Prevalence and risk factors for hypertension in hemophilia

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

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

Risk of Intracranial Hemorrhage in Persons with Hemophilia A in the United States: Real-World Retrospective Cohort Study Using the ATHNdataset

Introduction

Intracranial hemorrhage (ICH), a serious complication in persons with hemophilia A (PWHA), causes high rates of mortality and morbidity. Identified ICH risk factors from patient data spanning 1998-2008 require reassessment in light of changes in the current treatment landscape.

Aim and methods

PWHA identified in the ATHNdataset were evaluated retrospectively to assess incidence of ICH and determine the association between ICH risk and key characteristics using time-to-event analyses (Cox proportional-hazards models, survival curves, and sensitivity analyses).

Results

Over a median follow-up time of 10.7 patient-years, 135 of 7837 PWHA over 2 years of age in the ATHNdataset (1.7%) experienced an ICH. Stratification by prophylaxis status and inhibitor status resulted in an incidence rate (IR) ratio (IRR) (IR+/IR-) of 0.63 (95% confidence interval [CI], 0.43-0.94; P=0.020) and 1.76 (95% CI, 0.97-3.20; P=0.059), respectively. Characteristics associated with greater risk of developing ICH include being aged 2-12 years; being covered by Medicaid; having had HIV, hepatitis C, or hypertension; and never having received factor VIII or prophylactic treatment. In multivariable analysis with interaction, the estimated hazard ratio for PWHA never receiving prophylaxis was 7.67 (95% CI, 2.24-26.30), which shrunk to 2.03 (95% CI, 1.30-9.12) in bootstrapping analysis and 3.09 in the highest-penalty ridge-regression analysis but was still significant. Inhibitor status was found not to be statistically associated with ICH in all analyses.

Conclusion

These results align with previous studies demonstrating that prophylaxis confers a protective effect against ICH. Previously, inhibitor positivity had been shown to increase risk for ICH; however, this study did not corroborate those findings.

Safety and efficacy of combined dual antiplatelet therapy and factor VIII prophylaxis in patients with haemophilia A after acute coronary syndrome

INTRODUCTION

The increased life expectancy of patients with haemophilia A (HA) has led to a growing prevalence of cardiovascular risk factors and events. There is still scarce evidence on the safety and appropriate duration of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) in HA patients.

AIM

We describe our experience on the clinical management of Italian HA patients after ACS.

METHODS

Nine patients with congenital HA treated with DAPT after a revascularization procedure performed for ACS have been enrolled and followed at the Angelo Bianchi Bonomi Haemophilia and Thrombosis Center in Milan between 2005 and September 2022. The safety and efficacy of DAPT with or without FVIII prophylaxis were assessed.

RESULTS

Ten ACS events occurred in the nine HA patients (four mild and five severe). All events were treated with percutaneous transluminal coronary angioplasty with deployment of 1 to 3 drug-eluting stents followed by DAPT for 1-12 months. All patients except one were treated with FVIII prophylaxis during DAPT aimed at achieving FVIII trough levels ≥20-30 IU/dL. DAPT was effective in all cases in preventing early ACS recurrence, with only a late recurrence. We observed two clinically relevant non-major bleeds (one in a patient without FVIII prophylaxis) and three minor bleeds. No venous thrombosis occurred.

CONCLUSION

The long-term secondary antithrombotic prevention consisting of DAPT and FVIII prophylaxis achieving a trough level of 20-30 IU/dL can be effective and safe in HA patients.

