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Barca-Hernando M, García-Ortega A, Martínez-Meñaca A, Ramírez-Martín MP, Rivas-Guerrero A, Tenes A. [Pulmonary Embolism]. OPEN RESPIRATORY ARCHIVES 2024; 6:100342. [PMID: 39035608 PMCID: PMC11259928 DOI: 10.1016/j.opresp.2024.100342] [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: 03/17/2024] [Accepted: 05/22/2024] [Indexed: 07/23/2024] Open
Abstract
Pulmonary embolism (PE), the most severe form of presentation of venous thromboembolic disease (VTE), currently represents a foremost healthcare issue due to its high impact in terms of morbidity, mortality, costs, and resource consumption. Early mortality associated with PE is primarily due to hemodynamic instability, exacerbation of pre-existing conditions, or major complications of antithrombotic therapies. Beyond the risk of death, there are relevant complications related to PE, such as bleedings, VTE recurrences, and persistence of residual respiratory symptoms; the latter complication related to PE is mainly characterized by two entities, chronic thromboembolic pulmonary hypertension and chronic thromboembolic disease. Significant scientific advances made in recent years have allowed for the improvement of both diagnostic and therapeutic management of the disease, as outlined in this document through a series of relevant issues about PE that are answered with the most up-to-date scientific evidence.
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Affiliation(s)
- María Barca-Hernando
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Alberto García-Ortega
- Servicio de Neumología, Hospital Doctor Peset, Valencia, España
- Fundación para el Fomento de la Investigación Sanitaria de la Comunidad Valenciana (FISABIO), Valencia, España
| | - Amaya Martínez-Meñaca
- Servicio de Neumología, Hospital Universitario Marqués de Valdecilla. ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, España
- Instituto de Investigación Valdecilla (IDIVAL), Santander, España
| | - M. Purificación Ramírez-Martín
- Servicio de Neumología, Unidad de Enfermedades Vasculares Pulmonares, Complejo Hospitalario Universitario Nuestra Señora de la Candelaria, Tenerife, España
| | - Agustina Rivas-Guerrero
- Servicio de Neumología, Hospital Universitario Donostia, San Sebastián, España
- Instituto de Investigación Sanitaria Biogipuzkoa, San Sebastián, España
| | - Andrés Tenes
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
- IRYCIS, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, España
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2
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Kimmerle AR, Noflatscher M, Raggam RB. Optimal long-term anticoagulation after acute pulmonary embolism: current state of the art and a look into the near future. Curr Opin Pulm Med 2024; 30:421-428. [PMID: 38989794 DOI: 10.1097/mcp.0000000000001106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize the current state of the art and future directions in optimal long-term anticoagulation following acute pulmonary embolism (PE). RECENT FINDINGS Actual studies and guidelines underscore the preference for direct oral anticoagulants (DOAC) in standard therapeutic doses for maintenance therapy post-PE, while considering patient-specific factors and dose-reduction criteria. Risk stratification should always include the assessment of concomitant trigger- or risk factors regarding their strength and persistence. The use of tools like specific scores can facilitate the identification of optimal candidates for long-term therapy, emphasizing once more personalized approaches and strategies. Special patient groups, such as cancer associated thrombosis, chronic thromboembolic pulmonary hypertension or antiphospholipid syndrome require even more tailored therapy approaches. SUMMARY Optimal long-term anticoagulation post-PE should be guided by straightforward and individual risk assessment strategies. The array of indications for DOACs has gotten wider in last years, also within special patient groups. Still, chronic thromboembolic pulmonary hypertension and antiphospholipid syndrome remains domain of vitamin K agonists.
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Affiliation(s)
| | - Maria Noflatscher
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Reinhard Bernd Raggam
- Department of Internal Medicine, Division of Angiology, Medical University of Graz, Graz
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3
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Woodward G, Drasar E, Pancham S, Sadasivam N, Thachil J, Brewin J. Prevention and management of indwelling catheter-related thrombosis in sickle cell disease and thalassaemia: A British Society for Haematology Good Practice Paper. Br J Haematol 2024. [PMID: 39086097 DOI: 10.1111/bjh.19650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 07/06/2024] [Indexed: 08/02/2024]
Affiliation(s)
- George Woodward
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Emma Drasar
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Shivan Pancham
- Sandwell and West Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jecko Thachil
- Manchester University NHS Foundation Trust, Manchester, UK
| | - John Brewin
- King's College Hospital NHS Foundation Trust, London, UK
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Gołąb A, Plicner D, Konieczyńska M, Broniatowska E, Undas A. Poor patients' knowledge about venous thromboembolism and its therapy is associated with increased risk of major bleeding and discontinuation of anticoagulation: A cohort study. Medicine (Baltimore) 2024; 103:e38697. [PMID: 38996155 PMCID: PMC11245249 DOI: 10.1097/md.0000000000038697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 06/04/2024] [Indexed: 07/14/2024] Open
Abstract
It has been shown that patients' knowledge about venous thromboembolism (VTE) and its therapy is suboptimal, which might reduce compliance and worsen prognosis. We investigated whether low VTE patients' knowledge affects their clinical outcomes during long-term follow-up. We evaluated 151 consecutive patients (51.8 ± 15.7 years) after unprovoked VTE, who were recruited from the outpatient clinic (Krakow, Poland). All patients received anticoagulant treatment, mostly with direct oral anticoagulants (n = 113, 74.8%). The modified Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ-VTE; 16 questions) was used to assess the knowledge of VTE and anticoagulant therapy. During a median follow-up of 58.0 months, VTE recurrence, major bleeding, and anticoagulation withdrawal were recorded. The median percentage of correct responses was 62.5% (12.5-100%) and was inversely correlated with age (P < .01). Diabetic patients and those with positive family history of VTE had lower overall scoring compared to the remainder (both P < .05). Major bleeding (n = 10, 6.6%) and anticoagulation withdrawal (n = 28, 18.5%), but not VTE recurrence (n = 12, 7.9%), were associated with lower overall scoring compared to the remainder (48.8% ± 12.5% vs 63.8% ± 16.3%, P = .003 and 55.3% ± 14.7% vs 64.4% ± 16.3%, P = .040, respectively). Major bleeding was independently associated with the female sex (hazard ratio [HR] 6.18; 95% confidence interval [CI] 1.15-33.19, P = .034), younger age (HR per 10 years 0.55; 95% CI 0.34-0.90, P = .016), OAC therapy discontinuation (HR 6.69; 95% CI 1.62-27.70), and lower overall scoring of JAKQ-VTE (HR 0.60 per 10 percentage points; 95% CI 0.40-0.92, P = .019). Insufficient knowledge about VTE and anticoagulant treatment predisposes to a higher risk of major bleeding and therapy discontinuation, but not VTE recurrence in unprovoked VTE patients during long-term follow-up.
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Affiliation(s)
- Aleksandra Gołąb
- Faculty of Medicine and Dentistry, Pomeranian Medical University in Szczecin, Szczecin, Poland
- Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
| | - Dariusz Plicner
- Unit of Experimental Cardiology and Cardiac Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
- Department of Cardiovascular Surgery and Transplantation, John Paul II Hospital, Krakow, Poland
| | - Małgorzata Konieczyńska
- Department of Diagnostic Medicine, John Paul II Hospital, Krakow, Poland
- Department of Thromboembolic Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Elżbieta Broniatowska
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Anetta Undas
- Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
- Department of Thromboembolic Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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Mittman BG, Sheehan M, Kojima L, Casacchia NJ, Lisheba O, Hu B, Pappas MA, Rothberg MB. Development and internal validation of the Cleveland Clinic Bleeding Model to predict major bleeding risk at admission in medical inpatients. J Thromb Haemost 2024:S1538-7836(24)00389-1. [PMID: 39002732 DOI: 10.1016/j.jtha.2024.06.025] [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: 02/29/2024] [Revised: 05/16/2024] [Accepted: 06/10/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Guidelines recommend pharmacologic VTE prophylaxis for acutely ill medical patients at acceptable bleeding risk, but only the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) model has been validated for bleeding risk assessment. OBJECTIVES We developed and internally validated a risk assessment model (RAM) to predict major in-hospital bleeding using risk factors at admission and compared our model with IMPROVE. METHODS We selected patients admitted to medical services at 10 hospitals in the Cleveland Clinic Health System from 2017 to 2020. We identified major bleeding according to the International Society on Thrombosis and Haemostasis criteria, using a combination of diagnostic codes and laboratory values, and confirmed events with chart review. We fit a least absolute shrinkage selection operator logistic regression model in the training set and compared the discrimination and calibration of our model with the IMPROVE model in the validation set. RESULTS Among 46 314 admissions, 268 (0.58%) had a major bleed. The final RAM included 16 risk factors, of which prior bleeding (odds ratio [OR] = 4.83), peptic ulcer (OR = 3.82), history of sepsis (OR = 3.26), and steroid use (OR = 2.59) were the strongest. The Cleveland Clinic Bleeding Model had better discrimination than IMPROVE (area under the receiver operating characteristics curve = 0.85 vs 0.70; P < .001) and, at equivalent sensitivity (52%), categorized fewer patients as high risk (7.2% vs 11.8%; P < .001). Calibration was adequate (Brier score = 0.0057). CONCLUSION Using a large population of medical inpatients with verified major bleeding events, we developed and internally validated a RAM for major bleeding whose performance surpassed the IMPROVE model.
