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Horner DE, Davis S, Pandor A, Shulver H, Goodacre S, Hind D, Rex S, Gillett M, Bursnall M, Griffin X, Holland M, Hunt BJ, de Wit K, Bennett S, Pierce-Williams R. Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis. Health Technol Assess 2024; 28:1-166. [PMID: 38634415 PMCID: PMC11056814 DOI: 10.3310/awtw6200] [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: 04/19/2024] Open
Abstract
Background Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs. Objectives We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research. Design We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines. Setting NHS hospitals, with primary data collection at four sites. Participants Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions. Interventions Prophylaxis for all patients, none and according to selected risk assessment models. Main outcome measures Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models. Results We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%. Limitations Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias. Conclusions Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research. Future work Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation. Study registration This study is registered as PROSPERO CRD42020165778 and Researchregistry5216. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in Health Technology Assessment; Vol. 28, No. 20. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Daniel Edward Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Oxford Road, Manchester, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Shulver
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Saleema Rex
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael Gillett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matthew Bursnall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Xavier Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Beverley Jane Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, King's Healthcare Partners, London, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queens University, Kingston, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shan Bennett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Davis S, Goodacre S, Horner D, Pandor A, Holland M, de Wit K, Hunt BJ, Griffin XL. Effectiveness and cost effectiveness of pharmacological thromboprophylaxis for medical inpatients: decision analysis modelling study. BMJ MEDICINE 2024; 3:e000408. [PMID: 38389721 PMCID: PMC10882286 DOI: 10.1136/bmjmed-2022-000408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/03/2024] [Indexed: 02/24/2024]
Abstract
Objective To determine the balance of costs, risks, and benefits for different thromboprophylaxis strategies for medical patients during hospital admission. Design Decision analysis modelling study. Setting NHS hospitals in England. Population Eligible adult medical inpatients, excluding patients in critical care and pregnant women. Interventions Pharmacological thromboprophylaxis (low molecular weight heparin) for all medical inpatients, thromboprophylaxis for none, and thromboprophylaxis given to higher risk inpatients according to risk assessment models (Padua, Caprini, IMPROVE, Intermountain, Kucher, Geneva, and Rothberg) previously validated in medical cohorts. Main outcome measures Lifetime costs and quality adjusted life years (QALYs). Costs were assessed from the perspective of the NHS and Personal Social Services in England. Other outcomes assessed were incidence and treatment of venous thromboembolism, major bleeds including intracranial haemorrhage, chronic thromboembolic complications, and overall survival. Results Offering thromboprophylaxis to all medical inpatients had a high probability (>99%) of being the most cost effective strategy (at a threshold of £20 000 (€23 440; $25 270) per QALY) in the probabilistic sensitivity analysis, when applying performance data from the Padua risk assessment model, which was typical of that observed across several risk assessment models in a medical inpatient cohort. Thromboprophylaxis for all medical inpatients was estimated to result in 0.0552 additional QALYs (95% credible interval 0.0209 to 0.1111) while generating cost savings of £28.44 (-£47 to £105) compared with thromboprophylaxis for none. No other risk assessment model was more cost effective than thromboprophylaxis for all medical inpatients when assessed in deterministic analysis. Risk based thromboprophylaxis was found to have a high (76.6%) probability of being the most cost effective strategy only when assuming a risk assessment model with very high sensitivity is available (sensitivity 99.9% and specificity 23.7% v base case sensitivity 49.3% and specificity 73.0%). Conclusions Offering pharmacological thromboprophylaxis to all eligible medical inpatients appears to be the most cost effective strategy. To be cost effective, any risk assessment model would need to have a very high sensitivity resulting in widespread thromboprophylaxis in all patients except those at the very lowest risk, who could potentially avoid prophylactic anticoagulation during their hospital stay.
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Affiliation(s)
- Sarah Davis
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Daniel Horner
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Department of Emergency and Intensive Care Medicine, Northern Care Alliance Foundation Trust, Salford, UK
- Division of Immunology, Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Abdullah Pandor
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Beverley J Hunt
- Department of Thrombosis & Haemostasis, Kings Healthcare Partners, London, UK
| | - Xavier Luke Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Wang H, Klok FA, Rosendaal FR, Cushman M, van Hylckama Vlieg A. Health-related quality of life after first venous thromboembolism in individuals aged 70 years and older. Res Pract Thromb Haemost 2023; 7:102144. [PMID: 37601012 PMCID: PMC10439441 DOI: 10.1016/j.rpth.2023.102144] [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: 03/06/2023] [Revised: 06/06/2023] [Accepted: 06/21/2023] [Indexed: 08/22/2023] Open
Abstract
Background There is limited information on short- and long-term effects of venous thromboembolism (VTE) on health-related quality of life (HRQoL) in the elderly. Objectives To assess change in generic HRQoL and disease-specific HRQoL in patients 1 year after the VTE. Methods The Age and Thrombosis, Acquired and Genetic risk factors in the elderly (AT-AGE) study is a 2-center case-control study performed in Leiden, the Netherlands, and Vermont, United States, among individuals aged ≥70 years. We measured generic HRQoL using the 36-item Short Form Health Survey (SF-36) and disease-specific HRQoL using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms Questionnaire (VEINES-QoL/Sym) and the Pulmonary Embolism-Specific Quality of Life Questionnaire (PEmb-QoL). All patients completed these questionnaires shortly after their VTE and 1 year later, while controls completed the 36-item Short Form Health Survey questionnaire once. Linear regression for change in quality of life scores was performed and adjusted for potential confounders. Results For the current analysis, we included patients who were visited twice (n = 316) and controls (n = 427) with HRQoL information. Mean age of patients and controls was similar (78.8 vs 75.5 years). In patients who survived at least 1 year after the VTE, generic HRQoL improved for both summary scores, but it did not reach the level of the age-matched controls: physical and mental summary scores increased by 5.6 and 5.5 points, respectively, but compared with controls, remained 8.2 and 6.4 points lower. For disease-specific HRQoL, the Pulmonary Embolism-Specific Quality of Life Questionnaire overall score decreased from 21.7% to 15.2%, indicating improved HRQoL. Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms Questionnaire scores did not change over time. Conclusion Overall, the quality of life of patients with VTE was worse than that of controls after 1 year, indicating a long-term impact of VTE diagnosis in the elderly.
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Affiliation(s)
- Huijie Wang
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A. Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Schreurs RHP, Joore MA, ten Cate H, ten Cate-Hoek AJ. Development of a Consensus-Based Cross-Domain Protocol for the Management of Elastic Compression Stocking Therapy in Patients With Deep Venous Thrombosis and Chronic Venous Disease: A Modified Delphi Study. Front Cardiovasc Med 2022; 9:891364. [PMID: 35665269 PMCID: PMC9160232 DOI: 10.3389/fcvm.2022.891364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/04/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Elastic compression stocking (ECS) therapy is commonly used in patients with deep venous thrombosis (DVT) and chronic venous disease (CVD). The provision of ECS therapy is complex, and studies indicate a lack of practical guidance and suboptimal collaboration among health care professionals. We aimed to reach consensus on critical issues of ECS therapy among the involved health care professionals and patients. Methods A three-round modified Delphi analysis was performed in the Netherlands in which 56 health care professionals (internists, dermatologists, general practitioners, emergency room nurses, home care nurses, medical stocking suppliers, and occupational therapists) and seven patients were invited. The 21 statements included in this analysis were based on information collected from a previously conducted Functional Resonance Analysis Method and Realist Evaluation. We used 7-point Likert scale questions and a 75% threshold for consensus. Results Of the 63 persons invited for this study, 59 (94%) agreed to participate and responded in the first questionnaire round; of whom 52 were health care professionals and seven were patients (five DVT and two CVD). The overall response rate for the three questionnaire rounds was 91%. After completion of the rounds, full consensus was achieved on 19 out of 21 statements. No consensus was reached on the need for a follow-up appointment for CVD patients and who should be responsible to determine the ECS type (custom-made or standard). Conclusion We identified 19 consensus-driven recommendations on treatment decisions and collaboration in ECS therapy among an interdisciplinary panel of health care professionals and patients. These recommendations form a basis for consensus-driven optimization of ECS therapy and should ideally be incorporated in a general cross-domain protocol for ECS therapy in patients with DVT and CVD.