Serum uric acid is independently associated with hypertension in patients with polymyositis and dermatomyositis

Serum uric acid (UA), as an antioxidant, has been associated with hypertension in the general population. Hypertension is highly prevalent in patients with polymyositis and dermatomyositis (PM/DM). Owning elevated levels of reactive oxygen species, patients with PM/DM have lower concentrations of UA in comparison with healthy people. We explored a potential association between UA levels and hypertension in PM/DM and evaluated whether this association is independent of hypertension risk factors, PM/DM characteristics and relevant drugs. A total of 472 PM/DM patients were assessed. UA and related laboratory data were measured. Demographic, hypertension-related factors, PM/DM characteristics and drug use were assessed as potential covariates. Results were analyzed using logistic models to test the independence of the association between UA and hypertension. UA levels were higher in hypertension subjects compared to non-hypertensive PM/DM patients [284.70 (239.93-357.38) vs 264.00(222.50-322.75), p = .017]. When adjusted for hypertension risk factors, PM/DM characteristics and drugs, the odds of being a hypertensive PM/DM patient per 1 μmol/L UA increase were significantly increased: odds ratio = 1.473 (95% confidence interval:1.063-2.042, p = .020). This cross-sectional study suggests that UA levels are independently associated with hypertension in PM/DM patients.

Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research priorities to transform the care of people with hemophilia

BACKGROUND

Decades of research have transformed hemophilia from severely limiting children's lives to a manageable disorder compatible with a full, active life, for many in high-income countries. The direction of future research will determine whether exciting developments truly advance health equity for all people with hemophilia (PWH). National Hemophilia Foundation (NHF) and American Thrombosis and Hemostasis Network conducted extensive inclusive all-stakeholder consultations to identify the priorities of people with inherited bleeding disorders and those who care for them.

RESEARCH DESIGN AND METHODS

Working group (WG) 1 of the NHF State of the Science Research Summit distilled the community-identified priorities for hemophilia A and B into concrete research questions and scored their feasibility, impact, and risk.

RESULTS

WG1 defined 63 top priority research questions concerning arthropathy/pain/bone health, inhibitors, diagnostics, gene therapy, the pediatric to adult transition of care, disparities faced by the community, and cardiovascular disease. This research has the potential to empower PWH to thrive despite lifelong comorbidities and achieve new standards of wellbeing, including psychosocial.

CONCLUSIONS

Collaborative research and care delivery will be key to capitalizing on current and horizon treatments and harnessing technical advances to improve diagnostics and testing, to advance health equity for all PWH.

Health and quality of life of patients with haemophilia: A national study of 124 Danish men

PURPOSE

In the past decades, haemophilia treatment has greatly improved the health of persons with haemophilia (PWH). This study compares PWH to the general population on social conditions and health.

METHODS

In December 2021, all Danes with moderate or severe haemophilia A or B, or von Willebrands disease type 3 were invited to participate in an online self-report survey concerning sociodemographic factors, self-rated health, teeth status, chronic health conditions, symptoms and loneliness. This study compares responses from the 124 adult male PWH with responses from a male general population sample (N = 4849). Analyses used logistic regression, controlling for age and highest completed education.

RESULTS

Fewer PWH were in the oldest age group (65-84 years). Controlling for age, no significant differences were found regarding cohabitation status or education. Fewer PWH were employed (OR = .48, [.33-.71])-particularly in the 45-64 age group. PWH were less likely to report good health (OR = .49, [.31-.77]). The odds of joint disease was much higher (OR = 13.00, [8.37-20.28]). Also, hypertension (OR = 2.25, [1.13-5.65]) and previous stroke (OR = 2.51, [1.44-3.50]) were more frequent. PWH were more likely to report pain in the arms/hands/legs/hips (OR = 2.94, [1.92-4.52]), but less likely to report pain in the head/neck/shoulder (OR = .66, [.45-.96]).

CONCLUSION

The disease burden of haemophilia has improved so PWH resembles the general population in areas such as marriage and education. However, even for young PWH, the disease still imposes a significant burden from hemophilia arthropathy and pain in extremities and joints. Middle-aged PWH also have poorer levels of employment than same-aged peers.

