Cardiovascular risk assessment in haemophilia patients

Reducing the risk of atherosclerotic cardiovascular disease in people with hemophilia: the importance of primary prevention

Revolutionary advances in the treatment of hemophilia has led to a significant improvement in life expectancy. Associated with this has been an increase in age-related diseases especially atherosclerotic cardiovascular disease (CVD). While people with hemophilia (PWH) develop atherosclerosis at rates similar to those of the general population, rates of atherothrombosis and mortality related to CVD have been much lower, due to their hypocoagulable state. Changing treatment paradigms, aimed at reducing the risk of bleeding by improving hemostasis to levels approaching normality, has meant that the protection they are thought to have had may be lost. CVD risk factors are just as common in PWH as in the general population, but appear to be undertreated. In particular, primary prevention of CVD is vital in all individuals, but particularly in PWH as treatment of established CVD can be difficult. Active identification and management of CVD risk factors, such as obesity, physical inactivity, hypertension, and hypercholesterolemia, is required. In particular, statins have been shown to significantly reduce cardiovascular and all-cause mortality with few adverse events and no increased risk of bleeding in the general population, and their use needs urgent assessment in PWH. Further longitudinal research into preventing CVD in PWH, including accurate CVD risk assessment, is required to optimize prevention and management.

Cardiovascular Risk Scores among Asymptomatic Adults with Haemophilia

BACKGROUND

The mortality rate of Brazilian people with haemophilia (PwH) is decreasing, but the relative incidence of deaths associated with cardiovascular disease (CVD) is increasing.

OBJECTIVES

We aimed to describe the CVD risk score of PwH according to Pooled Cohort Equations Risk (PCER) Calculator tool and its treatment recommendations. We also compared the PCER estimates with the respective Framingham Risk Score (FRS).

METHODS

This cross-sectional study included male PwH ≥ 40 years treated at the Comprehensive Haemophilia Treatment Centre of Pernambuco (Recife/Brazil). PwH with a previous CVD event or a low-density lipid cholesterol ≥ 5.0 mmol/L were excluded. Interviews, medical file reviews, and blood tests were performed. The PCER tool was used to estimate the CVD risk and compare it with the respective FRS. A p-value < 0.05 was accepted as statistically significant.

RESULTS

Thirty PwH were included. Median age was 51.5 [interquartile range-IQR; 46.0-59.5] years. The prevalence of obesity, systemic arterial hypertension, diabetes mellitus, hypertriglyceridaemia, hypercholesterolaemia, and hypoHDLaemia were 20%, 67%, 24%, 14%, 47%, and 23%, respectively. The median PCER score was 6.9% [IQR; 3.1-13.2], with 50% having a high risk (PCER ≥ 7.5%). Statin use was suggested for 54% of PwH. Blood pressure was poorly controlled in 47% of PwH. The agreement between PCER and FRS was 80% (κ = 0.60; p = 0.001).

CONCLUSIONS

Half of the male people with haemophilia aged 40 years or older had a 10-year high risk of developing CVD with strong recommendations to improve control of dyslipidaemia and blood pressure.

Increased acute care utilisation, comorbidities and mortality in adults with haemophilia: A population-based cohort study from 2012 to 2019

INTRODUCTION

Improvements in treatment strategies have led to increased life expectancy of persons with haemophilia (PWH). Consequently, age-related comorbidities become increasingly relevant.

AIM

To evaluate the prevalence of age-related comorbidities, mortality, health service utilisation and predictors of hospitalisation in PWH compared to the general population.

METHODS

We conducted a population-based retrospective cohort study using linked administrative data. Men with haemophilia were identified in Alberta, Canada (2012-2019) with a validated case definition and were age-matched with male population controls. We calculated the prevalence of major comorbidities, all-cause mortality, and examined health service utilisation including Emergency Department visits and hospitalisations. Logistic regression was applied to identify predictors of hospitalisation.

RESULTS

We identified 198 and 329 persons with moderately severe haemophilia and mild/moderate, respectively. Moderately severe haemophilia had a higher risk of death (standardised mortality ratio 3.2, 95% confidence interval [CI] 1.4-6.3) compared to the general population. PWH had a significantly higher prevalence of hypertension, liver diseases and malignancies than controls. Moderately severe haemophilia was associated with significantly higher rates of hospitalisations (52.5% vs. 14.5%), Emergency Department visits (89.1% vs. 62.7%) and intensive care admissions (8.9% vs. 2.3%). Age > 65 years (adjusted odds ratio [aOR] 6.8) and presence of multiple comorbidities (aOR 3.9) were significant predictors of hospitalisations among PWH.

CONCLUSION

Despite advanced care, haemophilia is associated with higher acute care utilisation than the general population, highlighting the substantial burden of illness on patients and the health care system.

Evaluation of cardiovascular disease risk factors, inflammatory markers and subclinical atherosclerosis in patients with hemophilia

Aim: To assess and compare the risk factors of cardiovascular disease (CVD) between patients with hemophilia (PwH) and healthy controls in a single center cohort in Turkey. Material and Methods: Anthropometric parameters including height, weight, and body mass index were recorded. Fasting glucose, HbA1c, high sensitive C-Reactive Protein (hs-CRP), adiponectin, lipid parameters (total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides) were assessed. International Physical Activity Questionnaires (IPAQ) and carotid intima media thickness (CIMT) measurements were performed. The data from PwH (n=80) and healthy controls (n=36) were compared. Independent associates of CIMT value were analyzed. Results: Hypertension, diabetes mellitus, metabolic syndrome and smoking frequencies were remarkable in PwH. Family history of CVD was significantly more frequent ( p=0.005) and when considered with IPAQ scores; PwH was much more sedentary than controls (p&lt;0.001). Total cholesterol, LDL-cholesterol were significantly higher in the control group (p =0.003,=0.003) while hs-CRP levels were higher in PwH (p=0.009). Age and IPAQ score were significant independent predictors of CIMT (p=0.004 and 0.003, respectively). Conclusion: As a result of aging; PwH exposure to the same CVD risk factors as the general population. Screening for CVD risk factors in PwH other than hemophilia evaluation will be essential.