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Affiliation(s)
- Rachel H. P. Schreurs
- Laboratory for Clinical Thrombosis and Haemostasis, Thrombosis Expert Centre Maastricht, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
- *Correspondence: Rachel H. P. Schreurs,
| | - Manuela A. Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Thrombosis Expert Centre Maastricht, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, Netherlands
| | - Arina J. ten Cate-Hoek
- Laboratory for Clinical Thrombosis and Haemostasis, Thrombosis Expert Centre Maastricht, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
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Huang J, Liu XY, Wu ZP, Ma YK. Quality of Life Status and Influencing Factors Among Patients with Deep Vein Thrombosis. Patient Prefer Adherence 2022; 16:949-956. [PMID: 35422616 PMCID: PMC9005138 DOI: 10.2147/ppa.s353128] [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: 12/20/2021] [Accepted: 03/18/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of the study was to describe the quality of life (QoL) status and investigate the influencing factors of QoL among patients with deep vein thrombosis (DVT). METHODS A retrospective analysis at a single center was performed, and the clinical data of 161 patients with DVT admitted to West China Hospital of Sichuan University from June 2019 to June 2020 were collected with the Villalta scale, Hospital Anxiety and Depression Scale (HADS), and Chronic Venous Insufficiency Questionnaire (CIVIQ). The relationship between QoL and influencing factors, including characteristics, course of DVT, postthrombotic syndrome (PTS), psychological status, and behaviors, was analyzed by Student's t-test, analysis of variance and multiple linear regression. RESULTS A total of 161 patients who completed all the questionnaires between 2019 and 2020 were included, and 110 patients (68%) were male. The mean QoL score acquired by the CIVIQ scale was 74.18±8.44, and the results showed significant differences between patients of different ages, genders, behaviors and psychological statuses (P < 0.05). Multiple regression analysis showed that age (P = 0.024), negative mood (P < 0.001), CCI index (P < 0.001), PTS (P < 0.001) and regular exercise (P = 0.002) influenced the CIVIQ scale evaluation model, in which exercise regularly was a protective factor for QoL, and age, negative mood, CCI index and PTS were risk factors for QoL. CONCLUSION The QoL of DVT patients was impaired and associated with age, mood, CCI index and PTS. Regular exercise is beneficial for improving the quality of life of DVT patients.
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Affiliation(s)
- Jing Huang
- Department of Vascular Surgery, West China Hospital, Sichuan University, West China School of Nursing, Sichuan University, Chengdu, People’s Republic of China
- Department of Orthopedics, Orthopedic Reaserch Institute, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Xiao-yan Liu
- Department of Vascular Surgery, West China Hospital, Sichuan University, West China School of Nursing, Sichuan University, Chengdu, People’s Republic of China
- Department of Orthopedics, Orthopedic Reaserch Institute, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Zhou-peng Wu
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Correspondence: Zhou-peng Wu, Department of Vascular Surgery, West China Hospital, Sichuan University, No. 37 Guoxuexiang Wuhou District, Chengdu, Sichuan, People’s Republic of China, Email
| | - Yu-kui Ma
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
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Kabrhel C, Vinson DR, Mitchell AM, Rosovsky RP, Chang AM, Hernandez‐Nino J, Wolf SJ. A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel. J Am Coll Emerg Physicians Open 2021; 2:e12588. [PMID: 34950930 PMCID: PMC8673564 DOI: 10.1002/emp2.12588] [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: 08/26/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence-based recommendations and practical advice to help clinicians safely treat patients with low-risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow-up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web-based "point-of-care tools."
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular EmergenciesMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David R. Vinson
- Department of Emergency Medicine, Kaiser Permanente Division of Research and the CREST Network, Oakland, CAKaiser Permanente Roseville Medical CenterRosevilleCaliforniaUSA
| | - Alice Marina Mitchell
- Department of Emergency Medicine, Richard L. Roudebush VAMCIndiana University School of MedicineIndianapolisIndianaUSA
| | - Rachel P. Rosovsky
- Division of HematologyDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anna Marie Chang
- Department of Emergency MedicineThomas Jefferson University HospitalsPhiladelphiaPennsylvaniaUSA
| | | | - Stephen J. Wolf
- Department of Emergency MedicineDenver Health and University of Colorado School of MedicineDenverColoradoUSA
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Jørgensen H, Horváth-Puhó E, Laugesen K, Brækkan S, Hansen JB, Sørensen HT. Risk of a permanent work-related disability pension after incident venous thromboembolism in Denmark: A population-based cohort study. PLoS Med 2021; 18:e1003770. [PMID: 34464405 PMCID: PMC8443033 DOI: 10.1371/journal.pmed.1003770] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 09/15/2021] [Accepted: 08/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Long-term complications of venous thromboembolism (VTE) hamper physical function and impair quality of life; still, it remains unclear whether VTE is associated with risk of permanent work-related disability. We aimed to assess the association between VTE and the risk of receiving a permanent work-related disability pension and to assess whether this association was explained by comorbidities such as cancer and arterial cardiovascular disease. METHODS AND FINDINGS A Danish nationwide population-based cohort study consisting of 43,769 individuals aged 25 to 66 years with incident VTE during 1995 to 2016 and 218,845 birth year-, sex-, and calendar year-matched individuals from the general population, among whom 45.9% (N = 120,540) were women, was established using Danish national registries. The cohorts were followed throughout 2016, with permanent work-related disability pension as the outcome. Hazard ratios (HRs) with 95% confidence intervals (CIs) for disability pension were computed and stratified by sex and age groups (25 to 34, 35 to 44, 45 to 54, and 55 to 66 years of age) and adjusted for comorbidities and socioeconomic variables. Permanent work-related disability pensions were granted to 4,415 individuals with VTE and 9,237 comparison cohort members (incidence rates = 17.8 and 6.2 per 1,000 person-years, respectively). VTE was associated with a 3-fold (HR 3.0, 95% CI: 2.8 to 3.1) higher risk of receiving a disability pension. Adjustments for socioeconomic status and comorbidities such as cancer and cardiovascular diseases reduced the estimate (HR 2.3, 95% CI: 2.2 to 2.4). The risk of disability pension receipt was slightly higher in men than in women (HR 2.5, 95% CI: 2.3 to 2.6 versus HR 2.1, 95% CI: 2.0 to 2.3). As this study is based on medical and administrative registers, information on post-VTE care, individual health behavior, and workplace factors linked to disability pension in the general population are lacking. Furthermore, as disability pension schemes vary, our results might not be directly generalizable to other countries or time periods. CONCLUSIONS In this study, incident VTE was associated with increased risk of subsequent permanent work-related disability, and this association was still observed after accounting for comorbidities such as cancer and cardiovascular diseases. Our results emphasize the social consequences of VTE and may help occupational and healthcare professionals to identify vulnerable individuals at risk of permanent exclusion from the labor market after a VTE event.
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Affiliation(s)
- Helle Jørgensen
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
- * E-mail:
| | | | - Kristina Laugesen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Sigrid Brækkan
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Giustozzi M, Valerio L, Agnelli G, Becattini C, Fronk EM, Klok FA, Konstantinides SV, Vedovati MC, Cohen AT, Barco S. Sex-specific differences in the presentation, clinical course, and quality of life of patients with acute venous thromboembolism according to baseline risk factors. Insights from the PREFER in VTE. Eur J Intern Med 2021; 88:43-51. [PMID: 33810940 DOI: 10.1016/j.ejim.2021.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Sex and the presence of specific provoking risk factors, along with age, influence the presentation and prognosis of venous thromboembolism (VTE). We investigated the presentation, course and quality of life in women and men with acute VTE classified according to their VTE provoking factors. METHODS PREFER in VTE is an international, non-interventional registry of patients with a first episode of acute symptomatic VTE. Baseline provoking factors were classified as follows: major transient, minor transient, active cancer, and none identifiable. The primary outcome was recurrent VTE. Quality of life and treatment satisfaction were secondary outcomes. RESULTS Of 3,455 patients with acute VTE, 1,623 (47%) were women. The mean age at the time of VTE was 61 (SD 18) in women, 60 (SD 15) in men. The distribution of provoking risk factors was similar between sexes, despite a tendency for higher frequency of minor and major transient risk factors in women, and cancer or unprovoked VTE in men. At 12-month follow-up, VTE recurrence was reported in 74 (6.5%) women and 80 (6.4%) men (absolute risk difference -0.1%, 95% CI -1.9%; +2.1%). In patients with unprovoked VTE, the VTE recurrence rate was 38/612 (6.2%) in women and 53/798 (6.6%) in men (absolute risk difference -0.4, 95% CI -3.0; +2.1%). Multivariable Cox regressions confirmed the absence of sex differences. Quality of life and treatment satisfaction scores one year after VTE were lower in women than in men irrespective of the provoking risk factors (p<0.001 for both scores). CONCLUSIONS Despite differences in the provoking risk factors for VTE, women and men had a similar rate VTE recurrence at one year. After acute VTE, women had lower quality of life and treatment satisfaction scores.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy.