Prevalence of selected bleeding and thrombotic events in persons with hemophilia versus the general population: A scoping review

Life expectancy for persons with hemophilia has increased over recent decades due to advances in treatment practice and patient care. Those with hemophilia are now more likely to be affected by conditions associated with aging, such as myocardial infarction, hemorrhagic/ischemic stroke, deep vein thrombosis, pulmonary embolism, and intracranial hemorrhage. Here, we describe the results of a literature search designed to summarize current data on the prevalence of the above selected bleeding and thrombotic events in persons with hemophilia vs the general population. A total of 912 articles published between 2005 and 2022 were identified in a search of BIOSIS Previews, Embase, and MEDLINE databases conducted in July 2022. Case studies, conference abstracts, review articles, studies focusing on hemophilia treatments or surgical outcomes, and studies examining patients with inhibitors only were excluded. After screening, 83 relevant publications were identified. The prevalence of bleeding events was consistently higher in hemophilia populations vs reference populations (hemorrhagic stroke, 1.4%-5.31% vs 0.2%-0.97%; intracranial hemorrhage, 1.1%-10.8% vs 0.04%-0.4%). Serious bleeding events showed a high rate of mortality with standardized mortality ratios for intracranial hemorrhage ranging from 3.5 to 14.88. Although 9 studies reported lower prevalence of arterial thrombosis (myocardial infarction/stroke) in hemophilia vs general populations, 5 studies reported higher or comparable prevalence in hemophilia. Prospective studies are therefore needed to understand the prevalence of bleeding and thrombotic events in hemophilia populations, particularly with the observed increases in life expectancy and availability of novel treatments.

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

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

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

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

Prevalence of comorbid conditions among older males with haemophilia receiving care in haemophilia treatment centers in the United States

INTRODUCTION

Increased survival among men with haemophilia has brought with it an increased risk of age-related comorbidities that may be challenging to treat in the presence of a bleeding disorder.

AIM

Estimate the prevalence of several age-related comorbidities among older males with haemophilia receiving care in the U.S. haemophilia treatment center (HTC) network compared to that among the general population.

METHODS

People with bleeding disorders who receive care in network HTCs can volunteer to participate in a surveillance registry that collects detailed clinical information including the presence of comorbid conditions at annual visits. We used registry data collected on males with haemophilia age 45 years and older to calculate lifetime prevalence of obesity, diabetes, hypertension, cardiovascular disease, renal disease, cancer, anxiety and depression. Comparable data on the U.S. general male population was obtained from the National Health Interview Survey.

RESULTS

During the surveillance period, 1592 middle-aged (45-64 years) and 645 older (≥65 years) patients with haemophilia had comorbidity data collected during 6435 HTC visits. Most haemophilia patients in both age groups had a higher prevalence of anxiety, depression and diabetes, but a lower prevalence of hypertension, coronary heart disease, stroke and myocardial infarction compared to the general U.S. male population. In addition, middle-aged patients had lower rates of leukemia, whereas older patients had higher rates of obesity than the general population.

CONCLUSION

These findings highlight the mental stress associated with this chronic condition and support continued public health obesity prevention efforts in the haemophilia community.

Outcomes of COVID-19 in Adult Males With Hemophilia A: A Propensity Score-Matched Analysis

Background Hypercoagulability is a major pathologic event in COVID-19. Factor VIII plays an important role in hemostasis, and high levels of factor VIII have been shown to be associated with an increased risk of thrombosis and severe disease. Little is known about the impact of COVID-19 on clinical outcomes in patients with hemophilia A. Methodology Retrospective data of adult male patients with COVID-19 with and without hemophilia A were retrieved from the TriNetX database (Cambridge, USA). The 1:1 propensity score-matching was performed to balance baseline characteristics. Patients were matched for age, race, body mass index, and medical comorbidities. Thirty-day outcomes were assessed. Results We identified 1,758 patients with pre-existing hemophilia A diagnosis prior to COVID-19 diagnosis and 5,191,908 comparators. After 1:1 propensity score matching, groups were balanced on demographics and comorbidities. All-cause mortality rates were similar between the two groups (HR 0.805; 95% CI 0.467-1.389). The frequency of severe infection, ICU admission, and composite thrombotic events did not differ between the groups. Patients with hemophilia A were hospitalized more frequently than those without a history of hemophilia A (19.2% vs. 14.4%; p<0.05). Additionally, gastrointestinal (GI) bleeding and composite bleeding events occurred more frequently in patients with hemophilia A (3.2% vs. 2.2%; p<0.05 and 4.0% vs. 2.8%; p<0.05, respectively). Conclusions The mortality of individuals with hemophilia A due to COVID-19 is comparable to the general population but with higher risks of hospitalization and bleeding.