Cardiovascular Risk Factors in Patients with Congenital Hemophilia: A Focus on Hypertension

Aging hemophiliacs face cardiovascular disease. Lots of evidence has been gathered that hemophiliacs have a more unfavorable cardiovascular profile than the general population does, especially due to the increased prevalence of hypertension (HTN). Among the existing scattered evidence, our study provides the most comprehensive and systematized analysis of the determinants of HTN in hemophiliacs. We discussed the contribution to the HTN substrate of hemophilia-specific factors, such as type, severity and the presence of inhibitors. The complex mechanism of kidney dysfunction in relation to hematuria and viral infections was meticulously addressed. Furthermore, we highlighted the new pathogenic concepts of endothelial dysfunction and the association between HTN and hemophilic arthropathy. The clustering of cardiovascular risk factors is common in hemophiliacs, and it enhances the negative vascular effect of HTN and aggravates HTN. It usually leads to an increased risk for coronary and cerebrovascular events. Our work provides reliable evidence to guide and improve the management of HTN in hemophiliacs.

Prevalence of cardiovascular diseases and risk factors in adult patients with haemophilia: a cross-sectional study in a tertiary care hospital clinic in Sri Lanka

Background

Management of cardiovascular disease (CVD) in patients with haemophilia is extremely challenging. Therefore, knowing the prevalence of CVD and risk factors in this population is imperative.

Methods

All consented patients ≥ 18 years of age attending the haemophilia clinic at a tertiary care centre were recruited to the study. Data were collected using a pretested, investigator administered questionnaire. Seated blood pressure, anthropometric measurements and blood samples were obtained using standard techniques. Lipid profile and fasting plasma glucose were estimated. Prevalence of risk factors for CVD was compared with those of age matched males in the general population. P values < 0.05 were considered significant.

Results

Of the total 109 participants, 92 (84.4%) had haemophilia A. The median age of the study group was 36 years. Three (2.8%) had at least one cardiovascular disease. There were 10 (9.2%), 30 (27.5%), 13 (11.9%) and 4 (3.7%) participants with diabetes, hypertension, current smoking and obesity (Body Mass Index (BMI) ≥ 30 kg/m²) respectively. 32 (29.4%) and 37 (33.9%) participants had waist circumference ≥ 90 cm and waist hip ratio ≥ 0.9 respectively. 38 (34.9%) had total cholesterol ≥ 200 mg/dl, 43 (39.5%) had low density lipoprotein (LDL) cholesterol ≥ 130 mg/dl, 25 (22.9%) had triglycerides (TG) ≥ 150 mg/dl and 58 (53.2%) had High density lipoprotein (HDL) cholesterol < 40 mg/dl. Diabetes was significantly associated with factor levels below 5% (p = 0.038). BMI, waist circumference and dyslipidaemia in the study were significantly higher compared to the general population.

Conclusion

The study signifies an increased prevalence of risk factors for CVD among patients with haemophilia and the need for preventive measures.

Diabetes, hepatitis C and human immunodeficiency virus influence hypertension risk differently in cohorts of haemophilia patients, veterans and the general population

INTRODUCTION

The reasons for the high prevalence of hypertension in persons with haemophilia (PWH) are poorly understood.

AIM

To examine the roles of diabetes, Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) in the etiology of hypertension for PWH.

METHODS

Retrospective cross-sectional design. Adult PWH (n = 691) were divided into two groups: (A) free of diabetes, HCV and HIV; (B) with diabetes and/or HCV positivity and/or HIV positivity. Each group was matched by race and age with random samples from the general population of the US (National Health and Nutrition Examination Surveys, NHANES) and outpatients at the Veterans Affairs Medical Center (VAMC) in San Diego. Generalized additive models (GAMs) were fitted for graphical analysis of hypertension risk over the lifespan.

RESULTS

In Group A, PWH had the highest prevalence of hypertension compared to NHANES and VAMC, especially in young adults. In Group B, diabetes increased the risk of hypertension for all three cohorts (PWH, NHANES and VAMC), especially for PWH. In PWH, hypertension risk was also increased by HIV, in NHANES by HCV, and in VAMC by HCV and HIV.

CONCLUSION

Diabetes conferred the greatest risk of hypertension for all three cohorts. However, curves of hypertension in relation to age revealed that diabetes, HCV and HIV modulated hypertension risk differently in PWH. PWH experienced a disproportionally high risk increase with diabetes. Therefore, haemophilia care should include screening for hypertension and diabetes at a young age.

Cardiovascular disease in hereditary haemophilia: The challenges of longevity

The development of effective and safe treatments has significantly increased the life expectancy of persons with haemophilia (PWH). This has been accompanied by an increase in the comorbidities of ageing including cardiovascular disease, which poses particular challenges due to the opposing risks of bleeding from haemophilia and antithrombotic treatments versus thrombosis. Although mortality secondary to coronary artery disease in PWH is less than in the general population, the rate of atherosclerosis appears similar. The prevalence of atrial fibrillation in PWH and risk of secondary thromboembolic stroke are not well established. PWH can be safely supported through acute coronary interventions but data on the safety and efficacy of long-term antithrombotics are scarce. Increased awareness and research on cardiovascular disease in PWH will be crucial to improve primary prevention, acute management, secondary prevention and to best support ageing PWH.

Estimating the risk of thrombotic events in people with congenital hemophilia A using US claims data

Aim: Compare thrombotic risk in people with congenital hemophilia A (PwcHA) to the general non-hemophilia A (HA) population. Patients & methods: US claims databases were analyzed to identify PwcHA. Incidence rates of myocardial infarction, pulmonary embolism, ischemic stroke, deep vein thrombosis and device-related thrombosis were compared with a matched cohort without HA. Results: Over 3490 PwcHA were identified and 16,380 individuals matched. PwcHA had a similar incidence of myocardial infarction and pulmonary embolism compared with the non-HA population, but a slightly higher incidence of ischemic stroke and deep vein thrombosis. The incidence of device-related thrombosis was significantly higher in PwcHA. Conclusion: This analysis suggests that PwcHA are not protected against thrombosis, and provides context to evaluate thrombotic risk of HA treatments.