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Affiliation(s)
- Benjamin G Mittman
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA.
| | - Megan Sheehan
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lisa Kojima
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicholas J Casacchia
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Oleg Lisheba
- Enterprise Analytics eResearch Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bo Hu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew A Pappas
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
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May JE, Moll S. How I treat the co-occurrence of venous and arterial thromboembolism: anticoagulation, antiplatelet therapy, or both? Blood 2024; 143:2351-2362. [PMID: 38364188 DOI: 10.1182/blood.2023021638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/17/2024] [Accepted: 02/12/2024] [Indexed: 02/18/2024] Open
Abstract
ABSTRACT Arterial and venous thromboses are classically considered distinct disease states, with arterial thrombosis mediated predominantly by platelets and therefore, treated with antiplatelet therapy, and venous thrombosis mediated by the plasmatic coagulation system and treated with anticoagulation. However, co-occurrence of arterial and venous events is common, and there is increasing evidence of shared risk factors and pathophysiologic overlap. This presents a management challenge: does the patient with venous and arterial thrombosis, require anticoagulation, antiplatelet therapy, or both? Herein, we present a structured approach to the evaluation and management of patients with venous thrombosis who are also at risk for or have a history of an arterial thromboembolic event. We emphasize the importance of defining the indications for antithrombotic therapy, as well as the evaluation of factors that influence both thrombotic and bleeding risk, including disorder-specific and patient-specific factors, as well as the inherent risk balance of antithrombotic therapy regimens. We illustrate this approach in 4 cases, discussing the unique considerations and recent updates in the management of venous thrombosis, acute noncardioembolic ischemic stroke, coronary artery disease and acute myocardial infarction, and peripheral artery disease after revascularization.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Stephan Moll
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Gil-Díaz A, Martín Guerra J, Parra Caballero P, Puche Palao G, Muñoz-Rivas N, Ruiz-Giménez Arrieta N. Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the venous thromboembolism group of the Spanish Society of Internal Medicine. Rev Clin Esp 2024; 224:300-313. [PMID: 38641173 DOI: 10.1016/j.rceng.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/08/2024] [Indexed: 04/21/2024]
Abstract
Deep vein thrombosis (DVT) of the limbs is a common disease and causes significant morbidity and mortality. It is frequently the prelude to pulmonary embolism (PE), it can recur in 30% of patients and in 25-40% of cases they can develop post-thrombotic syndrome (PTS), with a significant impact in functional status and quality of life. This document contains the recommendations on the diagnosis and treatment of acute DVT from the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI). PE and thrombosis of unusual venous territories (cerebral, renal, mesenteric, superficial, etc.) are outside its scope, as well as thrombosis associated with catheter and thrombosis associated with cancer, which due to their peculiarities will be the subject of other positioning documents of the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI).
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Affiliation(s)
- A Gil-Díaz
- Servicio de Medicina Interna, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain; Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - J Martín Guerra
- Servicio Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - P Parra Caballero
- Servicio Medicina Interna, Hospital Universitario de la Princesa, Madrid, Spain; Universidad Autónoma Madrid, Madrid, Spain
| | - G Puche Palao
- Unidad de Enfermedad Tromboembólica Avanzada, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - N Muñoz-Rivas
- Servicio Medicina Interna, Hospital Universitario Infanta Leonor, Madrid, Spain; Universidad Complutense Madrid, Madrid, Spain.
| | - N Ruiz-Giménez Arrieta
- Servicio Medicina Interna, Hospital Universitario de la Princesa, Madrid, Spain; Universidad Autónoma Madrid, Madrid, Spain
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Linnemann B, Beyer-Westendorf J, Espinola-Klein C, Mühlberg KS, Müller OJ, Klamroth R. Management of Deep Vein Thrombosis: An Update Based on the Revised AWMF S2k Guideline. Hamostaseologie 2024; 44:97-110. [PMID: 38688268 DOI: 10.1055/a-2178-6574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are the most common manifestations of venous thromboembolism (VTE). Most DVTs affect the lower-extremity veins. Since the symptoms of DVT are non-specific, a prompt and standardised diagnostic work-up is essential to minimise the risk of PE in the acute phase and to prevent thrombosis progression, post-thrombotic syndrome and VTE recurrence in the long-term. Only recently, the AWMF S2k guidelines on Diagnostics and Therapy of Venous Thrombosis and Pulmonary Embolism have been revised. In the present article, we summarize current evidence and guideline recommendations focusing on lower-extremity DVT (LEDVT). Depending on whether the diagnostic work-up is performed by a specialist in vascular medicine or by a primary care physician, different diagnostic algorithms are presented that combine clinical probability, D-dimer testing and diagnostic imaging. The diagnosis of ipsilateral recurrent DVT poses a particular challenge and is presented in a separate algorithm. Anticoagulant therapy is an essential part of therapy, with current guidelines clearly favouring regimens based on direct oral anticoagulants over the traditional sequential therapy of parenteral anticoagulants and vitamin K antagonists. For most DVTs, a duration of therapeutic-dose anticoagulation of at least 3 to 6 months is considered sufficient, and this raises the question of the risk of VTE recurrence after discontinuation of anticoagulation and the need for secondary prophylaxis in the long-term. Depending on the circumstances and trigger factors that have contributed to the occurrence of DVT, management strategies are presented that allow decision-making taking into account the individual bleeding risk and patient's preferences.
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Affiliation(s)
- Birgit Linnemann
- Cardiology III - Angiology, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Haematology, Department of Medicine I, Carl Gustav Carus University Hospital, University Hospital Carl-Gustav Carus, Dresden, Germany
| | - Christine Espinola-Klein
- Cardiology III - Angiology, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Katja S Mühlberg
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Oliver J Müller
- Department of Internal Medicine III, University Hospital Schleswig - Holstein, Campus Kiel, Kiel, Germany
| | - Robert Klamroth
- Department of Internal Medicine, Angiology and Haemostaseology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
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Burggraaf-van Delft JLI, van Rein N, Bemelmans RHH, van den Berg JWK, Bruggeman CY, Cloos-van Balen M, Coppens M, Eefting M, Ende-Verhaar Y, van Es N, van Guldener C, de Jong WK, Kleijwegt F, Koster T, Kroon C, Kuipers S, Leentjens J, Luijten D, Mairuhu ATA, Meijer K, van de Ree MA, Roos R, Schrover I, Swart-Heikens J, van der Velden AWG, van den Akker-van Marle EM, le Cessie S, Geersing GJ, Middeldorp S, Huisman MV, Klok FA, Cannegieter SC. Tailored anticoagulant treatment after a first venous thromboembolism: protocol of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study - cohort-based randomised controlled trial. BMJ Open 2024; 14:e078676. [PMID: 38521524 PMCID: PMC10961563 DOI: 10.1136/bmjopen-2023-078676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/06/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Patients with a first venous thromboembolism (VTE) are at risk of recurrence. Recurrent VTE (rVTE) can be prevented by extended anticoagulant therapy, but this comes at the cost of an increased risk of bleeding. It is still uncertain whether patients with an intermediate recurrence risk or with a high recurrence and high bleeding risk will benefit from extended anticoagulant treatment, and whether a strategy where anticoagulant duration is tailored on the predicted risks of rVTE and bleeding can improve outcomes. The aim of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study is to evaluate the outcomes of tailored duration of long-term anticoagulant treatment based on individualised assessment of rVTE and major bleeding risks. METHODS AND ANALYSIS The L-TRRiP study is a multicentre, open-label, cohort-based, randomised controlled trial, including patients with a first VTE. We classify the risk of rVTE and major bleeding using the L-TRRiP and VTE-BLEED scores, respectively. After 3 months of anticoagulant therapy, patients with a low rVTE risk will discontinue anticoagulant treatment, patients with a high rVTE and low bleeding risk will continue anticoagulant treatment, whereas all other patients will be randomised to continue or discontinue anticoagulant treatment. All patients will be followed up for at least 2 years. Inclusion will continue until the randomised group consists of 608 patients; we estimate to include 1600 patients in total. The primary outcome is the combined incidence of rVTE and major bleeding in the randomised group after 2 years of follow-up. Secondary outcomes include the incidence of rVTE and major bleeding, functional outcomes, quality of life and cost-effectiveness in all patients. ETHICS AND DISSEMINATION The protocol was approved by the Medical Research Ethics Committee Leiden-Den Haag-Delft. Results are expected in 2028 and will be disseminated through peer-reviewed journals and during (inter)national conferences. TRIAL REGISTRATION NUMBER NCT06087952.
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Affiliation(s)
| | - Nienke van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Remy H H Bemelmans
- Department of Internal Medicine, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | | | - Coty Y Bruggeman
- Department of Internal Medicine, Martini Ziekenhuis, Groningen, Groningen, The Netherlands
| | - Marissa Cloos-van Balen
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, Zuid-Holland, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, Noord-Holland, The Netherlands
| | - Matthijs Eefting
- Department of Internal Medicine, Ikazia Ziekenhuis, Rotterdam, Zuid-Holland, The Netherlands
| | - Yvonne Ende-Verhaar
- Department of Internal Medicine, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, Noord-Holland, The Netherlands
| | - Coen van Guldener
- Department of Internal Medicine, Amphia Ziekenhuis, Breda, North Brabant, The Netherlands
| | - Wouter K de Jong
- Department of Pulmonology, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Fleur Kleijwegt
- Department of Internal Medicine, Rode Kruis Ziekenhuis, Beverwijk, Noord-Holland, The Netherlands
| | - Ted Koster
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, Zuid-Holland, The Netherlands
| | - Cees Kroon
- Department of Internal Medicine, Ziekenhuis Nij Smellinghe, Drachten, Friesland, The Netherlands
| | - Saskia Kuipers
- Department of Internal Medicine, ADRZ, Goes, Zeeland, The Netherlands
| | - Jenneke Leentjens
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, The Netherlands
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Karina Meijer
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Marcel A van de Ree
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Rick Roos
- Department of Internal Medicine, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Ilse Schrover
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Janneke Swart-Heikens
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | | | | | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Clinical Epidemiology, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Geert-Jan Geersing
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, The Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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10
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Fard SS, Perkins TJ, Wells PS. Machine learning analysis of bleeding status in venous thromboembolism patients. Res Pract Thromb Haemost 2024; 8:102403. [PMID: 38706783 PMCID: PMC11066547 DOI: 10.1016/j.rpth.2024.102403] [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: 03/06/2024] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 05/07/2024] Open
Abstract
Background Anticoagulation therapy is the mainstay of therapy for patients with venous thromboembolism (VTE). However, continuing or stopping anticoagulants after the first 3 to 6 months is a difficult decision that requires ascertainment of the risk of bleeding and recurrent VTE. Despite the development of several statistical models to predict bleeding, the benefit of machine learning (ML) models has not been investigated in depth. Objectives To assess the benefits of ML algorithms in bleeding risk evaluation in VTE patients and gain insight into their baseline information. Methods The baseline clinical, demographic, and genotype information was collected for 2542 patients with VTE who were on extended anticoagulation therapy. Six unsupervised dimensionality reduction and clustering ML algorithms were used to visualize and cluster the data for patients with major bleeding (118 patients) and nonbleeders. Eight supervised ML algorithms were trained and compared with the previously derived clinical models using a 5-fold nested cross-validation scheme. Results The baseline dataset for bleeders and nonbleeders showed a high degree of similarity. Two novel clusters were discovered within the dataset for bleeders based on the presence of isolated pulmonary embolism or isolated deep vein thrombosis, though the difference in bleeding risks was not statistically significant (P = .32). The supervised analysis showed that the ML and clinical models have similar discrimination (c-statistics, ∼62%) and calibration performance (Brier score, ∼0.045). Conclusion The clinical variables recorded at baseline are not distinctive enough to improve bleeding prediction beyond the performance of the existing models, and other strategies or data modalities should be considered.
