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Jara-Palomares L, Bikdeli B, Jiménez D, Muriel A, Demelo-Rodríguez P, Moustafa F, Villalobos A, López-Miguel P, López-Jiménez L, Otálora S, Peris ML, Amado C, Chopard R, Rivera-Cívico F, Monreal M. Risk of recurrence after discontinuing anticoagulation in patients with COVID-19- associated venous thromboembolism: a prospective multicentre cohort study. EClinicalMedicine 2024; 73:102659. [PMID: 38828131 PMCID: PMC11139764 DOI: 10.1016/j.eclinm.2024.102659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 06/05/2024] Open
Abstract
Background The clinical relevance of recurrent venous thromboembolism (VTE) after discontinuing anticoagulation in patients with COVID-19-associated VTE remains uncertain. We estimated the incidence rates and mortality of VTE recurrences developing after discontinuing anticoagulation in patients with COVID-19-associated VTE. Methods A prospective, multicenter, non-interventional study was conducted between March 25, 2020, and July 26, 2023, including patients who had discontinued anticoagulation after at least 3 months of therapy. All patients from the registry were analyzed during the study period to verify inclusion criteria. Patients with superficial vein thrombosis, those who did not receive at least 3 months of anticoagulant therapy, and those who were followed for less than 15 days after discontinuing anticoagulation were excluded. Outcomes were: 1) Incidence rates of symptomatic VTE recurrences, and 2) fatal PE. The rate of VTE recurrences was defined as the number of patients with recurrent VTE divided by the patient-years at risk of recurrent VTE during the period when anticoagulation was discontinued. Findings Among 1106 patients with COVID-19-associated VTE (age 62.3 ± 14.4 years; 62.9% male) followed-up for 12.5 months (p25-75, 6.3-20.1) after discontinuing anticoagulation, there were 38 VTE recurrences (3.5%, 95% confidence interval [CI]: 2.5-4.7%), with a rate of 3.1 per 100 patient-years (95% CI: 2.2-4.2). No patient died of recurrent PE (0%, 95% CI: 0-7.6%). Subgroup analyses showed that patients with diagnosis in 2021-2022 (vs. 2020) (Hazard ratio [HR] 2.86; 95% CI 1.45-5.68) or those with isolated deep vein thrombosis (vs. pulmonary embolism) (HR 2.31; 95% CI 1.19-4.49) had significantly higher rates of VTE recurrences. Interpretation In patients with COVID-19-associated VTE who discontinued anticoagulation after at least 3 months of treatment, the incidence rate of recurrent VTE and the case-fatality rate was low. Therefore, it conceivable that long-term anticoagulation may not be required for many patients with COVID-19-associated VTE, although further research is needed to confirm these findings. Funding Sanofi and Rovi, Sanofi Spain.
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Affiliation(s)
- Luis Jara-Palomares
- Respiratory Department, Virgen del Rocio Hospital and Instituto de Biomedicina, Sevilla, CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
- YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA
- Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigacion Sanitaria IRYCIS, Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Medicine Department, Universidad de Alcalá, Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigacion Sanitaria IRYCIS, CIBERESP, Madrid, Spain
- University of Alcala, Madrid, Spain
| | - Pablo Demelo-Rodríguez
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Farès Moustafa
- Department of Emergency, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Aurora Villalobos
- Department of Internal Medicine, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Patricia López-Miguel
- Department of Pneumonology, Hospital General Universitario de Albacete, Albacete, Spain
| | | | - Sonia Otálora
- Department of Internal Medicine, Hospital Universitario Virgen de Arrixaca, Murcia, Spain
| | - María Luisa Peris
- Department of Internal Medicine, Consorcio Hospitalario Provincial de Castellón, Universidad Cardenal Herrera-CEU, CEU Universities, Castellón, Spain
| | - Cristina Amado
- Department of Internal Medicine, Hospital Sierrallana, Santander, Spain
| | - Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
| | | | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Spain
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Schulman S, Arnold DM, Bradbury CA, Broxmeyer L, Connors JM, Falanga A, Iba T, Kaatz S, Levy JH, Middeldorp S, Minichiello T, Nazy I, Ramacciotti E, Resnick HE, Samama CM, Sholzberg M, Thachil J, Zarychanski R, Spyropoulos AC. 2023 ISTH update of the 2022 ISTH guidelines for antithrombotic treatment in COVID-19. J Thromb Haemost 2024; 22:1779-1797. [PMID: 38503600 DOI: 10.1016/j.jtha.2024.02.011] [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: 12/23/2023] [Revised: 01/31/2024] [Accepted: 02/13/2024] [Indexed: 03/21/2024]
Abstract
Based on emerging evidence from the COVID-19 pandemic, the International Society on Thrombosis and Haemostasis (ISTH) guidelines for antithrombotic treatment in COVID-19 were published in 2022. Since then, at least 16 new randomized controlled trials have contributed additional evidence, which necessitated a modification of most of the previous recommendations. We used again the American College of Cardiology Foundation/American Heart Association methodology for assessment of level of evidence (LOE) and class of recommendation (COR). Five recommendations had the LOE upgraded to A and 2 new recommendations on antithrombotic treatment for patients with COVID-19 were added. Furthermore, a section was added to answer questions about COVID-19 vaccination and vaccine-induced immune thrombotic thrombocytopenia (VITT), for which studies have provided some evidence. We only included recommendations with LOE A or B. Panelists agreed on 19 recommendations, 4 for nonhospitalized, 5 for noncritically ill hospitalized, 3 for critically ill hospitalized, and 2 for postdischarge patients, as well as 5 for vaccination and VITT. A strong recommendation (COR 1) was given for (a) use of prophylactic dose of low-molecular-weight heparin or unfractionated heparin in noncritically ill patients hospitalized for COVID-19, (b) for select patients in this group, use of therapeutic-dose low-molecular-weight heparin/unfractionated heparin in preference to prophylactic dose, and (c) for use of antiplatelet factor 4 enzyme immunoassays for diagnosing VITT. A strong recommendation was given against (COR 3) the addition of an antiplatelet agent in hospitalized, noncritically ill patients. These international guidelines provide recommendations for countries with diverse healthcare resources and COVID-19 vaccine availability.
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Affiliation(s)
- Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Obstetrics and Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.
| | - Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | | | - Lisa Broxmeyer
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Jean Marie Connors
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anna Falanga
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy; University of Milan Bicocca, Monza, Italy
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University, Tokyo, Japan
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina, USA
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tracy Minichiello
- Division of Hematology, San Francisco VA Medical Center, University of California, San Francisco, San Francisco, California, USA
| | - Ishac Nazy
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Eduardo Ramacciotti
- Science Valley Research Institute, São Paulo, Brazil; Hospital e Maternidade Christóvão da Gama, Grupo Leforte, Santo André, São Paulo, Brazil
| | | | - Charles Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, Groupe Hospitalo-Universitaire, Assistance Publique-Hôpitaux de Paris Centre -Université Paris Cité, Cochin Hospital, Paris, France
| | - Michelle Sholzberg
- Departments of Medicine and Laboratory Medicine and Pathobiology, St Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| | - Ryan Zarychanski
- Sections of Hematology/Oncology and Critical Care, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA
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3
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Wang J, Ho P, Nandurkar H, Lim HY. Overall haemostatic potential assay for prediction of outcomes in venous and arterial thrombosis and thrombo-inflammatory diseases. J Thromb Thrombolysis 2024:10.1007/s11239-024-02975-2. [PMID: 38649560 DOI: 10.1007/s11239-024-02975-2] [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] [Accepted: 03/28/2024] [Indexed: 04/25/2024]
Abstract
Thromboembolic diseases including arterial and venous thrombosis are common causes of morbidity and mortality globally. Thrombosis frequently recurs and can also complicate many inflammatory conditions through the process of 'thrombo-inflammation,' as evidenced during the COVID-19 pandemic. Current candidate biomarkers for thrombosis prediction, such as D-dimer, have poor predictive efficacy. This limits our capacity to tailor anticoagulation duration individually and may expose lower risk individuals to undue bleeding risk. Global coagulation assays, such as the Overall Haemostatic Potential (OHP) assay, that investigate fibrin generation and fibrinolysis, may provide a more accurate and functional assessment of hypercoagulability. We present a review of fibrin's critical role as a central modulator of thrombotic risk. The results of our studies demonstrating the OHP assay as a predictive biomarker in venous thromboembolism, chronic renal disease, diabetes mellitus, post-thrombotic syndrome, and COVID-19 are discussed. As a comprehensive and global measurement of fibrin generation and fibrinolytic capacity, the OHP assay may be a valuable addition to future multi-modal predictive tools in thrombosis.
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Affiliation(s)
- Julie Wang
- Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia.
| | - Prahlad Ho
- Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | - Harshal Nandurkar
- Australian Centre for Blood Diseases, Monash Health, Melbourne, Australia
| | - Hui Yin Lim
- Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
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4
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Sohval S, Naymagon L. The Role of Hereditary Thrombophilia Testing in Management of First-Time Pulmonary Embolism. Heart Lung Circ 2024; 33:533-537. [PMID: 38453604 DOI: 10.1016/j.hlc.2023.12.020] [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: 08/10/2023] [Revised: 12/02/2023] [Accepted: 12/28/2023] [Indexed: 03/09/2024]
Abstract
AIM Hereditary thrombophilia (HT) testing is frequently conducted during the evaluation of patients with pulmonary embolism (PE). However, the utility of routine HT testing in this setting is unclear. We sought to assess the association of HT with risk of recurrent venous thromboembolism (VTE) following first-time PE. METHODS We conducted a multi-hospital retrospective study. Two hundred and ninety (290) patients with a first-time PE, who had been tested for HT, completed at least 3 months of therapeutic anticoagulation (AC), subsequently discontinued AC, and were followed for at least 36 months thereafter, were included. RESULTS HT was present in 48 of the 290 included patients (17%). Median follow-up after discontinuing AC was 61 months (interquartile range, 43-79 months). The overall recurrence rate of VTE during follow-up was 58 per 290 (20%). A total of 47 of 242 patients (19%) in the HT-absent group had a recurrent VTE, compared with 11 of 48 (22%) in the HT-present group. There was no significant difference in VTE-free survival between groups on Kaplan-Meier analysis; the hazard ratio (HR) for VTE recurrence for those with HT compared to those without (HR HT-present: HT-absent) was 1.240 (95% confidence interval [CI] 0.614-2.502; p=0.548). On multivariable analysis, HT was not associated with risk of recurrent VTE (HR 1.262; 95% CI 0.640-2.488), and the only variable associated with VTE recurrence was unprovoked PE (HR 2.954; 95% CI 1.64-5.314). CONCLUSIONS These findings demonstrate that the presence of HT is not associated with the risk of recurrent VTE following first PE, and support limiting the use of HT testing among patients with first PE.
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Affiliation(s)
- Sophie Sohval
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leonard Naymagon
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Burggraaf-van Delft JLI, van Rein N, Bemelmans RHH, van den Berg JWK, Bruggeman CY, Cloos-van Balen M, Coppens M, Eefting M, Ende-Verhaar Y, van Es N, van Guldener C, de Jong WK, Kleijwegt F, Koster T, Kroon C, Kuipers S, Leentjens J, Luijten D, Mairuhu ATA, Meijer K, van de Ree MA, Roos R, Schrover I, Swart-Heikens J, van der Velden AWG, van den Akker-van Marle EM, le Cessie S, Geersing GJ, Middeldorp S, Huisman MV, Klok FA, Cannegieter SC. Tailored anticoagulant treatment after a first venous thromboembolism: protocol of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study - cohort-based randomised controlled trial. BMJ Open 2024; 14:e078676. [PMID: 38521524 PMCID: PMC10961563 DOI: 10.1136/bmjopen-2023-078676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/06/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Patients with a first venous thromboembolism (VTE) are at risk of recurrence. Recurrent VTE (rVTE) can be prevented by extended anticoagulant therapy, but this comes at the cost of an increased risk of bleeding. It is still uncertain whether patients with an intermediate recurrence risk or with a high recurrence and high bleeding risk will benefit from extended anticoagulant treatment, and whether a strategy where anticoagulant duration is tailored on the predicted risks of rVTE and bleeding can improve outcomes. The aim of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study is to evaluate the outcomes of tailored duration of long-term anticoagulant treatment based on individualised assessment of rVTE and major bleeding risks. METHODS AND ANALYSIS The L-TRRiP study is a multicentre, open-label, cohort-based, randomised controlled trial, including patients with a first VTE. We classify the risk of rVTE and major bleeding using the L-TRRiP and VTE-BLEED scores, respectively. After 3 months of anticoagulant therapy, patients with a low rVTE risk will discontinue anticoagulant treatment, patients with a high rVTE and low bleeding risk will continue anticoagulant treatment, whereas all other patients will be randomised to continue or discontinue anticoagulant treatment. All patients will be followed up for at least 2 years. Inclusion will continue until the randomised group consists of 608 patients; we estimate to include 1600 patients in total. The primary outcome is the combined incidence of rVTE and major bleeding in the randomised group after 2 years of follow-up. Secondary outcomes include the incidence of rVTE and major bleeding, functional outcomes, quality of life and cost-effectiveness in all patients. ETHICS AND DISSEMINATION The protocol was approved by the Medical Research Ethics Committee Leiden-Den Haag-Delft. Results are expected in 2028 and will be disseminated through peer-reviewed journals and during (inter)national conferences. TRIAL REGISTRATION NUMBER NCT06087952.