Cardiovascular risk factors among adult patients with haemophilia

Since the introduction of episodic and prophylactic treatments with safer factor concentrates, the life expectancy of people with haemophilia (PwH) has improved considerably. Ageing-related diseases such as cardiovascular disease (CVD) have also become more prevalent in PwH. This cross-sectional study aimed to evaluate CVD risk factors and estimate 10-year risk for CVD events among PwH. Male patients ≥ 30 years were interviewed and examined. Blood tests were performed at the local laboratory. Eighty-two patients were included, of whom 83% had haemophilia A and half had severe disease. Median age at study entry was 43.0 years (interquartile range [IQR], 36.0-51.3). Prevalence of obesity, systemic arterial hypertension (SAH) and diabetes mellitus were 16%, 60% and 16%, respectively. Hypertriglyceridaemia, hypercholesterolaemia and low HDL blood levels were present in 18%, 41% and 30% of patients, respectively. Metabolic syndrome was found in 37%. The Framingham Risk Score showed that 39% of PwH had a high risk of developing cardiovascular events in the following 10 years. We conclude that, in this cohort, PwH have a higher prevalence of SAH when compared with Brazilian men without haemophilia and about two-fifths have a high risk of developing a CVD event in the following 10 years.

Mortality in congenital hemophilia A - a systematic literature review

Against a background of a rapidly evolving treatment landscape, a contemporary, evidence-based consolidated understanding of mortality in people with congenital hemophilia A (PwcHA) is lacking. This systematic literature review examines the available data on mortality and causes of death in PwcHA to enable a better understanding of fatalities in PwcHA and evaluate the impact of new treatment paradigms on mortality. A systematic literature review of observational studies was conducted by searching Medline, Embase, and clinical trials registries for articles published from January 2010 to March 2020, using the search terms: hemophilia A (HA), mortality, cause of death. Interventional studies, studies not reporting fatalities, and those reporting only on hemophilia B, acquired HA, or mixed other coagulopathies were excluded. Overall, 7818 unique records were identified and 17 were analyzed. Of these, six reported mortality rates and five reported mortality ratios. Mortality generally decreased over time, despite a spike associated with human immunodeficiency virus (HIV)/hepatitis C virus (HCV) infection in the 1980s and 1990s. Mortality was strongly correlated with age and hemophilia severity. People with hemophilia had a raised mortality risk compared with the general population, particularly in severe hemophilia, and when infected with HIV or HCV. Causes of death varied across populations, countries, and time in 15 identified studies; however, incomplete and heterogeneous reporting limits evidence. Hemorrhage, HIV, HCV, and hepatic disease were the leading causes of death. A unified approach to reporting mortality and cause of death is needed to understand mortality in PwcHA as treatments continue to advance.

The Need for Comprehensive Care for Persons with Chronic Immune Thrombocytopenic Purpura

Chronic platelet disorders (CPD), including chronic immune thrombocytopenic purpura (cITP), thrombotic thrombocytopenic purpura (TTP) and platelet function disorders are among the most common bleeding disorders and are associated with morbidity and mortality. The clinical phenotype and complexity of cITP is much like that of hemophilia. In cITP and hemophilia, bleeding is problematic for many, complicating employability, insurability and overall quality-of-life (QoL). While myriad drug therapies are available for cITP and hemophilia, each are variable in their effectiveness, very few (except for clotting factor concentrates for hemophilia) alter the natural history of the disorder and sometimes contribute to specific morbidities and mortality. Like in hemophilia, the management of cITP is not solely based on access to effective treatment but also includes accurate diagnosis and comprehensive care by a multidisciplinary team of specialists trained in the management of bleeding disorders. The model of comprehensive care in Hemophilia Treatment Centers (HTCs) has been recognized as highly effective, improving life expectancy for persons with hemophilia. cITP, and other CPDs, are complex disorders requiring specialized care. However, an integrated care model with a systematic and reliable population-based surveillance program does not exist. Extending the Comprehensive Care model with all its related benefits to the community of persons with cITP is sorely needed. This review will focus on cITP as a prototype chronic platelet disorder that could benefit greatly from the Comprehensive Care model.

Evaluation of Ischemic Heart Disease Factors in Hemophilia Patients in Khorramabad

BACKGROUND

Evaluation of risk factors associated with coronary artery disease and cardiac health in hemophilia patients is necessary to prevent the onset of ischemic heart disease. In this study, we evaluated the cardiovascular status of hemophilic patients in Lorestan province for the early onset of ischemic heart disease.

METHODS

In this cross-sectional descriptive study, a total of 80 patients presenting severe hemophilia, a detailed questionnaire-based investigation was conducted to analyze the prevalence of cardiovascular risk factors in severe hemophilic patients. In patients with hemophilia, body mass index (BMI), blood pressure, diabetes, LDL, cholesterol and HDL, the risk of cardiovascular death was estimated using a predictive risk predictor algorithm of Europe SCORE.

RESULTS

The mean age of the patients was 25 years, where all the patients were non-diabetic. Echocardiography did not show any wall motion abnormality and changes in the T wave and dysrhythmia were also not seen by ECG. 7 patients had high blood pressure, 11 had abnormal HDL, and 1 had abnormal LDL. In this study, serum LDL and HDL levels were not significantly correlated with age and BMI. Conversely, age and BMI were significantly associated with hypertension. Hypertension was observed in people over the age of 25 years and in overweighed individuals. 78.8% had normal BMI and 21.3% were overweighed. There was no significant correlation between serum LDL, serum HDL, and blood pressure and sex. The levels of abnormal LDL and HDL were higher in men than in women.

CONCLUSION

ECG findings from our study did not report any significant cardiac abnormalities among hemophilic patients. Cardiovascular risk factors were not significantly correlated in these patients.