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy
| | | | - Frederikus A Klok
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Maria Cristina Vedovati
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy
| | - Alexander T Cohen
- Guy's and St Thomas' NHS Foundation Trust, King's College London, Department of Haematology, London, United Kingdom
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
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Li KX, Diendéré G, Galanaud J, Mahjoub N, Kahn SR. Micronized purified flavonoid fraction for the treatment of chronic venous insufficiency, with a focus on postthrombotic syndrome: A narrative review. Res Pract Thromb Haemost 2021; 5:e12527. [PMID: 34027293 PMCID: PMC8128666 DOI: 10.1002/rth2.12527] [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: 11/15/2020] [Revised: 03/14/2021] [Accepted: 04/06/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Postthrombotic syndrome (PTS) is a form of secondary chronic venous insufficiency (CVI) that occurs after deep vein thrombosis (DVT). Effective treatments for PTS are lacking. Micronized purified flavonoid fraction (MPFF) is a venoactive drug used in the treatment of CVI. OBJECTIVE To determine whether MPFF is a good candidate to explore as a therapeutic agent for PTS. METHODS We performed a narrative review in which we identified 14 systematic reviews, 33 randomized controlled trials, and 19 observational studies that discussed the use of MPFF in CVI, as well as studies that reported on the mechanistic action of MPFF in relation to the pathophysiology of PTS. RESULTS MPFF targets a number of pathophysiologic components of PTS. Based on animal models and human studies investigating objective vascular and lymphatic measures, MPFF promotes venous recanalization after DVT, decreases venous remodeling and reflux, inhibits inflammatory processes, improves venous tone and stasis, improves lymphatic circulation, improves capillary hyperpermeability, and decreases tissue hypoxia. Furthermore, MPFF shows promise in improving clinical manifestations, quality of life, and objective venous parameters of CVI. Studies suggest good patient acceptability and tolerability with the use of MPFF in CVI. CONCLUSION MPFF is a good candidate to explore as a potential therapy for PTS. Confirmatory high-quality studies are still needed to reinforce the evidence supporting the use of MPFF in CVI. Double-blind randomized controlled trials with clinical endpoints are needed to assess the clinical efficacy of MPFF in the treatment of PTS.
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Affiliation(s)
- Ke Xuan Li
- Faculty of MedicineMcGill UniversityMontrealQCCanada
| | - Gisele Diendéré
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC)Center for Clinical Epidemiology of the Lady Davis Institute for Medical ResearchMontrealQCCanada
| | - Jean‐Philippe Galanaud
- Department of MedicineSunnybrook Health Sciences Centre and University of TorontoTorontoONCanada
| | - Nada Mahjoub
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC)Center for Clinical Epidemiology of the Lady Davis Institute for Medical ResearchMontrealQCCanada
| | - Susan R. Kahn
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC)Center for Clinical Epidemiology of the Lady Davis Institute for Medical ResearchMontrealQCCanada
- Department of MedicineSir Mortimer B Davis Jewish General HospitalMontrealQCCanada
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10
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Cohen CT, Kirk S, Desai SB, Kukreja KU, Srivaths L. Diagnosis, Clinical Characteristics, and Treatment Modalities of Adolescent May-Thurner Syndrome-associated Deep Venous Thrombosis. J Pediatr Hematol Oncol 2021; 43:e346-e350. [PMID: 33093351 DOI: 10.1097/mph.0000000000001968] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/13/2020] [Indexed: 12/17/2022]
Abstract
May-Thurner syndrome (MTS) predisposes individuals to develop lower extremity deep venous thrombosis (DVT) because of compression of the left common iliac vein. Diagnosis of the anatomic obstruction is critical for effective therapy, as treatment by interventional radiology is often required in addition to anticoagulation to prevent thrombus progression and recurrence. The authors performed a retrospective review of adolescent patients who presented with MTS-associated DVT at a pediatric tertiary care center from 2009 to 2018 to assess for delays in MTS diagnosis after the presentation. Fourteen patients (median age 16.5 y, range, 13.8 to 17.9 y) were included, no DVTs were provoked by a central venous catheter. The median time from DVT to MTS diagnosis was 0.65 months (range, 0 to 21.5 mo). The initial imaging modalities used for DVT diagnosis were not able to diagnosis MTS. All patients were treated with anticoagulation and 13 underwent interventional therapy. Four patients had thrombus progression or recurrence, whereas 6 had complete thrombus resolution on follow-up imaging. Three patients who had a delayed MTS diagnosis had clinical worsening despite therapeutic anticoagulation requiring rehospitalization. Adolescent patients with "unprovoked" left lower extremity DVT should undergo appropriate imaging to diagnose MTS to allow for adequate medical and interventional therapy.
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Affiliation(s)
- Clay T Cohen
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer and Hematology Centers
| | - Susan Kirk
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer and Hematology Centers
| | - Sudhen B Desai
- Department of Radiology, Section of Interventional Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Kamlesh U Kukreja
- Department of Radiology, Section of Interventional Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lakshmi Srivaths
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer and Hematology Centers
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11
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Aksoy A, Colak S, Yagiz B, Coskun BN, Omma A, Yildiz Y, Sari A, Atas N, Ilgin C, Karadag Ö, Erden A, Dalkilic E, Bolca N, Ergelen R, Onur MR, Direskeneli H, Alibaz-Oner F. Predictors for the risk and severity of post-thrombotic syndrome in vascular Behçet's disease. J Vasc Surg Venous Lymphat Disord 2021; 9:1451-1459. [PMID: 33618067 DOI: 10.1016/j.jvsv.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 02/04/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Deep vein thrombosis (DVT) of the lower extremities is the most common form of vascular involvement in Behçet disease (BD), frequently leading to post-thrombotic syndrome (PTS) as a disabling complication. We have described the clinical characteristics and predictors of PTS presence among patients with BD and lower extremity DVT. We also used venous Doppler ultrasound (US) examinations in our assessment. METHODS Patients with BD (n = 205; 166 men, 39 women; age 39 ± 9.5 years) and a history of DVT were investigated. The Villalta scale was used to assess the presence and severity of PTS. Doppler US examinations were performed within 1 week of the clinical evaluation. The total number of vessels with reflux, thrombi, recanalization, and collateral vessels were calculated. RESULTS Of the 205 patients with BD, 62% had had PTS and 18% had had severe PTS. Patients with PTS had had greater reflux (P = .054) and thrombosis (P = .02) scores compared with patients without PTS. Treatment with anticoagulation (AC), immunosuppressive (IS) therapy, or AC combined with IS drugs did not affect the occurrence of PTS. However, patients treated with IS therapy, with or without AC drugs, had a decreased incidence of severe PTS compared with the AC-only group (P = .017). Patients treated with AC plus IS agents also had increased collateral scores compared with patients treated with only IS drugs. Interferon-α use seemed to provide better recanalization scores compared with azathioprine only (1.0 [range, 0-14] vs 2.5 [range, 0-10]; P = .010). CONCLUSION Patients with BD and DVT have a high risk of developing severe PTS. IS treatment decreases the development of severe PTS. AC therapy might influence the course of PTS by increasing the collateral scores, and the use of interferon-α also increased recanalization scores. Routine assessment with Doppler US examinations could be helpful in the prediction of severe PTS.