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Affiliation(s)
| | - Nienke van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Remy H H Bemelmans
- Department of Internal Medicine, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | | | - Coty Y Bruggeman
- Department of Internal Medicine, Martini Ziekenhuis, Groningen, Groningen, The Netherlands
| | - Marissa Cloos-van Balen
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, Zuid-Holland, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, Noord-Holland, The Netherlands
| | - Matthijs Eefting
- Department of Internal Medicine, Ikazia Ziekenhuis, Rotterdam, Zuid-Holland, The Netherlands
| | - Yvonne Ende-Verhaar
- Department of Internal Medicine, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, Noord-Holland, The Netherlands
| | - Coen van Guldener
- Department of Internal Medicine, Amphia Ziekenhuis, Breda, North Brabant, The Netherlands
| | - Wouter K de Jong
- Department of Pulmonology, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Fleur Kleijwegt
- Department of Internal Medicine, Rode Kruis Ziekenhuis, Beverwijk, Noord-Holland, The Netherlands
| | - Ted Koster
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, Zuid-Holland, The Netherlands
| | - Cees Kroon
- Department of Internal Medicine, Ziekenhuis Nij Smellinghe, Drachten, Friesland, The Netherlands
| | - Saskia Kuipers
- Department of Internal Medicine, ADRZ, Goes, Zeeland, The Netherlands
| | - Jenneke Leentjens
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, The Netherlands
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Karina Meijer
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Marcel A van de Ree
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Rick Roos
- Department of Internal Medicine, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Ilse Schrover
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Janneke Swart-Heikens
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | | | | | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Clinical Epidemiology, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Geert-Jan Geersing
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, The Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Ruigómez A, Schink T, Voss A, Herings RMC, Smits E, Swart-Polinder K, Balabanova Y, Brobert G, Suzart-Woischnik K, García Rodríguez LA. Safety profile of rivaroxaban in first-time users treated for venous thromboembolism in four European countries. PLoS One 2024; 19:e0298596. [PMID: 38451960 PMCID: PMC10919665 DOI: 10.1371/journal.pone.0298596] [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: 07/05/2023] [Accepted: 01/28/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The European rivaroxaban post-authorization safety study evaluated bleeding risk among patients initiated on rivaroxaban or vitamin K antagonists for the treatment and secondary prevention of venous thromboembolism in routine clinical practice. METHODS Cohorts were created using electronic healthcare databases from the UK, the Netherlands, Germany and Sweden. Patients with a first prescription of rivaroxaban or vitamin K antagonist during the period from December 2011 (in the UK, January 2012) to December 2017 (in Germany, December 2016) for venous thromboembolism indication, with no record of atrial fibrillation or recent cancer history, were observed until the occurrence of each safety outcome (hospitalization for intracranial, gastrointestinal, urogenital or other bleeding), death or study end (December 2018; in Germany, December 2017). Crude incidence rates of each outcome per 100 person-years were computed. RESULTS Overall, 44 737 rivaroxaban and 45 842 vitamin K antagonist patients were enrolled, mean age, 59.9-63.8 years. Incidence rates were similar between rivaroxaban and vitamin K antagonist users with some exceptions, including higher incidence rates for gastrointestinal bleeding in rivaroxaban users than in vitamin K antagonist users. Among rivaroxaban users, mortality and bleeding risk generally increased with age, renal impairment and diabetes. CONCLUSIONS This study provides further data from routine clinical practice that broadly support safety profile of rivaroxaban for VTE indication and complement findings from previous randomized clinical trials.
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Affiliation(s)
- Ana Ruigómez
- Spanish Centre for Pharmacoepidemiological Research (CEIFE), Madrid, Spain
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
| | - Annemarie Voss
- Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
| | | | - Elisabeth Smits
- PHARMO Institute for Drug Outcomes Research, Utrecht, Netherlands
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Laganà A, Assanto GM, Masucci C, Passucci M, Donzelli L, Serrao A, Baldacci E, Santoro C, Chistolini A. Secondary Prophylaxis of Venous Thromboembolism (VTE) with Low Dose Apixaban or Rivaroxaban: Results from a Patient Population with More than 2 Years of Median Follow-up. Mediterr J Hematol Infect Dis 2024; 16:e2024020. [PMID: 38468835 PMCID: PMC10927198 DOI: 10.4084/mjhid.2024.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/08/2024] [Indexed: 03/13/2024] Open
Abstract
Background Direct oral anticoagulants (DOACs) are widely used for the treatment and secondary prophylaxis of venous thromboembolism (VTE). Nowadays, DOACs represent the gold standard for long-term anticoagulation, with low-intensity DOACs administration becoming increasingly used worldwide in such scenario. Albeit low-intensity apixaban and rivaroxaban are approved for clinical usage as secondary VTE prophylaxis, there are few literature data regarding their efficacy and safety with a long follow-up. Objectives The aim of our study was to evaluate the efficacy and safety of low-dose DOACs for VTE secondary prophylaxis in patients at high risk of VTE recurrence. Methods We retrospectively evaluated patients who required long-term anticoagulant secondary prophylaxis to prevent recurrent VTE, treated with apixaban 2.5 mg BID or rivaroxaban 10 mg daily with a follow-up ≥ 12 months. Results The examined patients were 323. The median low-dose DOAC administration time was 25.40 months (IQR 13.93-45.90). Twelve (3.7%) VTE recurrences were observed; 21 bleeding events were registered (6.5%), including one episode of Major bleeding (MB) (0.3%), 8 Clinically relevant nonmajor bleeding (CRNMB) (2.5%) and 12 minor bleeding (3.7%). No statistically significant difference in the rate of VTE recurrence and/or bleeding events emerged between the rivaroxaban and apixaban groups. Patients included in the study for multiple episodes of VTE presented a significantly higher risk of a new VTE recurrence during low-intensity DOAC. Conclusions Our data suggest that low-dose DOACs may be effective and safe in secondary VTE prophylaxis in patients at high risk of VTE recurrence; however, attention might be needed in their choice in such a scenario for patients who experienced multiple episodes of VTE.
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Affiliation(s)
- Alessandro Laganà
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | | | - Chiara Masucci
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Mauro Passucci
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Livia Donzelli
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Alessandra Serrao
- Haematology and Stem Cell Transplant Unit, A. O. San Camillo Forlanini (LR), Rome, Italy
| | - Erminia Baldacci
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Cristina Santoro
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Antonio Chistolini
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
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8
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Palareti G, Antonucci E, Bucherini E, Caronna A, Chistolini A, Di Giorgio A, Di Giulio R, Falanga A, Fregoni V, Garzia M, Mastroiacovo D, Marzolo M, Pancani R, Pastori D, Podda GM, Rigoni AM, Ria L, Sivera P, Testa S, Visonà A, Parisi R, Poli D, Investigators OBOTSTARTPOSTVTE. Long-Term Outcomes in Two-Year Follow-Up after Primary Treatment in Patients with a Prior Venous Thromboembolic Event: A Prospective, Observational, Real-Life Study. J Clin Med 2024; 13:1343. [PMID: 38592175 PMCID: PMC10931842 DOI: 10.3390/jcm13051343] [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: 01/24/2024] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Patients with acute venous thromboembolism (VTE) need anticoagulation (AC) therapy for at least 3/6 months (primary treatment); after that period, they should receive a decision on the duration of therapy. METHODS This study examined the complications occurring during two years of follow-up (FU) in patients with a first VTE who were recruited in 20 clinical centers and had discontinued or prolonged AC. They were included in the START2-POST-VTE prospective observational study. RESULTS A total of 720 patients (53.5% males) who, after the completion of primary treatment, had received the decision to continue (n = 281, 39%; 76.1% with a DOAC) or discontinue (n = 439, 61%) AC were followed up for 2 years (total FU = 1318 years). The decision to prolong or suspend AC was made in similar proportions in patients with unprovoked or provoked index events. Courses of sulodexide treatment or Aspirin (100 mg daily) were prescribed to 20.3% and 4.5%, respectively, of the patients who discontinued AC. The bleeding rate was significantly higher in patients who extended AC (1.6% pt/y) than in those who stopped AC (0.1% pt/y; p = 0.001) and was higher in patients using standard-dose DOACs (3.1% pt/y) than in those using reduced-dose DOACs (0.4% pt/y). The recurrent VTE rates were similar between the two groups (2.2% pt/y during AC vs. 3% pt/y off AC). CONCLUSION Physicians' decisions about AC duration were independent of the unprovoked/provoked nature of the index event. The bleeding rate was higher in patients who continued AC using standard-dose DOACs. Surprisingly, the rate of thrombotic recurrence was not different between those who continued or discontinued AC. Randomized studies comparing different procedures to decide on the duration of AC after a first VTE are needed.
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Affiliation(s)
| | | | - Eugenio Bucherini
- SS Medicina Vascolare e Angiologia, AUSL Romagna, 48121 Ravenna, Italy;
| | - Antonella Caronna
- Centro per la Diagnosi e la Sorveglianza della Malattia Tromboembolica, UO Medicina Interna D’urgenza, Azienda Ospedaliero Universitaria Policlinico di Modena, Ospedale Civile Baggiovara, 41124 Modena, Italy;
| | - Antonio Chistolini
- Dipartimento di Medicina Traslazionale e di Precisione Sapienza Università di Roma, 00197 Roma, Italy;
| | - Angela Di Giorgio
- Angiologia Diagnostica Vascolare Non Invasiva, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Rosella Di Giulio
- U.O. Programma Dipartimentale di Ecografia-AUSL, 40133 Bologna, Italy;
| | - Anna Falanga
- School of Medicine, Università di Milano Bicocca, 20126 Milano, Italy;
- Immunoematologia e Medicina Trasfusionale ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Vittorio Fregoni
- U.O.C. Medicina Generale, Ospedale di Sondalo, ASST della Valtellina e dell’Alto Lario, 23035 Sondalo, Italy;
| | - Mariagrazia Garzia
- UOC Ematologia-Trapianto Cellule Staminali, Azienda Ospedaliera S.Camillo-Forlanini, 00152 Roma, Italy;
| | - Daniela Mastroiacovo
- UOSD Angiologia e Diagnostica Vascolare, Ospedale SS Filippo e Nicola, Avezzano (L’Aquila), 67051 L’Aquila, Italy;
| | - Marco Marzolo
- UOS Angiologia Medica, Ospedale di Rovigo, 45100 Rovigo, Italy;
| | - Roberta Pancani
- U.O. Pneumologia, Dipartimento Cardiotoraco-Vascolare, Azienda Ospedaliero-Universitaria Pisana, Ospedale di Cisanello, 56126 Pisa, Italy;
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00197 Roma, Italy;
| | - Gian Marco Podda
- Medicina Generale 2, ASST Santi Paolo e Carlo, Università degli Studi di Milano, 20142 Milano, Italy;
| | - Anna Maria Rigoni
- UOC di Angiologia, Azienda Ospedaliero Universitaria Integrata, 37126 Verona, Italy;
| | - Luigi Ria
- UO Medicina Interna, Presidio Ospedaliero di Gallipoli (Lecce), 73014, Gallipoli, Italy;
| | - Piera Sivera
- S.C.D.U. EMATOLOGIA Azienda Ospedaliera Ordine Mauriziano, 10128 Torino, Italy;
| | - Sophie Testa
- Centro Emostasi e Trombosi, ASST Cremona, 26100 Cremona, Italy;
| | - Adriana Visonà
- UOC Angiologia, Dipartimento di Medicina Clinica, Azienda ULSS 2 Marca Trevigiana, Ospedale San Giacomo Apostolo, 31033 Castelfranco Veneto, Italy;
| | - Roberto Parisi
- UOSD Ipertensione e Patologie Endocrine Metaboliche Angiologiche, Ospedale SS. Giovanni e Paolo, 30122 Venezia, Italy;
| | - Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, 50134 Firenze, Italy;
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Lindegaard SF, Højen AA, Rolving N. Electronic adaptation and danish cross-cultural translation of PEmb-QoL and VEINES-QoL/Sym for patients with venous thromboembolism. J Patient Rep Outcomes 2024; 8:21. [PMID: 38407682 PMCID: PMC10897079 DOI: 10.1186/s41687-024-00698-9] [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: 06/13/2023] [Accepted: 02/07/2024] [Indexed: 02/27/2024] Open
Abstract
PURPOSE Most patient-reported outcome (PROs) used in thrombosis research and clinical practice are delivered using technology like online questionnaires. However, only few have undergone formal electronic adaptation from paper to digital versions, threatening the validity and reliability of the PROs. The present study aimed to perform an electronic adaption and cross-cultural translation of two PROs measuring health-related quality of life in a Danish cohort of patients with venous thrombosis (VTE), specifically the VEINES-QoL/Sym questionnaire and the PEmb-QoL questionnaire. METHODS The electronic adaption and cross-cultural translation processes followed the international guidelines recommended by ISPOR. The migration of the questionnaires from paper to electronic versions was conducted in the Research Electronic Data Capture (REDCap). Following approval of the electronically adapted and translated versions, a pretest of the questionnaires was performed by cognitive interviewing patients with VTE recruited from a hospital setting. RESULTS Nine men and ten women between the age of 19 and 73 years participated in cognitive interviews. The questionnaires were successfully adapted from paper to electronic versions, and during the migration process only a few modifications to the content and format were made. Most comments were related to technicalities, e.g. touch functions and checkboxes. The cross-cultural translation of both questionnaires was satisfactory, as only minor rephrasing was required. CONCLUSIONS The original and Danish version of VEINES-QoL/Sym and PEmb-QoL were successfully adapted into electronic versions and are ready to share for REDCap users. Furthermore, the Danish versions of the two questionnaires have shown satisfactory face validity.
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Affiliation(s)
- Stine Foged Lindegaard
- Danish Center for Health Services Research, Aalborg University Hospital and Aalborg University , Aalborg, Denmark
| | - Anette Arbjerg Højen
- Danish Center for Health Services Research, Aalborg University Hospital and Aalborg University , Aalborg, Denmark
| | - Nanna Rolving
- Department of Physical and Occupational Therapy, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N, 8200, Denmark.