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

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Blood pressure in persons with haemophilia with a focus on haemophilia-specific risk factors

INTRODUCTION

Persons with haemophilia (PWH) have a higher prevalence of hypertension compared to the general population, which cannot be explained entirely by the usual cardiovascular risk factors. Neutralizing antibodies (inhibitors) against clotting factors might have some relation to cardiovascular disease in PWH. However, whether inhibitors facilitate hypertension is unknown.

AIM

We investigated the relationship between hypertension/blood pressure and inhibitors in PWH. Additional goals were to determine the relationships with haemophilia type, race, and viral status.

METHODS

Records were extracted retrospectively for PWH (age ≥18 years) between 2003 and 2014 from four Hemophilia Treatment Centers in North America and included demographics, weight, height, haemophilia type/severity, HCV and HIV infection status, hypertension, use of anti-hypertensive medications, and inhibitor status. We fitted semiparametric generalized additive models (GAMs) to describe adjusted curves of blood pressure (BP) against age.

RESULTS

Among 691 PWH, 534 had haemophilia A and 157 had haemophilia B, with a median age of 39 years (range 18 to 79). Forty-four PWH (6.5%) had a history of inhibitors, without evidence for a higher prevalence of hypertension or higher BP. A higher prevalence of hypertension and higher BP were noted for haemophilia A (vs. haemophilia B), coinfection with HCV/HIV (vs. uninfected), or moderate haemophilia (vs. severe haemophilia).

CONCLUSION

While there was no signal to suggest that a history of inhibitors is associated with hypertension, differences based on haemophilia type, severity, and viral infection status were identified, encouraging prospective investigations to better delineate haemophilia-specific risk factors for hypertension.

Cardiovascular disease in hereditary haemophilia: The challenges of longevity

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

Cardiovascular risk factors among adult patients with haemophilia

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

Mechanisms of Bone Remodeling Disorder in Hemophilia

Hemophilia is caused by a lack of antihemophilic factor(s), for example, factor VIII (FVIII; hemophilia A) and factor IX (FIX; hemophilia B). Low bone mass is widely reported in epidemiological studies of hemophilia, and patients with hemophilia are at an increased risk of fracture. The detailed etiology of bone homeostasis imbalance in hemophilia is unclear. Clinical and experimental studies show that FVIII and FIX are involved in bone remodeling. However, it is likely that antihemophilic factors affect bone biology through thrombin pathways rather than via their own intrinsic properties. In addition, among patients with hemophilia, there are pathophysiological processes in several systems that might contribute to bone loss. This review summarizes studies on the association between hemophilia and bone remodeling, and might shed light on the challenges facing the care and prevention of osteoporosis and fracture in patients with hemophilia.

Prophylaxis for hemophilia A without inhibitors: treatment options and considerations

INTRODUCTION

Hemophilia A is a bleeding disorder traditionally managed with standard half-life (SHL) factor (F) VIII concentrates. Extended half-life (EHL) FVIII products and emicizumab-kywh, a nonfactor therapy, are newer treatment options. Additional nonfactor agents and gene therapy are expected to reach the market in the near future.

AREAS COVERED

A PubMed (MEDLINE) search from 1962 to April 2020 related to hemophilia A, its management, and the products currently available for prophylaxis was performed to comprehensively review these topics and analyze the benefits and drawbacks of each therapeutic.