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Affiliation(s)
- Aysun Aksoy
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Marmara University, Istanbul, Turkey.
| | - Seda Colak
- Division of Rheumatology, Numune Education and Research Hospital, Ankara, Turkey
| | - Burcu Yagiz
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Uludag University, Bursa, Turkey
| | - Belkıs Nihan Coskun
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Uludag University, Bursa, Turkey
| | - Ahmet Omma
- Division of Rheumatology, Numune Education and Research Hospital, Ankara, Turkey
| | - Yasin Yildiz
- Department of Internal Medicine, School of Medicine, Marmara University, Istanbul, Turkey
| | - Alper Sari
- Vasculitis Research Centre, Hacettepe University, Ankara, Turkey
| | - Nuh Atas
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Gazi University, Ankara, Turkey
| | - Can Ilgin
- Department of Public Health, School of Medicine, Marmara University, Istanbul, Turkey
| | - Ömer Karadag
- Vasculitis Research Centre, Hacettepe University, Ankara, Turkey
| | - Abdülsamet Erden
- Vasculitis Research Centre, Hacettepe University, Ankara, Turkey
| | - Ediz Dalkilic
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Uludag University, Bursa, Turkey
| | - Naile Bolca
- Department of Radiology, Uludag University School of Medicine, Bursa, Turkey
| | - Rabia Ergelen
- Department of Radiology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Mehmet Ruhi Onur
- Department of Radiology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Haner Direskeneli
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Marmara University, Istanbul, Turkey
| | - Fatma Alibaz-Oner
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Marmara University, Istanbul, Turkey
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Incidence of Deep Vein Thrombosis and Its Effect on Health-Related Quality of Life Among Nurses of Greek Public Hospitals: A Multicenter Study. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1337:37-45. [DOI: 10.1007/978-3-030-78771-4_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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13
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Abstract
Stenosis of the iliac veins is common in patients with chronic venous insufficiency. The article describes the methods for the diagnosis and treatment of iliac vein stenosis. The causes of iliac vein stenosis include extravasal compression or the consequences of ileofemoral thrombosis. Stenosis of the iliac veins exists in 1/4 of the entire adult population, but clinical manifestations do not occur in all patients. Stenosis of the iliac veins should be considered in case of an unknown edema, more often in the left lower extremity, since venous duplex ultrasound of lower extremities is not sensitive and specific enough when examining the veins above the inguinal ligament. The most accurate diagnostic method is intravascular ultrasound (IVUS) but the appeared computed tomography angiography (CTA) and magnetic resonance angiography (MRA) with high-quality images have become a good replacement for IVUS. The main method of treatment of iliac vein stenosis, besides stenting, isindispensable drug therapy consisting of antithrombotic and phlebotonic drugs.
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Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2020; 61:9-82. [PMID: 33334670 DOI: 10.1016/j.ejvs.2020.09.023] [Citation(s) in RCA: 298] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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15
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Galanaud JP, Righini M, Le Collen L, Douillard A, Robert-Ebadi H, Pontal D, Morrison D, Barrellier MT, Diard A, Guénnéguez H, Brisot D, Faïsse P, Accassat S, Martin M, Delluc A, Solymoss S, Kassis J, Carrier M, Quéré I, Kahn SR. Long-term risk of postthrombotic syndrome after symptomatic distal deep vein thrombosis: The CACTUS-PTS study. J Thromb Haemost 2020; 18:857-864. [PMID: 31899848 DOI: 10.1111/jth.14728] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/08/2019] [Accepted: 12/31/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND After a proximal lower limb deep vein thrombosis (DVT; involving popliteal veins or above), up to 40% of patients develop postthrombotic syndrome (PTS) as assessed by the Villalta scale (VS). Poor initial anticoagulant treatment is a known risk factor for PTS. The risk of developing PTS after isolated distal DVT (infra-popliteal DVT without pulmonary embolism), and the impact of anticoagulant treatment on this risk, are uncertain. METHODS Long-term follow-up of CACTUS double-blind trial comparing 6 weeks of s.c. nadroparin (171 IU/kg/d) versus s.c. placebo for a first symptomatic isolated distal DVT. At least 1 year after randomization, patients had a PTS assessment in clinic or by phone using the VS. RESULTS After a median follow-up of 6 years, PTS was present in 30% (n = 54) of the 178 patients who had a PTS assessment. PTS was moderate or severe in 24% (n = 13) of cases. There was no statistically significant difference in prevalence of PTS in the nadroparin versus placebo groups (29% versus 32%, P = .6), except in patients without evidence of primary chronic venous insufficiency (9% versus 24%, P = .04). Rates of venous thromboembolism recurrence during follow-up in the nadroparin and placebo groups were, respectively, 8% (n = 7) and 14% (n = 13; P = .2). CONCLUSION After a first isolated distal DVT, the risk of PTS is substantial but much lower than that reported after proximal DVT. Anticoagulation with nadroparin doesn't provide any clear benefit to prevent PTS, except in patients without preexisting chronic venous insufficiency. Anticoagulation might be associated with a lower risk of venous thromboembolism recurrence.
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Affiliation(s)
- Jean-Philippe Galanaud
- Department of Vascular Medicine, Montpellier University Hospital and University of Montpellier, Montpellier, France
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Lorris Le Collen
- Department of Vascular Medicine, Montpellier University Hospital and University of Montpellier, Montpellier, France
| | - Aymeric Douillard
- Clinical Research and Epidemiology Unit, University Hospital, Montpellier, France
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Daniel Pontal
- Department of Vascular Medicine, Montpellier University Hospital and University of Montpellier, Montpellier, France
| | - David Morrison
- Department of Medicine and Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | | | | | | | - Dominique Brisot
- Vascular Medicine Unit, Clinique du Parc, Castelnau Le Lez, France
| | | | - Sandrine Accassat
- Clinical Investigation Centre, Saint Etienne University Hospital, Saint Etienne, France
| | | | - Aurélien Delluc
- Department of Medicine, Brest University Hospital, Brest, France
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Susan Solymoss
- Division of Hematology, St Mary's Hospital, Montreal, QC, Canada
| | - Jeannine Kassis
- Division of Hematology, Hôpital Rosemont-Maisonneuve, Montréal, QC, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Isabelle Quéré
- Department of Vascular Medicine, Montpellier University Hospital and University of Montpellier, Montpellier, France
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Boon GJAM, Barco S, Bertoletti L, Ghanima W, Huisman MV, Kahn SR, Noble S, Prandoni P, Rosovsky RP, Sista AK, Siegerink B, Klok FA. Measuring functional limitations after venous thromboembolism: Optimization of the Post-VTE Functional Status (PVFS) Scale. Thromb Res 2020; 190:45-51. [PMID: 32298840 DOI: 10.1016/j.thromres.2020.03.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION We recently proposed a scale for assessment of patient-relevant functional limitations following an episode of venous thromboembolism (VTE). Further development of this post-VTE functional status (PVFS) scale is still needed. METHODS Guided by the input of VTE experts and patients, we refined the PVFS scale and its accompanying manual, and attempted to acquire broad consensus on its use. RESULTS A Delphi analysis was performed involving 53 international VTE experts with diverse scientific and clinical backgrounds. In this process, the number of scale grades of the originally proposed PVFS scale was reduced and descriptions of the grades were improved. After these changes, a consensus was reached on the number/definitions of the grades, and method/timing of the scale assessment. The relevance and potential impact of the scale was confirmed in three focus groups totaling 18 VTE patients, who suggested additional changes to the manual, but not to the scale itself. Using the improved manual, the κ-statistics between PVFS scale self-reporting and its assessment via the structured interview was 0.75 (95%CI 0.58-1.0), and 1.0 (95%CI 0.83-1.0) between independent raters of the recorded interview of 16 focus groups members. CONCLUSION We improved the PVFS scale and demonstrated broad consensus on its relevance, optimal grades, and methods of assessing among international VTE experts and patients. The interobserver agreement of scale grade assignment was shown to be good-to-excellent. The PVFS scale may become an important outcome measure of functional impairment for quality of patient care and in future VTE trials.
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Affiliation(s)
- G J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany; Clinic of Angiology, University Hospital of Zurich, Zurich, Switzerland
| | - L Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Étienne, Saint-Étienne, France; INSERM UMR 1059 and CIC 1408, Université Jean-Monnet, Saint-Étienne, France
| | - W Ghanima
- Department of Oncology, Østfold Hospital Trust, Kalnes, Norway; Department Medicine and Research, Østfold Hospital Trust, Kalnes, Norway
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S R Kahn
- Division of Clinical Epidemiology, Department of Medicine, Jewish General Hospital, Montreal, QC, Canada
| | - S Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - P Prandoni
- Arianna Foundation on Anticoagulation, Bologna, Italy
| | - R P Rosovsky
- Department of Medicine, Hematology/Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - A K Sista
- Department of Radiology, New York University School of Medicine, New York, NY, United States
| | - B Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.
