Clinical prediction rules for mortality in patients with pulmonary embolism and cancer to guide outpatient management: a meta-analysis

ET1 acts as a potential plasma biomarker and therapeutic target in deep venous thrombosis rat model

Deep venous thrombosis (DVT) is the third leading cause of death in cardiovascular disease, following heart attacks and strokes. Early diagnosis and intervention are crucial for effective DVT therapy. We aim to investigate whether endothelin-1 (ET-1) could serve as an early diagnostic marker or a potential therapeutic target in a DVT rat model. CCK8 assay, invasion assay, and flow cytometry were used to detect the proliferation, migration and apoptosis of HUVECs, respectively. Elisa assay was used to detect ET-1 and coagulation factor VII in cell supernatant and rat?s plasma. Western blot was used to detect antioxidant signaling protein. Inferior vena cava stenosis was used to construct the DVT rat model. Lentivirus mediated overexpression of ET-1 in HUVECs impaired the cell proliferation and migration, increased cell apoptosis, inhibited the antioxidant signaling pathway proteins expression (e.g., NQO1, GCLC, Nrf-2), and upregulated coagulation factor VII. Furthermore, overexpression of ET-1 further impaired antioxidant signaling pathway protein in response to H2O2 treatment. However, lentivirus mediated ET-1 knockdown and BQ123 (an ET-1 inhibitor), showed the opposite results with ET-1 overexpression. We then established a DVT rat model by inferior vena cava stenosis. The stenosis induced early expression of ET-1 and coagulation factor VII in plasma at day 1 and restore their level at day 10. BQ123 could downregulate the coagulation factor VII to ameliorate the stenosis effects. Our findings suggest that ET-1 might serve as an early diagnostic marker for DVT rat model and a potential therapeutic target for treating DVT.

[Translation into French and republication of: "Home treatment for patients with cancer-associated venous thromboembolism"]

Patients hospitalised with acute venous thromboembolism (VTE), and notably patients with pulmonary embolism, often remain in hospital for extended periods due to the perceived risk of complications. However, several studies have shown that home treatment of selected patients is feasible and safe, with a low incidence of adverse events. This may offer clear benefits for patients' quality of life, hospital planning and cost to the health service. Nonetheless, there is a need for a VTE risk-stratification tool specifically addressing prognosis in patients with cancer. This may aid in the selection of low-risk patients with cancer and VTE who are suitable for outpatient treatment. Although several prognostic scores have been proposed, we suggest using a pragmatic clinical decision-making tool such as the Hestia criteria for selecting patients for home care in everyday clinical practice. Once patients have been discharged, it is mandatory to monitor patients regularly (we suggest after 3 days, 10 days, 1 month and 3 months, or more frequently if needed) with the involvement of a multidisciplinary team, so that appropriate and timely remedial action can be taken in case of warning signs of complications. If patients are selected carefully and monitored effectively, many patients who experience acute VTE can be cared for safely at home.

Home treatment for patients with cancer-associated venous thromboembolism

Patients hospitalised with acute venous thromboembolism (VTE), and notably patients with pulmonary embolism, often remain in hospital for extended periods due to the perceived risk of complications. However, several studies have shown that home treatment of selected patients is feasible and safe, with a low incidence of adverse events. This may offer clear benefits for patients' quality of life, hospital planning and cost to the health service. Nonetheless, there is a need for a VTE risk-stratification tool specifically addressing prognosis in patients with cancer. This may aid in the selection of low-risk patients with cancer and VTE who are suitable for outpatient treatment. Although several prognostic scores have been proposed, we suggest using a pragmatic clinical decision-making tool such as the Hestia criteria for selecting patients for home care in everyday clinical practice. Once patients have been discharged, it is mandatory to monitor patients regularly (we suggest after 3 days, 10 days, 1 month and 3 months, or more frequently if needed) with the involvement of a multidisciplinary team, so that appropriate and timely remedial action can be taken in case of warning signs of complications. If patients are selected carefully and monitored effectively, many patients who experience acute VTE can be cared for safely at home.