EXPERT OPINION

Prophylaxis with SHL FVIII concentrates remains the standard of care for patients with severe hemophilia A and may also be considered for selected individuals with moderate disease. Several years of real-world experience with EHL FVIII, emicizumab-kywh, and other agents in development will be necessary to determine their ultimate roles in the prevention of bleeding and its complications. Gene therapy may not provide a permanent cure for hemophilia A.

Cardiac surgery in patients with Hemophilia:is it safe?

Background

The life expectancy of hemophiliacs is similar to that of the general population. As a result, the prevalence of age-related cardiovascular diseases has increased. We present our experience with hemophilia patients who underwent cardiac surgery in our Medical Center between 2004 and 2019.

Methods

All hemophilia patients who underwent cardiac surgery were identified, and their peri-operative data evaluated retrospectively.

Results

Ten patients were identified: six with hemophilia-A, one with hemophilia-B, and three with hemophilia-C (factor XI deficiency). Cardiac procedures included ten coronary artery bypass grafts and one aortic valve replacement. Hemophilia-A and B patients were treated with factor substitution, whereas patients with factor XI deficiency were treated with fresh frozen plasma. One patient died, and one patient suffered from non-active gastrointestinal bleeding.

Conclusions

While major cardiac surgery can be performed safely on patients with hemophilia, a multidisciplinary team approach and strict postoperative monitoring are essential in order to achieve optimal results.

Macroscopic hematuria as a risk factor for hypertension in ageing people with hemophilia and a family history of hypertension

Ageing people with hemophilia (PWH) have a higher prevalence of hypertension than the general population. This study aimed to determine whether macroscopic hematuria was associated with hypertension in PWH in a post hoc analysis using data from a cross-sectional study conducted by the ADVANCE Working Group (the H3 study), which included PWH ≥ 40 years of age. Data from 16 contributing centers, located in 13 European countries and Israel, were analyzed using logistic regression models. Of 532 recruited PWH in the H3 study, 117 had hypertension and a positive family history of hypertension (hypertension FH+), 75 had hypertension and a negative family history of hypertension (hypertension FH-), 290 had no diagnosis of hypertension, and the remaining 50 had missing hypertension data. Logistic regressions showed that macroscopic hematuria was associated with hypertension FH+, both in the univariate (OR = 1.84 [1.17-2.90], P = .01) and in the multivariate model (OR = 1.80 [1.03-3.16], P = .04). Macroscopic hematuria was not associated with hypertension FH-. Moreover, in a multivariate logistic regression the odds of hypertension FH+ were increased with the number of macroscopic hematuria episodes. The association between macroscopic hematuria and hypertension was significant for PWH with a family history of hypertension.

Intracranial haemorrhage in children and adults with haemophilia A and B: a literature review of the last 20 years

Intracranial haemorrhage (ICH) is the most serious event in haemophiliacs, resulting in high rates of mortality and disability. Although the use of a prophylaxis regimen has improved outcomes, the mortality caused by ICH is still around 20%. ICH is more frequent at two different ages: in childhood (mostly in children aged ≤2 years) and in adulthood (with known risk factors such as hypertension and age ≥60 years). Our review shows how ICH remains one of the worst problems of patients with haemophilia. Greater attention to risk factors and early symptoms, together with an appropriate early prophylaxis, may reduce the risk of severe intracranial haemorrhagic events.

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

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effects of six-week resistance, aerobic and combined exercises on the pro-inflammatory and anti-inflammatory markers in overweight patients with moderate haemophilia A: A randomized controlled trial

INTRODUCTION

Overweight increases the secretion of pro-inflammatory cytokines and serves as a major risk factor for arthropathy and cardiovascular diseases (CVD). This condition is becoming increasingly prevalent among patients with haemophilia (PWH). Different forms of exercise training could favourably modify weight-related complications, cardiovascular risk factors and the inflammation.

AIM

To investigate the effects of resistance, aerobic and combined exercises on the pro-inflammatory and anti-inflammatory markers in overweight patients with moderate haemophilia A.