Myocardial functions, blood pressure changes, and arterial stiffness in children with severe hemophilia A

INTRODUCTION

Prolonging the life span of patients with hemophilia has led to the emergence of comorbidities. Cardiovascular diseases are one of the important causes of mortality in patients with hemophilia. This study investigated the myocardial functions, blood pressure changes, arterial stiffness, and risk factors associated with cardiovascular diseases in children with hemophilia.

MATERIAL AND METHODS

In total, 17 children with severe hemophilia A and 23 healthy children were included in the study. Myocardial functions were evaluated using standard and tissue Doppler echocardiography. Peripheral and central blood pressure measurements were performed, and arterial stiffness was evaluated. Carotid intima-media thicknesses (CIMT) serum glucose, insulin, insulin resistance index, and lipoprotein levels were measured.

RESULTS

There were no differences between the two groups in terms of age, and biochemical parameters (P > 0.05). The HDL-C levels in the hemophilia group were lower than those in the control group (P < 0.05). Five of the patients had insulin resistance (29.4%), whereas four had low HDL-C levels (23.5%). There were no differences between the groups in terms of the CIMT, peripheral blood pressure, and central systolic blood pressure (P > 0.05). In the hemophilia group, central diastolic blood pressure (cDBP), arterial stiffness, and myocardial performance index were higher (P < 0.05, P = 0.01, P < 0.01), whereas the ejection time was shorter than in the control group (P < 0.05).

CONCLUSIONS

Compared with the control group, there is an onset of arterial stiffness, cDBP values tend to increase, and serum HDL-C levels are lower in the hemophilia group. Moreover, myocardial systolic functions demonstrate a deterioration that becomes more prominent with the increase in arterial stiffness.

BAY 81-8973 demonstrated efficacy, safety and joint status improvement in patients with severe haemophilia A in the LEOPOLD I extension for ≤2 years

OBJECTIVES

BAY 81-8973 (Kovaltry^® ), a full-length, unmodified, recombinant human factor VIII, provided excellent bleeding control for patients with haemophilia A in the pivotal 1-year LEOPOLD I trial. The LEOPOLD I extension evaluated long-term efficacy and safety of BAY 81-8973 prophylaxis.

METHODS

After completing LEOPOLD I, patients continued receiving 20-50 IU/kg BAY 81-8973 two- or three-times weekly in the extension. Outcomes included annualised bleeding rate (ABR) and haemostasis during surgery.

RESULTS

Fifty-five patients aged 12-65 years participated in the extension. Median (range) exposure days during the 2-year total study period was 309 (115-355). No patient switched regimens. Median (Q1; Q3) ABR for all bleeds was 2.0 (1.0; 6.1) during the pivotal study, 2.0 (0.0; 5.2) during the extension, and 2.0 (0.5; 5.5) combined. The proportion of joint bleeds affecting target joints decreased (pivotal study: 90.9%, extension: 60.0%). Haemostasis was assessed as excellent/good in all five major surgeries. One serious adverse event (myocardial infarction) occurred in a patient with cardiovascular risk factors. No patients developed inhibitors.

CONCLUSIONS

BAY 81-8973 prophylaxis efficacy outcomes in the pivotal study were maintained or, in the case of joint protection, improved during the extension, with a safety and tolerability profile consistent with previous experience.

Aging with Hemophilia: The Challenge of Appropriate Drug Prescription

In high-income countries persons with severe hemophilia (PWH) A and B are aging, like their age-matched peers without hemophilia from the general population. Aging is associated not only with the comorbidities stemming from their inherited bleeding disorder (arthropathy, chronic viral infections such as hepatitis and AIDS) but also with the multiple chronic ailments associated with aging (cancer, cardiovascular disease, COPD). Multimorbidity is inevitably associated with polypharmacy, i.e., the chronic daily intake of at least five drugs, and with the related risk of severe adverse events associated with the use of inappropriate drugs and drug-drug interactions. Information on the pattern of drug prescription and usage by PWH is relatively scanty, but on the whole, the available data indicate that the rate of polypharmacy, as well as the risk of drug-drug interaction, is relatively low in PWH and better than that in their age peers without hemophilia followed by general practitioners. It is believed that this advantage results from the collaborative coordination on drug prescribing exerted, through their integration with practitioners and organ specialists, by specialized hemophilia treatment centers in the frame of comprehensive care programs. However, the available cross-sectional data were mainly obtained in relatively young PWH, so that there is a need to obtain more accurate data from the ongoing prospective studies that are being carried out in more and more progressively aging PWH.

Screening urinalysis demonstrates that haematuria is a frequent finding in persons with haemophilia treated at a paediatric haemophilia treatment centre

INTRODUCTION

Haematuria is a recognized complication of haemophilia A and B (HA, HB). Adult persons with haemophilia (PWH) have a higher prevalence of renal disease than the general population. There is limited literature investigating the prevalence of haematuria in paediatric PWH.

AIM

Our paediatric haemophilia treatment centre (HTC) had previously used quality improvement methods to increase the frequency of screening urinalyses at annual comprehensive visits. We retrospectively reviewed the data collected to determine the prevalence of haematuria and explore for associations in those with haematuria.

METHODS

Retrospective chart review to identify the frequency of haematuria on screening urinalysis in all male PWH ≥2 years old. Haematuria was defined as ≥3 red blood cells (RBCs) per high power field. Univariate logistic regression was performed to evaluate for associations with haematuria.

RESULTS

A total of 93 patients met eligibility criteria. Sixty-seven with HA (11 mild, 17 moderate, 39 severe) and 26 with HB (three mild, 16 moderate, seven severe). Forty-two of ninety-three (45%) patients were identified as having haematuria (median RBCs 7, mean RBCs 332). Of those with haematuria, 76% were identified by screening UA, as opposed to clinical symptoms, and 52% had recurrent haematuria. Older age and HA were associated with an increased likelihood of haematuria.

CONCLUSIONS

Our study demonstrated that the prevalence of haematuria was high in PWH treated at our paediatric HTC. Future investigation is needed to determine the population-wide prevalence of haematuria in paediatric PWH and its impact on renal function.

