as peculiarities of diagnosis and treatment of this rare condition.

Pathologic Antibodies to Platelet Factor 4 after ChAdOx1 nCoV-19 Vaccination

BACKGROUND

The mainstay of control of the coronavirus disease 2019 (Covid-19) pandemic is vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Within a year, several vaccines have been developed and millions of doses delivered. Reporting of adverse events is a critical postmarketing activity.

METHODS

We report findings in 23 patients who presented with thrombosis and thrombocytopenia 6 to 24 days after receiving the first dose of the ChAdOx1 nCoV-19 vaccine (AstraZeneca). On the basis of their clinical and laboratory features, we identify a novel underlying mechanism and address the therapeutic implications.

RESULTS

In the absence of previous prothrombotic medical conditions, 22 patients presented with acute thrombocytopenia and thrombosis, primarily cerebral venous thrombosis, and 1 patient presented with isolated thrombocytopenia and a hemorrhagic phenotype. All the patients had low or normal fibrinogen levels and elevated d-dimer levels at presentation. No evidence of thrombophilia or causative precipitants was identified. Testing for antibodies to platelet factor 4 (PF4) was positive in 22 patients (with 1 equivocal result) and negative in 1 patient. On the basis of the pathophysiological features observed in these patients, we recommend that treatment with platelet transfusions be avoided because of the risk of progression in thrombotic symptoms and that the administration of a nonheparin anticoagulant agent and intravenous immune globulin be considered for the first occurrence of these symptoms.

CONCLUSIONS

Vaccination against SARS-CoV-2 remains critical for control of the Covid-19 pandemic. A pathogenic PF4-dependent syndrome, unrelated to the use of heparin therapy, can occur after the administration of the ChAdOx1 nCoV-19 vaccine. Rapid identification of this rare syndrome is important because of the therapeutic implications.

Study protocol for a multicentre prospective cohort study to identify predictors of adverse outcome in older medical emergency department patients (the Risk Stratification in the Emergency Department in Acutely Ill Older Patients (RISE UP) study)

BACKGROUND

Older patients (≥65 years old) experience high rates of adverse outcomes after an emergency department (ED) visit. Reliable tools to predict adverse outcomes in this population are lacking. This manuscript comprises a study protocol for the Risk Stratification in the Emergency Department in Acutely Ill Older Patients (RISE UP) study that aims to identify predictors of adverse outcome (including triage- and risk stratification scores) and intends to design a feasible prediction model for older patients that can be used in the ED.

METHODS

The RISE UP study is a prospective observational multicentre cohort study in older (≥65 years of age) ED patients treated by internists or gastroenterologists in Zuyderland Medical Centre and Maastricht University Medical Centre+ in the Netherlands. After obtaining informed consent, patients characteristics, vital signs, functional status and routine laboratory tests will be retrieved. In addition, disease perception questionnaires will be filled out by patients or their caregivers and clinical impression questionnaires by nurses and physicians. Moreover, both arterial and venous blood samples will be taken in order to determine additional biomarkers. The discriminatory value of triage- and risk stratification scores, clinical impression scores and laboratory tests will be evaluated. Univariable logistic regression will be used to identify predictors of adverse outcomes. With these data we intend to develop a clinical prediction model for 30-day mortality using multivariable logistic regression. This model will be validated in an external cohort. Our primary endpoint is 30-day all-cause mortality. The secondary (composite) endpoint consist of 30-day mortality, length of hospital stay, admission to intensive- or medium care units, readmission and loss of independent living. Patients will be followed up for at least 30 days and, if possible, for one year.

DISCUSSION

In this study, we will retrieve a broad range of data concerning adverse outcomes in older patients visiting the ED with medical problems. We intend to develop a clinical tool for identification of older patients at risk of adverse outcomes that is feasible for use in the ED, in order to improve clinical decision making and medical care.

TRIAL REGISTRATION

Retrospectively registered on clinicaltrials.gov ( NCT02946398 ; 9/20/2016).