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10
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Maughan BC, Jarman AF, Redmond A, Geersing GJ, Kline JA. Pulmonary embolism. BMJ 2024; 384:e071662. [PMID: 38331462 DOI: 10.1136/bmj-2022-071662] [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: 02/10/2024]
Affiliation(s)
- Brandon C Maughan
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Angela F Jarman
- Department of Emergency Medicine, University of California Davis, Sacramento, CA
| | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Jeffrey A Kline
- Department of Emergency Medicine, Wayne State School of Medicine, Detroit, MI
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11
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de Winter MA, Xu Y, Stacey D, Wells PS. Qualitative experiences, values, and decisional needs of patients with unprovoked venous thromboembolism who suffer bleeding-"This pill will keep you alive tonight". Res Pract Thromb Haemost 2024; 8:102360. [PMID: 38559571 PMCID: PMC10978529 DOI: 10.1016/j.rpth.2024.102360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 04/04/2024] Open
Abstract
Background Contemporary guidelines recommend extended-duration anticoagulation among patients with a first unprovoked venous thromboembolism (VTE). Little is known about whether this recommendation aligns with patient values after a bleeding complication. Objectives To explore the experiences, values, and decisional needs of patients with unprovoked VTE related to extended-duration treatment after an anticoagulant-associated bleed. Methods In this descriptive, qualitative study, face to face online semistructured interviews were conducted with patients with unprovoked VTE who had experienced bleeding and continued anticoagulant treatment in one academic hospital in Canada. Data were analyzed using directed content analysis to identify themes. Themes were mapped onto the Ottawa Decisional Support Framework to identify decisional needs. Results Between September and December 2021, 14 patients were interviewed (age 41-69 years; 9 females). Many patients were not aware of the option to stop anticoagulation and had limited understanding of the decision about treatment duration. Despite the negative quality-of-life impact of clinically relevant bleeding during VTE treatment, the majority continued anticoagulation due to emotional trauma of VTE diagnosis, a perception that bleeding would be more manageable than VTE recurrence, a desire to maintain a connection to subspecialty care or non-VTE related benefits (eg, cancer diagnosis, protection from COVID-19). Patients' decisional needs included lack of choice awareness, inadequate support for participation, lack of personalized risk stratification, and inadequate information on monitoring and managing heavy menstrual bleeding. Conclusion Despite the impact of anticoagulant-associated bleeding on quality of life, patients preferred continuing with anticoagulation for reasons extending beyond secondary VTE prevention. Effective decision-support interventions are needed to address unmet decisional needs.
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Affiliation(s)
- Maria A. de Winter
- Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Diakonessenhuis, Utrecht, The Netherlands
| | - Yan Xu
- Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dawn Stacey
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Philip S. Wells
- Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Yıldız Z, Kayğın MA, Özkara T, Limandal HK, Diler MS, Çüçen Dayı HI, Ergün S, Dağ Ö. Effects of Deep Venous Thrombosis Treatments on Early and Long-term Quality of Life: Medical Therapy vs. Systemic Thrombolysis vs. Pharmacomechanical Thrombolysis. Vasc Endovascular Surg 2024; 58:5-12. [PMID: 37321364 DOI: 10.1177/15385744231184654] [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] [Indexed: 06/17/2023]
Abstract
OBJECTIVES The present study aimed to compare the effects of medical therapy (MT), systemic thrombolysis (ST), and pharmacomechanical thrombolysis (PMT) methods used in our clinic for the treatment of deep venous thrombosis (DVT) on symptom reduction, the incidence of post-thrombotic syndrome (PTS) development, and quality of life. METHODS Data from160 patients diagnosed with acute DVT between January 2012 and May 2021 and treated and followed up in our clinic were retrospectively analyzed. The patients were divided into three groups according to treatment method. The patients who received MT treatment were defined as Group 1, anticoagulant treatment after ST as Group 2, and anticoagulant treatment after PMT as Group 3. The patients were called to the outpatient clinic, informed consent was obtained, EuroQol-5D-3 L (EQ-5D-3 L) scoring and Villalta scoring were performed, and anamnesis was taken. RESULTS A total of 160 patients were included, with 71 (44.4%) patients in Group 1, 45 (28.1%) in Group 2, and 44 (27.5%) in Group 3. The mean age was 48.9 ± 14.9 years for Group 1, 42.2 ± 10.8 for Group 2, and 29.0 ± 7.2 for Group 3. When the time to return to normal life and the EQ-5D-3 L score index were compared, the differences between Groups 1 and 2 and between Groups 1 and 3 were statistically significant (P = .000 and P = .000, respectively). However, the differences between Groups 2 and 3 were statistically insignificant (P = .213 andp = .074, respectively). When Villalta scores and EQ Visual Analogue Scale (EQ-VAS) scores were compared between groups, the difference between all groups was statistically significant (P = .000). CONCLUSIONS The medical treatment alone was observed to be insufficient in terms of symptomatic improvement, development of PTS, quality of life, and long-term complications. When the ST and PMT groups were compared, it was determined that PMT treatment was more advantageous in terms of EQ-VAS score and PTS development, although there was no statistical difference regarding complications, such as return to normal life and long-term quality of life, the incidence of recurrent DVT development, and pulmonary thromboembolism incidence.
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Affiliation(s)
- Ziya Yıldız
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Mehmet A Kayğın
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Taha Özkara
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Hüsnü K Limandal
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Mevriye S Diler
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Hatice I Çüçen Dayı
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Servet Ergün
- Department of Pediatric Cardiovacscular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Özgür Dağ
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
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Czuprynska J, Arya R. Balancing the risks of recurrent venous thromboembolism and bleeding with extended anticoagulation: oh, for a crystal ball! Res Pract Thromb Haemost 2024; 8:102316. [PMID: 38356852 PMCID: PMC10865474 DOI: 10.1016/j.rpth.2024.102316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/02/2024] [Indexed: 02/16/2024] Open
Affiliation(s)
- Julia Czuprynska
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Roopen Arya
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital NHS Foundation Trust, London, UK
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14
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de Winter MA, Thavorn K, Hageman SH, Nijkeuter M, Wells PS. Balancing risks of recurrent venous thromboembolism and bleeding with extended anticoagulation: a decision analysis. Res Pract Thromb Haemost 2024; 8:102274. [PMID: 38222076 PMCID: PMC10784302 DOI: 10.1016/j.rpth.2023.102274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 10/25/2023] [Accepted: 11/11/2023] [Indexed: 01/16/2024] Open
Abstract
Background A decision to stop or continue anticoagulation after 3 months of anticoagulation for venous thromboembolism (VTE) should be made by weighing individual risks of recurrence and bleeding. Objectives To determine the optimal ratio of recurrence risk reduction to increase the risk of bleeding in terms of maximizing quality-adjusted life years (QALYs) gained. Methods Using a microsimulation model, outcomes within 5 years were simulated after assigning extended treatment if absolute recurrence risk reduction outweighed absolute increase in clinically relevant bleeding risk (International Society on Thrombosis and Haemostasis definition), weighted by a certain ratio. Data were simulated based on the Bleeding Risk Study, a prospective cohort including patients after ≥3 months of anticoagulation for unprovoked VTE or provoked VTE with history of VTE. The VTE-PREDICT risk score was used to estimate 5-year risks of recurrent VTE and clinically relevant bleeding. Results Among 10,000 individuals (mean age, 60.2 years, 36% female), the ratio of 0.90 (95% CI, 0.51-3.40; ie, bleeding is considered 0.90 the severity of recurrent VTE), with 99% of patients assigned extended anticoagulation, was considered optimal and resulted in 93 (95% CI, -23 to 203) additional QALYs compared with the least favorable ratio (5.10, 0% extended anticoagulation). At the optimal ratio, treatment based on VTE-PREDICT yielded 44 (95% CI, -69 to 157) additional QALYs versus standard of care. Conclusion With the current evidence, the optimal ratio between relevant bleeding risk and absolute recurrence risk reduction remains uncertain. Our results confirm that clinical equipoise exists regarding the decision to stop or continue anticoagulation after initial VTE treatment, emphasizing the importance of shared decision-making.
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Affiliation(s)
- Maria A. de Winter
- Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Diakonessenhuis, Utrecht, The Netherlands
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Steven H.J. Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mathilde Nijkeuter
- Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Philip S. Wells
- School of Epidemiology and Public Health, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Kyrle PA, Eischer L, Šinkovec H, Gressenberger P, Gary T, Brodmann M, Heinze G, Eichinger S. The Vienna Prediction Model for identifying patients at low risk of recurrent venous thromboembolism: a prospective cohort study. Eur Heart J 2024; 45:45-53. [PMID: 37769352 PMCID: PMC10757868 DOI: 10.1093/eurheartj/ehad618] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 08/16/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND AND AIMS Patients with unprovoked venous thromboembolism (VTE) have a high recurrence risk, and guidelines suggest extended-phase anticoagulation. Many patients never experience recurrence but are exposed to bleeding. The aim of this study was to assess the performance of the Vienna Prediction Model (VPM) and to evaluate if the VPM accurately identifies these patients. METHODS In patients with unprovoked VTE, the VPM was performed 3 weeks after anticoagulation withdrawal. Those with a predicted 1-year recurrence risk of ≤5.5% were prospectively followed. Study endpoint was recurrent VTE over 2 years. RESULTS A total of 818 patients received anticoagulation for a median of 3.9 months. 520 patients (65%) had a predicted annual recurrence risk of ≤5.5%. During a median time of 23.9 months, 52 patients had non-fatal recurrence. The recurrence risk was 5.2% [95% confidence interval (CI) 3.2-7.2] at 1 year and 11.2% (95% CI 8.3-14) at 2 years. Model calibration was adequate after 1 year. The VPM underestimated the recurrence risk of patients with a 2-year recurrence rate of >5%. In a post-hoc analysis, the VPM's baseline hazard was recalibrated. Bootstrap validation confirmed an ideal ratio of observed and expected recurrence events. The recurrence risk was highest in men with proximal deep-vein thrombosis or pulmonary embolism and lower in women regardless of the site of incident VTE. CONCLUSIONS In this prospective evaluation of the performance of the VPM, the 1-year rate of recurrence in patients with unprovoked VTE was 5.2%. Recalibration improved identification of patients at low recurrence risk and stratification into distinct low-risk categories.
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Affiliation(s)
- Paul A Kyrle
- Division of Hematology and Hemostasis, Department of Medicine I, Medical University of Vienna, Vienna A-1090, Austria
- Karl Landsteiner Institute of Thrombosis Research, Vienna A-1020, Austria
| | - Lisbeth Eischer
- Division of Hematology and Hemostasis, Department of Medicine I, Medical University of Vienna, Vienna A-1090, Austria
| | - Hana Šinkovec
- Center for Medical Statistics, Informatics and Intelligent Systems, Institute of Clinical Biometrics, Medical University of Vienna, Vienna A-1090, Austria
| | - Paul Gressenberger
- Division of Angiology, Department of Medicine, Medical University of Graz, Graz A-8010, Austria
| | - Thomas Gary
- Division of Angiology, Department of Medicine, Medical University of Graz, Graz A-8010, Austria
| | - Marianne Brodmann
- Division of Angiology, Department of Medicine, Medical University of Graz, Graz A-8010, Austria
| | - Georg Heinze
- Center for Medical Statistics, Informatics and Intelligent Systems, Institute of Clinical Biometrics, Medical University of Vienna, Vienna A-1090, Austria
| | - Sabine Eichinger
- Division of Hematology and Hemostasis, Department of Medicine I, Medical University of Vienna, Vienna A-1090, Austria
- Karl Landsteiner Institute of Thrombosis Research, Vienna A-1020, Austria
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Affiliation(s)
- Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Peter Verhamme
- KU Leuven Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, Leuven, Belgium
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Chiasakul T, Bauer KA. The dos, don'ts, and nuances of thrombophilia testing. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:593-599. [PMID: 38066917 PMCID: PMC10727021 DOI: 10.1182/hematology.2023000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Considerable progress has been made in elucidating genetic and biologic risk factors for venous thromboembolism (VTE). Despite being able to identify heritable defects in a substantial proportion of patients with VTE, testing has not, in general, proven useful in management. Despite efforts to reduce inappropriate testing, it often falls to the hematologist to consult on patients having undergone thrombophilia testing. Through a series of cases, we discuss how D-dimer testing can be helpful in VTE recurrence risk stratification in younger women as well as how to approach patients with persistently elevated D-dimer levels in the absence of thrombosis. While elevated factor VIII coagulant activity levels are a significant risk factor for a first episode of VTE, its biologic basis is not fully understood, and studies have not shown it to be a useful predictor of recurrence. Abnormal results of genetic tests for methylene tetrahydrofolate reductase or plasminogen activator 1 promoter polymorphisms may be encountered, which carry little if any thrombotic risk and should never be ordered. We also discuss protein S deficiency, the most difficult of the hereditary thrombophilias to diagnose due to a wider "normal" range in the general population as compared with protein C, the presence of both free and bound forms in plasma, and the characteristics of the various assays in use. We also present a rare type of protein C deficiency that can be missed by functional assays using an amidolytic rather than a clotting end point.
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Affiliation(s)
- Thita Chiasakul
- Center of Excellence in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Kenneth A Bauer
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Becattini C. Provoked vs minimally provoked vs unprovoked VTE: does it matter? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:600-605. [PMID: 38066936 PMCID: PMC10727063 DOI: 10.1182/hematology.2023000492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Venous thromboembolism (VTE) is a multifactorial disease, and its risk depends on exposure to risk factors and predisposing conditions. Based on their strength of association with a VTE episode, risk factors are classified as major or minor and determined using a temporal pattern to be transient or persistent. All patients with VTE should receive anticoagulant treatment for at least 3 months in the absence of an absolute contraindication. Beyond this period, selected patients may be candidates for an extended phase of anticoagulation aimed at secondary VTE prevention. The risk of recurrent VTE if anticoagulation is discontinued is probably the main driver of decision-making regarding extended treatment. The risk of recurrence after VTE associated with major risk factors is low if the risk factor is no longer present. In this case, treatment can be discontinued. If the major risk factor is persistent, anticoagulation should be continued. After VTE occurring in the absence of risk factors, anticoagulation should probably be continued indefinitely if the risk for bleeding is low and preferably with minimal effective doses of anticoagulants. VTE occurring after exposure to minor risk factors is probably the most challenging situation, especially if the clinical manifestation was acute pulmonary embolism. Understanding the actual role of minor risk factors in the occurrence of VTE helps in estimating the risk of recurrence and avoiding the dangers associated with unnecessary anticoagulation. The availability of safer strategies for anticoagulation could allow personalized strategies for secondary prevention of VTE.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
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Park H, Jones BL, Huang PL, Kang HR, Dietrich EA, DeRemer CE, Lo-Ciganic WH. Trajectories of Oral Anticoagulation Adherence and Associated Clinical Outcomes During Long-Term Anticoagulation Among Medicare Beneficiaries With Venous Thromboembolism. Ann Pharmacother 2023; 57:1349-1360. [PMID: 36999519 DOI: 10.1177/10600280231155489] [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] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Little is known about anticoagulation medication nonadherence patterns impacting effectiveness and safety outcomes in clinical practice. OBJECTIVE We identified adherence trajectories of extended therapy with direct-acting oral anticoagulants (DOACs) and warfarin after 6 months initial anticoagulant therapy among Medicare beneficiaries with venous thromboembolism (VTE). We further assessed the associated recurrent VTE and major bleeding risks. METHODS Using group-based trajectory models, this retrospective cohort study identified distinct beneficiary subgroups with similar adherence patterns of extended-phase anticoagulant treatment (DOACs or warfarin) for patients with VTE who completed 6 months of initial anticoagulant treatment. We examined associations between adherence trajectories and risks of recurrent VTE and major bleeding using inverse probability treatment weighted Cox proportional hazards models. RESULTS Compared with no extended treatment, consistently high DOAC adherence was associated with decreased recurrent VTE risk (hazard ratio [HR] = 0.33, 95% confidence interval [CI] = 0.21-0.51) without increased major bleeding risk, and consistently high warfarin adherence was associated with decreased recurrent VTE risk (HR = 0.62, 95% CI = 0.40-0.95) and increased major bleeding risk (HR = 1.64, 95% CI = 1.12-2.41). Gradually declining adherence to DOACs (HR = 1.80, 95% CI = 1.07-3.03) or warfarin (HR = 2.34, 95% CI = 1.57-3.47) was associated with increased bleeding risk with no change in recurrent VTE risk. CONCLUSION AND RELEVANCE This real-world evidence suggests persistently adhering to extended DOAC therapy is associated with lower recurrent VTE risk without increasing major bleeding among Medicare beneficiaries with VTE. Persistently adhering to extended warfarin therapy was associated with lower recurrent VTE risk but higher major bleeding risk.