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Affiliation(s)
| | - Theodore J. Perkins
- The Ottawa Hospital Research Institute, the Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
| | - Philip S. Wells
- The Ottawa Hospital Research Institute, the Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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11
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Incomenoy S, Saokaew S, Poonchuay N. SAMe-TT 2R 2 to Predict Clinical Outcomes and Time in Therapeutic Range in Patients on Vitamin K Antagonists: A Systematic Review and Meta-Analysis. Ann Pharmacother 2024; 58:126-139. [PMID: 37125752 DOI: 10.1177/10600280231166643] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND The SAMe-TT2R2 score identifies patients on vitamin K antagonists (VKAs) who are more likely to have poor time in therapeutic range (TTR); however, the association between SAMe-TT2R2 and clinical outcomes remains controversial. OBJECTIVES The objective is to assess the association of SAMe-TT2R2 score with clinical outcomes and poor TTR in patients on VKAs. METHODS We searched using the term "SAMe-TT2R2." Original articles reporting clinical outcomes and SAMe-TT2R2 scores before October 2021 were included. Odds ratios (ORs) of clinical outcomes, diagnostic accuracy parameters of poor TTR (<60%-70%), and mean TTR were extracted. Meta-analysis was performed using random-effects models. RESULTS Ten studies were included (N = 22 894); 4 showed pooled changes in TTR of -3.61% (95% CI:-4.88% to -2.35%) and -3.98% (95% CI: -6.08% to -1.87%) at SAMe-TT2R2 scores ≥2 and ≥3, respectively, compared with lower scores. The diagnostic accuracy parameters for poor TTR were too heterogeneous to conclude. SAMe-TT2R2 ≥3 significantly correlated with all adverse events (OR = 1.43 [95% CI: 1.29-1.54; P < 0.001]), composite thromboembolism (OR = 1.53 [95% CI: 1.19-1.97; P = 0.001]), and composite bleeding (OR = 1.33 [95% CI: 1.12-1.59; P = 0.001] regardless of the indication, while an SAMe-TT2R2 ≥2 significantly correlated with mortality (OR = 1.32 [95% CI: 1.02-1.70; P = 0.033]). We found no relationship between an SAMe-TT2R2 ≥3 and mortality or between a score ≥2 and clinical outcomes. CONCLUSIONS AND RELEVANCE Patients on VKAs with SAMe-TT2R2 ≥3 experienced more adverse events, bleeding, and thromboembolism compared with patients who had an SAMe-TT2R2 <3. However, the score had limited and inconclusive predictability for poor TTR in the study.
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Affiliation(s)
- Supatcha Incomenoy
- Department of Pharmaceutical Care, School of Pharmacy, Walailak University, Nakhon Si Thammarat, Thailand
| | - Surasak Saokaew
- Division of Social and Administrative Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Natnicha Poonchuay
- Department of Pharmaceutical Care, School of Pharmacy, Walailak University, Nakhon Si Thammarat, Thailand
- Drug and Cosmetics Excellence Center, Walailak University, Nakhon Si Thammarat, Thailand
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12
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Porres-Aguilar M, Mukherjee D, Didia SC, Lazo-Langner A. Which are the optimal thromboprophylaxis strategies for hospitalized patients with COVID-19? current controversies. Vascular 2024; 32:220-225. [PMID: 36076354 PMCID: PMC9459371 DOI: 10.1177/17085381221126235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Novel coronavirus 2019 (COVID-19) represents a significant risk factor for the development of venous thromboembolism (VTE) in hospitalized with both moderate and severe/critical COVID-19. Herein, we present a brief updated review on emerging robust data on diverse thromboprophylaxis strategies used to mitigate VTE complications, as well as a personal point of view of current controversies in regards the use of therapeutic and prophylactic anticoagulation strategies, particularly in the moderately-ill subgroup of patients with COVID-19.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine,
Divisions of Hospital and Adult Clinical Thrombosis Medicine, Texas Tech University Health Sciences
Center and Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular
Diseases, Texas Tech University Health Sciences
Center and Paul L. Foster School of Medicine, El Paso, TX, USA
| | - S. Claudia Didia
- Department of Internal Medicine,
Divisions of Hospital and Adult Clinical Thrombosis Medicine, Texas Tech University Health Sciences
Center and Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Alejandro Lazo-Langner
- Division of Hematology, Departments
of Medicine and Epidemiology/Biostatistics, Western University, London, ON, Canada
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13
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Kawakado K, Tsubata Y, Hotta T, Yamasaki M, Ishikawa N, Fujitaka K, Kubota T, Kobayashi K, Isobe T. Risk Factors for Bleeding Events in Japanese Patients with Advanced Lung Cancer: Data from the Rising-VTE/NEJ037 Study. Cancers (Basel) 2024; 16:301. [PMID: 38254791 PMCID: PMC10814048 DOI: 10.3390/cancers16020301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Despite the occurrence of various hemorrhagic events during advanced lung cancer treatment, few researchers have reported on their risk factors. Moreover, the development of cancer-related thromboembolism indicates anticoagulant use. However, adverse events such as bleeding should be monitored. In this study, we aimed to identify factors that influence the onset of hemorrhagic events in patients with lung cancer. The Rising-VTE/NEJ037 study was a multicenter, prospective, observational study. A total of 1008 patients with lung cancer who were unsuitable for radical resection or radiation were enrolled and followed up for 2 years. Multivariate analysis using a Cox proportional hazard model was performed to compare the outcomes of the time to the onset of hemorrhagic events for 2 years after registration. Hemorrhagic events occurred in 115 patients (11.4%), with 35 (30.4%) experiencing major bleeding. Significant risk factors included venous thromboembolism (VTE) (hazard ratio [HR]: 4.003, p < 0.001) and an Eastern Cooperative Oncology Group Performance Status score of 1 (HR: 2.476, p < 0.001). Factors that significantly reduced hemorrhagic event risk were female sex (HR: 0.454, p = 0.002) and M1a status (HR: 0.542, p = 0.038). VTE is a risk factor for hemorrhagic events in patients with advanced lung cancer, and risks associated with anticoagulant therapy should be considered.
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Affiliation(s)
- Keita Kawakado
- Department of Internal Medicine, Division of Medical Oncology and Respiratory Medicine, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo 693-8501, Japan; (K.K.); (T.H.); (T.I.)
| | - Yukari Tsubata
- Department of Internal Medicine, Division of Medical Oncology and Respiratory Medicine, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo 693-8501, Japan; (K.K.); (T.H.); (T.I.)
| | - Takamasa Hotta
- Department of Internal Medicine, Division of Medical Oncology and Respiratory Medicine, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo 693-8501, Japan; (K.K.); (T.H.); (T.I.)
| | - Masahiro Yamasaki
- Department of Respiratory Disease, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital, 1-9-6, Senda-Machi, Naka-ku, Hiroshima 730-8619, Japan;
| | - Nobuhisa Ishikawa
- Department of Respiratory Medicine, Hiroshima Prefectural Hospital, 1-5-54 Ujina-Kanda, Minami-ku, Hiroshima 734-8530, Japan;
| | - Kazunori Fujitaka
- Department of Respiratory Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan;
| | - Tetsuya Kubota
- Department of Respiratory Medicine and Allergology, Kochi University Hospital, 185-1 Kohasu, Oko-Cho, Nankoku 783-8505, Japan;
| | - Kunihiko Kobayashi
- Department of Respiratory Medicine, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka 350-1298, Japan;
| | - Takeshi Isobe
- Department of Internal Medicine, Division of Medical Oncology and Respiratory Medicine, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo 693-8501, Japan; (K.K.); (T.H.); (T.I.)
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14
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Ortiz Gómez S, Ruiz-Talero P, Muñoz O, Hoyos Pumarejo LM. Validation of the RIETE, Kuijer, and HAS-BLED Models to Assess 3-Month Bleeding Risk in Anticoagulated Patients Diagnosed with Venous Thromboembolic Disease. Clin Appl Thromb Hemost 2024; 30:10760296241271351. [PMID: 39106353 PMCID: PMC11307365 DOI: 10.1177/10760296241271351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 06/19/2024] [Accepted: 07/01/2024] [Indexed: 08/09/2024] Open
Abstract
OBJECTIVE To evaluate the discriminative ability and calibration of the RIETE, Kuijer, and HAS-BLED models for predicting 3-month bleeding risk in patients anticoagulated for venous thromboembolism (VTE). METHODS External validation study of a prediction model based on a retrospective cohort of patients with VTE seen at the Hospital Universitario San Ignacio, Bogotá (Colombia) between July 2021 and June 2023. The calibration of the scales was evaluated using the Hosmer-Lemeshow test and the ratio of observed to expected events (ROE) within each risk category. Discriminatory ability was assessed using the area under the curve (AUC) of a ROC curve. RESULTS We analyzed 470 patients (median age 65 years, female sex 59.3%) with a diagnosis of deep vein thrombosis in most cases (57.4%), 5.7% bleeding events were observed. Regarding calibration, adequate calibration cannot be ruled out given the limited number of events. The discriminatory ability was limited with an area under the curve (AUC) of 0.48 (CI 0.37-0.59) for Kuijer Score, 0.58 (CI 0.47-0.70) for HAS-BLED and 0.64 (CI 0.51-0.76) for RIETE. CONCLUSION The Kuijer, HAS-BLED, and RIETE models in patients with VTE generally do not adequately estimate the risk of bleeding at three months, with a low ability to discriminate high-risk patients. Cautious interpretation is recommended until further evidence is available.