Tumor-Specific D-Dimer Concentration Ranges and Influencing Factors: A Cross-Sectional Study

D-dimer level in cancer patients is associated with risk of venous thromboembolism and deep venous thrombosis. Most cancer patients have "abnormal" D-dimer levels based on the current normal reference range. To investigate tumor-specific D-dimer reference range, we compared D-dimer levels for nine different tumour types with healthy controls by using simultaneous quantile regression and constructing a median, 5th percentile, and 95th percentile model of normal tumour D-dimer concentration. Associations with tumour primary site, stage, pathological type, and treatment were also explored. Additionally, 190 patients were tracked to reveal the relevance of initial D-dimer levels to cancer prognosis. D-dimer ranges (median, 5th, 95th) in various cancers (mg/L) were: liver 1.12, 0.27, 5.25; pancreatic 0.96, 0.23, 4.81; breast 0.44, 0.2, 2.17; gastric 0.65, 0.22, 5.03; colorectal 0.73, 0.22, 4.45; lung 0.7, 0.25, 4.0; gynaecological 0.61, 0.22, 3.98; oesophageal 0.23, 0.7, 3.45; and head and neck 0.22, 0.44, 2.19. All were significantly higher than that of healthy controls (0.18, 0.07, 0.57). D-dimer peaked 1-2 days postoperatively but had decreased to the normal range by 1 week. Additionally, cancer patients with high initial D-dimer were shown a tendency of poor prognosis in survival rate. In conclusion, D-dimer levels in cancer depend on patient age, tumour primary site, and tumour stage. Thrombosis prevention is necessary if D-dimer has not decreased to the tumor-specific baseline a week after surgery.

Guideline on aspects of cancer-related venous thrombosis

The guideline was drafted by a writing group identified by the Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology (BCSH). All the authors are consultants in haematology in the UK. A search was performed of PubMed and Embase using the term 'cancer' combined with 'thrombosis', 'treatment', 'prophylaxis' and 'clinical presentation'. The search covered articles published up until December 2014. Only human studies were included and articles not written in English were excluded. References in recent reviews were also examined. The writing group produced the draft guideline, which was subsequently revised by consensus by members of the Haemostasis and Thrombosis Task Force of the BCSH and the BCSH executive. The guideline was then reviewed by the sounding board of the British Society for Haematology (BSH). This comprises 50 or more members of the BSH who have reviewed the guidance and commented on the content and application to the UK setting. The 'GRADE' system was used to quote levels and grades of evidence, details of which can be found at: http://www.bcshguidelines.com/BCSH_PROCESS/EVIDENCE_LEVELS_AND_GRADES_OF_RECOMMENDATION/43_GRADE.html. The objective of this guideline is to provide healthcare professionals with clear guidance on the prevention and management of venous thromboembolism (VTE) in patients with cancer and to advise on an approach to screening for cancer in patients with unprovoked VTE in whom cancer was not initially suspected based on clinical grounds.

D-dimer levels and 90-day outcome in patients with acute pulmonary embolism with or without cancer

BACKGROUND

The prognostic value of D-dimer testing in patients with acute pulmonary embolism (PE) has not been thoroughly studied.

METHODS

We used the RIETE Registry data to assess the 90-day prognostic value of increased IL Test D-dimer levels at baseline in patients with PE, according to the presence or absence of cancer.

RESULTS

As of May 2013, 3,283 patients with acute PE underwent D-dimer testing using IL Test D-dimer. Among 2,588 patients without cancer, those with D-dimer levels in the highest quartile had a higher rate of fatal PE (2.6% vs. 0.9%; p=0.002), fatal bleeding (1.1% vs. 0.3%; p=0.017) and all-cause death (9.1% vs. 4.4%; p<0.001) at 90 days compared with those with levels in the lowest quartiles. Among 695 patients with cancer, those with levels in the highest quartile had a similar rate of fatal PE or fatal bleeding but higher mortality (35% vs. 24%; p<0.01). On multivariate analysis, non-cancer patients with D-dimer levels in the highest quartile had an increased risk for fatal PE (odds ratio [OR]: 3.3; 95% CI: 1.6-6.6), fatal bleeding (OR: 4.3; 95% CI: 1.4-13.7) and all-cause death (OR: 2.1; 95% CI: 1.4-3.1) compared with patients with levels in the lowest quartiles.

CONCLUSIONS

Non-cancer patients with acute PE and IL Test D-dimer levels in the highest quartile had an independently higher risk for fatal PE, fatal bleeding and all-cause death at 90 days than those with levels in the lowest quartiles. In patients with cancer, D-dimer levels failed to predict fatal PE or fatal bleeding.

Circulating microparticle tissue factor, thromboembolism and survival in pancreaticobiliary cancers

BACKGROUND

Tissue factor (TF), the physiologic initiator of coagulation, is over-expressed in pancreatic cancer, and is associated with a pro-coagulant and pro-angiogenic state. We hypothesized that in patients with pancreaticobiliary cancers (PBC), elevated circulating microparticle-associated TF (MP-TF) activity would be associated with thrombosis and worsened survival.

PATIENTS AND METHODS

Clinical data and plasma were obtained for consecutive patients with PBC seen at Roswell Park Cancer Institute from 2005-08. MP-TF activity levels were measured using a TF-dependent FXa generation assay.