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Affiliation(s)
- Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Bobby L Jones
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Pei-Lin Huang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Hye-Rim Kang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Eric A Dietrich
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Christina E DeRemer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL, USA
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20
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Glise Sandblad K, Schulman S, Rosengren A, Sörbo J, Philipson J, Hansson PO. Association of type of oral anticoagulation with risk of bleeding in 45,114 patients with venous thromboembolism during initial and extended treatment-A nationwide register-based study. J Intern Med 2023; 294:743-760. [PMID: 37641391 DOI: 10.1111/joim.13712] [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] [Indexed: 08/31/2023]
Abstract
BACKGROUND Safety data for different anticoagulant medications in venous thromboembolism (VTE) are scarce, in particular for extended treatment. OBJECTIVES To compare major bleeding rates depending on the choice of anticoagulation during initial (first 6 months) and extended treatment (6 months up to 5 years). METHODS A nationwide register-based study including cancer-free patients with a first-time VTE between 2014 and 2020. Cox proportional hazards models were used to compare bleeding rates. RESULTS We included 6558 patients on warfarin, 18,196 on rivaroxaban, and 19,498 on apixaban. At 6 months, 4750 (72.4%) remained on warfarin, 11,366 (62.5%) on rivaroxaban, and 11,940 (61.2%) on apixaban. During initial treatment, major bleeding rates were 3.86 (95% CI 3.14-4.58), 2.93 (2.55-3.31), and 1.95 (1.65-2.25) per 100 patient-years for warfarin, rivaroxaban, and apixaban, respectively, yielding adjusted hazard ratios (aHRs) of 0.89 (95% CI 0.71-1.12) for rivaroxaban versus warfarin, 0.55 (0.43-0.71) for apixaban versus warfarin, and 0.62 (0.50-0.76) for apixaban versus rivaroxaban. During extended treatment, major bleeding rates were 1.55 (1.19-1.91), 1.05 (0.85-1.26), and 0.96 (0.78-1.15) per 100 patient-years for warfarin, rivaroxaban, and apixaban, respectively, with aHRs of 0.72 (0.53-0.99) for rivaroxaban versus warfarin, 0.60 (0.44-0.82) for apixaban versus warfarin, and 0.85 (0.64-1.12) for apixaban versus rivaroxaban. Previous bleeding and increasing age were risk factors for bleeding both during initial and extended treatment. CONCLUSION Apixaban had a lower bleeding risk than warfarin or rivaroxaban during initial treatment. During extended treatment, bleeding risk was similar for apixaban and rivaroxaban, and higher with warfarin.
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Affiliation(s)
- Katarina Glise Sandblad
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Jan Sörbo
- Department of Clinical Physiology, Region Västra Götaland, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden
| | - Jacob Philipson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Per-Olof Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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21
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Kaneda K, Yamashita Y, Morimoto T, Chatani R, Nishimoto Y, Ikeda N, Kobayashi Y, Ikeda S, Kim K, Inoko M, Takase T, Tsuji S, Oi M, Takada T, Otsui K, Kimura T. Anticoagulation strategies and long-term recurrence in patients with venous thromboembolism in the era of direct oral anticoagulants. Eur J Intern Med 2023; 118:59-72. [PMID: 37574348 DOI: 10.1016/j.ejim.2023.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND There has been limited data on anticoagulation strategies and long-term recurrence in patients with venous thromboembolism (VTE) in the era of direct oral anticoagulant (DOAC). METHODS The COMMAND VTE Registry-2 is a multicenter retrospective cohort study enrolling 5197 consecutive patients with acute symptomatic VTE between January 2015 and August 2020 among 31 centers in Japan. In this primary report, the entire cohort was divided into 5 groups; major transient risk factors (N = 475, 9.1%), minor transient risk factors (N = 788, 15%), unprovoked (N = 1913, 37%), non-malignant persistent risk factors (N = 514, 9.9%), and active cancer (N = 1507, 29%) groups. RESULTS DOACs were administered in 79% of patients who received oral anticoagulants. Discontinuation of anticoagulant at 1 year was most frequent in the major transient risk factors group (57.2%, 46.3%, 29.1%, 32.0%, and 45.6%). The cumulative 5-year incidence of recurrent VTE was lowest in the major transient risk factors group (2.6%, 6.4%, 11.0%, 12.1%, and 10.1%, P < 0.001). The cumulative 5-year incidence of major bleeding was highest in the active cancer group (9.8%, 11.4%, 11.0%, 15.5%, and 20.4%, P < 0.001). After discontinuation of anticoagulation therapy, the cumulative 5-year incidence of recurrent VTE was highest in the unprovoked group (3.3%, 11.0%, 24.9%, 17.5%, and 11.8%, P < 0.001). CONCLUSIONS In this large real-world VTE registry, anticoagulation strategies and long-term recurrence widely differed depending on the baseline characteristics. Detailed risk stratifications of recurrent VTE could be useful for decision-making of anticoagulation strategies, whereas the bleeding-risk assessment might be especially important in the era of DOAC. CLINICAL TRIAL REGISTRATION URL: http://www.umin.ac.jp/ctr/index.htm Unique identifier: UMIN000044816.
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Affiliation(s)
- Kazuhisa Kaneda
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Nobutaka Ikeda
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Shuhei Tsuji
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Takuma Takada
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunori Otsui
- Department of General Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
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22
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Xu Y, Khan F, Kovacs MJ, Sabri E, Carrier M, Righini M, Kahn SR, Wells PS, Anderson DR, Chagnon I, Crowther MA, White RH, Rodger M, Le Gal G. Serial D-dimers after anticoagulant cessation in unprovoked venous thromboembolism: Data from the REVERSE cohort study. Thromb Res 2023; 231:32-38. [PMID: 37801772 DOI: 10.1016/j.thromres.2023.09.012] [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: 06/16/2023] [Revised: 08/24/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION While several risk stratification tools have been developed to predict the risk of recurrence in patients with an unprovoked venous thromboembolism (VTE), only 1 in 4 patients are categorized as low-risk. Rather than a one-time measure, serial D-dimer assessment holds promise to enhance the prediction of VTE recurrence after oral anticoagulant (OAC) cessation. METHODS Using the REVERSE cohort, we compared VTE recurrence among patients with normal D-dimer levels (<490 ng/mL among males under age 70, <500 ng/mL in others) at OAC cessation and 1-month follow-up, to those with an elevated D-dimer level at either timepoint. We also evaluated VTE recurrence based on absolute increase in D-dimer levels between the two timepoints (e.g., ∆D-dimer) according to quartiles. RESULTS Among 214 patients with serial D-dimer levels measured at OAC cessation and 1-month follow-up, an elevated D-dimer level at either timepoint was associated with a numerically higher risk of recurrent VTE than patients with normal D-dimer levels at both timepoints (6.9 % vs. 4.2 % per year, hazard ratio 1.6; 95 % CI 0.9-2.7). Among women with <2 HERDOO2 criteria, a normal D-dimer level at both timepoints predicted a very low risk of recurrent VTE during follow-up (0.8 % per year, 95 % CI 0.1-2.8). Irrespective of baseline value, recurrent VTE risk was only 3 % per year (95 % CI 1.4-5.6) among patients in the lowest ∆D-dimer quartile. CONCLUSION Serial normal D-dimer levels have the potential to identify patients at a low risk of recurrent VTE. In addition, ∆D-dimer, irrespective of its elevation above cutoff threshold, may predict recurrent VTE.
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Affiliation(s)
- Yan Xu
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada
| | - Faizan Khan
- O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Michael J Kovacs
- Department of Medicine, Western University, London, Ontario, Canada
| | - Elham Sabri
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Righini
- Department of Medicine, University of Geneva, Geneva, Switzerland
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, Canada
| | - Philip S Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard H White
- School of Medicine, University of California Davis, Davis, CA, United States of America
| | - Marc Rodger
- Department of Medicine, University of Geneva, Geneva, Switzerland
| | - Grégoire Le Gal
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
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23
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Baumgartner C, Tritschler T, Aujesky D. Subsegmental Pulmonary Embolism. Hamostaseologie 2023. [PMID: 37871632 DOI: 10.1055/a-2163-3111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023] Open
Abstract
Subsegmental pulmonary embolism (SSPE) is increasingly diagnosed with the growing use and technological advancements of multidetector computed tomography pulmonary angiography. Its diagnosis is challenging, and some presumed SSPE may actually represent imaging artifacts. Indirect evidence and results from small observational studies suggest that SSPE may be more benign than more proximal pulmonary embolism, and may thus not always require treatment. Therefore, guidelines suggest to consider a management strategy without anticoagulation in selected patients with SSPE at low risk of recurrent venous thromboembolism (VTE), in whom proximal deep vein thrombosis is excluded. Recently, a large prospective study among low-risk patients with SSPE who were left untreated showed a higher VTE recurrence risk than initially deemed acceptable by the investigators, and thus was prematurely interrupted after recruitment of 97% of the target population. However, the risk-benefit ratio of anticoagulation for low-risk patients with SSPE remains unclear, and results from randomized trials are needed to answer the question about their optimal management.
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Affiliation(s)
- Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, 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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24
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Johnsen SP, Jensen M, Münster AM, Frost L, Harboe L, Poulsen PB, Albertsen IE, Vinter N, Grove EL, Larsen TB. Small-Area Analysis of Treatment and Clinical Outcomes in Patients with Venous Thromboembolism in Denmark: A Nationwide Cohort Study. Thromb Haemost 2023; 123:978-988. [PMID: 37054981 DOI: 10.1055/a-2073-4336] [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: 04/15/2023]
Abstract
OBJECTIVES To investigate geographical variation in initiation and extended treatment with anticoagulants and clinical outcomes among patients hospitalized with first-time venous thromboembolism (VTE) in Denmark between 2007 and 2018. METHODS Using nationwide health care registries, we identified all patients with a first-time VTE hospital diagnosis supported by imaging data from 2007 to 2018. Patients were grouped according to residential region (5) and municipality (98) at the time of VTE diagnosis. Cumulative incidence of initiation of and extended (beyond 365 days) anticoagulation treatment as well as clinical outcomes, including recurrent VTE, major bleeding, and all-cause death, were assessed. Sex- and age-adjusted relative risks (RRs) of the outcomes were computed when comparing across individual regions and municipalities. Overall geographic variation was quantified by computing the median RR. RESULTS We identified 66,840 patients with a first-time VTE hospitalization. A difference in initiation of anticoagulation treatment of more than 20 percentage points between regions was observed (range: 51.9-72.4%, median RR: 1.09, 95% confidence interval [CI]: 1.04-1.13). Variation was also observed for extended treatment (range: 34.2-46.9%, median RR: 1.08, 95% CI: 1.02-1.14). The cumulative incidence of recurrent VTE ranged from 3.6 to 5.3% at 1 year (median RR: 1.08, 95% CI: 1.01-1.15). The difference remained after 5 years, and variation was also observed for major bleeding (median RR: 1.09, 95% CI: 1.03-1.15), whereas it appeared smaller for all-cause mortality (median RR: 1.03, 95% CI: 1.01-1.05). CONCLUSION Substantial geographical variation in anticoagulation treatment and clinical outcomes occurs in Denmark. These findings indicate a need for initiatives to ensure uniform high-quality care for all VTE patients.