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Gómez-Cuervo C, Díaz-Pedroche C, Pérez-Jacoiste Asín A, Lalueza A, Díaz-Simón R, Lumbreras C. Quality of Life After a Venous Thrombosis in Elderly Patients: Results From a Prospective Spanish Cohort. Arch Bronconeumol 2020; 56:187-188. [DOI: 10.1016/j.arbres.2019.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/30/2019] [Accepted: 09/18/2019] [Indexed: 11/30/2022]
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18
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Pandor A, Horner D, Davis S, Goodacre S, Stevens JW, Clowes M, Hunt BJ, Nokes T, Keenan J, de Wit K. Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation. Health Technol Assess 2019; 23:1-190. [PMID: 31851608 PMCID: PMC6936165 DOI: 10.3310/hta23630] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Thromboprophylaxis can reduce the risk of venous thromboembolism (VTE) during lower-limb immobilisation, but it is unclear whether or not this translates into meaningful health benefit, justifies the risk of bleeding or is cost-effective. Risk assessment models (RAMs) could select higher-risk individuals for thromboprophylaxis. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of different strategies for providing thromboprophylaxis to people with lower-limb immobilisation caused by injury and to identify priorities for future research. DATA SOURCES Ten electronic databases and research registers (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, the Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluation Database, Science Citation Index Expanded, ClinicalTrials.gov and the International Clinical Trials Registry Platform) were searched from inception to May 2017, and this was supplemented by hand-searching reference lists and contacting experts in the field. REVIEW METHODS Systematic reviews were undertaken to determine the effectiveness of pharmacological thromboprophylaxis in lower-limb immobilisation and to identify any study of risk factors or RAMs for VTE in lower-limb immobilisation. Study quality was assessed using appropriate tools. A network meta-analysis was undertaken for each outcome in the effectiveness review and the results of risk-prediction studies were presented descriptively. A modified Delphi survey was undertaken to identify risk predictors supported by expert consensus. Decision-analytic modelling was used to estimate the incremental cost per quality-adjusted life-year (QALY) gained of different thromboprophylaxis strategies from the perspectives of the NHS and Personal Social Services. RESULTS Data from 6857 participants across 13 trials were included in the meta-analysis. Thromboprophylaxis with low-molecular-weight heparin reduced the risk of any VTE [odds ratio (OR) 0.52, 95% credible interval (CrI) 0.37 to 0.71], clinically detected deep-vein thrombosis (DVT) (OR 0.40, 95% CrI 0.12 to 0.99) and pulmonary embolism (PE) (OR 0.17, 95% CrI 0.01 to 0.88). Thromboprophylaxis with fondaparinux (Arixtra®, Aspen Pharma Trading Ltd, Dublin, Ireland) reduced the risk of any VTE (OR 0.13, 95% CrI 0.05 to 0.30) and clinically detected DVT (OR 0.10, 95% CrI 0.01 to 0.94), but the effect on PE was inconclusive (OR 0.47, 95% CrI 0.01 to 9.54). Estimates of the risk of major bleeding with thromboprophylaxis were inconclusive owing to the small numbers of events. Fifteen studies of risk factors were identified, but only age (ORs 1.05 to 3.48), and injury type were consistently associated with VTE. Six studies of RAMs were identified, but only two reported prognostic accuracy data for VTE, based on small numbers of patients. Expert consensus was achieved for 13 risk predictors in lower-limb immobilisation due to injury. Modelling showed that thromboprophylaxis for all is effective (0.015 QALY gain, 95% CrI 0.004 to 0.029 QALYs) with a cost-effectiveness of £13,524 per QALY, compared with thromboprophylaxis for none. If risk-based strategies are included, it is potentially more cost-effective to limit thromboprophylaxis to patients with a Leiden thrombosis risk in plaster (cast) [L-TRiP(cast)] score of ≥ 9 (£20,000 per QALY threshold) or ≥ 8 (£30,000 per QALY threshold). An optimal threshold on the L-TRiP(cast) receiver operating characteristic curve would have sensitivity of 84-89% and specificity of 46-55%. LIMITATIONS Estimates of RAM prognostic accuracy are based on weak evidence. People at risk of bleeding were excluded from trials and, by implication, from modelling. CONCLUSIONS Thromboprophylaxis for lower-limb immobilisation due to injury is clinically effective and cost-effective compared with no thromboprophylaxis. Risk-based thromboprophylaxis is potentially optimal but the prognostic accuracy of existing RAMs is uncertain. FUTURE WORK Research is required to determine whether or not an appropriate RAM can accurately select higher-risk patients for thromboprophylaxis. STUDY REGISTRATION This study is registered as PROSPERO CRD42017058688. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John W Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Beverley J Hunt
- Haemostasis Research Unit, King's College London, London, UK
| | - Tim Nokes
- Department of Haematology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jonathan Keenan
- Department of Haematology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Kerstin de Wit
- Department of Medicine, Hamilton General Hospital, Hamilton, ON, Canada
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Rosovsky R, Zhao K, Sista A, Rivera‐Lebron B, Kabrhel C. Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions. Res Pract Thromb Haemost 2019; 3:315-330. [PMID: 31294318 PMCID: PMC6611377 DOI: 10.1002/rth2.12216] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 04/09/2019] [Indexed: 12/20/2022] Open
Abstract
Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Although new therapeutic tools and strategies have recently been developed for the diagnosis and treatment of patients with PE, the outcomes for patients who present with massive or high-risk PE remain dismal. To address this crisis, pulmonary embolism response teams (PERTs) are being created around the world in an effort to immediately and simultaneously engage multiple specialists to determine the best course of action and coordinate the clinical care for patients with acute PE. The scope of this review is to describe the PERT model and purpose, present the structure and organization, examine the available evidence for efficacy and usefulness, and propose future directions for research that is needed to demonstrate the value of PERT and determine if this multidisciplinary approach represents a new standard of care.
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Affiliation(s)
- Rachel Rosovsky
- Division of Hematology & OncologyDepartment of MedicineMassachusetts HospitalBostonMassachusetts
| | - Ken Zhao
- Division of Interventional RadiologyDepartment of RadiologyNew York University Langone Medical CenterNew YorkNew York
| | - Akhilesh Sista
- Division of Interventional RadiologyDepartment of RadiologyNew York University Langone Medical CenterNew YorkNew York
| | - Belinda Rivera‐Lebron
- Division of Pulmonary, Allergy and Critical Care MedicineDepartment of MedicineUniversity of PittsburghPittsburghPennsylvania
| | - Christopher Kabrhel
- Center for Vascular EmergenciesDepartment of Emergency MedicineMassachusetts General HospitalBostonMassachusetts
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Radaideh Q, Patel NM, Shammas NW. Iliac vein compression: epidemiology, diagnosis and treatment. Vasc Health Risk Manag 2019; 15:115-122. [PMID: 31190849 PMCID: PMC6512954 DOI: 10.2147/vhrm.s203349] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/29/2019] [Indexed: 11/26/2022] Open
Abstract
Iliac vein compression (LIVC) is a prevalent finding in the general population, but a smaller number of patients are symptomatic. ILVC should be considered in symptomatic patients with unexplained unilateral lower leg swelling. Patients typically complain of one or more of the following symptoms: lower leg pain, heaviness, venous claudication, swelling, hyperpigmentation and ulceration. ILVC can be thrombotic, combined with acute or chronic DVT, or non-thrombotic. ILVC is best diagnosed with intravascular ultrasound (IVUS), but computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have emerged as valid screening tests. Venography underestimates the severity of ILVC but may provide insights into the anatomy and the presence of collaterals. Based on current available evidence, endovascular therapy with stenting remains the main treatment strategy for ILVC. Dedicated nitinol venous stents are currently under review by the Food and Drug Administration for potential approval in the United States. These stents have been released outside the US. There is no consensus to the optimal anticoagulation regimen post-ILVC stenting. Oral anticoagulants, however, remain a preferred therapy in patients with history of thrombotic ILVC. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/InSwn2AebNY
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Affiliation(s)
- Qais Radaideh
- Midwest Cardiovascular Research Foundation, Davenport, IA, USA
| | - Neel M Patel
- Midwest Cardiovascular Research Foundation, Davenport, IA, USA
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Klok FA, Barco S, Siegerink B. Measuring functional limitations after venous thromboembolism: A call to action. Thromb Res 2019; 178:59-62. [PMID: 30980999 DOI: 10.1016/j.thromres.2019.04.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/02/2019] [Accepted: 04/04/2019] [Indexed: 12/27/2022]
Abstract
The main objectives of therapeutic trials in venous thromboembolism (VTE) are to prevent recurrent VTE, major bleeding and death. While these outcomes are indeed highly relevant, they are also rare and do not fully capture the overall functional outcome of VTE patients. Importantly, functional limitations after VTE are prevalent after both deep vein thrombosis and pulmonary embolism occurring in up to 50% of patients. These post-VTE syndromes are associated with a decreased quality of life, higher risk of depressive disorders, unemployment and increased utilization of healthcare resources. Because of the major impact of functional limitations on individual patients and society as a whole, development of tools able to capture functional outcomes in clinical trials are urgently needed. We anticipate that a standardized post-VTE functional status scale will aid in demarcating effective and ineffective VTE therapies on functional outcomes in trials with appropriately powered sample sizes, as well as pave the road for value-based healthcare. The scale that we have in mind covers the entire spectrum of functional outcomes ranging from no symptoms to death. Moreover, it focuses on both limitations in usual activity as well as changes in lifestyle. The scale is not meant to replace current diagnostic or prognostic scores for post-VTE syndromes, but to be used as an outcome measure to evaluate the overall consequences of VTE on functional status. This review is a call for action to the VTE community to join forces and support further development of the proposed scale, a process of which we summarize the necessary steps.