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Affiliation(s)
- Stephanie Ortiz Gómez
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Paula Ruiz-Talero
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- Department of Internal Medicine, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Oscar Muñoz
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- Department of Internal Medicine, Hospital Universitario San Ignacio, Bogotá, Colombia
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15
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Yamashita Y, Morimoto T, Muraoka N, Oyakawa T, Umetsu M, Akamatsu D, Nishimoto Y, Sato Y, Takada T, Jujo K, Minami Y, Ogihara Y, Dohi K, Fujita M, Nishikawa T, Ikeda N, Hashimoto G, Otsui K, Mori K, Sueta D, Tsubata Y, Shoji M, Shikama A, Hosoi Y, Tanabe Y, Chatani R, Tsukahara K, Nakanishi N, Kim K, Ikeda S, Mo M, Yoshikawa Y, Kimura T. Edoxaban for 12 Months Versus 3 Months in Patients With Cancer With Isolated Distal Deep Vein Thrombosis (ONCO DVT Study): An Open-Label, Multicenter, Randomized Clinical Trial. Circulation 2023; 148:1665-1676. [PMID: 37638968 DOI: 10.1161/circulationaha.123.066360] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND The optimal duration of anticoagulation therapy for isolated distal deep vein thrombosis in patients with cancer is clinically relevant, but the evidence is lacking. The prolonged anticoagulation therapy could have a potential benefit for prevention of thrombotic events; however, it could also increase the risk of bleeding. METHODS In a multicenter, open-label, adjudicator-blinded, randomized clinical trial at 60 institutions in Japan, we randomly assigned patients with cancer with isolated distal deep vein thrombosis, in a 1-to-1 ratio, to receive either a 12-month or 3-month edoxaban treatment. The primary end point was a composite of a symptomatic recurrent venous thromboembolism (VTE) or VTE-related death at 12 months. The major secondary end point was major bleeding at 12 months, according to the criteria of the International Society on Thrombosis and Haemostasis. The primary hypothesis was that a 12-month edoxaban treatment was superior to a 3-month edoxaban treatment with respect to the primary end point. RESULTS From April 2019 through June 2022, 604 patients were randomized, and after excluding 3 patients who withdrew consent, 601 patients were included in the intention-to-treat population: 296 patients in the 12-month edoxaban group and 305 patients in the 3-month edoxaban group. The mean age was 70.8 years, 28% of the patients were men, and 20% of the patients had symptoms of deep vein thrombosis at baseline. The primary end point of a symptomatic recurrent VTE event or VTE-related death occurred in 3 of the 296 patients (1.0%) in the 12-month edoxaban group and in 22 of the 305 patients (7.2%) in the 3-month edoxaban group (odds ratio, 0.13; 95% CI, 0.03-0.44). The major secondary end point of major bleeding occurred in 28 of the 296 patients (9.5%) in the 12-month edoxaban group and in 22 of the 305 patients (7.2%) in the 3-month edoxaban group (odds ratio, 1.34; 95% CI, 0.75-2.41). The prespecified subgroups did not affect the estimates on the primary end point. CONCLUSIONS In patients with cancer with isolated distal deep vein thrombosis, 12 months was superior to 3 months for an edoxaban treatment with respect to the composite outcome of a symptomatic recurrent VTE or VTE-related death. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03895502.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Yamashita, Y. Yoshikawa)
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan (T.M.)
| | - Nao Muraoka
- Division of Cardiology, Shizuoka Cancer Center, Japan (N.M., T.O.)
| | - Takuya Oyakawa
- Division of Cardiology, Shizuoka Cancer Center, Japan (N.M., T.O.)
| | - Michihisa Umetsu
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan (M.U., D.A.)
| | - Daijirou Akamatsu
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan (M.U., D.A.)
| | - Yuji Nishimoto
- Division of Cardiology, Osaka General Medical Center, Japan (Y.N.)
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Japan (Y.S.)
| | - Takuma Takada
- Department of Cardiology, Tokyo Women's Medical University, Japan (T.T., K.J., Y.M.)
| | - Kentaro Jujo
- Department of Cardiology, Tokyo Women's Medical University, Japan (T.T., K.J., Y.M.)
| | - Yuichiro Minami
- Department of Cardiology, Tokyo Women's Medical University, Japan (T.T., K.J., Y.M.)
| | - Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y.O., K.D.)
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y.O., K.D.)
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute, Japan (M.F., T.N.)
| | - Tatsuya Nishikawa
- Department of Onco-Cardiology, Osaka International Cancer Institute, Japan (M.F., T.N.)
| | - Nobutaka Ikeda
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan (N.I., G.H.)
| | - Go Hashimoto
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan (N.I., G.H.)
| | - Kazunori Otsui
- Department of General Internal Medicine, Kobe University Graduate School of Medicine, Japan (K.O., K.M.)
| | - Kenta Mori
- Department of General Internal Medicine, Kobe University Graduate School of Medicine, Japan (K.O., K.M.)
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (D.S.)
| | - Yukari Tsubata
- Department of Internal Medicine, Division of Medical Oncology and Respiratory Medicine, Shimane University Faculty of Medicine, Izumo, Japan (Y. Tsubata)
| | - Masaaki Shoji
- Department of Cardiovascular Medicine, National Cancer Center Hospital, Tokyo, Japan (M.S.)
| | - Ayumi Shikama
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Japan (A.S.)
| | - Yutaka Hosoi
- Department of Cardiovascular Surgery, Kyorin University Faculty of Medicine, Tokyo, Japan (Y.H.)
| | - Yasuhiro Tanabe
- Department of Cardiology, St Marianna University School of Medicine, Kawasaki, Japan (Y. Tanabe)
| | - Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Japan (R.C.)
| | - Kengo Tsukahara
- Division of Cardiology, Fujisawa City Hospital, Japan (K.T.)
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan (N.N.)
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Japan (K.K.)
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan (S.I.)
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Japan (M.M.)
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Yamashita, Y. Yoshikawa)
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Japan (T.K.)
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16
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Schaefer JK, Grant PJ. A need to refine venous thromboembolism risk assessment: the challenge of optimizing patient selection for thromboprophylaxis among hospitalized adults. Res Pract Thromb Haemost 2023; 7:102258. [PMID: 38193062 PMCID: PMC10772884 DOI: 10.1016/j.rpth.2023.102258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
- Jordan K. Schaefer
- Department of Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI
| | - Paul J. Grant
- Department of Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, MI
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17
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Zhang L, Ding YJ, Sun XW, Lin YN, Zhou JP, Li SQ, Li QY. Combined aspartate aminotransferase level and PE-SARD score predict 1-month bleeding risk in acute pulmonary embolism. Am J Med Sci 2023; 366:286-290. [PMID: 37481206 DOI: 10.1016/j.amjms.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 04/11/2023] [Accepted: 07/18/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Anti-coagulation is the cornerstone management of acute pulmonary embolism (PE), which is a double-edged sword, as it increases the risk of bleeding. Thus, predicting bleeding risk is necessary. The liver produces most coagulation factors to maintain the coagulation balance. However, the association between liver dysfunction markers and bleeding risk has not been thoroughly investigated. METHODS A single-center, retrospective analysis of patients with acute PE was performed. First, the authors studied the association between liver dysfunction indexes and the 1-month bleeding risk. Then, they investigated whether it is more effective to predict the bleeding risk using a new joint model, i.e., adding liver dysfunction indexes to the PE-SARD score, which is the first score to assess the bleeding risk of acute PE. RESULTS Among 469 patients with acute PE, 34 patients (7.2%) had bleeding events within 1 month after the onset. The levels of aspartate aminotransferase (AST) were higher in the bleeding group compared with the non-bleeding group (36.0 [18.25-90.0] vs. 23.0 [18.0-31.0], p = 0.008). Compared with AST<40, the odds ratios of 80≤AST<120 and AST≥120 were significant (8.825 [2.449-31.804] and 8.023 [2.543-25.315] respectively, p<0.01), even when adjusted for nine confounding factors (p<0.05). The area under the curve of PE-SARD combined with AST was significantly higher than that of the PE-SARD score (p = 0.02). CONCLUSIONS In PE patients, AST is an independent factor in predicting the 1-month bleeding risk, and a novel joint model that combines AST and PE-SARD score improved the predictive efficiency for the 1-month bleeding risk.