RESULTS

The study population comprised 117 patients, including pancreatic (n=80), biliary (n=34) or unknown primary histologically consistent with PBC (n=3). Of these, 52 patients (44.5%) experienced thromboembolism, including pulmonary embolism (n=15), deep venous thrombosis (n=21) and other arterial or venous events (n=32). Mean TF was 2.15 (range 0.17- 31.01) pg/mL. Median survival was 98.5 days for MP-TF activity ≥ 2.5 pg/mL versus 231 days for MP-TF activity<2.5 pg/mL (p<0.0001). In multivariate analysis, elevated MP-TF activity was associated with both VTE (OR 1.4, 95% CI 1.1-1.6) and mortality (HR 2.5, 95% CI 1.4-4.5).

CONCLUSIONS

Elevated circulating MP-TF activity is associated with thrombosis and worsened survival in patients with PBC. MP-TF activity as a prognostic biomarker warrants further prospective evaluation.

[Identification of patients at high risk of cancer after a venous thromboembolic disease]

OBJECTIVE

Assessment of cancer screening in the context of venous thromboembolic disease (VTE) remains controversial. We tried to characterize a population at high risk of developing cancer among patients suffering from VTE.

METHOD

We conducted a retrospective ancillary case-control study among patients with VTE who later had a positive diagnosis of cancer. We assessed the association of cancer with characteristic features of VTE and with the results for four biological markers.

RESULTS

Our population included 142 patients (53% men, median age 71 years). Two years after VTE, 24 patients (17%) had cancer. Median values for D-dimers, fibrin monomers and SP-selectin were significantly higher among patients who developed cancer. Logistic regression enabled us to identify two parameters targeting patients with a high risk of cancer: bilateral venous thrombosis (OR: 4.41, 95%CI: 1.41-13.78, P=0.01) and D-dimers superior to 3.8 μg/mL (OR: 3.68, 95%CI: 1.36-9.94, P=0.01). The information provided by these two characteristics was additive; 58% of patients in our population who had both factors developed cancer.

CONCLUSION

Bilateral venous thrombosis and D-dimers superior to 3.8 μg/mL are highly associated with carcinoma. This result requires a prospective validation. It could be useful in limiting the screening process to the population most at risk.

Management of venous thromboembolism--controversies and the future

Despite the availability of comprehensive evidence-based guidelines there are difficult and controversial areas in the management of venous thromboembolism. Institutions and even countries disagree on the importance of calf vein thrombosis, with some rigorously detecting and treating it and others deliberately not looking for it. The need to treat proximal deep vein thrombosis and pulmonary embolism is accepted but which patients with an unprovoked first event should have long-term anticoagulation has become a difficult clinical decision. We are uncertain how to reduce the incidence of post-thrombotic syndrome seen in a substantial number of patients. How hard to look for an undiagnosed underlying cancer has become a contentious issue particularly in the United Kingdom following the recent publication of a guideline from the National Institute for Health and Clinical Excellence. Whilst we are wrestling with these dilemmas we are entering an era of new anticoagulants and have to solve the logistical problems of introducing them into clinical practice despite cost pressures. These issues will be explored in this review.

Current status of the Korean venous thromboembolism registry

The Korean venous thromboembolism (VTE) registry, which was initiated by the Working Parties of Korean Society on Thrombosis and Hemostasis, and the Korean Society of Hematology, is a web-based multicenter registry (http://kdvt.chamc.co.kr) for recruiting consecutive VTE patients. The aim of the registry is to prospectively collect data on the epidemiology and clinical outcomes of VTE from a large, unselected cohort of patients, and to provide data on the true incidence and management of VTE in the real-world. By the end of 2007, the starting year of the registry, 840 patients were registered. By the end of 2008, 1,121 were registered, with 1,289 by the end of 2009, and 1,463 by April 2010 from 11 hospitals. The first report on the epidemiologic characteristics of 596 consecutive VTE patients was released in October 2007.

Help me, Doctor! My D-dimer is raised

Although optimal strategy for management of patients with suspected venous thromboembolism depends on local expertise and cost, diagnostic algorithms including clinical assessment and D-dimer have been validated in several trials. However, a new paradigm shift is emerging, giving an extended role of D-dimer measurement in clinical practice. D-dimer is a useful biomarker to help determine initial anticoagulant therapy in patients with thrombosis. Emerging evidence also endorses a 'predictive' role for raised D-dimer levels, since its measurement provides prognostic indications for a variety of conditions, including venous thromboembolism, disseminated intravascular coagulation, cardiovascular disease, infectious diseases, and cancer. Additional investigation is needed to clarify whether raised D-dimer is an epiphenomenon or it is actively involved in pathophysiology. Further studies are also required to establish whether D-dimer testing, alone or combined with other prognostic indicators, can be used to identify patient candidates for further triage and treatment. Nevertheless, the hazard(s) associated with raised D-dimer in plasma requires re-emphasis in the teaching of post-graduates, junior doctors and medical students, including the most effective treatments to inhibit clot spread and decrease the probability of further significant thrombotic incidents even in the absence of any 'detectable' thrombosis.