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Affiliation(s)
- Søren P Johnsen
- Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Martin Jensen
- Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Anna Marie Münster
- Unit for Thrombosis Research, Hospital of South West Jutland, Esbjerg, Denmark
| | - Lars Frost
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | | | | | - Ida E Albertsen
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Nicklas Vinter
- Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Erik L Grove
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Torben B Larsen
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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25
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van Hylckama Vlieg MA, Nasserinejad K, Visser C, Bramer WM, Ashrani AA, Bosson JL, Crusan DJ, D'Alessio A, Fluharty ME, Ģībietis V, Hansson PO, Hara N, Jara-Palomares L, Kraaijpoel N, Mahé I, Marshall A, Ogino Y, Otero R, Versmissen J, Klok FA, Kruip MJ, van der Rijt CC, Geijteman EC. The risk of recurrent venous thromboembolism after discontinuation of anticoagulant therapy in patients with cancer-associated thrombosis: a systematic review and meta-analysis. EClinicalMedicine 2023; 64:102194. [PMID: 37731937 PMCID: PMC10507196 DOI: 10.1016/j.eclinm.2023.102194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 09/22/2023] Open
Abstract
Background The optimal duration of anticoagulation in patients with active cancer and venous thromboembolism (VTE) is unknown. Current clinical guidelines advocate anticoagulant therapy for 3-6 months and to continue anticoagulant therapy for as long as the cancer is active. However, an adequate systematic review on the rate of recurrent VTE after discontinuation of anticoagulant therapy has not been performed. Methods For this systemic review and meta-analysis, we searched Embase.com, Medline (Ovid), Web of Science, Cochrane Library, and Google Scholar, from database inception to February 16, 2023, for studies on anticoagulant therapy in patients with cancer and the recurrence of venous thromboembolism after discontinuation of this therapy. We included randomised controlled trials and cohort studies published in English that reported on patients who met the following: cancer and a first VTE, completed at least 3 months of anticoagulant therapy, were followed after discontinuation of anticoagulant therapy, and with symptomatic recurrent VTE as an outcome during follow-up. Study-level data were requested from study authors. The primary outcome was the rate of recurrent VTE after discontinuation of anticoagulant therapy. A Bayesian random-effects meta-analysis was used to estimate the rate of recurrent VTE per 100 person-years for the pooled studies at different time intervals after discontinuation of anticoagulation therapy. We also calculated the cumulative VTE recurrence rate at different time intervals. Forest plots were mapped and the results were summarized by the median and 95% credible interval (CIs). This study was registered with PROSPERO, CRD42021249060. Findings Of 3856 studies identified in our search, 33 studies were identified for inclusion. After requesting study-level data, 14 studies involving 1922 patients with cancer-associated thrombosis were included. The pooled rate of recurrent VTE per 100 person-years after discontinuation of anticoagulant therapy was 14.6 events (95% credible interval 6.5-22.8) in the first three months, decreasing to 1.1 events (95% CI 0.3-2.1) in year 2-3, and 2.2 events (95% CI 0.0-4.4) in year 3-5 after discontinuation of anticoagulant therapy. The cumulative VTE recurrence rate was 28.3% (95% CI 15.6-39.6%) at 1 year; 31.1% (95% CI 16.5-43.8%) at 2 years; 31.9% (95% CI 16.8-45.0%) at 3 years; and 35.0% (95% CI 16.8-47.4%) at 5 years after discontinuation of anticoagulant therapy. Interpretation This meta-analysis demonstrates a high rate of recurrent VTE over time after discontinuation of anticoagulant therapy in patients with cancer-associated thrombosis. Our results support the current clinical guidelines to continue anticoagulant therapy in patients with active cancer. Funding Erasmus MC.
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Affiliation(s)
| | - Kazem Nasserinejad
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Innovative Statistical Consulting, Therapeutics Development Team, Cytel Inc., Massachusetts, USA
| | - Chantal Visser
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wichor M. Bramer
- Medical Library, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Aneel A. Ashrani
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jean-Luc Bosson
- Department of Public Health, Grenoble-Alpes University Hospital and TIMC-IMAG, Grenoble, France
| | - Daniel J. Crusan
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Andrea D'Alessio
- Department of Medical Oncology and Internal Medicine, Policlinico San Marco, Istituti Ospedalieri Bergamaschi, Bergamo, Italy
| | | | - Valdis Ģībietis
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia
| | - Per-Olof Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Region Västra Götaland, Sweden
| | - Nobuhiro Hara
- Department of Cardiology, IMS Katsushika Heart Center, Tokyo, Japan
| | - Luis Jara-Palomares
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
- CIBERES, ISCIII, Madrid, Spain
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC/University of Amsterdam, Amsterdam, the Netherlands
| | - Isabelle Mahé
- Université Paris Cité, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris, INSERM, UMR_ S1140 Innovative Therapies in Haemostasis, Paris, France
| | - Andrea Marshall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Yutaka Ogino
- Department of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Remedios Otero
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
- CIBERES, ISCIII, Madrid, Spain
| | - Jorie Versmissen
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine and Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke J.H.A. Kruip
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | - Eric C.T. Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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26
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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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Pu H, Song J, He Z, Wang F, Hu J, Huang S, Yin M, Li W, Liu X, Lu X, Liu G. Assessing outcomes after thrombectomy with or without iliac vein stenting for young provoked DVT patients with iliac vein stenosis. Thromb J 2023; 21:96. [PMID: 37715246 PMCID: PMC10503137 DOI: 10.1186/s12959-023-00537-9] [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: 05/18/2023] [Accepted: 08/29/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND This study aimed to assess the outcomes of thrombectomy with/without iliac vein stenting for young and transiently provoked DVT patients with iliac vein stenosis. METHODS This is a retrospective analysis of a prospectively collected multicenter database. Acute, transiently provoked DVT patients between 18 and 45 years old with iliac vein stenosis were included. All patients underwent thrombectomy. Outcomes including the Villalta score, the VEINES-QOL score, and adverse events were evaluated. RESULTS The data of 522 patients were collected of whom 75 were included, 58 underwent thrombectomy alone (nonstenting group) and 17 underwent thrombectomy and stenting (stenting group). Within 6 months, the Villalta score of patients in stenting group is lower than that of patients in nonstenting group (6 mo: 0.73 ± 0.77 vs. 1.41 ± 0.56, p = .0004), and the VEINES-QOL score of stenting group is higher than that of nonstenting group (6 mo: 89.00 ± 2.94 vs. 87.47 ± 3.72, p = .2141). At the following follow-ups, the Villalta score (12 mo: 0.56 ± 0.49 vs. 0.60 ± 0.58, p = .8266) and VEINES-QOL score (12 mo: 88.36 ± 2.29 vs. 88.31 ± 3.36, p = .9604) between the two groups are similar. CONCLUSION The stenting group had better efficacy within 6 months after intervention, while there was no significant difference in the symptom, signs, and quality of life between two groups after 6 months within a 2-year follow-up. TRIAL REGISTRATION This study was registered in the Chinese Clinical Trial Registry (Registration Number: ChiCTR2200056073).
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Affiliation(s)
- Hongji Pu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Rd, Shanghai, 200011 P. R. China
- The Vascular Center, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Jumin Song
- Department of Vascular Surgery, Fengcheng Hospital, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Zhijun He
- Department of General Surgery, Shanghai University of Medicine & Health Sciences affiliated Zhoupu Hospital, Shanghai, P. R. China
| | - Fuyin Wang
- Department of Orthopedics, Putuo Hospital of Zhejiang, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhoushan, P. R. China
| | - Jiateng Hu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Rd, Shanghai, 200011 P. R. China
- The Vascular Center, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Sheng Huang
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Rd, Shanghai, 200011 P. R. China
- The Vascular Center, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
- Department of Vascular Surgery, Fengcheng Hospital, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Minyi Yin
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Rd, Shanghai, 200011 P. R. China
- The Vascular Center, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
- Department of Vascular Surgery, Fengcheng Hospital, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Weimin Li
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Rd, Shanghai, 200011 P. R. China
- The Vascular Center, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
- Department of Vascular Surgery, Fengcheng Hospital, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Xiaobing Liu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Rd, Shanghai, 200011 P. R. China
- The Vascular Center, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
- Department of Vascular Surgery, Fengcheng Hospital, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Rd, Shanghai, 200011 P. R. China
- The Vascular Center, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
- Department of Vascular Surgery, Fengcheng Hospital, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Guang Liu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Rd, Shanghai, 200011 P. R. China
- The Vascular Center, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
- Department of Vascular Surgery, Fengcheng Hospital, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
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Mwansa H, Zghouzi M, Barnes GD. Unprovoked Venous Thromboembolism: The Search for the Cause. Med Clin North Am 2023; 107:861-882. [PMID: 37541713 DOI: 10.1016/j.mcna.2023.05.006] [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: 08/06/2023]
Abstract
Venous thromboembolism (VTE) is a common vascular disorder encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). There is no data on global estimates of VTE prevalence and incidence. Most patients with unprovoked VTE require secondary thromboprophylaxis upon the completion of the primary treatment phase if they have no high bleeding risk. Risk prediction models can help identify patients at low VTE recurrence risk who may discontinue anticoagulation upon the completion of the primary treatment phase.
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Affiliation(s)
- Hunter Mwansa
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Mohamed Zghouzi
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA.
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Potere N, Abbate A, Kanthi Y, Carrier M, Toldo S, Porreca E, Di Nisio M. Inflammasome Signaling, Thromboinflammation, and Venous Thromboembolism. JACC Basic Transl Sci 2023; 8:1245-1261. [PMID: 37791298 PMCID: PMC10544095 DOI: 10.1016/j.jacbts.2023.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 10/05/2023]
Abstract
Venous thromboembolism (VTE) remains a major health burden despite anticoagulation advances, suggesting incomplete management of pathogenic mechanisms. The NLRP3 (NACHT-, LRR- and pyrin domain-containing protein 3) inflammasome, interleukin (IL)-1, and pyroptosis are emerging contributors to the inflammatory pathogenesis of VTE. Inflammasome pathway activation occurs in patients with VTE. In preclinical models, inflammasome signaling blockade reduces venous thrombogenesis and vascular injury, suggesting that this therapeutic approach may potentially maximize anticoagulation benefits, protecting from VTE occurrence, recurrence, and ensuing post-thrombotic syndrome. The nonselective NLRP3 inhibitor colchicine and the anti-IL-1β agent canakinumab reduce atherothrombosis without increasing bleeding. Rosuvastatin reduces primary venous thrombotic events at least in part through lipid-lowering independent mechanisms, paving the way to targeted anti-inflammatory strategies in VTE. This review outlines recent preclinical and clinical evidence supporting a role for inflammasome pathway activation in venous thrombosis, and discusses the, yet unexplored, therapeutic potential of modulating inflammasome signaling to prevent and manage VTE.
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Affiliation(s)
- Nicola Potere
- Department of Medicine and Ageing Sciences, “G. d'Annunzio” University, Chieti, Italy
| | - Antonio Abbate
- Robert M. Berne Cardiovascular Research Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Yogendra Kanthi
- Vascular Thrombosis & Inflammation Section, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Stefano Toldo
- Robert M. Berne Cardiovascular Research Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Ettore Porreca
- Department of Innovative Technologies in Medicine and Dentistry, School of Medicine and Health Sciences, “G. d'Annunzio” University, Chieti, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, “G. d'Annunzio” University, Chieti, Italy
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Della Corte V, Riolo R, Scaglione S, Pecoraro R, Tuttolomondo A. The Role of Biomarkers, Metabolomics, and COVID-19 in Venous Thromboembolism-A Review of Literature. Int J Mol Sci 2023; 24:13411. [PMID: 37686216 PMCID: PMC10488048 DOI: 10.3390/ijms241713411] [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: 05/31/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
In recent years, the field of venous thromboembolism has undergone numerous innovations, starting from the recent discoveries on the role of biomarkers, passing through the role of metabolomics in expanding our knowledge on pathogenic mechanisms, which have opened up new therapeutic targets. A variety of studies have contributed to characterizing the metabolic phenotype that occurs in venous thromboembolism, identifying numerous pathways that are altered in this setting. Among these pathways are the metabolism of carnitine, tryptophan, purine, and fatty acids. Furthermore, new evidence has emerged with the recent COVID-19 pandemic. Hypercoagulability phenomena induced by this viral infection appear to be related to altered von Willebrand factor activity, alteration of the renin-angiotensin-aldosterone system, and dysregulation of both innate and adaptive immunity. This is the first literature review that brings together the most recent evidence regarding biomarkers, metabolomics, and COVID-19 in the field of venous thromboembolism, while also mentioning current therapeutic protocols.
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Affiliation(s)
- Vittoriano Della Corte
- Internal Medicine and Stroke Care Ward, Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialities (PROMISE) “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy
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31
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Mitchell A, Hill B. The vascular system and associated disorders. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:718-724. [PMID: 37596081 DOI: 10.12968/bjon.2023.32.15.718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
The vascular system, also called the circulatory system, is made up of the vessels that carry blood and lymph fluid through the body. The arteries and veins carry blood all over the body, sending oxygen and nutrients to the body tissues and taking away waste materials. This is a complex system in the body and can be affected by diseases with different pathogenic mechanisms. This article describes the pathophysiology of the main diseases of arteries and the venous system.
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Affiliation(s)
- Aby Mitchell
- Senior Lecturer in Nursing Education, Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London
| | - Barry Hill
- Associate Professor of Nursing and Critical Care, Northumbria University, Newcastle upon Tyne
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32
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Zhao Y, Luo Y, Cheng Y, Wang H, Du H, Sun J, Xu M, Xiong W. Optimal length of oral anticoagulant treatment for maximum benefit within 5 years after discontinuation of oral anticoagulants in patients with acute pulmonary embolism who require secondary thromboprophylaxis. BMJ Open Respir Res 2023; 10:e001856. [PMID: 37597971 PMCID: PMC10441053 DOI: 10.1136/bmjresp-2023-001856] [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: 05/30/2023] [Accepted: 08/11/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Extended oral anticoagulant (OA) use is recommended in patients with acute pulmonary embolism (PE) who require secondary thromboprophylaxis. Nevertheless, the optimal length of OA use for the maximum long-term benefit in this patient population has been undefined to date. METHODS A retrospective study was performed to explore the role of different length of overall OA use (group 1 (≥1 year of OA use and <2 years of OA use), group 2 (≥2 years of OA use and <3 years of OA use), group 3 (≥ 3 years of OA use)) in outcomes within 5 years after OA discontinuation in patients with acute PE, who required secondary thromboprophylaxis. The primary outcome was mortality rates. The secondary outcomes comprised venous thromboembolism (VTE) recurrence, major bleeding during OA use and net clinical benefit. Net clinical benefit was defined as the composite of recurrent VTE and major bleeding. RESULTS For a total of 385 patients in group 1 (n=220), group 2 (n=110) and group 3 (n=55), the PE-related mortality in group 1 was higher than that in group 2 (p=0.034) and 3 (p=0.040), respectively, whereas were similar between groups 2 and 3 (p=1.000). The net clinical benefit in group 1 was less than that in group 2 (p=0.024), whereas similar with that in group 3 (p=0.526). The net clinical benefit was comparable between groups 2 and 3 (p=0.716). The length of OA use was positively associated with major bleeding (HR, 2.510 (0.293 to 3.485), p=0.001), whereas negatively associated with PE-related mortality (HR, 0.668 (0.196 to 2.832), p=0.025) and VTE recurrence (HR, 0.694 (0.174 to 2.300), p=0.036), respectively. The sensitivity and specificity of the length of OA use for the tendency of PE-related mortality was 70.2% and 46.2%, respectively. The area under the curve (AUC) was 0.654 (0.514 to 0.793) (p=0.029). The sensitivity and specificity of the length of OA use for the tendency of net clinical benefit was 86.8% and 64.3%, respectively. The AUC was 0.628 (0.565 to 0.690) (p<0.001) CONCLUSIONS: For patients with acute PE who require secondary thromboprophylaxis, 2 to 3 years (30 months preferred) of overall OA use after a diagnosis of acute PE could be an optimal length to achieve maximum benefit within 5 years after OA discontinuation.