Off-pump technique and replacement therapy for coronary artery bypass surgery in a patient with hemophilia B

Antithrombotic treatment and perioperative management in patients with hemophilia remains a challenge. As life expectancy in these patients is increasing, a concern about cardiovascular diseases is emerging. Herein we present the case of a 68 year-old patient with mild hemophilia B and multivessel coronary disease who underwent coronary artery bypass grafting (CABG) surgery. Off-pump surgery with continuous infusion FIX treatment was performed successfully with stable factor IX levels, and no bleeding or thrombotic complications. There is a paucity of cases reported regarding management of CABG in this population. To our knowledge, this is the first patient with mild hemophilia B that underwent CABG surgery with off-pump technique, that seems to be a secure and effective procedure.

Evaluation of Unfavorable Cardiovascular and Metabolic Risk Factors in Children and Young Adults with Haemophilia

OBJECTIVE

Increased risk of unfavorable cardiovascular risk factors has been recognised in ageing patients with haemophilia (PwH), but needs further studies in younger patients. The purpose of this study was to assess obesity, hypertension (HT), metabolic variables, insulin resistance and metabolic syndrome in young PwH.

METHODS

Forty-eight haemophilia A and B patients and 35 age and sex matched healthy controls were included in the study. Anthropometric measurements, blood pressure (BP), fasting glucose and insulin levels, serum lipids and diet were evaluated. The metabolic syndrome was defined according to the criteria of the International Diabetes Federation for pediatric and adult age groups.

RESULTS

The mean age of PwH was 21±9 years (range, 6-40 years). Of those ≥18 years, 46% were were obese/overweight while there were no obese/overweight cases in the <18 year-old patients. Obesity was more prevalent in PwH with arthropathy (p=0.017). Seven percent of the PwH between 10 and 18 years-old and 25% of those ≥18 years had metabolic syndrome. There was no difference in metabolic syndrome frequency between PwH and controls >10 years-old (19.5% vs 10% respectively, p=0.34). Fifty percent of the PwH ≥18 years-old had elevated BP or HT. Fasting blood glucose levels of PwH were significantly higher compared to controls (p=0.02).

CONCLUSION

Our study showed that obesity, HT and metabolic syndrome are frequent problems, especially in PwH with arthropathy. Early prevention and management of overweight, obesity and their sequelae must be addressed in clinical practice in order to maximize the overall health of the haemophilia population.

A cross-sectional analysis of cardiovascular disease in the hemophilia population

Men with hemophilia were initially thought to be protected from cardiovascular disease (CVD), but it is now clear that atherothrombotic events occur. The primary objective of the CVD in Hemophilia study was to determine the prevalence of CVD and CVD risk factors in US older men with moderate and severe hemophilia and to compare findings with those reported in age-comparable men in the Atherosclerosis Risk in Communities (ARIC) cohort. We hypothesized if lower factor levels are protective from CVD, we would see a difference in CVD rates between more severely affected and unaffected men. Beginning in October 2012, 200 patients with moderate or severe hemophilia A or B (factor VIII or IX level ≤ 5%), aged 54 to 73 years, were enrolled at 19 US hemophilia treatment centers. Data were collected from patient interview and medical records. A fasting blood sample and electrocardiogram (ECG) were obtained and assayed and read centrally. CVD was defined as any angina, any myocardial infarction by ECG or physician diagnosis, any self-reported nonhemorrhagic stroke or transient ischemic attack verified by physicians, or any history of coronary bypass graft surgery or coronary artery angioplasty. CVD risk factors were common in the population. Compared with men of similar age in the ARIC cohort, patients with hemophilia had significantly less CVD (15% vs 25.8%; P < .001). However, on an individual patient level, CVD events occur and efforts to prevent cardiovascular events are warranted. Few men were receiving secondary prophylaxis with low-dose aspirin, despite published opinion that it can be used safely in this patient population.

Obesity in the global haemophilia population: prevalence, implications and expert opinions for weight management

Overweight and obesity may carry a significant disease burden for patients with haemophilia (PWH), who experience reduced mobility due to joint inflammation, muscle dysfunction and haemophilic arthropathy. This review aimed to define the prevalence and clinical impact of overweight/obesity in the global population of PWH. A detailed literature search pertaining to overweight/obesity in haemophilia in the last 15 years (2003-2018) was conducted, followed by a meta-analysis of epidemiological data. The estimated pooled prevalence of overweight/obesity in European and North American PWH was 31%. Excess weight in PWH is associated with a decreased range in motion of joints, accelerated loss of joint mobility and increase in chronic pain. Additionally, the cumulative disease burden of obesity and haemophilia may impact the requirement for joint surgery, occurrence of perioperative complications and the prevalence of anxiety and depression that associates with chronic illness. Best practice guidelines for obesity prevention and weight management, based on multidisciplinary expert perspectives, are considered for adult and paediatric PWH. Recommendations in the haemophilia context emphasize the importance of patient education and tailoring engagement in physical activity to avoid the risk of traumatic bleeding.

Cardiovascular comorbidities in a United States patient population with hemophilia A: A comprehensive chart review

PURPOSE

Previous retrospective claims database analyses reported increased prevalence and earlier onset of cardiovascular comorbidities in patients with versus without hemophilia A. A comprehensive chart review was designed to further investigate previous findings.

METHODS

This retrospective chart review study was conducted at Henry Ford Health System (Detroit, MI, USA). Baseline demographics, bleeding events, treatment parameters, coexisting diseases, hemophilia-associated events, Charlson Comorbidity Index score, and prevalence of 12 cardiovascular risk factors and associated diseases were compared between hemophilia A and control cohorts. P values from a chi-square test for categorical variables and a t test for continuous variables were calculated. Because of small sample sizes (N = 0-90, most <50), statistical differences between cohorts were also assessed using absolute standardized difference.