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Affiliation(s)
- Liu Zhang
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China; Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong Jie Ding
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China; Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xian Wen Sun
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China; Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Ni Lin
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China; Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Ping Zhou
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China; Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shi Qi Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China; Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing Yun Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China; Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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18
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Chowdary P, Agarwal B, Peralta MR, Bhagani S, Lee S, Goldring J, Lipman M, Waqif E, Phillips M, Philippou H, Foley JH, Mutch NJ, Ariëns RAS, Stringer KA, Ricciardi F, Watissée M, Hughes D, Nathwani A, Riddell A, Patch D, Buckley J, De Neef M, Dimber R, Diaz-Garcia C, Patel H, Nandani A, Dissanayake U, Chadwick N, Alkhatip AAAMM, Watkinson P, Raith E, Singh S, Wolff T, Jha R, Brill SE, Bakhai A, Evans A, Gilani F, Gomez K. Nebulized Recombinant Tissue Plasminogen Activator (rt-PA) for Acute COVID-19-Induced Respiratory Failure: An Exploratory Proof-of-Concept Trial. J Clin Med 2023; 12:5848. [PMID: 37762789 PMCID: PMC10531875 DOI: 10.3390/jcm12185848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Acute lung injury in COVID-19 results in diffuse alveolar damage with disruption of the alveolar-capillary barrier, coagulation activation, alveolar fibrin deposition and pulmonary capillary thrombi. Nebulized recombinant tissue plasminogen activator (rt-PA) has the potential to facilitate localized thrombolysis in the alveolar compartment and improve oxygenation. In this proof-of-concept safety study, adults with COVID-19-induced respiratory failure and a <300 mmHg PaO2/FiO2 (P/F) ratio requiring invasive mechanical ventilation (IMV) or non-invasive respiratory support (NIRS) received nebulized rt-PA in two cohorts (C1 and C2), alongside standard of care, between 23 April-30 July 2020 and 21 January-19 February 2021, respectively. Matched historical controls (MHC; n = 18) were used in C1 to explore efficacy. Safety co-primary endpoints were treatment-related bleeds and <1.0-1.5 g/L fibrinogen reduction. A variable dosing strategy with clinical efficacy endpoint and minimal safety concerns was determined in C1 for use in C2; patients were stratified by ventilation type to receive 40-60 mg rt-PA daily for ≤14 days. Nine patients in C1 (IMV, 6/9; NIRS, 3/9) and 26 in C2 (IMV, 12/26; NIRS, 14/26) received nebulized rt-PA for a mean (SD) of 6.7 (4.6) and 9.1(4.6) days, respectively. Four bleeds (one severe, three mild) in three patients were considered treatment related. There were no significant fibrinogen reductions. Greater improvements in mean P/F ratio from baseline to study end were observed in C1 compared with MHC (C1; 154 to 299 vs. MHC; 154 to 212). In C2, there was no difference in the baseline P/F ratio of NIRS and IMV patients. However, a larger improvement in the P/F ratio occurred in NIRS patients (NIRS; 126 to 240 vs. IMV; 120 to 188) and fewer treatment days were required (NIRS; 7.86 vs. IMV; 10.5). Nebulized rt-PA appears to be well-tolerated, with a trend towards improved oxygenation, particularly in the NIRS group. Randomized clinical trials are required to demonstrate the clinical effect significance and magnitude.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Banwari Agarwal
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Maria Rita Peralta
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Sanjay Bhagani
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Simon Lee
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - James Goldring
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London NW1 2BU, UK
| | - Marc Lipman
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London NW1 2BU, UK
- UCL Respiratory, University College London, London WC1E 6JF, UK;
| | - Emal Waqif
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Mark Phillips
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Helen Philippou
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | | | - Nicola J. Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences & Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Robert A. S. Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - Kathleen A. Stringer
- Department of Clinical Pharmacy, College of Pharmacy University of Michigan, Ann Arbor, MI 48109, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London WC1E 6BT, UK
| | | | - Derralynn Hughes
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Amit Nathwani
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London WC1H 9AX, UK
| | - David Patch
- Department of Hepatology, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Jim Buckley
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Mark De Neef
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Rahul Dimber
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Cecilia Diaz-Garcia
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Honey Patel
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Aarti Nandani
- Clinical Trials Pharmacy, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Upuli Dissanayake
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Nick Chadwick
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Ahmed A. A. M. M. Alkhatip
- Department of Anaesthesia, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
- Department of Anaesthesia, Faculty of Medicine, Beni-Suef University Hospital, Beni-Suef University, Beni-Suef 2721562, Egypt
| | - Peter Watkinson
- NIHR Biomedical Research Centre Oxford, Oxford University Hospitals NHS Trust, University of Oxford, Oxford OX3 9DU, UK
| | - Eamon Raith
- Bloomsbury Institute for Intensive Care Medicine, Department of Experimental and Translational Medicine, University College London, London WC1E 6JF, UK
- Discipline of Acute Care Medicine, School of Medicine, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Suveer Singh
- Department of Respiratory and Critical Care Medicine, Chelsea & Westminster Hospital, London SW10 9NH, UK
- Department of Adult Intensive Care, Royal Brompton Hospital, London SW3 6NP, UK
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK
| | - Tony Wolff
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Rajeev Jha
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Simon E. Brill
- UCL Respiratory, University College London, London WC1E 6JF, UK;
| | - Ameet Bakhai
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Department of Cardiology, Royal Free London NHS Foundation Trust, London NW3 2PS, UK
| | - Alison Evans
- University College London (UCL)/University College London Hospitals NHS Trust (UCLH) Joint Research Office, London WC1E 6BT, UK; (A.E.)
| | - Farhat Gilani
- University College London (UCL)/University College London Hospitals NHS Trust (UCLH) Joint Research Office, London WC1E 6BT, UK; (A.E.)
| | - Keith Gomez
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
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19
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van der Horst SFB, Martens ESL, den Exter PL, Bos MHA, van Mens TE, Huisman MV, Klok FA. Idarucizumab for dabigatran reversal: A systematic review and meta-analysis of indications and outcomes. Thromb Res 2023; 228:21-32. [PMID: 37267671 DOI: 10.1016/j.thromres.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Idarucizumab has been approved to reverse the anticoagulant effect of dabigatran. However, there is little knowledge of the effectiveness and safety of idarucizumab in daily practice. AIMS This systematic review and meta-analysis aims to evaluate the use, effectiveness and outcomes of idarucizumab. METHODS A systematic literature search was performed up to September 8th 2022. Original studies including patients prescribed idarucizumab, evaluating prescription indications, prescription appropriateness, haemostatic efficacy and/or the occurrence of adverse events were eligible. Case-reports and studies performed in patients ≤18 years or in healthy volunteers were excluded. Study selection and data extraction were performed by two independent reviewers. Pooled estimates were calculated using the random-effects model, after Freeman-Tukey double-arcsine transformation. RESULTS Thirty studies comprising 3602 patients were included. Idarucizumab was prescribed for bleeding (63.1 %, 95%CI 57.0 %-69.0 %), invasive procedures (30.5 %, 95%CI: 24.1 %-37.2 %), to enable thrombolysis (range: 2.0 %-27.3 %), dabigatran intoxication without bleeding (range: 3.6 %-7.0 %) or unspecified reasons (range: 0.4 %-18.8 %). Overall, 2.8 % (95%CI 0.5 %-6.2 %) of prescription indications were reported to be inappropriate upon post-hoc evaluation. Hemostatic effectiveness was achieved in 77.7 % (95%CI 66.7 %-87.2 %) and peri-procedural haemostasis was normal in 98.5 % (95%CI 86.6 %-100 %) of patients. The pooled incidences of all-cause mortality and thromboembolic events at any follow-up duration were 13.6 % (95%CI 9.6 %-17.9 %) and 2.0 % (95%CI 0.8 %-3.4 %), respectively. CONCLUSION Idarucizumab was mainly prescribed in the setting of bleeding. The reported hemostatic effectiveness was good, especially perioperatively, and the incidence of thromboembolic events was low. Patients with dabigatran-associated bleeding or requiring an urgent procedure nonetheless face a high mortality risk.
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Affiliation(s)
- S F B van der Horst
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - E S L Martens
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - P L den Exter
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - M H A Bos
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
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20
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Mittman BG, Sheehan M, Kojima L, Cassachia N, Lisheba O, Hu B, Pappas M, Rothberg MB. A Novel Risk Assessment Model Predicts Major Bleeding Risk at Admission in Medical Inpatients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.29.23289304. [PMID: 37205327 PMCID: PMC10187332 DOI: 10.1101/2023.04.29.23289304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Venous thromboembolism (VTE) is the leading cause of preventable hospital death in the US. Guidelines from the American College of Chest Physicians and American Society for Hematology recommend providing pharmacological VTE prophylaxis to acutely or critically ill medical patients at acceptable bleeding risk, but there is currently only one validated risk assessment model (RAM) for estimating bleeding risk. We developed a RAM using risk factors at admission and compared it with the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) model. Methods A total of 46,314 medical patients admitted to a Cleveland Clinic Health System hospital from 2017-2020 were included. Data were split into training (70%) and validation (30%) sets with equivalent bleeding event rates in each set. Potential risk factors for major bleeding were identified from the IMPROVE model and literature review. Penalized logistic regression using LASSO was performed on the training set to select and regularize important risk factors for the final model. The validation set was used to assess model calibration and discrimination and compare performance with IMPROVE. Bleeding events and risk factors were confirmed through chart review. Results The incidence of major in-hospital bleeding was 0.58%. Active peptic ulcer (OR = 5.90), prior bleeding (OR = 4.24), and history of sepsis (OR = 3.29) were the strongest independent risk factors. Other risk factors included age, male sex, decreased platelet count, increased INR, increased PTT, decreased GFR, ICU admission, CVC or PICC placement, active cancer, coagulopathy, and in-hospital antiplatelet drug, steroid, or SSRI use. In the validation set, the Cleveland Clinic Bleeding Model (CCBM) had better discrimination than IMPROVE (0.86 vs. 0.72, p < .001) and, at equivalent sensitivity (54%), categorized fewer patients as high-risk (6.8% vs. 12.1%, p < .001). Conclusions From a large population of medical inpatients, we developed and validated a RAM to accurately predict bleeding risk at admission. The CCBM may be used in conjunction with VTE risk calculators to decide between mechanical and pharmacological prophylaxis for at-risk patients.
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Affiliation(s)
- Benjamin G Mittman
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Megan Sheehan
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH
| | - Lisa Kojima
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH
| | | | - Oleg Lisheba
- Enterprise Analytics eResearch Department, Cleveland Clinic, Cleveland, OH
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Matthew Pappas
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH
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21
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Shevell L, Ochs M, Schaefer J. Prophylactic Anticoagulation in Patients with Cancer: When and How? Curr Oncol Rep 2023; 25:201-209. [PMID: 36705880 DOI: 10.1007/s11912-023-01358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Cancer-associated thrombosis is a leading cause of death among patients with cancer. Historically, thromboprophylaxis efforts have focused on the highest risk patients with cancer, including post-operative patients and hospitalized patients. This review covers not only thromboprophylaxis for these groups but also emerging data supporting prophylaxis in ambulatory medical oncology patients. RECENT FINDINGS Several leading guidelines, backed by clinical trial data, now support the use of direct oral anticoagulants for select high-risk outpatients for primary thromboprophylaxis. However, uptake of these findings remains low. Pharmacologic venous thromboembolism prophylaxis strategies continue to improve. However, it remains challenging to balance competing risks of bleeding and thrombosis. The morbidity and mortality associated with cancer associated thrombosis may be preventable. Understanding advancements in risk prediction, anticoagulant options, and implementation of existing data, is critical to provide optimal patient care.