Prevalence, Trends, and Outcomes of Pulmonary Embolism Treated with Mechanical and Surgical Thrombectomy from a Nationwide Inpatient Sample

Pulmonary embolism (PE) is the third most common vascular disease in the US, a frequently underdiagnosed and potentially fatal condition where embolic material blocks one or more pulmonary arteries impairing blood flow. In this study, we aim to describe the prevalence, outcomes, and predictors of mortality of PE patients treated with mechanical (MT) and surgical thrombectomy (ST). This is a retrospective study using the Agency for Healthcare Research and Quality’s HCUP NIS data from 2010−2018. We used the ninth and tenth revisions of the International Classification of Diseases clinical modification codes (ICD-9-CM and ICD-10-CM) to identify patients admitted with a primary diagnosis of PE (ICD-10-CM codes I26.02, I26.09, I26.92, I26.93, I26.94, and I26.99; ICD-9-CM codes 415.11, 415.13, and 415.19). We extracted demographics, hospital-level, and patient-level characteristics, and defined the severity of comorbid conditions using Deyo modification of the Elixhauser Comorbidity Index. The primary outcomes of interest were the utilization trends of PE (treated with MT and ST); the secondary outcomes were mortality, discharge to facility, peri-procedural complications, and length of hospital (LOS) stay; the tertiary outcome was to identify the predictors of in-hospital mortality. From 2010−2018, there were 1,627,718 hospitalizations for PE, of which 6531 (0.39%) underwent MT and 3465 (0.21%) underwent ST. The utilization trend of MT increased from 336 (0.20%) in 2010 to 1655 (0.87%) in 2018; the utilization trend of ST was 260 (0.15%) in 2010 and 430 (0.23%) in 2018. The unadjusted in-hospital mortality for MT was 9.1% with the mean LOS being 7(±0.3) days; for ST, mortality was 13.9% with a mean LOS of 13(±0.4) days. The occurrences of periprocedural complications for MT and ST were as follows: invasive mechanical ventilation was 13.8% and 32%; cardiopulmonary bypass was 3.3% and 68.3%; pulmonary embolectomy surgery was 1.7%; and bleeding complications were 1.4% and 3.4%. Predictors associated with in-hospital mortality for MT were: increasing age (OR 1.2, 95% CI 1.0−1.3, p < 0.026), female sex (OR 1.9, 95% CI 1.2−2.8, p < 0.004), large hospitals (OR 2.2, 95% 1.4−3.5, p < 0.001), and teaching hospitals (OR 1.8, 95% CI 1.1−3.1, p < 0.023). The predictor of in-hospital mortality for ST was increasing age (OR 1.2, 95% CI 1.0−1.4, p < 0.046). The number of MT procedures performed has rapidly increased over the past decade. Further studies are warranted to determine their rise and therapeutic use.

Clinical practice guidelines for the treatment and prevention of cancer-associated thrombosis

The risk of venous thromboembolism (VTE) is increased in patients with cancer and is greatest in those with cancers of the pancreas, stomach, brain, lung and ovary, late stage disease and in those undergoing treatment including chemotherapy, hormonal therapy, or surgery. VTE in patients with cancer is associated with a variety of adverse consequences including an increased risk of VTE recurrence, major bleeding, and early mortality. A VTE risk score for ambulatory patients receiving cancer chemotherapy has been extensively validated and has been used to select high risk patients for thromboprophylaxis trials. Several randomized controlled trials (RCTs) and meta-analyses of these trials have confirmed that LMWHs can significantly reduce the risk of VTE in patients with cancer. While the direct oral anticoagulants (DOACs) have been approved for the general population, previous guideline panels discouraged their use due to a lack of cancer-specific data. Recently RCTs for the treatment of established VTE in patients with cancer have demonstrated that the risk of recurrent VTE is lower while the risk of bleeding greater with DOACs compared to LMWH. Two thromboprophylaxis trials comparing low dose DOACs to placebo in high risk patients receiving cancer therapy have recently reported similar rates of VTE occurrence at 6 months in the control arms. A meta-analysis of the pooled results from these trials in higher risk ambulatory patients receiving cancer therapy confirmed a significant reduction in overall VTE incidence as well as pre-planned secondary outcomes on treatment. Several clinical practice guidelines addressing VTE in patients with malignant disease have been updated including those from the American Society of Clinical Oncology (ASCO). The addition of DOACs as an option for the management of VTE in patients with cancer is the latest major change to previous guidelines issued by these organizations. The updated recommendations from these guidelines are summarized in this review.

Prognosis in patients with cancer-associated venous thromboembolism: Comparison of the RIETE-VTE and modified Ottawa score

BACKGROUND

The RIETE-VTE score was derived to risk-stratify patients with cancer-associated venous thromboembolism (CAT).

OBJECTIVES

To externally validate the RIETE-VTE score and to compare its prognostic performance with the modified Ottawa score.