RESULTS

Both groups were well matched by age, race, healthcare payer, and study year. The Charlson Comorbidity Index score was similar between groups. Prevalence of bleeds, hepatitis B and C, and HIV/AIDS was higher in the hemophilia cohort. Hemophilia A severity was severe, moderate, mild, or unknown in 52.7%, 10.8%, 10.8%, and 25.7% of patients, respectively. Prevalence of 12 cardiovascular risk factors and diseases was numerically higher in the control cohort, but differences were statistically significant (P ≤ 0.05) only for diabetes and hyperlipidemia. Meaningful statistical differences using standardized differences were not reached for venous and arterial thrombosis and atrial fibrillation.

CONCLUSIONS

This retrospective chart review did not confirm statistically significant differences in cardiovascular comorbidities and their earlier onset in hemophilia A versus controls. Results suggest numerically higher comorbidities in controls.

Current concepts in the management of stable ischemic heart disease and acute coronary syndrome in patients with hemophilia

Coronary artery disease (CAD), including stable ischemic heart disease (SIHD) and acute coronary syndrome (ACS), remains the leading cause of death in the US and one of the primary modalities used in the treatment of CAD is percutaneous coronary intervention (PCI). Despite the potential benefits of PCI in high risk CAD patients, the risk of hemorrhage presents a dilemma in the treatment of patients with hemophilia A and B. In an attempt to provide guidance on the management of SIHD and ACS in patients with hemophilia, we present the case of a patient with moderate hemophilia B and ACS who subsequently underwent PCI followed by a review of the associated literature.

Increased prevalence of hypertension in haemophilia patients

An increased prevalence of hypertension is reported in haemophilia patients, but data from large, unbiased studies are lacking. The aim of our study was to cross-sectionally assess the prevalence of hypertension in a large cohort of 701 haemophilia patients. Blood pressure (BP) measurements performed in 386 Dutch and 315 UK haemophilia patients aged 30 years or older were analysed and compared with the general age-matched male population. Mean values of up to three BP measurements were used when available. Hypertension was defined as BP over 140/90 mmHg and/or the use of antihypertensive medication. A total of 49% of patients had severe haemophilia. Mean age was 49.8 years. The prevalence of hypertension was significantly higher in haemophilia patients (49%, 95% confidence interval [CI] 45–53) than in the general population (40%, 95% CI 37–43). The prevalence of hypertension was higher in patients with severe haemophilia than in those with non-severe disease, but similar across haemophilia types and in Dutch and UK patients. Multiple BP measurements were available for 70%.The prevalence of hypertension was similar in patients with multiple BP measurements and the complete cohort. Hypertension was not significantly associated with renal function, a history of renal bleeding or with infection with hepatitis C or HIV, but it was associated with overweight/obesity and age. In conclusion, the prevalence of hypertension is higher in haemophilia patients than in the general population. The cause of this increased prevalence is unknown. Blood pressure measurements should be part of standard care in haemophilia patients aged 30 years or older.

Unfavourable cardiovascular disease risk profiles in a cohort of Dutch and British haemophilia patients

Cardiovascular disease (CVD) mortality is reported to be decreased in haemophilia patients, but reports on the prevalence of CVD risk factors are conflicting. A cross-sectional assessment of CVD risk profiles was performed in a large cohort of haemophilia patients. Baseline data on CVD risk factors of 709 Dutch and UK haemophilia patients aged ≥ 30 years were analysed and compared with the general age-matched male population. CVD risk profiles were assessed using the QRISK®2–2011 and SCORE algorithms. Although QRISK®2 was only validated in the UK, comparison with SCORE indicated similar properties of QRISK®2 in both Dutch and UK patients (correlation 0.86). Mean age was 49.8 years. Hypertension was more common in haemophilia patients than in the general population (49% vs. 40%), while the prevalences of obesity and hypercholesterolaemia were lower (15 vs. 20% and 44 vs. 68%, respectively), and those of diabetes and smoking were similar. The predicted 10-year QRISK®2 risk was significantly higher in haemophilia patients than in the general population (8.9 vs. 6.7%), indicating more unfavourable cardiovascular disease risk profiles. This increased risk became apparent after the age of 40 years. Our results indicate an increased prevalence of hypertension and overall more unfavourable CVD risk profiles in haemophilia patients compared with the general age-matched male population.

Two global haemostatic assays as additional tools to monitor treatment in cases of haemophilia A

Haemophilia A patients with similar levels of factor VIII (FVIII) may have different bleeding phenotypes and responses to treatment with FVIII concentrate. Therefore, a test which determines overall haemostasis may be appropriate for treatment monitoring in some patients. We studied two global haemostatic methods: endogenous thrombin potential (ETP) and overall haemostatic potential (OHP) before and after injection of FVIII concentrate in patients with haemophilia A treated prophylactically and on-demand. A significant correlation between FVIII and both ETP and OHP was observed, while ETP and OHP differed between patients with severe and mild clinical phenotypes. Both ETP and OHP differed significantly between severe, moderate and mild haemophilia A and controls. ETP and OHP increased after intravenous injection of FVIII concentrate in both groups of patients, but in spite of higher pre-treatment values of both ETP and OHP in patients treated prophylactically, and much higher post-treatment FVIII levels in comparison with the values in patients treated on-demand, no difference after treatment was observed for either ETP or OHP. ETP and OHP may be additional alternatives for monitoring (and even for individual tailoring) treatment in patients with haemophilia A.