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Affiliation(s)
- Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
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Zhang Z, Song K, Yao Y, Jiang T, Pan P, Jiang Q. Incidence and Risk Factors for Post-Thrombotic Syndrome in Patients With Deep Vein Thrombosis Following Total Knee and Hip Arthroplasty. J Arthroplasty 2019; 34:560-563. [PMID: 30503320 DOI: 10.1016/j.arth.2018.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/22/2018] [Accepted: 10/08/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Deep vein thrombosis (DVT) is common after total joint arthroplasty (TJA), and can cause the sequela of post-thrombotic syndrome (PTS), which is associated with decreased quality of life and increased treatment cost. The purpose of this study is to determine the incidence and risk factors for PTS in patients with DVT following primary unilateral total knee and hip arthroplasty. METHODS We conducted this follow-up study involving patients developing DVT after primary unilateral total knee arthroplasty or total hip arthroplasty at our institution between April 2010 and March 2017. Each patient received a follow-up clinical interview regarding PTS-related symptoms and signs. We introduced demographic, clinical, and surgical data into the analysis to identify the risk factors for PTS. RESULTS A total of 182 patients with postoperative DVT were enrolled with a mean follow-up time of 3.6 years. The incidence of PTS was 9.3% in patients developing DVT after TJA. Malignancy (P = .033), previous surgery in ipsilateral lower extremity (P = .013), and blood transfusion (P = .022) appeared to be the risk factors for PTS. CONCLUSION We determined the incidence and risk factors for PTS in patients with DVT following TJA. Preventive measures should be used for patients at high risk of PTS.
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Affiliation(s)
- Zhe Zhang
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, People's Republic of China; Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, Jiangsu, People's Republic of China
| | - Kai Song
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, People's Republic of China; Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, Jiangsu, People's Republic of China
| | - Yao Yao
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, People's Republic of China; Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, Jiangsu, People's Republic of China
| | - Tao Jiang
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, People's Republic of China; Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, Jiangsu, People's Republic of China
| | - Pin Pan
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, People's Republic of China; Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, Jiangsu, People's Republic of China
| | - Qing Jiang
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, People's Republic of China; Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, Jiangsu, People's Republic of China
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Persian Version of VEINES-QOL/Sym Questionnaire in Iranian Patients With Deep Venous Thrombosis: Cross-Cultural Adaptation and Psychometric Properties. J Nurs Meas 2018; 26:E98-E113. [PMID: 30567954 DOI: 10.1891/1061-3749.26.2.e98] [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: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE The present study was done to assess the cultural adaption and psychometric properties of Persian version of VEINES-QOL/Sym questionnaire in Iranian patients with deep venous thrombosis (DVT). METHODS This cross-cultural psychometrics study was conducted in 2016. About 270 DVT patients completed a Persian version of the VEINES-QOL/Sym questionnaire. The face, content, and construct validity were assessed. Internal consistency, test-retest, and construct reliability (CR) were used to assess reliability. RESULTS Three-factor solution was extracted that explaining 71.373% of the total variance. Goodness-of-fit indices (GFI; χ2(68) =332.037, p < .05, χ2/df = 4.882, GFI = .862, CFI = .928, NFI = .914, IFI = .928, RMSEA (90% confidence interval) =.091 [.081, .110]) in the final VEINES-QOL/Sym questionnaire structure demonstrated the adequacy of the three-domain structure. The reliability was greater than .70. CONCLUSIONS The VEINES-QOL/Sym questionnaire was found to be a valid and reliable assessment tool for quality of life in Iranian patients with DVT.
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Reduced incidence of vein occlusion and postthrombotic syndrome after immediate compression for deep vein thrombosis. Blood 2018; 132:2298-2304. [PMID: 30237155 DOI: 10.1182/blood-2018-03-836783] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/02/2018] [Indexed: 11/20/2022] Open
Abstract
Thus far, the association between residual vein occlusion and immediate compression therapy and postthrombotic syndrome is undetermined. Therefore, we investigated whether compression therapy immediately after diagnosis of deep vein thrombosis affects the occurrence of residual vein obstruction (RVO), and whether the presence of RVO is associated with postthrombotic syndrome and recurrent venous thromboembolism. In a prespecified substudy within the IDEAL (individualized duration of elastic compression therapy against long-term duration of therapy for prevention of postthrombotic syndrome) deep vein thrombosis (DVT) study, 592 adult patients from 10 academic and nonacademic centers across The Netherlands, with objectively confirmed proximal DVT of the leg, received no compression or acute compression within 24 hours of diagnosis of DVT with either multilayer bandaging or compression hosiery (pressure, 35 mm Hg). Presence of RVO and recurrent venous thromboembolism was confirmed with compression ultrasonography and incidence of postthrombotic syndrome as a Villalta score of at least 5 at 6 and 24 months. The average time from diagnosis until assessment of RVO was 5.3 (standard deviation, 1.9) months. A significantly lower percentage of patients who did receive compression therapy immediately after DVT had RVO (46.3% vs 66.7%; odds ratio, 0.46; 95% confidence interval, 0.27-0.80; P = .005). Postthrombotic syndrome was less prevalent in patients without RVO (46.0% vs 54.0%; odds ratio, 0.65; 95% confidence interval, 0.46-0.92; P = .013). Recurrent venous thrombosis showed no significant association with RVO. Immediate compression should therefore be offered to all patients with acute DVT of the leg, irrespective of severity of complaints. This study was registered at ClinicalTrials.gov (NCT01429714) and the Dutch Trial registry in November 2010 (NTR2597).
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Abstract
PURPOSE OF REVIEW Patients suffering from acute lower extremity deep vein thrombosis (DVT) are at risk for developing chronic limb pain, heaviness, and fatigue, known as the post-thrombotic syndrome (PTS). RECENT FINDINGS Although several studies have shown that catheter-directed therapy reduces clot burden and may improve clinical outcomes, the multicenter randomized controlled ATTRACT trial showed no difference in PTS or quality of life at 2 years between patients treated with pharmacomechanical catheter-directed thrombolysis (PCDT) and those treated with anticoagulation alone, and a higher major bleeding rate in the PCDT group. PCDT is not indicated for most patients diagnosed with lower extremity DVT. Since PCDT may benefit patients with iliofemoral DVT, intervention can be considered in this subset of patients if they are at low risk of bleeding.
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Affiliation(s)
- Ronald S Winokur
- Department of Radiology, Division of Interventional Radiology, Weill Cornell Medicine, 2315 Broadway, 4th Floor, New York, NY, 10024, USA.
| | - Akhilesh K Sista
- Department of Radiology, Division of Interventional Radiology, New York University-Langone School of Medicine, 660 1st Avenue, Room 318, New York, NY, 10016, USA
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Abstract
Pulmonary embolism (PE) is caused by emboli, which have originated from venous thrombi, travelling to and occluding the arteries of the lung. PE is the most dangerous form of venous thromboembolism, and undiagnosed or untreated PE can be fatal. Acute PE is associated with right ventricular dysfunction, which can lead to arrhythmia, haemodynamic collapse and shock. Furthermore, individuals who survive PE can develop post-PE syndrome, which is characterized by chronic thrombotic remains in the pulmonary arteries, persistent right ventricular dysfunction, decreased quality of life and/or chronic functional limitations. Several important improvements have been made in the diagnostic and therapeutic management of acute PE in recent years, such as the introduction of a simplified diagnostic algorithm for suspected PE as well as phase III trials demonstrating the value of direct oral anticoagulants in acute and extended treatment of venous thromboembolism. Future research should aim to address novel treatment options (for example, fibrinolysis enhancers) and improved methods for predicting long-term complications and defining optimal anticoagulant therapy parameters in individual patients, and to gain a greater understanding of post-PE syndrome.