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Affiliation(s)
- Yunfeng Zhao
- Department of Pulmonary and Critical Care Medicine, Punan Hospital, Pudong New District, Shanghai, China
| | - Yong Luo
- Department of Pulmonary and Critical Care Medicine, Chongming Hospital, Shanghai University of Medicine and Health Science, Shanghai, China
| | - Yi Cheng
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hongwei Wang
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - He Du
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jinyuan Sun
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mei Xu
- Department of General Practice, North Bund Community Health Service Center, Hongkou District, Shanghai, China
| | - Wei Xiong
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Becattini C, Agnelli G. Residual Thrombosis: Still Relevant in the Direct Oral Anticoagulant (DOAC) Era? Thromb Haemost 2023; 123:747-749. [PMID: 37236228 DOI: 10.1055/a-2102-0376] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
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Hu Y, Liu S, Wang L, Liu Y, Zhang D, Zhao Y. Treatment-free survival after discontinuation of immune checkpoint inhibitors in mNSCLC: a systematic review and meta-analysis. Front Immunol 2023; 14:1202822. [PMID: 37520573 PMCID: PMC10373084 DOI: 10.3389/fimmu.2023.1202822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
Background Recent research has suggested that patients with metastatic non-small cell lung cancer (mNSCLC) can achieve ongoing response after discontinuation of immune checkpoint inhibitor (ICI), but the best time to discontinue and the factors influencing efficacy remain unknown. Method A systematic search was performed for prospective clinical trials in patients with mNSCLC treated with ICIs published up to July 10, 2022. Eligible studies reported treatment-free survival (TFS) after discontinuation of ICI in partial objective responders. We calculated objective response rate (ORR) and TFS using random-effects models with respective 95% confidence intervals (Cis), and performed subgroup analyses to discuss the specific associations between ORR and TFS and the associated influencing factors. Results Across the 26 cohorts (3833 patients) included, the weighted mean ORR for all patients was 29.30% (95% CI 24.28% to 34.57%), with ICI plus chemotherapy (48.83%, 95% CI 44.36% to 53.30%) significantly higher than monotherapy (23.40%, 95% CI 18.53% to 28.62%). 395 patients were all patients who were complete or partial responders in the study, 194 discontinued ICI treatment, and nearly 35.5% achieved a durable response. No significant differences in TFS were found between subgroups according to the ICI regimen classification. Four cohorts of patients who completed 35 courses of treatment showed high levels of pooled TFS at 6 (80.18%, 95% CI 53.03% to 97.87%) and 12 months (66.98%, 95% CI 46.90% to 84.47%). Three cohorts of patients discontinued ICI treatment due to treatment-related adverse events (TRAEs) with the TFS rates at 6 (76.98%, 95% CI 65.79% to 86.65%) and 12 months (64.79%, 95% CI 50.20% to 78.19%). Conclusion Patients with mNSCLC were able to achieve ongoing responses after discontinuation of ICI. In conclusion, the results of this meta-analysis indicate that different treatment regimens, different drugs or different treatment durations may have an impact on TFS.
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Affiliation(s)
| | | | | | | | | | - Yinlong Zhao
- Department of Nuclear Medicine, The Second Hospital of Jilin University, Changchun, China
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Li W, Cao S, Liu B, Zhang Z, Liu Z, Feng H. Influence of the 4G/5G polymorphism of plasminogen activator inhibitor-1 gene in acute unprovoked deep vein thrombosis and residual vein thrombosis. J Vasc Surg Venous Lymphat Disord 2023; 11:748-753. [PMID: 36907506 DOI: 10.1016/j.jvsv.2023.02.007] [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: 11/29/2022] [Revised: 02/04/2023] [Accepted: 02/07/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Plasminogen activator inhibitor-1 (PAI-1) is an important inhibitor of plasminogen activator, but the role of the PAI-1 4G/5G polymorphism in deep vein thrombosis (DVT) has been contradictory. In this study, we investigated the distribution of the PAI-1 4G/5G genotype in Chinese patients with DVT compared with healthy controls and the association between the PAI-1 4G/5G genotype and the persistence of residual venous occlusion (RVO) after different treatments. METHODS The PAI-1 4G/5G genotype was determined by fluorescence in situ hybridization in 108 patients with unprovoked DVT and 108 healthy controls. The patients with DVT were treated with catheter-based therapy or anticoagulation only. RVO was assessed by duplex sonography during the follow-up. RESULTS Thirty-two patients (29.6%) were homozygous for 4G (4G/4G), 62 patients (57.4%) were heterozygous for 4G/5G, and 14 patients (13%) were homozygous for 5G (5G/5G). No significant difference in genotype frequency was found between patients with DVT and controls. A total of 86 patients completed follow-up of ultrasound examination with a mean follow-up of 13.4 ±7.2 months. The results of patients with RVO were significantly different between homozygous 4G carriers (76.9%), heterozygous 4G/5G (58.3%), and homozygous carriers of 5G (33.3%) (P <.05) at the end of follow-up. Catheter-based therapy showed a better result in patients who were noncarriers of 4G (P = .045). CONCLUSIONS The PAI-1 4G/5G genotype was not a relevant predictor for DVT in Chinese patients, but is a risk factor for persistent RVO after idiopathic DVT.
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Affiliation(s)
- Wenrui Li
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Saisai Cao
- Department of Plastic Surgery, Peking University People's Hospital, Beijing, China
| | - Bin Liu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhiwen Zhang
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Liu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hai Feng
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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Khan F, Coyle D, Thavorn K, van Katwyk S, Tritschler T, Hutton B, Le Gal G, Rodger MA, Fergusson DA. Indefinite Anticoagulant Therapy for First Unprovoked Venous Thromboembolism : A Cost-Effectiveness Study. Ann Intern Med 2023. [PMID: 37364263 DOI: 10.7326/m22-3559] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Clinical practice guidelines recommend indefinite anticoagulation for a first unprovoked venous thromboembolism (VTE). OBJECTIVE To estimate the benefit-harm tradeoffs of indefinite anticoagulation in patients with a first unprovoked VTE. DESIGN Markov modeling study. DATA SOURCES Systematic reviews and meta-analyses for the long-term risks and case-fatality rates of recurrent VTE and major bleeding. Published literature for costs, quality of life, and other clinical events. TARGET POPULATION Patients with a first unprovoked VTE who have completed 3 to 6 months of initial anticoagulant treatment. TIME HORIZON Lifetime. PERSPECTIVE Canadian health care public payer. INTERVENTION Indefinite anticoagulation with direct oral anticoagulants. OUTCOME MEASURES Recurrent VTE events, major bleeding events, costs in 2022 Canadian dollars (CAD), and quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS When compared with discontinuing anticoagulation after initial treatment in a hypothetical cohort of 1000 patients aged 55 years, indefinite anticoagulation prevented 368 recurrent VTE events, which included 14 fatal pulmonary emboli, but induced an additional 114 major bleeding events, which included 30 intracranial hemorrhages and 11 deaths from bleeding. Indefinite anticoagulation cost CAD $16 014 more per person and did not increase QALYs (-0.075 per person). RESULTS OF SENSITIVITY ANALYSIS Model results were most sensitive to the case-fatality rate of major bleeding and the annual risk for major bleeding during extended anticoagulation. LIMITATION The model assumed that risks for recurrent VTE and major bleeding measured in clinical trials at 1 year remained constant during extended anticoagulation. CONCLUSION Clinicians should use shared decision making to incorporate individual patient preferences and values when considering treatment duration for unprovoked VTE. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Faizan Khan
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada (F.K.)
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada (D.C.)
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa; and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (K.T.)
| | | | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T.)
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (B.H.)
| | - Grégoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute; and Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (G.L.G.)
| | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, Québec, Canada (M.A.R.)
| | - Dean A Fergusson
- School of Epidemiology and Public Health, University of Ottawa; Clinical Epidemiology Program, Ottawa Hospital Research Institute; and Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (D.A.F.)
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Lian TY, Cao Y. Prediction of recurrent venous thromboembolism: The writing is on the wall. J Thromb Haemost 2023; 21:1420-1422. [PMID: 37179071 DOI: 10.1016/j.jtha.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Tian-Yu Lian
- Medical Science Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunshan Cao
- Department of Cardiology, Pulmonary Vascular Disease Center, Gansu Provincial Hospital, Lanzhou, China.
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Weinberg I, Elgendy IY, Dicks AB, Marchena PJ, Malý R, Francisco I, Pedrajas JM, Font C, Hernández-Blasco L, Monreal M. Comparison of Presentation, Treatment, and Outcomes of Venous Thromboembolism in Long-Term Immobile Patients Based on Age. J Gen Intern Med 2023; 38:1877-1886. [PMID: 36750505 PMCID: PMC10271988 DOI: 10.1007/s11606-023-08058-x] [Citation(s) in RCA: 2] [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: 07/26/2022] [Accepted: 01/26/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Chronic immobility is prevalent, especially as people age. However, little is known about venous thromboembolism (VTE) outcomes in this population. OBJECTIVE To compare the presentation, treatment, and outcomes in chronically immobile (>8 weeks) patients older vs. younger than 75 who presented with VTE. DESIGN An observational international registry of patients with VTE. PARTICIPANTS Patients with acute VTE from the "Registro Informatizado Enfermedad TromboEmbolica" (RIETE) registry who were chronically immobile. MAIN MEASURES Baseline characteristics, presenting signs and symptoms, treatment and outcomes including major bleeding, recurrent VTE, and mortality. KEY RESULTS Among 4612 immobile patients (mean age 75.7 years, 34% male), 2127 (46%) presented with pulmonary embolism (PE). Patients >75 years presented more often with dyspnea (44% vs. 38%) or altered mental status (23% vs. 8.1%) and less often with chest pain (13% vs. 18%). The median duration of anticoagulation was shorter in older compared with younger patients [126 vs. 169 days]. During the first 90 days of anticoagulation, major bleeding (4.0% vs. 2.2%), PE-related death (2.5% vs. 1.1%), and bleeding-related death (0.78% vs. 0.26%) occurred more frequently among older patients. In 3550 patients who received anticoagulation beyond 90 days, older patients had more major bleeding [4.23 vs. 2.21 events per 100 patient years]. After anticoagulation discontinuation, recurrent VTE and major bleeding occurred in 11.8 and 9.25 and 1.49 and 0.69 events per 100 patient years, respectively, both in similar rates in both groups. In multivariable analysis, after stopping anticoagulation, VTE recurrence was inversely associated with long-term facility residence [OR 0.51 (0.28-0.92)], anemia [OR 0.63 (0.42-0.95)], and anticoagulation duration < 90 days [OR 0.38 (0.27-0.54)]. CONCLUSIONS Chronically immobilized patients older than 75 years presenting with VTE experience a high rate of adverse events including major bleeding and recurrent VTE. When considering treatment beyond 90 days, we should account for bleeding, recurrence risk, and associated mortality.
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Affiliation(s)
- Ido Weinberg
- Vascular Medicine, Cardiology Division, Massachusetts General Hospital, 55 Fruit Street, GRB-852G, Boston, MA, 02114, USA.
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Andrew B Dicks
- Department of Vascular Surgery, Prisma Health/USC School of Medicine Greenville, Greenville, SC, USA
| | - Pablo J Marchena
- Department of Internal Medicine and Emergency, Parc Sanitari Sant Joan de Déu-Hospital General, Barcelona, Spain
| | - Radovan Malý
- Department of Cardiovascular Medicine I, Charles University in Prague, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Iria Francisco
- Department of Internal Medicine, Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain
| | - José M Pedrajas
- Department of Internal Medicine, Hospital Clínico San Carlos, Madrid, Spain
| | - Carme Font
- Department of Medical Oncology, Hospital Clínic, Barcelona, Spain
| | - Luis Hernández-Blasco
- Department of Pneumonology, Hospital General Universitario de Alicante, ISABIAL, UMH, Alicante, Spain
| | - Manuel Monreal
- Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Murcia, Spain
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Alberts M, Zhdanava M, Pilon D, Caron-Lapointe G, Lefebvre P, Bookhart B, Kharat A. Venous thromboembolism recurrence among one-and-done direct oral anticoagulant users: a retrospective longitudinal study. Int J Clin Pharm 2023:10.1007/s11096-023-01589-7. [PMID: 37204616 PMCID: PMC10366276 DOI: 10.1007/s11096-023-01589-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/30/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are the American Society of Hematology guideline-recommended treatment for venous thromboembolism (VTE) in the United States (US). AIM To compare risk of VTE recurrence between patients who, following the first fill, discontinued ("one-and-done") versus those who continued ("continuers") DOACs. METHOD Open source US insurance claims data (04/1/2017 to 10/31/2020) were used to select adult patients with VTE initiated on DOACs (index date). Patients with only one DOAC claim during the 45-day landmark period (starting on the index date) were classified as one-and-done and the remaining as continuers. Inverse probability of treatment weighting was used to reweight baseline characteristics between cohorts. VTE recurrence based on the first post-index deep vein thrombosis or pulmonary embolism event was compared using weighted Kaplan-Meier and Cox proportional hazard models from landmark period end to clinical activity or data end. RESULTS 27% of patients initiating DOACs were classified as one-and-done. After weighting, 117,186 and 116,587 patients were included in the one-and-done and continuer cohorts, respectively (mean age 60 years; 53% female; mean follow-up 15 months). After 12 months of follow-up, the probability of VTE recurrence was 3.99% and 3.36% in the one-and-done and continuer cohorts; the risk of recurrence was 19% higher in the one-and-done cohort (hazard ratio [95% confidence interval] = 1.19 [1.13, 1.25]). CONCLUSION Substantial proportion of patients discontinued DOAC therapy after the first fill, which was associated with significantly higher risk of VTE recurrence. Early access to DOACs should be encouraged to reduce the risk of VTE recurrence.