Evaluation of Heart Function in Patients With Hemophilia

There are conflicting reports about the protective effect of hemophilia on the occurrence of ischemic heart disease. This study focuses on evaluation of heart function in patients with hemophilia. Cross-sectional, case–control study was done on all patients with hemophilia A or B who came to hemophilia center, and data were compared to controls. The data were collected from their charts, and heart function was evaluated by 2-dimensional, Doppler and pulse tissue Doppler. The serum troponin I level was measured in all patients as a marker of myocardial damage. Fifty patients with hemophilia took part in this study. All of them were male with mean age 29.1 years. Systolic blood pressure (mean = 121.52 ± 11 vs 115.61 ± 9.81, P = .038) and diastolic (mean = 81.94 ± 4.51 vs 75.21 ± 3.95, P = .042) blood pressure were higher in the patients. Five (10%) patients had systolic hypertension and 7 (14%) patients had diastolic hypertension. The M-mode echocardiography results showed that interventricular septum in diastole in patients with hemophilia (mean 1.143 ± 0.29) was significantly thicker than the control group (mean 0.828 ± 0.22, P < .001). Tissue Doppler echocardiography showed that late diastolic velocity of septum (Aa; P = .030), systolic velocity (S) of lateral mitral valve ( P = .006), late diastolic velocity of lateral mitral (Aa) annulus ( P = .038), and late velocity of (Aa) tricuspid ( P = .004) had significant difference compared with the control group ( P < .05). Troponin enzyme level was < 0.1 in all patients. Patients with hemophilia had higher blood pressure and more hypertension. Echocardiographic study of patients with hemophilia showed some increase in septal thickness and changes in diastolic dysfunction

The Hypertension of Hemophilia Is Not Explained by the Usual Cardiovascular Risk Factors: Results of a Cohort Study

Background. The etiology of the high prevalence of hypertension among patients with hemophilia (PWH) remains unknown. Methods. We compared 469 PWH in the United States with males from the National Health and Nutrition Examination Survey (NHANES) to determine whether differences in cardiovascular risk factors can account for the hypertension in hemophilia. Results. Median systolic and diastolic BP were higher in PWH than NHANES (P < 0.001) for subjects not taking antihypertensives. Those taking antihypertensives showed similar differences. Differences in both systolic and diastolic BP were especially marked among adults <30 years old. Differences between PWH and NHANES persisted after adjusting for age and risk factors (body mass index, renal function, cholesterol, smoking, diabetes, Hepatitis C, and race). Conclusions. Systolic and diastolic BP are higher in PWH than in the general male population and especially among PWH < 30 years old. The usual cardiovascular risk factors do not account for the etiology of the higher prevalence of hypertension in hemophilia. New investigations into the missing link between hemophilia and hypertension should include age of onset of hypertension and hemophilia-specific morbidities such as the role of inflammatory joint disease.

How I treat patients with inherited bleeding disorders who need anticoagulant therapy

Situations that ordinarily necessitate consideration of anticoagulation, such as arterial and venous thrombotic events and prevention of stroke in atrial fibrillation, become challenging in patients with inherited bleeding disorders such as hemophilia A, hemophilia B, and von Willebrand disease. There are no evidence-based guidelines to direct therapy in these patients, and management strategies that incorporate anticoagulation must weigh a treatment that carries a risk of hemorrhage in a patient who is already at heightened risk against the potential consequences of not treating the thrombotic event. In this paper, we review atherothrombotic disease, venous thrombotic disease, and atrial fibrillation in patients with inherited bleeding disorders, and discuss strategies for using anticoagulants in this population using cases to illustrate these considerations.

Prevalence and Risk Factors Associated With Hypertension in Hemophilia: Cross-Sectional Analysis of a National Discharge Register

Introduction:

Improved life expectancy of persons with hemophilia (PWHs) has led to a greater interest in the role of age-related chronic diseases, such as hypertension, in this cohort. Several observational studies have reported an increased prevalence of hypertension in PWHs; however, this has not been assessed using a large, national database in the United States.

Aims:

We hypothesized the prevalence of hypertension is increased in PWHs and compared the prevalence of hypertension and associated risk factors among patients with and without hemophilia.

Methods:

A cross-sectional analysis was performed using discharge data among adult males from the National Inpatient Sample over the 3-year period, 2009 to 2011. Hypertension was compared across groups using Rao-Scott χ2 test. Multivariable logistic regression was used to estimate the odds of hypertension in patients with hemophilia after adjustment for hypertension-associated risk factors.

Results:

The prevalence of hypertension in patients with hemophilia was less than the prevalence of hypertension in patients without hemophilia (39.5% vs 56.3%, P < .001). Hemophilia was associated with a decreased odds of hypertension after adjusting for associated risk factors (odds ratio: 0.87; 95% confidence interval: 0.81-0.94).

Conclusion:

In contrast to the findings of several other recent studies, we report a decreased prevalence of hypertension in PWHs. The discrepancy among the reported prevalence of hypertension in our study and several others highlights the potential biases inherent to retrospective and cross-sectional studies and underscores the need for well-designed prospective studies to determine the true incidence of hypertension in PWHs, which may lie somewhere in between our findings and the findings of others.

Managing older patients with hemophilia

With access to safe factor products, the life expectancy of persons with hemophilia (PWHs) has increased almost 10-fold over the past 7 decades. Unfortunately, hand in hand with this success comes the burden of aging. As PWHs age, they are subject to develop many of the same risk factors as the general population, including increasing rates of hypertension, obesity, and diabetes. Such comorbidities predispose them to chronic diseases, such as cardiovascular disease and chronic kidney disease, although how their coagulopathy affects the expression of these conditions remains unclear. The older hemophilia population faces additional challenges, such as chronic joint arthropathy, which provokes falls and fractures, and complications related to HIV and hepatitis C infections, which greatly affect the incidence of cancer and liver disease. In light of the paucity of evidence-based guidelines to direct therapy, a new challenge has arisen for hematologists to optimally manage these complex age-related issues. In general, elderly PWHs should be treated similarly to their peers without hemophilia, with the addition of factor replacement therapy as appropriate. Primary prevention of risk factors should be emphasized, and close coordination between specialties is essential. This review will focus on common complications affecting the older hemophilia population, including cardiovascular disease, malignancy, liver disease, renal insufficiency, and joint disease.

Does deficiency of von Willebrand factor protect against cardiovascular disease? Analysis of a national discharge register

INTRODUCTION

von Willebrand factor (VWF) plays a critical role in platelet adhesion and aggregation after vascular injury and at sites of high shear rate. Elevated VWF levels are associated with an increased risk of ischemic cardiovascular events; however, it is unclear whether VWF deficiency is protective against atherosclerosis. We aimed to compare the prevalence of cardiovascular disease (CVD) among patients with and without von Willebrand disease (VWD).