METHODS

Forty-eight patients with moderate haemophilia A, aged 35-55 years, and body mass index (BMI) of 25-30 kg/m² were randomly assigned to resistance training (RT, n = 12), aerobic (AT, n = 12), combined training (CT, n = 12) and control (n = 12) groups. The patients participated in 45-minutes exercise sessions three times a week for 6 weeks. Waist circumference (WC), waist-to-hip ratio (WHR), fat mass, fat-free mass, interleukin-10 (IL-10), adiponectin, tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6) and high sensitive C-reactive protein (hs-CRP) were measured before and after the 6 weeks of training.

RESULTS

There was significant decrease in WC, WHR, BMI and weight in the AT, RT and CT groups as compared to the control group. Total HJHS scores decreased in the AT, RT, CT groups compared to the control groups (P ≤ 0.001). The decrease in hs-CRP, IL-6 and TNF-α in the CT group was significant compared to the control group (P ≤ 0.02). The increase in IL-10 and adiponectin was not significant in the RT, AT and CT groups compared to the control group.

CONCLUSION

CT was the most effective training mode for decreasing the pro-inflammatory cytokines and increasing anti-inflammatory markers in overweight patients with haemophilia A.

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

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

Haemophilia and ageing

Advances in the development of effective and safe treatments for haemophilia over the last 50 years have resulted in a significant increase in the life expectancy of persons with haemophilia (PWH). The management of this new cohort of middle-aged and elderly PWH is challenging because of the opposing risks of haemophilia and age-related cardiovascular disease and malignancy. Furthermore, this cohort of ageing PWH has the additional comorbidities of human immunodeficiency virus/hepatitis C and chronic haemophilic arthropathy. This article reviews the prevalence, underlying mechanisms and treatment strategies for managing these comorbidities. International collaboration is essential for registry data and further prospective trials to inform optimal evidence-based management for this rare disorder in the future.

A lower blood pressure threshold to define hypertension: the effect on prevalence, control rate, and constituent ratio of systolic and/or diastolic hypertension

OBJECTIVE

To evaluate the impact of the new US hypertension criteria [systolic blood pressure/diastolic blood pressure (SBP/DBP ≥130/80 mmHg)] on hypertension prevalence and the constituent ratio of three hypertension phenotypes.

PARTICIPANTS AND METHODS

This study included 1185 adult participants, who received blood pressure (BP) measurements for 3 days over a 7-day period. At each visit, the BP was measured three times and the average was used as the final value. The criteria of hypertension were if the participant had received treatment with antihypertensive drugs for at least 2 weeks, or SBP/DBP of at least 140/90 mmHg (old criteria) or at least 130/80 mmHg (new criteria) for the untreated participants. The diagnosis of hypertension was made on the basis of first-day BP values (epidemiological method) or the average of the 3-day BP values (clinical method), respectively. The constituent ratios of isolated systolic, isolated diastolic, and systolic-diastolic hypertension were evaluated.

RESULTS

When using the old criteria, the overall epidemiological prevalence of hypertension was 41.1% and the overall clinical prevalence of hypertension was 34.8%. When using the new criteria, these values increased to 64.3 and 57.4%, respectively. Meanwhile, against the old criteria, the new criteria increased the constituent ratio of systolic-diastolic hypertension from 24.4 to 50.5% (P<0.001) for the epidemiological method and from 19.1 to 45.7% (P<0.001) for the clinical method in the newly diagnosed hypertensive patients.

CONCLUSION

The hypertension criteria of at least 130/80 mmHg not only significantly increased the clinical prevalence of hypertension, but significantly altered the constituent ratio of three hypertension phenotypes among the newly diagnosed hypertensive patients.

Risk factors for cardiovascular disease in children and young adults with haemophilia

INTRODUCTION

The origins of cardiovascular disease (CVD) begin in childhood. The primary objective of this cross-sectional cohort study was to determine the prevalence of cardiovascular risk factors in patients with congenital haemophilia A or B followed at Rady Children's Hospital San Diego Hemophilia and Thrombosis Treatment Center (HTC). We hypothesized that cardiovascular risk factors could be identified as part of a comprehensive clinic visit.