PATIENTS/METHODS

We studied 178 elderly patients with CAT in a prospective multicenter cohort and assessed 30-day all-cause mortality, 90-day overall complications (mortality, major bleeding, or venous thromboembolism [VTE] recurrence), and 6-month VTE recurrence. Patients were stratified into RIETE-VTE and modified Ottawa score risk classes (low, intermediate, high). We compared the discriminative power (area under the receiver operating characteristic [ROC] curve) to predict mortality, overall complications, and VTE recurrence.

RESULTS

Fifteen patients (8.4%) died within 30 days, 42 (23.6%) experienced an overall complication by day 90, and 6 (3.4%) had recurrent VTE within 6 months. The RIETE-VTE and the modified Ottawa score classified similar proportions of patients as low risk (35.4% versus 31.5%; P = .37). No low-risk patient died within 30 days. Low-risk patients identified by the RIETE-VTE and modified Ottawa score had similar rates of overall complications (7.9% versus 8.9%) and VTE recurrence (1.6% versus 1.8%). The modified Ottawa score and the RIETE-VTE score had similar areas under the ROC curve for predicting all-cause mortality (0.84 versus 0.75; P = .21), overall complications (0.74 versus 0.68; P = .26), and VTE recurrence (0.67 versus 0.64; P = .78).

CONCLUSIONS

Both the RIETE-VTE and modified Ottawa score accurately identified elderly patients with CAT who are at low risk for short-term mortality and who are potential candidates for outpatient care.

Managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy

The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult, because management of cancer-associated thrombosis requires anticoagulation despite known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.

Managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy

The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult, because management of cancer-associated thrombosis requires anticoagulation despite known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.

Reducing the hospital burden associated with the treatment of pulmonary embolism

Pulmonary embolism (PE) is the most feared clinical presentation of venous thromboembolism (VTE). Patients with PE have traditionally been treated in hospital; however, many are at low risk of adverse outcomes and current guidelines suggest outpatient treatment as an option. Outpatient treatment of PE offers several advantages, including reduced risk of hospital-acquired conditions and potential cost savings. Despite this, patients with low-risk PE are still frequently hospitalized for treatment. This narrative review summarizes current guideline recommendations for the identification of patients with low-risk PE who are potentially suitable for outpatient treatment, using prognostic assessment tools (e.g. the Pulmonary Embolism Severity Index [PESI] and simplified PESI) and clinical exclusion criteria (e.g. Hestia criteria) alone or in combination with additional cardiac assessments. Treatment options are discussed along with recommendations for the follow-up of patients managed in the non-hospital environment. The available data on outpatient treatment of PE are summarized, including details on patient selection, anticoagulant choice, and short-term outcomes in each study. Accumulating evidence suggests that outcomes in patients with low-risk PE treated as outpatients are at least as good as, if not better than, those of patients treated in the hospital. With mounting pressures on health care systems worldwide, increasing the proportion of patients with PE treated as outpatients has the potential to reduce health care burdens associated with VTE.

Predictors of Early Mortality in Cancer-Associated Thrombosis: Analysis of the RIETE Database

Cancer-associated thrombosis (CT) carries a high, heterogeneous, and poorly predicted likelihood of mortality. Thus, we aimed to define predictors of 30-day mortality in 10,025 patients with CT. In a randomly selected derivation cohort, we used recursive partitioning analysis to detect variables that select for a risk of mortality within 30 days. In a validation cohort, we evaluated our results using Cochran–Armitage test. The most common types of cancer were lung (16%), breast (14%), and colorectal (14%); median age was 69 years (range, 14–101); most had metastatic disease (63%); 13% of patients died within 30 days. In the derivation cohort ( n  = 6,660), a white blood cell (WBC) count in the highest quartile predicted early mortality (odds ratio, 7.8; 95% confidence interval [CI], 4.6–13.1); and the presence of metastatic disease, pulmonary embolism (PE), and immobility defined the risk of those with normal WBC count. We defined death risk according four sequential questions: (1) Does the patient have an elevated WBC count? (Yes, group D). (2) If no, does the patient have metastasis? (No, group A). (3) If yes, is the patient immobile? (Yes, group D). (4) If no, does the patient have a PE? (Yes, group C; no, group B). In the validation cohort ( n  = 3,365), the 30-day risk of death was 2.9% in group A (95% CI, 1.9–4.3), compared with 25% in group D (95% CI, 22.5–27.5), and there was a rate escalation between groups ( p for trend < 0.01). In conclusion, with four sequential questions, the risk of death in CT can be easily stratified. An elevated WBC count at baseline predicted 30-day mortality better than metastases, PE, or immobility.