METHODS

A cross-sectional analysis was performed on discharge data for adults from the Nationwide Inpatient Sample (NIS) between the years 2009 and 2011. CVD was defined as ischemic heart disease, myocardial infarction, ischemic cerebrovascular disease, or peripheral vascular disease. For prevalence calculations and statistical analyses, we used discharge-level weights provided by the NIS to reflect national estimates. CVD was compared across groups by use of the Rao-Scott chi-square test. Multivariable logistic regression was used to estimate the likelihood of CVD in VWD patients after adjustment for age, gender, and CVD-related risk factors.

RESULTS

The prevalence of CVD in VWD patients was less than the prevalence of CVD in non-VWD patients (15.0% versus 26.0%). VWD was associated with a decreased likelihood of CVD after adjustment for age, gender, and CVD-related risk factors (odds ratio 0.85; 95% confidence interval 0.79-0.92).

DISCUSSION

These findings indicate that the risk of CVD is decreased among VWD patients, and that VWF deficiency may be protective against CVD.

Consensus review of the treatment of cardiovascular disease in people with hemophilia A and B

With advances in care, increasing numbers of people with hemophilia (PWH) achieve near-normal life expectancies and present with typical age-related cardiovascular conditions. Evidence-based guidelines for medical or surgical management of cardiovascular conditions in individuals with hemophilia are limited. Published recommendations exist for the management of some common cardiovascular conditions (eg, ischemic heart disease, atrial fibrillation), but identifying optimal strategies for anticoagulant or antithrombotic therapy constitutes the primary challenge of managing nonoperative cardiovascular disease (CVD) in PWH. In general, as long as factor concentrates or other hemostatic therapies maintain adequate hemostasis, the recommended medical and surgical management of CVD in PWH parallels that in individuals without hemophilia. The presence of factor inhibitors complicates hemophilia management. Published outcomes of CVD treatment in PWH are similar to those in the general population. Specific knowledge about factor replacement, factor inhibitors, and disease-specific treatment distinguishes the cardiovascular care of PWH from similar care of individuals without this rare bleeding disorder. Furthermore, a multidisciplinary approach incorporating a hematologist with an onsite coagulation laboratory, ideally associated with a hemophilia treatment center, is integral to the management of CVD in PWH.

Cardiovascular disease prevalence and relevance in haemophilia: a scoping review

The prevalence of cardiovascular disease (CVD) risk and events in patients with haemophilia (PWH) is expected to increase as the longevity of this cohort increases due to treatment advances since the 1950s. The aims of this study were to assess publications of CVD and haemophilia for robustness, determine if the increasing longevity of PWH and associated age-related CVD risk factors result in CVD events; assess the need for an extension of the circle of care for ageing PWH due to the shift in comorbidities. A scoping review was conducted, resulting in a final pool of 30 articles which were organized based on publication dates. A matrix was created to illustrate which articles cited articles published prior to its own publication. This led to the identification of the primary articles, receiving the highest number of citations by other publications, which drive the research pertaining to the study of age-related risk factors of CVD in PWH. The scoping review revealed 14 original articles, four of which indicated a protective effect of haemophilia toward CVD. Twelve articles demonstrated a similar prevalence of CVD in PWH compared to the general population while seven articles concluded a difference in the prevalence of CVD in the ageing haemophilia population. The existing literature presented conflicting evidence regarding the possibility of a protective effect of haemophilia against CVD. The scoping review was not able to finalize whether the longevity of PWH and their associated age-related CVD risk factors result in CVD events because the articles assessed reported conflicting results.

Recombinant factor VIIa enhances platelet deposition from flowing haemophilic blood but requires the contact pathway to promote fibrin deposition

In prior microfluidic studies with haemophilic blood perfused over collagen, we found that a severe deficiency (<1% factor level) reduced platelet and fibrin deposition, while a moderate deficiency (1-5%) only reduced fibrin deposition. We investigated: (i) the differential effect of rFVIIa (0.04-20 nm) on platelet and fibrin deposition, and (ii) the contribution of the contact pathway to rFVIIa-induced haemophilic blood clotting. Haemophilic or healthy blood with low and high corn trypsin inhibitor (CTI, 4 or 40 μg mL(-1) ) was perfused over collagen at an initial venous wall shear rate of 100 s(-1) . At 100 s(-1) wall shear rate, where FXIIa leads to thrombin production without added tissue factor, FXI-deficient blood (3%) or severely FVIII-deficient blood (<1%) produced no fibrin at either CTI level. Whereas rFVIIa potently enhanced platelet deposition, fibrin generation was not rescued. Distinct from the high CTI condition, engagement of the contact pathway (low CTI) in moderately FVIII-deficient (3%) or moderately FIX-deficient blood (5%) resulted in enhanced platelet and fibrin deposition following 4 nm rFVIIa supplementation. In mildly FVIII-deficient blood (15%) at <24 h since haemostatic therapy, rFVIIa enhanced both platelet and fibrin generation in either CTI condition although fibrin was produced more quickly and abundantly in low CTI. For tissue factor-free conditions of severe haemophilic blood clotting, we conclude that rFVIIa reliably generates low levels of 'signaling' thrombin sufficient to enhance platelet deposition on collagen, but is insufficient to drive fibrin polymerization unless potentiated by the contact pathway.

Cardiovascular risk in patients with hemophilia

Patients with hemophilia, who have a lifelong hypocoagulability, seem to have a lower cardiovascular mortality than the general population. Nevertheless, the prevalence of cardiovascular risk factors in patients with hemophilia is as prevalent as in the general population, and hypertension is even more common. Furthermore, hemophiliacs have the same degree of atherosclerosis as the general population. The reduced cardiovascular mortality may be explained by reduced thrombus formation resulting from hypocoagulability. On the other hand, hemophilia, which is associated with reduced thrombin generation, may also increase atherosclerotic plaque stability, as has been shown in mice. Because treatment of these events is extremely challenging in patients with increased bleeding tendency, detection and aggressive treatment of risk factors is mandatory.