MATERIALS AND METHODS

Standardized measurement of weight, height, waist circumference and blood pressure plus non-fasting glucose and lipid panel were performed. Participants and/or caregivers completed questionnaires about family history, medical history and lifestyle. Clinical data were abstracted from the medical record. Descriptive statistics, Student's t test, correlation, Mann-Whitney U test and chi-square test were performed to analyse the data.

RESULTS

Forty-three males (mean 12 years, range 5-20 years) enrolled. High rates of overweight and obesity, (pre)hypertension and abnormal lipids were identified. Subjects with normal weight had more days of >60 minutes of physical activity compared with those with overweight or obesity (5.2 ± 2.4 vs. 3.8 ± 2.5 day; P = 0.07). Higher weight was correlated with higher factor consumption (cor = 0.88; P < 0.001). There was no difference in target joints based on weight category (30% in normal weight vs. 25% in overweight or obese, χ2 = 0.11, P = 0.74), which may be attributed to high rates of prophylaxis.

CONCLUSIONS

Modifiable risk factors for CVD were identified as part of the study during comprehensive clinic visits. The HTC team may develop behavioural interventions to target cardiovascular risk reduction as part of the comprehensive care model.

Prevalence of Hypertension (HTN) and Cardiovascular Risk Factors in a Hospitalized Pediatric Hemophilia Population

Improved life expectancy in hemophilia has led to a greater interest in age-related disorders. Hypertension (HTN) as well as cardiovascular disease have been increasingly reported in hemophilic adults but there is currently very limited data in the pediatric population. We conducted a cross-sectional study using data from the 2012 National Health Cost and Utilization Project database to determine the prevalence of HTN and associated cardiovascular risk factors in a hospitalized pediatric hemophilia population, between the ages of 0 to 21 years, in comparison with the general pediatric population. The prevalence of HTN was significantly higher in children with hemophilia (CWH) in comparison with the general pediatric population (1.71% vs. 1.02%, P-value=0.005). When adjusting the analysis for sex, the prevalence of HTN in the hemophilia cohort remained higher, although not statistically significant (1.52% vs. 1.22%, P-value=0.2568). When examining the concomitant presence of ≥1 cardiovascular risk factors in the hypertensive subgroups, CWH had a higher prevalence of obesity (2.64% vs. 1.32%, P-value <0.0001). Interestingly, diabetes mellitus was more prevalent in nonhemophilic children (1.47% vs. 0.56%, P-value=0.0015). These data suggest that cardiovascular risk factors need to be closely monitored in CWH, and a better preventive strategy is likely needed to identify those hemophilic patients at higher risk of developing cardiovascular disease in adulthood.

Hemophilia patient with difficulty in blood pressure control

Hypertension prevalence is increasing in patients with hemophilia. Therefore it is an important complication of hemophilia. We aimed to present a 49-year-old male patient with hemophilia-A who presented with acute hemarthrosis and hypertensive attack. The patient was treated in our internal medicine clinic.

Diagnosis and care of patients with mild haemophilia: practical recommendations for clinical management

Mild haemophilia is defined by factor levels between 0.05 and 0.40 IU/mL and is characterised by traumatic bleeds. Major issues associated with mild haemophilia are that it may not present for many years after birth, and that awareness, even within families, may be low. Methodological problems exist in diagnosis, such as inconsistencies in results obtained from different assays used to measure factor levels in mild haemophilia. Advances in genetic testing provide insight into diagnosis as well as the likelihood of inhibitor development, which is not uncommon in patients with mild or moderate haemophilia and can increase morbidity. The management of patients with mild haemophilia is a challenge. This review includes suggestions around formulating treatment plans for these patients, encompassing the full spectrum from clinical care of the newly diagnosed neonate to that of the ageing patient with multiple comorbidities. Management strategies consider not only the vast differences in these patients' needs, but also risks of inhibitor development and approaches to optimally engage patients.