High D-dimer level is associated with increased 15-d and 3 months mortality through a more central localization of pulmonary emboli and serious comorbidity

High D-dimer levels are predictors of death in patients with pulmonary embolism (PE), as are more proximally located, larger emboli. The direct link between these three has not yet been described. A cohort of 674 consecutive patients with confirmed PE was studied. Patients were followed up for 3 months. D-dimer levels were measured only in patients with an unlikely clinical probability (n = 262). The odds ratio (OR) for death of all variables was calculated. Multivariate analysis was performed to identify independent risk factors for mortality. The best predictive D-dimer cut-off point for mortality was a concentration >3000 ng/ml FEU (OR 7.29). High D-dimer levels were correlated with active malignancy and age over 65 years, both being indicators of 3-month mortality. High D-dimer levels were also correlated with centrally located pulmonary emboli and 15-d mortality. The combination of high D-dimer levels and central emboli increased early mortality risk by 2.2. High D-dimer levels in patients with an unlikely clinical probability were associated with fatal outcome after PE. Centrally located pulmonary emboli were associated with higher D-dimer levels and worse 15-d mortality. Active malignancy, being an inpatient at time of diagnosis and age over 65 years were associated with higher D-dimer levels and worse 3-month survival.

Natural History of Right Ventricular Dysfunction After Acute Pulmonary Embolism

BACKGROUND

Acute pulmonary embolism (PE) associated with right ventricular (RV) dysfunction has an adverse prognosis. We investigated individual parameters of RV dysfunction after acute PE, assessing their correlation with the PE extent and recovery during 6 months.

METHODS

In all, 35 patients (age 63 +/- 18 years) with acute PE were prospectively investigated for 6 months with serial echocardiography, incorporating longitudinal myocardial-velocity and strain imaging. The extent of PE was quantified on day 1 by ventilation/perfusion pulmonary scintigraphy with PE defined as large when there was greater than 30% lung involvement.

RESULTS

PE extent correlated strongly with a number of parameters of RV function, and the strongest univariate correlates were tricuspid annular motion (TAM) (r = -0.65, P < .0001) and the ratio of RV apical to RV basal systolic velocity (r = 0.66, P < .0001). Multivariate analysis identified TAM (P < .0001) and RV basal late-diastolic velocity (P = .01) as independently predicting PE extent, with a combined correlation (R2 = 0.52, P < .0001). A TAM of less than 2.0 cm had sensitivity, specificity, and positive- and negative-predictive values of 75%, 84%, 75%, and 79%, respectively, in predicting large PE. Prospective follow-up identified that RV:left ventricular end-diastolic area ratio returned to normal within 6 weeks, whereas TAM and ratio of RV apical to RV basal systolic velocity normalized after 3 to 6 months.

CONCLUSION

TAM and ratio of RV apical to RV basal systolic velocity are useful indicators of the extent of PE, and provide unique insights into the recovery of RV function after acute PE.

Pathogenesis, clinical and laboratory aspects of thrombosis in cancer

The relationship between increased clotting and malignancy is well recognized, though the bidirectional development of this association is often overlooked. In the challenging cancer biology, transforming genes often act in concert with numerous epigenetic factors, including hypoxia, inflammation, contact between blood and cancer cells, and emission of procoagulant vesicles from tumors, to determine a net imbalance of the hemostatic potential which is detectable by a variety of laboratory tests. Procoagulant factors, in particular, are intimately involved in all aspects of hemostatic, cell proliferation and cellular signalling systems. However, the biggest as yet unresolved question is why cancer patients develop thrombosis? Since the thrombus itself does not apparently contributes directly to the tumor biology, enhanced hemostasis activation in cancer patients may be interpreted according to the most recent biological evidences. Coagulation and cancer biology interact bidirectionally in a "vicious cycle", in which greater tumor burden supplies greater procoagulants (tissue factor, cancer procoagulant) and thrombin, which would in turn act as strong promoters of cancer growth and spread. In this perspective, thrombosis may be interpreted as a epiphenomenon of an intricate an effective biological feedback to maintain or promote cancer progression. In this review article, we briefly analyze the pathogenesis, laboratory, clinical and therapeutic features of cancer and thrombosis.