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ten Cate‐Hoek AJ. Prevention and treatment of the post-thrombotic syndrome. Res Pract Thromb Haemost 2018; 2:209-219. [PMID: 30046723 PMCID: PMC6055553 DOI: 10.1002/rth2.12085] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/14/2018] [Indexed: 11/12/2022] Open
Abstract
Post thrombotic syndrome (PTS) is a common chronic complication of deep vein thrombosis of the leg (DVT). Treatment options are limited therefore emphasis is placed on its prevention. Several risk factors have been recognized, but were so far not used for risk stratification or translation into prediction models. Early interventions did not yet result in more successful preventive treatment strategies; for the acute phase of DVT there is equipoise on the value of elastic compression, as well as on catheter directed thrombolysis. There are no drugs specifically targeted at PTS prevention. The use of anticoagulant medication such as direct oral anticoagulants (DOACs) might decrease PTS incidence, but this needs to be corroborated. Both research into more effective treatment options as well as future PTS management may benefit from a uniform diagnostic strategy and the use of prediction rules to better allocate treatment and thereby increase treatment efficacy.
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Affiliation(s)
- Arina J. ten Cate‐Hoek
- Heart+ and Vascular Center, Internal MedicineCardiovascular Research InstituteMaastricht University Medical CenterMaastrichtthe Netherlands
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Coleman CI, Beyer-Westendorf J, Bunz TJ, Mahan CE, Spyropoulos AC. Postthrombotic Syndrome in Patients Treated With Rivaroxaban or Warfarin for Venous Thromboembolism. Clin Appl Thromb Hemost 2018. [PMID: 29514466 PMCID: PMC6714693 DOI: 10.1177/1076029618758955] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Postthrombotic syndrome (PTS) is a frequent complication of venous thromboembolism (VTE).
Using MarketScan claims data from January 2012 to June 2015, we identified adults with a
primary diagnosis code for VTE during a hospitalization/emergency department visit, ≥6
months of insurance coverage prior to the index event and newly started on rivaroxaban or
warfarin within 30 days of the index VTE. Patients with <4-month follow-up postindex
event or a claim for any anticoagulant during 6-month baseline period were excluded.
Differences in baseline characteristics between rivaroxaban and warfarin users were
adjusted for using inverse probability of treatment weights based on propensity scores.
Patients were followed for the development of PTS starting 3 months after the index VTE.
Cox regression was performed and reported as hazard ratios with 95% confidence intervals
(CIs). In total, 10 463 rivaroxaban and 26 494 warfarin users were followed for a mean of
16 ± 9 (range, 4-39) months. Duration of anticoagulation was similar between cohorts
(median = 6 months). Rivaroxaban was associated with a 23% (95% CI: 16-30) reduced hazard
of PTS versus warfarin. Rivaroxaban was associated with a significant risk reduction in
symptoms of PTS compared to warfarin in patients with VTE treated in routine practice.
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Affiliation(s)
- Craig I Coleman
- 1 Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Jan Beyer-Westendorf
- 2 Division Hematology, Department of Medicine I, Thrombosis Research Unit, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany.,3 Department of Hematology, Kings Thrombosis Service, Kings College London, London, United Kingdom
| | - Thomas J Bunz
- 4 New England Health Analytics, LLC, Granby, CT, USA
| | - Charles E Mahan
- 5 Presbyterian Healthcare Services, University of New Mexico, Albuquerque, NM, USA
| | - Alex C Spyropoulos
- 6 Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health System, Hofstra Northwell School of Medicine, Manhasset, NY, USA
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ten Cate-Hoek AJ, Amin EE, Bouman AC, Meijer K, Tick LW, Middeldorp S, Mostard GJM, ten Wolde M, van den Heiligenberg SM, van Wissen S, van de Poel MHW, Villalta S, Serné EH, Otten HM, Klappe EH, Bistervels IM, Lauw MN, Piersma-Wichers M, Prandoni P, Joore MA, Prins MH, ten Cate H, ten Cate-Hoek AJ, ten Cate H, Joore MA, Prins MH, Amin EE, Bouman AC, Meijer K, Piersma-Wichers M, Tick LW, Nijziel MR, Middeldorp S, Lauw M, Cheung YW, Mostard GJM, ten Wolde M, Bistervels IM, van den Heiligenberg SM, van Wissen S, van de Poel MHW, Otten HM, Serné EH, Klappe EH, Prandoni P, Vedovetto V, Villalta S. Individualised versus standard duration of elastic compression therapy for prevention of post-thrombotic syndrome (IDEAL DVT): a multicentre, randomised, single-blind, allocation-concealed, non-inferiority trial. LANCET HAEMATOLOGY 2018; 5:e25-e33. [DOI: 10.1016/s2352-3026(17)30227-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 11/30/2022]
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Voigtlaender M, Langer F. Direct oral anticoagulants for the treatment of cancer-associated venous thromboembolism. Hamostaseologie 2017; 37:241-255. [DOI: 10.5482/hamo-16-09-0036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 02/01/2017] [Indexed: 12/17/2022] Open
Abstract
SummaryCancer patients with venous thromboembolism (VTE) are at increased risk for both bleeding and VTE recurrence. Anticoagulation with low-molecular-weight heparin (LMWH) is the standard of care during the initial and longterm treatment phase (i.e. during the first 3 – 6 months of therapy) based on its overall beneficial safety and efficacy profile compared to vitamin K antagonists (VKAs). The direct oral anticoagulants (DOACs) rivaroxaban, apixaban, edoxaban, and dabigatran are approved for the treatment of acute VTE, and the combined six phase-3 trials have included > 1500 patients with active cancer, as defined by variable selection criteria. Subgroup analyses of these patients, either pooled or separately reported, suggest that DOACs could be a safe and efficacious alternative to VKA therapy for the treatment of cancer-associated VTE. However, the populations of cancer patients included in the DOAC and LMWH trials are not comparable with regard to mortality and VTE risk, and no specific data from direct head-to-head comparisons of DOACs with LMWHs are currently available. The use of DOACs for the management of VTE in cancer is thus not recommended by clinical practice guidelines.
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van Vuuren TM, van Laanen JHH, de Geus M, Nelemans PJ, de Graaf R, Wittens CHA. A randomised controlled trial comparing venous stenting with conservative treatment in patients with deep venous obstruction: research protocol. BMJ Open 2017; 7:e017233. [PMID: 28893753 PMCID: PMC5595185 DOI: 10.1136/bmjopen-2017-017233] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Deep venous obstruction (DVO) has a great impact on quality of life (QoL) comparable to angina pectoris or chronic pulmonary disease. Post-thrombotic scar formation and May-Thurner syndrome (MTS) are the most common causes of DVO. Conventional treatment of DVO focuses on reducing pain or leg swelling by use of (pain) medication and therapeutic elastic stockings. In the past, a venous bypass was offered in severe post-thrombotic cases, but this procedure showed bad clinical and patency outcomes. With the introduction of percutaneous angioplasty and dedicated venous stents new opportunities were created. Deep venous stenting has been shown to be effective in retrospective case series. However, there is no prior research in which QoL after interventional treatment is compared with QoL after conventional treatment. Currently, there is a debate about the true additional value of interventional treatment. We investigate whether those patients who are treated with stenting experience a change in short form 36 (SF-36) and the Veines-QoL/Sym questionnaires compared with conventionally treated patients. METHODS AND ANALYSIS This is a randomised trial comparing conservative deep venous management to interventional treatment. A total of 130 patients with post-thrombotic syndrome (PTS) or MTS, eligible for interventional percutaneous treatment, who did not have previous deep venous intervention will be included. Patients will be randomised to conservative treatment or venous stenting and stratified for the PTS or MTS subgroup. Conservative treatment consists of either one or a combination of pain medications, manual lymphatic drainage, compression stockings and regular post-thrombotic anticoagulant therapy.The primary outcome is the QoL change after 12 months compared with baseline QoL. Secondary outcomes are QoL changes at 6 weeks, clinical assessment of DVO, recurrence rate of deep venous thrombosis at 6 weeks and 12 months, and the total amount of working days lost. Intervention-specific outcomes include complications and patency. ETHICS AND DISSEMINATION The protocol is approved by the Medical Ethics Committee of Academisch ziekenhuis Maastricht/Universiteit Maastricht, The Netherlands (protocol number NLNL55641.068.15 / METC 161008).We aim to publish the results of this study in a peer reviewed journal and present our findings at national or international conferences. TRIAL REGISTRATION NUMBER The study protocol was registered at www.clinicaltrials.gov (registration number: NCT03026049) on 17 January 2017.