The hypertension of hemophilia is associated with vascular remodeling in the joint

OBJECTIVE

Hemophilic arthropathy is associated with pronounced vascular joint remodeling. Also, compared to the general population, PWH have a higher prevalence of hypertension not explained by usual risk factors. As vascular remodeling in various vascular beds is a hallmark of hypertension, we hypothesized that vascular joint remodeling is associated with elevated blood pressures and hypertension.

METHODS

Elbows, knees, and ankles of 28 adult PWH were evaluated for vascular abnormalities with MSKUS/PD, as well as for radiographic and clinical status and pain. Logistic and linear regression models were fitted to examine associations between hypertension, blood pressure, and PD score.

RESULTS

The extent of vascular abnormalities was associated with hypertension and blood pressures. Hypertensive patients had a higher PD score compared to nonhypertensive patients, and the risk of hypertension increased steeply with PD score. SBP was also strongly associated with PD score, while DBP was only weakly associated.

CONCLUSIONS

Vascular remodeling in hemophilic joints is associated with hypertension and elevated blood pressures. As hypertension is a grave risk factor for intracranial hemorrhage, a prominent cause of mortality in hemophilia patients, future studies are needed to address the causal pathways between vascular joint remodeling and blood pressure.

Evaluation of Heart Function in Patients With Hemophilia

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

Emergency department utilization by haemophilia patients in United States

INTRODUCTION

Patients with haemophilia are prone to medical emergencies. Emergency departments (ED) often do not have a haematologist on-call for consultation.

AIM

The aim of this study was to determine the utilization of ED by patients with haemophilia.

METHODS

Retrospective review of the 'National ED Database Sample' for years 2006-2013 was performed. Patient and hospital demographics were collected. Hospital charges were projected to national levels using discharge-weighted variables.

RESULTS

During the 8-year study period, haemophilia patients made 162 982 ED visits. This represents 0.016% of total ED visits nationwide. Children utilized ED the most. More than half of patients resided in metropolitan cities; 20% had over $63 000 annual household income. Government insurances were the largest primary payers; 30% had private insurance. In the year 2012, 4488 ED visits with 21 000 diagnoses codes were recorded. Mean age was 29 years. Cardiovascular were the most frequently reported complaints followed by injuries, haemorrhages and sepsis. Seventy percent patients were treated and released from the ED. Two patients died in ED, whereas 35 after admission to hospital. Cause of death included Sepsis (n = 26) and brain haemorrhage (n = 4). Among children, injuries were the most frequent complaints followed by joint/soft tissue disorders; fevers and central line complications. Average charge per visit at private vs. public hospital was $2988 and $2254 respectively (P = 0.03). National estimate of total charges was $60 million.

CONCLUSION

Patients with haemophilia have tendency to utilize ED. Hypertension was the single most common presenting complaint in adults. No deaths were reported in children from brain haemorrhage.

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

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

Comorbidities and inhibitors in adult patients with haemophilia: issues, costs and management strategies

Along with greater life expectancy in patients with haemophilia has been an increase in associated haemophilia-related (arthropathy, osteoporosis, viral infections) and age-related (cardiovascular disease, renal disease, cancer and others) comorbidities, many of which are only just emerging as the population ages. At present, experience in managing these comorbidities is limited. As the demographic shift continues, haemophilia care centres can expect to encounter more patients with greater levels of complexity. In the absence of evidence-based information to guide the management of adult patients with haemophilia, it is important that the scientific position be reviewed on a regular basis. To this end, several topics relevant to the clinical management of adult patients with haemophilia were examined in a symposium entitled Comorbidities and inhibitors in adult patients with haemophilia: issues, costs and management strategies held on 11 February 2015 in Helsinki, Finland, in conjunction with the 8th Annual Congress of the European Association for Haemophilia and Allied Disorders. This article is a summary of that event.

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

Introduction:

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

Aims:

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

Methods:

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

Results:

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

Conclusion:

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