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Affiliation(s)
- Lauren Shevell
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Madeleine Ochs
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Jordan Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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22
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Oleksiuk-Bójko M, Lisowska A. Venous thromboembolism: Why is it still a significant health problem? Adv Med Sci 2023; 68:10-20. [PMID: 36368288 DOI: 10.1016/j.advms.2022.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/08/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) remains the third leading cause of acute cardiovascular syndrome following myocardial infarction and ischemic stroke. The global burden of disease worldwide is high and shows a steady upward trend in recent years with an incidence of 1-2 per 1000 adults per year. The overarching goal of the initial management of VTE is to prevent early and late adverse outcomes. Rapid evaluation and therapeutic intervention is vital to improving prognosis. METHODS We searched PubMed, Science Direct and Scopus databases for articles published in the last 10 years. Additionally, some earlier articles were analyzed. RESULTS For the purposes of this review, we discussed how understanding the epidemiology of VTE and the current knowledge of early and late complications of this disease have shaped the current approach to VTE prevention. We also analyzed the current knowledge and the most up-to-date information about VTE in COVID-19 infection. Contemporary perspective presented in this article on mortality in VTE, the incidence of recurrences, the risk of major bleeding during therapy and the chronic complications indicate why this is a major challenge for today's medicine and a current target for further research. CONCLUSIONS Understanding the interaction between environmental and genetic factors appears to be crucial in the diagnostic process. It can provide insight into the pathophysiology of VTE, potentially identifying options for targeted prevention and treatment. However, due to differences in clinical presentation, diagnosing pulmonary embolism may not be an easy task which perfectly illustrates the scale and complexity of the disease.
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Affiliation(s)
- Monika Oleksiuk-Bójko
- Department of Cardiology, University Clinical Hospital in Bialystok, Bialystok, Poland
| | - Anna Lisowska
- Department of Cardiology, University Clinical Hospital in Bialystok, Bialystok, Poland.
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23
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Xie J, Prieto-Alhambra D. Is There a Role for Thromboprophylaxis in Selected Outpatients With COVID-19?-Reply. JAMA Intern Med 2023; 183:169-170. [PMID: 36534381 DOI: 10.1001/jamainternmed.2022.5881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Junqing Xie
- Centre for Statistics in Medicine and the National Institute for Health and Care Research, Biomedical Research Centre Oxford, University of Oxford, Oxford, UK
| | - Daniel Prieto-Alhambra
- Centre for Statistics in Medicine and the National Institute for Health and Care Research, Biomedical Research Centre Oxford, University of Oxford, Oxford, UK
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24
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Ballestri S, Romagnoli E, Arioli D, Coluccio V, Marrazzo A, Athanasiou A, Di Girolamo M, Cappi C, Marietta M, Capitelli M. Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review. Adv Ther 2023; 40:41-66. [PMID: 36244055 PMCID: PMC9569921 DOI: 10.1007/s12325-022-02333-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/21/2022] [Indexed: 01/25/2023]
Abstract
Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent conditions with a significant healthcare burden, and represent the main indications for anticoagulation. Direct oral anticoagulants (DOACs) are the first choice treatment of AF/VTE, and have become the most prescribed class of anticoagulants globally, overtaking vitamin K antagonists (VKAs). Compared to VKAs, DOACs have a similar or better efficacy/safety profile, with reduced risk of intracerebral hemorrhage (ICH), while the risk of major bleeding and other bleeding harms may vary depending on the type of DOAC. We have critically reviewed available evidence from randomized controlled trials and observational studies regarding the risk of bleeding complications of DOACs compared to VKAs in patients with AF and VTE. Special patient populations (e.g., elderly, extreme body weights, chronic kidney disease) have specifically been addressed. Management of bleeding complications and possible resumption of anticoagulation, in particular after ICH and gastrointestinal bleeding, are also discussed. Finally, some suggestions are provided to choose the optimal DOAC to minimize adverse events according to individual patient characteristics and bleeding risk.
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Affiliation(s)
- Stefano Ballestri
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy.
| | - Elisa Romagnoli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Dimitriy Arioli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Valeria Coluccio
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Alessandra Marrazzo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Afroditi Athanasiou
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Maria Di Girolamo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Cinzia Cappi
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Mariano Capitelli
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
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25
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Incidence and impact of anticoagulation-associated abnormal menstrual bleeding in women after venous thromboembolism. Blood 2022; 140:1764-1773. [PMID: 35925686 DOI: 10.1182/blood.2022017101] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/06/2022] [Indexed: 11/20/2022] Open
Abstract
Preliminary data and clinical experience have suggested an increased risk of abnormal uterine bleeding (AUB) in women of reproductive age treated with anticoagulants, but solid data are lacking. The TEAM-VTE study was an international multicenter prospective cohort study in women aged 18 to 50 years diagnosed with acute venous thromboembolism (VTE). Menstrual blood loss was measured by pictorial blood loss assessment charts at baseline for the last menstrual cycle before VTE diagnosis and prospectively for each cycle during 3 to 6 months of follow-up. AUB was defined as an increased score on the pictorial blood loss assessment chart (>100 or >150) or self-reported AUB. AUB-related quality of life (QoL) was assessed at baseline and the end of follow-up using the Menstrual Bleeding Questionnaire. The study was terminated early because of slow recruitment attributable to the COVID-19 pandemic. Of the 98 women, 65 (66%) met at least one of the 3 definitions of AUB during follow-up (95% confidence interval [CI], 57%-75%). AUB occurred in 60% of women (36 of 60) without AUB before VTE diagnosis (new-onset AUB; 95% CI, 47%-71%). Overall, QoL decreased over time, with a mean Menstrual Bleeding Questionnaire score increase of 5.1 points (95% CI, 2.2-7.9), but this decrease in QoL was observed only among women with new-onset AUB. To conclude, 2 of every 3 women who start anticoagulation for acute VTE experience AUB, with a considerable negative impact on QoL. These findings should be a call to action to increase awareness and provide evidence-based strategies to prevent and treat AUB in this setting. This was an academic study registered at www.clinicaltrials.gov as #NCT04748393; no funding was received.
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26
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Park H, Kang H, Huang P, Lo‐Ciganic W, DeRemer CE, Wilson D, Dietrich EA. Comparative effectiveness and safety of extended anticoagulant therapy among Medicare beneficiaries with venous thromboembolism. Clin Transl Sci 2022; 16:128-139. [PMID: 36200137 PMCID: PMC9841301 DOI: 10.1111/cts.13433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/16/2022] [Accepted: 09/28/2022] [Indexed: 02/06/2023] Open
Abstract
Guidelines recommend an extended course of anticoagulation therapy for patients who experienced venous thromboembolism (VTE) without transient provocation, however, optimal duration remains uncertain. We assessed effectiveness and safety of extended use of apixaban and warfarin greater than 6 months of initial treatment in patients with VTE. We conducted a retrospective cohort study of Medicare beneficiaries aged greater than or equal to 18 years with deep vein thrombosis or pulmonary embolism. Patients were required to have initiated anticoagulants within 30 days of their first VTE diagnosis, completed 6 months of initial anticoagulant treatment, and received extended phase treatment with apixaban (the apixaban group) or warfarin (the warfarin group) or no extended therapy. Multivariable Cox proportional hazards modeling with inverse probability treatment weighting was used to compare recurrent VTE, mortality, and major bleeding risks among the three groups. Mean extended-treatment duration was up to 10 months and 14 months in apixaban and warfarin groups, respectively. Compared with no extended treatment, apixaban use was associated with decreased risks of recurrent VTE (hazard ratio [HR] = 0.08, [95% confidence interval [CI]: 0.01-0.41]) and mortality (HR = 0.37, [95% CI: 0.27-0.51]) without increased major bleeding risk (HR = 1.29, [95% CI: 0.68-2.45]); warfarin use was associated not with recurrent VTE risk change but with increased major bleeding risk (HR = 2.14, [95% CI: 1.26-3.65]) and decreased mortality risk (HR = 0.39, [95% CI: 0.29-0.51]). Compared with warfarin, apixaban use was associated with decreased recurrent VTE (HR = 0.13, [95% CI: 0.03-0.63]) and major bleeding (HR = 0.56, [95% CI: 0.32-0.98]) risks. Subgroup and sensitivity analyses (e.g., intention-to-treat) findings remained consistent. Compared with warfarin or no extended therapy, extended-apixaban use was associated with reduced risk of recurrent VTE without increased major bleeding risk. Continuing anticoagulant therapy with apixaban greater than 6 months may be effective and safe.
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Affiliation(s)
- Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA,Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFloridaUSA
| | - Hye‐Rim Kang
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Pei‐Lin Huang
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Wei‐Hsuan Lo‐Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA,Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFloridaUSA
| | - Christina E. DeRemer
- Department of Pharmacotherapy and Translational Research, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Debbie Wilson
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Eric A. Dietrich
- Department of Pharmacotherapy and Translational Research, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
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27
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Givens G, Neu D, Marler J. The Risk of Major Bleeding With Apixaban Administration in Patients With Acute Kidney Injury. Ann Pharmacother 2022:10600280221129831. [PMID: 36239322 DOI: 10.1177/10600280221129831] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Apixaban is eliminated by the kidneys and in acute kidney injury (AKI) there is potential for an increase in apixaban exposure and bleeding events. In one instance, data have shown higher than normal bleed risk in patients with AKI, unless calibrated anti-factor Xa monitoring is used, which is not widely available. OBJECTIVE To evaluate bleeding with apixaban administration to hospitalized patients with an AKI in an unmonitored real-world scenario. METHODS We conducted a retrospective study of patients admitted to a large urban academic teaching hospital from April 2015 to March 2022, who received apixaban for venous thromboembolism or nonvalvular atrial fibrillation (NVAF). The primary outcome evaluated major bleeding when apixaban was administered to patients with or without an AKI. RESULTS A total of 232 patients were evaluated (116 per group). Most patients (79.7%) were on apixaban for NVAF, 32.7% had chronic kidney disease, 58.2% were on a medication increasing bleed risk, and HAS-BLED score was a median of 2 in both groups. No differences were noted between groups for bleeding (AKI group 7.8% vs non-AKI 3.4%; P = 0.15), and on regression analysis, coadministration of a P2Y12 inhibitor was predictive of major bleeding (odds ratio = 5.9; 95% confidence interval = 1.4-23.6). CONCLUSION AND RELEVANCE Although no differences between groups were noted, apixaban use in the AKI group resulted in a higher than normally reported incidence of apixaban-associated major bleeding, and concomitant antiplatelet use increased bleed risk as well. Cautious use of apixaban and further investigation with larger studies are warranted in this area.