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Affiliation(s)
| | | | | | | | | | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
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ten Cate V, Prochaska JH, Schulz A, Nagler M, Robles AP, Jurk K, Koeck T, Rapp S, Düber C, Münzel T, Konstantinides SV, Wild PS. Clinical profile and outcome of isolated pulmonary embolism: a systematic review and meta-analysis. EClinicalMedicine 2023; 59:101973. [PMID: 37152363 PMCID: PMC10154961 DOI: 10.1016/j.eclinm.2023.101973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
Background Isolated pulmonary embolism (PE) appears to be associated with a specific clinical profile and sequelae compared to deep vein thrombosis (DVT)-associated PE. The objective of this study was to identify clinical characteristics that discriminate both phenotypes, and to characterize their differences in clinical outcome. Methods We performed a systematic review and meta-analysis of studies comparing PE phenotypes. A systematic search of the electronic databases PubMed and CENTRAL was conducted, from inception until January 27, 2023. Exclusion criteria were irrelevant content, inability to retrieve the article, language other than English or German, the article comprising a review or case study/series, and inappropriate study design. Data on risk factors, clinical characteristics and clinical endpoints were pooled using random-effects meta-analyses. Findings Fifty studies with 435,768 PE patients were included. In low risk of bias studies, 30% [95% CI 19-42%, I 2 = 97%] of PE were isolated. The Factor V Leiden [OR: 0.47, 95% CI 0.37-0.58, I 2 = 0%] and prothrombin G20210A mutations [OR: 0.55, 95% CI 0.41-0.75, I 2 = 0%] were significantly less prevalent among patients with isolated PE. Female sex [OR: 1.30, 95% CI 1.17-1.45, I 2 = 79%], recent invasive surgery [OR: 1.31, 95% CI 1.23-1.41, I 2 = 65%], a history of myocardial infarction [OR: 2.07, 95% CI 1.85-2.32, I 2 = 0%], left-sided heart failure [OR: 1.70, 95% CI 1.37-2.10, I 2 = 76%], peripheral artery disease [OR: 1.36, 95% CI 1.31-1.42, I 2 = 0%] and diabetes mellitus [OR: 1.23, 95% CI 1.21-1.25, I 2 = 0%] were significantly more frequently represented among isolated PE patients. In a synthesis of clinical outcome data, the risk of recurrent VTE in isolated PE was half that of DVT-associated PE [RR: 0.55, 95% CI 0.44-0.69, I 2 = 0%], while the risk of arterial thrombosis was nearly 3-fold higher [RR: 2.93, 95% CI 1.43-6.02, I 2 = 0%]. Interpretation Our findings suggest that isolated PE appears to be a specific entity that may signal a long-term risk of arterial thrombosis. Randomised controlled trials are necessary to establish whether alternative treatment regimens are beneficial for this patient subgroup. Funding None.
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Affiliation(s)
- Vincent ten Cate
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jürgen H. Prochaska
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Schulz
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Markus Nagler
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Alejandro Pallares Robles
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - Kerstin Jurk
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thomas Koeck
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Steffen Rapp
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - Christoph Düber
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thomas Münzel
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Cardiology – Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stavros V. Konstantinides
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, University General Hospital, Greece
| | - Philipp S. Wild
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Institute of Molecular Biology (IMB), Mainz, Germany
- Corresponding author. Clinical Epidemiology, Preventive Cardiology and Preventive Medicine, Department of Cardiology, Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.
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Alberts M, Zhdanava M, Pilon D, Caron-Lapointe G, Lefebvre P, Bookhart B, Kharat A. Venous Thromboembolism Recurrence Among Patients Who Abandon Oral Anticoagulant Therapy in the USA: A Retrospective Longitudinal Study. Adv Ther 2023; 40:1750-1764. [PMID: 36823479 PMCID: PMC10070307 DOI: 10.1007/s12325-022-02391-z] [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: 10/07/2022] [Accepted: 11/27/2022] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Among patients with venous thromboembolism (VTE), direct oral anticoagulants (DOACs) are recommended for preventing thromboembolic recurrence, complications, and mortality. This study compared the risk of VTE recurrence among patients who abandoned their first DOAC fill ("abandoners") relative to patients who did not ("non-abandoners"). METHODS Adults with VTE who were prescribed DOACs were selected from Symphony Health, an ICON plc Company, PatientSource®, April 1, 2017 to October 31, 2020. Patients who abandoned their first (index) DOAC fill were classified as abandoners and patients with an approved index DOAC fill as non-abandoners. Baseline characteristics were balanced between cohorts using inverse probability of treatment weighting. VTE recurrence based on the first post-index VTE event (deep vein thrombosis or pulmonary embolism) was ascertained and compared between cohorts using weighted Kaplan-Meier and Cox proportional hazard models during the follow-up period (i.e., index DOAC fill date to end of clinical activity or data availability). RESULTS After weighting, 152,443 and 153,931 patients comprised the abandoner and non-abandoner cohorts, respectively (mean age 60 years; 53% female; mean follow-up duration 15 months). After 3 months of follow-up, the probability of VTE recurrence was 7.74% in the abandoner cohort and 4.65% in the non-abandoner cohort; the risk of recurrence was 72% higher in the abandoner versus non-abandoner cohort (hazard ratio [95% confidence interval] 1.72 [1.64, 1.82]; p < 0.0001). At 12 months, the probability of recurrence was 9.91% in the abandoner cohort and 6.89% in the non-abandoner cohort; the risk of recurrence was 53% higher in the abandoner versus non-abandoner cohort (1.53 [1.46, 1.61]; p < 0.0001). CONCLUSION Patients abandoning the first DOAC fill had significantly higher risk of VTE recurrence compared to patients who did not abandon the first fill. Ensuring proper access and encouraging early and continuous use of DOACs may help prevent severe and fatal complications among patients with VTE.
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Affiliation(s)
| | - Maryia Zhdanava
- Analysis Group, Inc, 1190 Avenue des Canadiens-de-Montréal, Suite 1500, Montréal, QC H3B 0G7 Canada
| | - Dominic Pilon
- Analysis Group, Inc, 1190 Avenue des Canadiens-de-Montréal, Suite 1500, Montréal, QC H3B 0G7 Canada
| | - Gabrielle Caron-Lapointe
- Analysis Group, Inc, 1190 Avenue des Canadiens-de-Montréal, Suite 1500, Montréal, QC H3B 0G7 Canada
| | - Patrick Lefebvre
- Analysis Group, Inc, 1190 Avenue des Canadiens-de-Montréal, Suite 1500, Montréal, QC H3B 0G7 Canada
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de Wit K, Ikesaka R, Chan N, Germini F. In reply. Ann Emerg Med 2023; 81:517-518. [PMID: 36948692 DOI: 10.1016/j.annemergmed.2022.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 03/24/2023]
Affiliation(s)
- Kerstin de Wit
- Departments of Emergency Medicine and Medicine, Queens University, Kingston, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rick Ikesaka
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Noel Chan
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Federico Germini
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Bakhsh E, Shaban M, Al Subaie S, Al Moshary M, AlSheef M. Exploring the Clinical Efficacy of Venous Thromboembolism Management in Saudi Arabian Hospitals: An Insight into Patient Outcomes. J Pers Med 2023; 13:jpm13040612. [PMID: 37108998 PMCID: PMC10141716 DOI: 10.3390/jpm13040612] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Venous thromboembolism (VTE) is a common condition that can recur, leading to multiple therapeutic strategies to prevent it. The aim of this study was to explore the clinical efficacy of VTE management in Saudi Arabian hospitals and to gain insights into patient outcomes. A retrospective single-center study was conducted that retrieved the data of all patients with VTE registered from January 2015 to December 2017. Patients of all age groups were included if they attended the thrombosis clinic at KFMC during the data collection period. The study analyzed the various therapeutic strategies used for VTE and their effect on patient outcomes. The results showed that 14.6% of the patients had provoked VTE, with a higher incidence among females and younger patients. The most commonly prescribed treatment was combination therapy, followed by warfarin, oral anticoagulants, and factor Xa inhibitor. Despite being prescribed treatment, 74.9% of the patients experienced recurrence of VTE. There was no associated risk factor for recurrence in 79.9% of the patients. Thrombolytic therapy and catheter-directed thrombolysis were found to be associated with a lower risk of VTE recurrence, while anticoagulation therapy, including oral anticoagulants, was associated with a higher risk. Vitamin K antagonist (warfarin) and factor Xa inhibitor (rivaroxaban) had a significant positive association with VTE recurrence, while the use of a direct thrombin inhibitor (dabigatran) showed a lower risk, but it was not statistically significant. The results of the study highlight the need for further research to determine the most effective therapeutic strategy for VTE management in Saudi Arabian hospitals. The findings also suggest that anticoagulation therapy, including oral anticoagulants, may increase the risk of VTE recurrence, while thrombolytic therapy and catheter-directed thrombolysis may lower the risk.
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Affiliation(s)
- Ebtisam Bakhsh
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11564, Saudi Arabia
| | - Mostafa Shaban
- Community Health Nursing Department, College of Nursing, Jouf University, Sakaka 72388, Saudi Arabia
| | - Sarah Al Subaie
- Medical Laboratory Scientific Officer, Ministry of Health, Riyadh 11671, Saudi Arabia
| | - May Al Moshary
- Department of Basic Science, College of Medicine, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
| | - Mohammed AlSheef
- Department of Medical Specialties, King Fahad Medical City, Riyadh 11671, Saudi Arabia
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Johnson MS, Spies JB, Scott KT, Kato BS, Mu X, Rectenwald JE, White RA, Lewandowski RJ, Khaja MS, Zuckerman DA, Casciani T, Gillespie DL. Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE): Outcomes at 12 months. J Vasc Surg Venous Lymphat Disord 2023; 11:573-585.e6. [PMID: 36872169 DOI: 10.1016/j.jvsv.2022.11.002] [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: 08/31/2022] [Revised: 10/11/2022] [Accepted: 11/20/2022] [Indexed: 02/25/2023]
Abstract
OBJECTIVE To determine the safety and effectiveness of vena cava filters (VCFs). METHODS A total of 1429 participants (62.7 ± 14.7 years old; 762 [53.3% male]) consented to enroll in this prospective, nonrandomized study at 54 sites in the United States between October 10, 2015, and March 31, 2019. They were evaluated at baseline and at 3, 6, 12, 18, and 24 months following VCF implantation. Participants whose VCFs were removed were followed for 1 month after retrieval. Follow-up was performed at 3, 12, and 24 months. Predetermined composite primary safety (freedom from perioperative serious adverse events [AEs] and from clinically significant perforation, VCF embolization, caval thrombotic occlusion, and/or new deep vein thrombosis [DVT] within 12-months) and effectiveness (composite comprising procedural and technical success and freedom from new symptomatic pulmonary embolism [PE] confirmed by imaging at 12-months in situ or 1 month postretrieval) end points were assessed. RESULTS VCFs were implanted in 1421 patients. Of these, 1019 (71.7%) had current DVT and/or PE. Anticoagulation therapy was contraindicated or had failed in 1159 (81.6%). One hundred twenty-six (8.9%) VCFs were prophylactic. Mean and median follow-up for the entire population and for those whose VCFs were not removed was 243.5 ± 243.3 days and 138 days and 332.6 ± 290 days and 235 days, respectively. VCFs were removed from 632 (44.5%) patients at a mean of 101.5 ± 72.2 days and median 86.3 days following implantation. The primary safety end point and primary effectiveness end point were both achieved. Procedural AEs were uncommon and usually minor, but one patient died during attempted VCF removal. Excluding strut perforation greater than 5 mm, which was demonstrated on 31 of 201 (15.4%) patients' computed tomography scans available to the core laboratory, and of which only 3 (0.2%) were deemed clinically significant by the site investigators, VCF-related AEs were rare (7 of 1421, 0.5%). Postfilter, venous thromboembolic events (none fatal) occurred in 93 patients (6.5%), including DVT (80 events in 74 patients [5.2%]), PE (23 events in 23 patients [1.6%]), and/or caval thrombotic occlusions (15 events in 15 patients [1.1%]). No PE occurred in patients following prophylactic placement. CONCLUSIONS Implantation of VCFs in patients with venous thromboembolism was associated with few AEs and with a low incidence of clinically significant PEs.
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Affiliation(s)
- Matthew S Johnson
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN.
| | - James B Spies
- Department of Radiology, MedStar Georgetown University Hospital, Washington, DC
| | | | | | | | - John E Rectenwald
- Section of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - Rodney A White
- Division of Vascular Surgery, Harbor-UCLA Medical Center, Torrance, CA; Heart and Vascular Institute, Long Beach Memorial Care, Long Beach, CA
| | | | - Minhaj S Khaja
- Division of Vascular and Interventional Radiology, University of Michigan, Ann Arbor, MI; Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, VA
| | - Darryl A Zuckerman
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO; Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Thomas Casciani
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN
| | - David L Gillespie
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Brockton, MA
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Johnson MS, Spies JB, Scott KT, Kato BS, Mu X, Rectenwald JE, White RA, Lewandowski RJ, Khaja MS, Zuckerman DA, Casciani T, Gillespie DL. Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE): Outcomes at 12 months. J Vasc Interv Radiol 2023; 34:517-528.e6. [PMID: 36841633 DOI: 10.1016/j.jvir.2022.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/05/2022] [Accepted: 11/20/2022] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVE To determine the safety and effectiveness of vena cava filters (VCFs). METHODS A total of 1429 participants (62.7 ± 14.7 years old; 762 [53.3% male]) consented to enroll in this prospective, nonrandomized study at 54 sites in the United States between October 10, 2015, and March 31, 2019. They were evaluated at baseline and at 3, 6, 12, 18, and 24 months following VCF implantation. Participants whose VCFs were removed were followed for 1 month after retrieval. Follow-up was performed at 3, 12, and 24 months. Predetermined composite primary safety (freedom from perioperative serious adverse events [AEs] and from clinically significant perforation, VCF embolization, caval thrombotic occlusion, and/or new deep vein thrombosis [DVT] within 12-months) and effectiveness (composite comprising procedural and technical success and freedom from new symptomatic pulmonary embolism [PE] confirmed by imaging at 12-months in situ or 1 month postretrieval) end points were assessed. RESULTS VCFs were implanted in 1421 patients. Of these, 1019 (71.7%) had current DVT and/or PE. Anticoagulation therapy was contraindicated or had failed in 1159 (81.6%). One hundred twenty-six (8.9%) VCFs were prophylactic. Mean and median follow-up for the entire population and for those whose VCFs were not removed was 243.5 ± 243.3 days and 138 days and 332.6 ± 290 days and 235 days, respectively. VCFs were removed from 632 (44.5%) patients at a mean of 101.5 ± 72.2 days and median 86.3 days following implantation. The primary safety end point and primary effectiveness end point were both achieved. Procedural AEs were uncommon and usually minor, but one patient died during attempted VCF removal. Excluding strut perforation greater than 5 mm, which was demonstrated on 31 of 201 (15.4%) patients' computed tomography scans available to the core laboratory, and of which only 3 (0.2%) were deemed clinically significant by the site investigators, VCF-related AEs were rare (7 of 1421, 0.5%). Postfilter, venous thromboembolic events (none fatal) occurred in 93 patients (6.5%), including DVT (80 events in 74 patients [5.2%]), PE (23 events in 23 patients [1.6%]), and/or caval thrombotic occlusions (15 events in 15 patients [1.1%]). No PE occurred in patients following prophylactic placement. CONCLUSIONS Implantation of VCFs in patients with venous thromboembolism was associated with few AEs and with a low incidence of clinically significant PEs.