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Affiliation(s)
- Timme Maj van Vuuren
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Vascular surgery, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Jorinde H H van Laanen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maaike de Geus
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Vascular surgery, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Patty J Nelemans
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Rick de Graaf
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Cees H A Wittens
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Vascular surgery, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Limburg, The Netherlands
- Department of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
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Kahn SR, Akaberi A, Granton JT, Anderson DR, Wells PS, Rodger MA, Solymoss S, Kovacs MJ, Rudski L, Shimony A, Dennie C, Rush C, Hernandez P, Aaron SD, Hirsch AM. Quality of Life, Dyspnea, and Functional Exercise Capacity Following a First Episode of Pulmonary Embolism: Results of the ELOPE Cohort Study. Am J Med 2017; 130:990.e9-990.e21. [PMID: 28400247 DOI: 10.1016/j.amjmed.2017.03.033] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND We aimed to evaluate health-related quality of life (QOL), dyspnea, and functional exercise capacity during the year following the diagnosis of a first episode of pulmonary embolism. METHODS This was a prospective multicenter cohort study of 100 patients with acute pulmonary embolism recruited at 5 Canadian hospitals from 2010-2013. We measured the outcomes QOL (by Short-Form Health Survey-36 [SF-36] and Pulmonary Embolism Quality of Life [PEmb-QoL] measures), dyspnea (by the University of California San Diego Shortness of Breath Questionnaire [SOBQ]) and 6-minute walk distance at baseline and 1, 3, 6, and 12 months after acute pulmonary embolism. Computed tomography pulmonary angiography was performed at baseline, echocardiogram was performed within 10 days, and cardiopulmonary exercise testing was performed at 1 and 12 months. Predictors of change in QOL, dyspnea, and 6-minute walk distance were assessed by repeated-measures mixed-effects models analysis. RESULTS Mean age was 50.0 years; 57% were male and 80% were treated as outpatients. Mean scores for all outcomes improved during 1-year follow-up: from baseline to 12 months, mean SF-36 physical component score improved by 8.8 points, SF-36 mental component score by 5.3 points, PEmb-QoL by -32.1 points, and SOBQ by -16.3 points, and 6-minute walk distance improved by 40 m. Independent predictors of reduced improvement over time were female sex, higher body mass index, and percent-predicted VO2 peak <80% on 1 month cardiopulmonary exercise test for all outcomes; prior lung disease and higher pulmonary artery systolic pressure on 10-day echocardiogram for the outcomes SF-36 physical component score and dyspnea score; and higher main pulmonary artery diameter on baseline computed tomography pulmonary angiography for the outcome PEmb-QoL score. CONCLUSIONS On average, QOL, dyspnea, and walking distance improve during the year after pulmonary embolism. However, a number of clinical and physiological predictors of reduced improvement over time were identified, most notably female sex, higher body mass index, and exercise limitation on 1-month cardiopulmonary exercise test. Our results provide new information on patient-relevant prognosis after pulmonary embolism.
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Affiliation(s)
- Susan R Kahn
- Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Montreal, Quebec, Canada; Department of Medicine, McGill University, Montreal, Quebec, Canada.
| | - Arash Akaberi
- Center for Clinical Epidemiology, Lady Davis Institute, Montreal, Quebec, Canada
| | - John T Granton
- Division of Respirology, Department of Medicine, University of Toronto, Ontario, Canada
| | - David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Philip S Wells
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ontario, Canada
| | - Marc A Rodger
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ontario, Canada
| | - Susan Solymoss
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Michael J Kovacs
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
| | - Lawrence Rudski
- Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada
| | - Avi Shimony
- Department of Cardiology, Ben Gurion University, Beer Sheva, Israel
| | - Carole Dennie
- Department of Diagnostic Imaging, University of Ottawa, Ontario, Canada
| | - Chris Rush
- Department of Nuclear Medicine, Jewish General Hospital, Montreal, Quebec, Canada
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Shawn D Aaron
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ontario, Canada
| | - Andrew M Hirsch
- Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada
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Galanaud JP, Monreal M, Kahn SR. Epidemiology of the post-thrombotic syndrome. Thromb Res 2017; 164:100-109. [PMID: 28844444 DOI: 10.1016/j.thromres.2017.07.026] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/20/2017] [Accepted: 07/21/2017] [Indexed: 01/15/2023]
Abstract
The post thrombotic syndrome (PTS) refers to clinical manifestations of chronic venous insufficiency (CVI) following a deep-vein thrombosis (DVT). PTS is the most frequent complication of DVT, which develops in 20 to 50% of cases after proximal DVT and is severe in 5-10% of cases. The reported prevalence of PTS differs widely among studies because of differences in study populations, tools used to assess PTS, and time interval between acute DVT and PTS assessment. The two most important predictors of PTS are extensive proximal character of DVT and previous ipsilateral DVT. Other reported risk factors include pre-existing CVI, obesity, quality of anticoagulant treatment, older age and residual venous obstruction. Standardization of PTS assessment tools combined with the development of patient self-reported PTS scales are likely to constitute a breakthrough in research of the epidemiology of PTS, by allowing comparison between studies, meta-analyses and increasing the feasibility of longer follow-up of DVT patients. This should enable identification of patient populations at high risk of severe PTS, new predictors of PTS and targets for potential new treatments. In this perspective, identification of biomarkers that are predictive of PTS such as markers of inflammation is crucial in ongoing research.
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Affiliation(s)
- Jean-Philippe Galanaud
- Department of General Internal Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada; Department of Internal Medicine, Montpellier University Hospital, Montpellier, France.
| | - Manuel Monreal
- Department of Internal Medicine, Hospital de Badalona Germans Trias I Pujol, Barcelona, Spain
| | - Susan R Kahn
- Department of Medicine, McGill University and Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, Canada
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Keita I, Aubin-Auger I, Lalanne C, Aubert JP, Chassany O, Duracinsky M, Mahé I. Assessment of quality of life, satisfaction with anticoagulation therapy, and adherence to treatment in patients receiving long-course vitamin K antagonists or direct oral anticoagulants for venous thromboembolism. Patient Prefer Adherence 2017; 11:1625-1634. [PMID: 29026288 PMCID: PMC5626412 DOI: 10.2147/ppa.s131157] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have shown non-inferiority and ease of use compared to vitamin K antagonists (VKA) in the treatment of venous thromboembolism (VTE). No study so far has been directed toward real-life experience of outpatients receiving anticoagulants for VTE in France. METHODS This is an observational descriptive real-life epidemiological study, using three validated questionnaires (Morisky Medication Adherence Scale-8, EQ-5D, and part 2 of the Perception of Anticoagulant Treatment Questionnaire), to assess adherence, quality of life, and satisfaction in 100 VTE outpatients receiving anticoagulation therapy by VKA (primary or switched from DOAC to VKA) or by DOAC (primary or switched from VKA to DOAC). RESULTS Patients were very much satisfied with their treatment in both DOAC and VKA groups. Despite advantages of DOACs, therapeutic adherence was only moderate. The best adherence scores were observed in the primary VKA switched to DOAC for at least 3 months (S-DOAC) subgroup. Quality of life was better in the DOAC group mainly because of the absence of the requirement for blood testing. Most of the complaints concerned the pain/discomfort dimension in the VKA group and anxiety/depression dimension in the DOAC group. CONCLUSION Patients were satisfied with their anticoagulant treatment, especially when they were involved in choosing the anticoagulant, and the treatment suited them. Quality of life of patients in the DOAC group was better than in the VKA group, but adherence remains to be improved. This study highlights the importance of the physician-patient relationship, pretreatment initiation, and follow-up of any anticoagulation therapy throughout.
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Affiliation(s)
- Ingre Keita
- Internal Medicine Department, Louis Mourier Hospital, APHP, Colombes
| | - Isabelle Aubin-Auger
- Paris 7 University
- General Medicine Department, Université Paris 7, Paris
- Recherche Clinique Ville-Hôpital, Méthodologies et Société (REMES) EA 7334, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Christophe Lalanne
- Recherche Clinique Ville-Hôpital, Méthodologies et Société (REMES) EA 7334, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Jean-Pierre Aubert
- Paris 7 University
- General Medicine Department, Université Paris 7, Paris
- Recherche Clinique Ville-Hôpital, Méthodologies et Société (REMES) EA 7334, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Olivier Chassany
- Paris 7 University
- Recherche Clinique Ville-Hôpital, Méthodologies et Société (REMES) EA 7334, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Martin Duracinsky
- Recherche Clinique Ville-Hôpital, Méthodologies et Société (REMES) EA 7334, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Isabelle Mahé
- Internal Medicine Department, Louis Mourier Hospital, APHP, Colombes
- Paris 7 University
- Recherche Clinique Ville-Hôpital, Méthodologies et Société (REMES) EA 7334, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Correspondence: Isabelle Mahé, Hôpital Louis Mourier, Service de Médecine Interne, Université Paris 7, APHP 178 rue des Renouillers, 92700 Colombes, France, Tel +33 1 47 60 64 90, Fax +33 1 47 60 64 91, Email
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