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Affiliation(s)
- Gabrielle Givens
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA
| | - Daniel Neu
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA
| | - Jacob Marler
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA.,Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, TN, USA
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28
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Højen AA, Nielsen PB, Overvad TF, Albertsen IE, Klok FA, Rolving N, Søgaard M, Ording AG. Long-Term Management of Pulmonary Embolism: A Review of Consequences, Treatment, and Rehabilitation. J Clin Med 2022; 11:jcm11195970. [PMID: 36233833 PMCID: PMC9571065 DOI: 10.3390/jcm11195970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 12/02/2022] Open
Abstract
The concept of pulmonary embolism is evolving. Recent and emerging evidence on the treatment of specific patient populations, its secondary prevention, long-term complications, and the unmet need for rehabilitation has the potential to change clinical practice for the benefit of the patients. This review discusses the recent evidence from clinical trials, observational studies, and guidelines focusing on anticoagulation treatment, rehabilitation, emotional stress, quality of life, and the associated outcomes for patients with pulmonary embolism. Guidelines suggest that the type and duration of treatment with anticoagulation should be based on prevalent risk factors. Recent studies demonstrate that an anticoagulant treatment that is longer than two years may be effective and safe for some patients. The evidence for extended treatment in cancer patients is limited. Careful consideration is particularly necessary for pulmonary embolisms in pregnancy, cancer, and at the end of life. The rehabilitation and prevention of unnecessary deconditioning, emotional distress, and a reduced quality of life is an important, but currently they are unmet priorities for many patients with a pulmonary embolism. Future research could demonstrate optimal anticoagulant therapy durations, follow-ups, and rehabilitation, and effective patient-centered decision making at the end of life. A patient preferences and shared decision making should be incorporated in their routine care when weighing the benefits and risks with primary treatment and secondary prevention.
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Affiliation(s)
- Anette Arbjerg Højen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Thure Filskov Overvad
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Clinical Pharmacology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Ida Ehlers Albertsen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 Leiden, The Netherlands
| | - Nanna Rolving
- Department of Physical and Occupational Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark
- Department of Public Health, Aarhus University, 8200 Aarhus, Denmark
| | - Mette Søgaard
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Anne Gulbech Ording
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
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29
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Escobar A, Salem AM, Dickson K, Johnson TN, Burk KJ, Bashoura L, Faiz SA. Anticoagulation and bleeding in the cancer patient. Support Care Cancer 2022; 30:8547-8557. [PMID: 35579752 PMCID: PMC9529787 DOI: 10.1007/s00520-022-07136-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Abstract
Cancer patients have an increased risk of bleeding compared to non-cancer patients with anticoagulant therapy. A bleeding risk assessment before initiation of anticoagulation is recommended. Currently low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are the mainstays of treatment for cancer-associated venous thromboembolism (VTE). Since DOACs are administered orally, they offer some convenience and ease of administration; however, LMWH may be preferred in certain cancers. Given the prevalence of anticoagulant therapies in cancer patients, clinical providers must be able to recognize potentially critical bleeding sites and modalities to reverse major hemorrhage. Reversal agents or antidotes to bleeding may be required when bleeding is persistent or life-threatening. These include vitamin K, fresh frozen plasma (FFP), protamine, prothrombin complex concentrate (PCC) or andexanet alfa, and idarucizumab. Inferior vena cava (IVC) filter insertion can be also considered in those with major bleeding. Evidence for timing and need for re-initiation of anticoagulant therapy after a major bleeding remains sparse, but a multi-disciplinary approach and shared decision-making can be implemented in the interim.
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Affiliation(s)
- Andres Escobar
- Divisions of Critical Care, Pulmonary and Sleep Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Ahmed M Salem
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kodwo Dickson
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tami N Johnson
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathyrn J Burk
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Saadia A Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA.
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30
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Matzdorff A. Venous Thromboembolism in Women with Cancer with an Additional Focus on Breast and Gynecological Cancers. Hamostaseologie 2022; 42:309-319. [DOI: 10.1055/a-1913-2873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractCancer-associated venous thromboembolism (VTE) is common in women with cancer. Many clinical practice guidelines provide guidance for prevention and treatment; however, there are no specific recommendations for women. This is unfortunate because the proportion of women with breast- and gynecological cancers is high among patients with cancer-associated VTE. Thromboembolism often heralds cancer progression and poor prognosis and should—besides adequate anticoagulant management—also prompt reassessment and, if necessary, changes in cancer treatment. Recently, the new class of direct-acting oral anticoagulants (DOACs) has started to replace low-molecular-weight heparin as standard thromboprophylaxis and therapy in cancer patients. They are very effective, but they also carry a relevant risk of bleeding. Therefore, despite their ease of use, not every tumor patient qualifies for a DOAC, and this is especially true for gynecological tumor patients. Each prescription must be weighed individually. This review addresses specific aspects of VTE prophylaxis and management in women with cancer. Every physician who treats breast and gynecological cancers should be familiar with prophylaxis, diagnosis, and therapy of cancer-associated VTE. At the same time, patients should be informed by their physician what symptoms to look for and whom to contact if these symptoms occur, even outside of office hours and on weekends.
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Affiliation(s)
- Axel Matzdorff
- Department of Internal Medicine II, Asklepios Clinic Uckermark, Schwedt, Germany
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31
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Goran K. Search for obtaining the highest net clinical benefit in pulmonary embolism patients: A new improvement considering the safety of thrombolysis. Thromb Res 2022; 218:5-7. [PMID: 35961066 DOI: 10.1016/j.thromres.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Koracevic Goran
- Department for Cardiovascular Diseases, University Clinical Center Nis, Medical Faculty, University of Nis, Serbia.
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32
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den Exter PL, Woller SC, Robert‐Ebadi H, Masias C, Morange P, Castelli D, Hansen J, Geersing G, Siegal DM, de Wit K, Klok FA. Management of bleeding risk in patients who receive anticoagulant therapy for venous thromboembolism: Communication from the ISTH SSC Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease. J Thromb Haemost 2022; 20:1910-1919. [PMID: 35735219 PMCID: PMC9545751 DOI: 10.1111/jth.15776] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022]
Abstract
Patients with acute venous thromboembolism (VTE) require anticoagulant therapy to prevent recurrent VTE and death, which exposes them to an inherent increased risk of bleeding. Identification of patients at high risk of bleeding, and mitigating this risk, is an essential component of the immediate and long-term therapeutic management of VTE. The bleeding risk can be estimated by either implicit judgment, weighing individual predictors (clinical variables or biomarkers), or by risk prediction tools developed for this purpose. Management of bleeding risk in clinical practice is, however, far from standardized. International guidelines are contradictory and lack clear and consistent guidance on the optimal management of bleeding risk. This report of the ISTH subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease summarizes the evidence on the prediction of bleeding in VTE patients. We systematically searched the literature and identified 34 original studies evaluating either predictors or risk prediction models for prediction of bleeding risk on anticoagulation in VTE patients. Based on this evidence, we provide recommendations for the standardized management of bleeding risk in VTE patients.
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Affiliation(s)
- Paul L. den Exter
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Scott C. Woller
- Department of MedicineIntermountain Medical CenterIntermountain HealthcareMurrayUtahUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Helia Robert‐Ebadi
- Division of Angiology and HemostasisGeneva University Hospitals and Faculty of MedicineGenevaSwitzerland
| | - Camila Masias
- Miami Cancer InstituteBaptist Health South Florida. Florida International University ‐ Herbert Wertheim College of MedicineMiamiFloridaUSA
| | - Pierre‐Emmanuel Morange
- Aix Marseille UnivINSERM 1263, INRAE 1260, C2VNMarseilleFrance
- Hematology DepartmentLa Timone University Hospital of MarseilleMarseilleFrance
| | | | - John‐Bjarne Hansen
- Thrombosis Research Center (TREC)Department of Clinical MedicineUiT – The Arctic University of Norway and University Hospital of North NorwayTromsøNorway
| | - Geert‐Jan Geersing
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Deborah M. Siegal
- Division of Hematology and ThromboembolismDepartment of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Kerstin de Wit
- Departments of Emergency Medicine and MedicineQueen's UniversityKingstonOntarioCanada
- Departments of Medicine and HEIMcMaster UniversityHamiltonOntarioCanada
| | - Frederikus A. Klok
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
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33
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Maestre A, Escribano JC, Lobo JL, Jara-Palomares L, Jiménez D, Bikdeli B, Armestar F, Bura-Riviere A, Lorenzo A, Monreal M. Major bleeding in patients with pulmonary embolism presenting with syncope. Eur J Clin Invest 2022; 52:e13774. [PMID: 35302666 DOI: 10.1111/eci.13774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/02/2022] [Accepted: 03/15/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Syncope has been shown to be a risk factor of bleeding in patients receiving thrombolytic therapy for acute pulmonary embolism (PE). Whether syncope predicts bleeding in a broader population of patients with PE remains unknown. METHODS We used the RIETE registry data to assess whether initial presentation with syncope could predict bleeding in PE patients receiving anticoagulant therapy, and to explore the association between presence of syncope and timing and site of major bleeding events. RESULTS Among 45,765 patients with acute PE from March 2001 to January 2021, 6760 (14.8%) had syncope. Patients with syncope were older and more likely to have hypotension, tachycardia, hypoxaemia or elevated troponin levels than those without syncope. They also were more likely to receive thrombolytics. During the first 90 days, 1097 patients (2.4%) suffered major bleeding (gastrointestinal 335, hematoma 271 and intracranial 163) and 3611 died (158 had fatal bleeding). Patients with syncope had a higher rate of major bleeding (odds ratio [OR]: 1.63; 95% CI: 1.41-1.89) and a nonsignificantly higher rate of fatal bleeding (OR: 1.47; 95% CI: 0.99-2.17) than those without syncope. Multivariable analysis confirmed that patients with syncope were at increased risk for major bleeding (adjusted hazard ratio [aHR]: 1.34; 95% CI: 1.15-1.55). On sensitivity analysis, the increased risk for major bleeding was confirmed in patients initially receiving anticoagulant therapy without thrombolytics at 7 days (aHR: 1.47; 95% CI: 1.13-1.91) and 90 days (aHR: 1.33; 95%CI: 1.13-1.56). DISCUSSION Syncope is a predictor of major bleeding events in patients with PE, even among those receiving anticoagulation monotherapy.