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Affiliation(s)
- Matthew S Johnson
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN.
| | - James B Spies
- Department of Radiology, MedStar Georgetown University Hospital, Washington, DC
| | | | | | | | - John E Rectenwald
- Section of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - Rodney A White
- Division of Vascular Surgery, Harbor-UCLA Medical Center, Torrance, CA; Heart and Vascular Institute, Long Beach Memorial Care, Long Beach, CA
| | | | - Minhaj S Khaja
- Division of Vascular and Interventional Radiology, University of Michigan, Ann Arbor, MI; Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, VA
| | - Darryl A Zuckerman
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO; Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Thomas Casciani
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN
| | - David L Gillespie
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Brockton, MA
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Niyomsri S, Nimworapan M, Wongcharoen W, Dilokthornsakul P. Economic Evaluation of Direct Oral Anticoagulants Compared to Warfarin for Venous Thromboembolism in Thailand: A Cost-Utility Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3176. [PMID: 36833871 PMCID: PMC9961808 DOI: 10.3390/ijerph20043176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/09/2023] [Accepted: 02/09/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have been used for venous thromboembolism (VTE) in Thailand. However, they have not been listed in the National List of Essential Medicines (NLEM). A cost-effectiveness analysis is needed to aid policymakers in deciding whether DOACs should be listed in the NLEM. This study aimed to assess the cost-effectiveness of DOACs for patients with VTE in Thailand. METHODS A cohort-based state transition model was constructed from a societal perspective with a lifetime horizon. All available DOACs, including apixaban, rivaroxaban, edoxaban, and dabigatran, were compared with warfarin. A 6-month cycle length was used to capture all costs and health outcomes. The model consisted of nine health states, including VTE on treatment, VTE off treatment, recurrent VTE, clinically relevant non-major bleeding, gastrointestinal bleeding, intracranial bleeding, post-intracranial bleeding, chronic thromboembolic pulmonary hypertension, and death. All inputs were based on a comprehensive literature review. The model outcomes included total cost and quality-adjusted life-years (QALYs) with a 3% annual discount rate. A fully incremental cost-effectiveness analysis and the incremental cost-effectiveness ratio (ICER) per QALY gained were calculated at a willingness-to-pay (WTP) of THB 160,000/QALY ($5003). The robustness of the findings was assessed using deterministic and probabilistic sensitivity analyses. RESULTS All DOACs were associated with a decreased risk of VTE recurrence and intracranial hemorrhage. In the base-case analysis, apixaban could increase 0.16 QALYs compared with warfarin. An ICER for apixaban was 269,809 Thai baht (THB)/QALY ($8437/QALY). Rivaroxaban had a better QALY than warfarin at 0.09 QALYs with an ICER of 757,363 THB/QALY ($23,682/QALY). Edoxaban and dabigatran could also increase by 0.10 QALYs with an ICER of 709,945 THB ($22,200) and 707,145 THB ($22,122)/QALY, respectively. Our probabilistic sensitivity analyses indicated that warfarin had a 99.8% possibility of being cost-effective, while apixaban had a 0.2% possibility of being cost-effective at the current WTP. Other DOACs had no possibility of being cost-effective. CONCLUSIONS All DOACs were not cost-effective for VTE treatment at the current WTP in Thailand. Apixaban is likely to be the best option among DOACs.
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Affiliation(s)
- Siwaporn Niyomsri
- Department of Medical Services, Ministry of Public Health, Nonthaburi 11000, Thailand
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2BN, UK
| | - Mantiwee Nimworapan
- Pharmaceutical Care Training Center (PCTC), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand
- Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Piyameth Dilokthornsakul
- Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand
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Robin P, Le Pennec R, Eddy M, Sikora L, Le Roux PY, Carrier M, Couturaud F, Tromeur C, Planquette B, Sanchez O, Pesavento R, Filippi L, Rodger MA, Kovacs MJ, Mallick R, Salaun PY, Le Gal G. Residual pulmonary vascular obstruction and recurrence after acute pulmonary embolism: a systematic review and meta-analysis of individual participant data. J Thromb Haemost 2023; 21:1519-1528.e2. [PMID: 36740040 DOI: 10.1016/j.jtha.2023.01.030] [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: 09/30/2022] [Revised: 01/02/2023] [Accepted: 01/20/2023] [Indexed: 02/05/2023]
Abstract
We aimed to assess the relationship between residual pulmonary vascular obstruction (RPVO) on planar lung scan after completion of at least 3 months of anticoagulant therapy for acute pulmonary embolism (PE) and the risk of recurrent venous thromboembolism (VTE) or death due to PE one year after treatment discontinuation. The systematic review was registered with the International Prospective Registry of Systematic Reviews (PROSPERO: CRD42017081080). The primary outcome measure was to generate a pooled estimate of the rate of recurrent VTE at one year in patient with RPVO diagnosed on planar lung scan after discontinuation of at least 3 months of anticoagulant treatment for an acute PE. Individual data were obtained for 809 patients. RPVO (ie, obstruction >0%) was found in 407 patients (50.3%) after a median of 6.6 months of anticoagulant therapy for a first acute PE. Recurrent VTE or death due to PE occurred in 114 patients (14.1%), for an annual risk of 6.4% (95% confidence interval, 4.7%-8.6%). Out of the 114 recurrent events, 63 occurred within one year after discontinuation of anticoagulant therapy corresponding to a risk of 8.1% (6.4%-9.8%) at 1 year. The risk of recurrent VTE at one year was 5.8% (4.4-7.2) in participants with RPVO <5%, vs 11.7% (9.5-13.8) in participants with RPVO ≥5%. RPVO is a significant predictor of the risk of recurrent venous thromboembolism. However, the risk of recurrent events remains too high in patients without residual perfusion defect for it to be used as a stand-alone test to decide on anticoagulation discontinuation.
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Affiliation(s)
- Philippe Robin
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Romain Le Pennec
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Maggie Eddy
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Pierre-Yves Le Roux
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada
| | - Francis Couturaud
- Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France; Département de Médecine Interne et Pneumologie, Centre Hospitalier Régional Universitaire de Brest, Brest, France
| | - Cécile Tromeur
- Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France; Département de Médecine Interne et Pneumologie, Centre Hospitalier Régional Universitaire de Brest, Brest, France
| | - Benjamin Planquette
- Service de Pneumologie et Soins Intensifs, AP-HP, Hôpital Européen Georges Pompidou, Paris, France; Université de Paris, INSERM, UMRS 1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | - Olivier Sanchez
- Service de Pneumologie et Soins Intensifs, AP-HP, Hôpital Européen Georges Pompidou, Paris, France; Université de Paris, INSERM, UMRS 1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | | | - Lucia Filippi
- Division of General Medicine, Alto Vicentino Hospital, Santorso, Italy
| | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, QC, Canada
| | | | - Ranjeeta Mallick
- Ottawa Methods Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Pierre-Yves Salaun
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada; Centre d'Investigation Clinique, Centre Hospitalier Régional et Universitaire de Brest, Brest, France.
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Role of factor VIII, IX, and XI in venous thrombosis recurrence risk in adults and children: A systematic review. Res Pract Thromb Haemost 2023; 7:100064. [PMID: 36852262 PMCID: PMC9958483 DOI: 10.1016/j.rpth.2023.100064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/05/2022] [Accepted: 01/03/2023] [Indexed: 02/05/2023] Open
Abstract
Background Predicting recurrent venous thromboembolic events (VTEs) is challenging in clinical practice for both adults and children, but it is relevant for clinical management. Identifying laboratory risk factors for VTE recurrence may aid in clinical decision-making. Objective The goal of this systematic review is to investigate the predictive role of FVIII, IX, or XI in recurrent VTE in adult and pediatric patients with a first VTE. Methods A systematic review of the published literature was conducted in databases MEDLINE In-Process, Other Nonindexed Citations, MEDLINE Epub Ahead of Print, EMBASE Classic + EMBASE (OvidSP), and Cochrane (Wiley). We included observational and interventional studies that comprised adults or children with a first VTE, FVIII, FIX, and/or FXI and objectively confirmed VTE recurrence. The quality in prognosis studies tool was used to assess the risk of bias. Results We identified 2177 unique studies, of which 19 were included (18 for adults and 1 for children). The risk of bias was overall low to moderate. The studies were heterogenous with regards to population (provoked/unprovoked primary VTE), exposure (type of assay and cut-off values), and statistical analysis results (measures of association and modeling strategy). In adults, contradictory evidence was found for FVIII and FXI as outcome predictors, while no research could establish if FIX predicts VTE recurrence. Data in pediatrics were limited. Given the extensive heterogeneity of the literature, a meta-analysis was not performed. Conclusions Overall, there is contradictory evidence that FVIII, FIX, or FXI predict recurrent VTE in adults and children. Addressing heterogeneity is a relevant aspect to consider in future studies investigating prognostic factors for VTE recurrence.
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Palareti G, Barinov V, Urbanek T, Cini M, Li YJ, Bouslama K, Matuška J, Mansilha A, Madaric J, Sokurenko GY, Andreozzi GM. Recurrences and bleeding during extended treatment of patients with venous thromboembolism: results of the international, prospective, observational WHITE study. INT ANGIOL 2023; 42:37-44. [PMID: 36714910 DOI: 10.23736/s0392-9590.22.04970-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Little data are available on real-life long-term treatments after a venous thromboembolism (VTE), and on recurrent VTE or bleeds events during treatments. METHODS We investigated the complications occurring during follow-up (FU) in VTE patients who had received the treatment decisions given by the clinical centers, active in 7 countries (China, Czechia, Poland, Portugal, Russia, Slovakia, Tunisia), which participated in the international, prospective, observational WHITE study. RESULTS FU information was collected in 1004 patients, recruited by 62 clinical centers (17 centers did not participate in FU collection). Extended treatments were proposed to 811 patients: direct oral anticoagulants (DOACs) (475), sulodexide (202), antiplatelet agents (73), vitamin K antagonists (VKAs) (45), low molecular weight heparin (LMWH) (16). All specific treatments were stopped in the remaining 193 patients. Patients who during FU used treatments different than those prescribed by the local investigators (263) or for other causes (26) were excluded from analysis. 50 primary events occurred throughout 1044 years FU in 715 patients, 4.8 incidence (×100 patient-years) [3.8 for recurrences, and 0.96 for bleeding (major or clinically relevant)]. Primary event incidence differed according to treatments (LMWH=33.3, antiplatelets =7.6, VKAs = 6.1, DOACs = 4.7, sulodexide = 4.2, all treatment stopped = 2.5), and differed across the involved countries. CONCLUSIONS DOACs were the most used drugs for extended treatments. Overall, the rate of primary events during FU was low. The investigators identified patients at low risk of recurrence and high bleeding risk. Sulodexide use for secondary prevention deserves further studies.
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Affiliation(s)
| | - Victor Barinov
- Central State Medical Academy of the Office of the President of the Russian Federation, Volynskaya Clinical Hospital N.1, Moscow, Russia
| | | | - Michela Cini
- Arianna Anticoagulazione Foundation, Bologna, Italy
| | - Young-Jun Li
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | | | | | | | - Juraj Madaric
- Clinic of Angiology, Comenius University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia
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Khan F, Thavorn K, Coyle D, van Katwyk S, Tritschler T, Hutton B, Le Gal G, Rodger M, Fergusson D. Protocol for a modelling study to assess the clinical and cost-effectiveness of indefinite anticoagulant therapy for first unprovoked venous thromboembolism. BMJ Open 2023; 13:e053927. [PMID: 36609323 PMCID: PMC9827190 DOI: 10.1136/bmjopen-2021-053927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Deciding whether to stop or extend anticoagulant therapy indefinitely after completing at least 3 months of initial treatment for a first unprovoked venous thromboembolism (VTE) remains a challenge for clinicians, patients and policy makers. Guidelines suggest an indefinite duration of anticoagulant therapy in these patients, yet its benefits, harms and costs have not been formally assessed. The aim of this proposed modelling study is to assess the differences in clinical benefits, harms and costs of stopping versus continuing anticoagulant therapy indefinitely for a first unprovoked VTE. METHODS AND ANALYSIS We will develop a probabilistic Markov model, adopting a 1-month cycle length and a lifetime horizon, to estimate life-years, quality-adjusted life-years, costs and the incremental cost-effectiveness ratios for a simulated population of patients with a first unprovoked VTE who will receive indefinite duration of anticoagulant therapy versus a population who will not receive extended treatment after completing 3 months of initial anticoagulant therapy. The economic evaluation will adopt a third-party payer perspective relating to a Canadian publicly funded healthcare system. Estimates for the probability of relevant clinical events will be informed by systematic reviews and meta-analyses, while costs and utility values will be obtained from published Canadian sources. Stratified analyses based on sex, age and site of initial VTE will also be performed to identify subgroups of patients with a first unprovoked VTE in whom continuing anticoagulant therapy indefinitely might prove to be clinically beneficial and cost-effective over stopping treatment. We will also conduct sensitivity and scenario analyses to assess robustness of study findings to changes in individual or groups of key parameters. ETHICS AND DISSEMINATION Ethical approval is not applicable for this study. The results will be disseminated through presentations at relevant conferences and in a manuscript that will be submitted to a peer-reviewed journal.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Sasha van Katwyk
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Tobias Tritschler
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of General Internal Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gregoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Québec, Canada
| | - Dean Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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