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Affiliation(s)
- Ana Maestre
- Department of Internal Medicine, Hospital Universitario del Vinalopo, Elche, Spain.,Medicine Department, Universidad Catolica San Antonio de Murcia, Murcia, Spain
| | | | - José Luis Lobo
- Respiratory Department, Hospital Universitario Araba, Álava, Spain
| | - Luis Jara-Palomares
- Respiratory Department, Hospital Universitario Virgen del Rocío and Instituto de Biomedicina, Sevilla, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain.,Medicine Department, Universidad de Alcala, Madrid, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Yale/YNHH Center for Outcomes Research & Evaluation (CORE), New Haven, Connecticut, USA.,Cardiovascular Research Foundation (CRF), New York, New York, USA
| | - Fernando Armestar
- Department of Intensive Care Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | - Alicia Lorenzo
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain.,Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
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34
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Mokgokong R, Khachatryan A, Quignot N, Chaves J, Moniot A, Gusto G. Comparative Analysis of All-Cause Health Care Resource Utilization and Costs Among Venous Thrombosis Patients Without Cancer Prescribed Apixaban or VKAs in France. Adv Ther 2022; 39:3766-3776. [PMID: 35767124 PMCID: PMC9309117 DOI: 10.1007/s12325-022-02200-7] [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: 04/12/2022] [Accepted: 05/19/2022] [Indexed: 11/27/2022]
Abstract
Introduction The direct oral anticoagulant (DOAC) apixaban has shown to have non-inferior efficacy and better safety than vitamin K antagonists (VKAs) in patients with venous thromboembolism (VTE). We determined whether healthcare resource use (HCRU) and direct all-cause medical and non-medical costs in patients with VTE in France differed between VKAs and apixaban. Methods A retrospective cohort study was conducted using French national health data from January 2013–June 2018 for anticoagulant-naïve adults hospitalized with VTE. All-cause costs and HCRU per patient per month (PPPM) were compared between apixaban and VKA cohorts created by 1:1 propensity score matching. Two-part models with bootstrapping were used to calculate marginal effects for costs and HCRU. Results The matched VKA and apixaban cohorts each comprised 7503 patients. Compared to VKAs, patients prescribed apixaban had significantly lower (P < 0.0001) mean all-cause costs PPPM for outpatient visits (€438.54 vs. €455.58), overall laboratory tests (€21.26 vs. €83.73), and hospitalizations (€249.48 vs. €343.82), but significantly higher (P < 0.0001) mean all-cause costs PPPM for overall drugs (€97.06 vs. €69.56) and medical procedures (€42.12 vs. €35.50). Mean total all-cause direct medical costs (€687.93 vs. €798.70) and total all-cause direct medical and non-medical costs (€771.60 vs. €883.66) were significantly lower (P < 0.0001) for apixaban. Mean HCRU PPPM showed similar trends. Subgroup analyses showed that, among patients with recurrent VTE, patients prescribed apixaban had significantly lower (P < 0.0001) all-cause costs PPPM for total medical costs (€17.26 vs. €18.12) and total all-cause direct medical and non-medical costs (€18.37 vs. €19.20) than patients prescribed VKAs. Similarly, among patients with bleeding, patients prescribed apixaban had significantly lower (P < 0.0001) all-cause costs PPPM for total medical costs (€15.34 vs. €32.61) and total all-cause direct medical and non-medical costs (€16.23 vs. €34.63) than patients prescribed VKAs. Conclusion Compared to VKAs, apixaban may be cost-saving in the treatment of patients hospitalized for acute VTE. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02200-7.
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Affiliation(s)
- Ruth Mokgokong
- Health Economics & Outcomes Research, Pfizer Ltd, Walton Oaks, Tadworth, KT20 7NS, UK.
| | | | | | - Jose Chaves
- Global Medical Affairs, Pfizer SLU, Internal Medicine, Madrid, Spain
| | - Audrey Moniot
- Medical Affairs, Pfizer SAS, Internal Medicine, Paris, France
| | - Gaelle Gusto
- Evidence and Access, Certara France, Paris, France
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35
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Anticoagulation strategies and clinical outcomes after bleeding events during anticoagulation therapy for venous thromboembolism in the practice-based Japanese registry. J Thromb Thrombolysis 2022; 54:524-534. [PMID: 35713842 DOI: 10.1007/s11239-022-02665-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 10/18/2022]
Abstract
There is a paucity of data on anticoagulation strategies and clinical outcomes after bleeding events for venous thromboembolism (VTE). In a multicenter Japanese registry enrolling 3027 patients with acute symptomatic VTE, after excluding 430 patients with thrombolysis and 207 patients without anticoagulation therapy, the current study population consisted of 2390 patients, who were divided into patients with major bleeding, clinically relevant non-major (CRNM) bleeding and no bleeding during anticoagulation therapy. All-cause death at 90 days after the bleeding events was evaluated as the primary outcome. There were 189 patients with major bleeding, 147 patients with CRNM bleeding, and 2054 patients without bleeding. Among 189 patients with major bleeding, 142 patients (75%) discontinued anticoagulants, of whom patients with temporary discontinuation and those with permanent discontinuation accounted for 63 patients (44%) and 79 patients (56%), and 58 patients (30.7%) died within 90 days after the bleeding events. The multivariable logistic regression model among patients with bleeding events revealed that active cancer and bleeding events within 90 days after VTE diagnosis were independently associated with 90-day mortality after the bleeding events (active cancer: OR 5.05, 95%CI 2.82-9.05; bleeding events within 90 days after VTE diagnosis: OR 2.23, 95%CI 1.25-3.96). In this practice-based large registry, anticoagulants were frequently discontinued in patients who experienced major bleeding events during anticoagulation therapy and nearly half of them restarted anticoagulants with mortality rate of approximately 30% within 90 days after the bleeding events, and active cancer was the most prevalent cause of death.Clinical trial registration COMMAND VTE Registry: http://www.umin.ac.jp/ctr/index.htm . Unique identifier: UMIN000021132.
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36
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Predicting major bleeding during extended anticoagulation for unprovoked or weakly provoked venous thromboembolism. Blood Adv 2022; 6:4605-4616. [PMID: 35679460 PMCID: PMC9636329 DOI: 10.1182/bloodadvances.2022007027] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/05/2022] [Indexed: 11/20/2022] Open
Abstract
No clinical prediction model has been specifically developed or validated to identify patients with unprovoked venous thromboembolism (VTE) who are at high risk of major bleeding during extended anticoagulation. In a prospective multinational cohort study of patients with unprovoked VTE receiving extended anticoagulation after completing ≥3 months of initial treatment, we derived a new clinical prediction model using a multivariable Cox regression model based on 22 prespecified candidate predictors for the primary outcome of major bleeding. This model was then compared with modified versions of 5 existing clinical scores. A total of 118 major bleeding events occurred in 2516 patients (annual risk, 1.7%; 95% confidence interval [CI], 1.4-2.1). The incidences of major bleeding events per 100 person-years in high-risk and non–high-risk patients, respectively, were 3.9 (95% CI, 3.0-5.1) and 1.1 (0.8-1.4) using the newly derived creatinine, hemoglobin, age, and use of antiplatelet agent (CHAP) model; 3.3 (2.6-4.1) and 1.0 (0.7-1.3) using modified ACCP score, 5.3 (0.6-19.2) and 1.7 (1.4-2.0) using modified RIETE score, 3.1 (2.3-3.9) and 1.1 (0.9-1.5) using modified VTE-BLEED score, 5.2 (3.3-7.8) and 1.5 (1.2-1.8) using modified HAS-BLED score, and 4.8 (1.3-12.4) and 1.7 (1.4-2.0) using modified outpatient bleeding index score. Modified versions of the ACCP, VTE-BLEED, and HAS-BLED scores help identify patients with unprovoked VTE who are at high risk of major bleeding and should be considered for discontinuation of anticoagulation after 3 to 6 months of initial treatment. The CHAP model may further improve estimation of bleeding risk by using continuous predictor variables, but external validation is required before its implementation in clinical practice.
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DeRemer CE, Dietrich EA, Kang HR, Huang PL, Lo-Ciganic WH, Park H. Comparison of effectiveness and safety for low versus full dose of apixaban during extended phase oral anticoagulation in patients with venous thromboembolism. J Intern Med 2022; 291:877-885. [PMID: 35192737 DOI: 10.1111/joim.13462] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The optimal dose of apixaban therapy to prevent asecondary venous thromboembolism (VTE) event remains unconfirmed. To investigate the effects of extended phase use of apixaban (2.5 vs. 5 mg twice daily) beyond 6 months of initial treatment on the risk of recurrent VTE and major bleeding events among patients with a history of VTE. METHODS A retrospective cohort analysis of two large national insurance claims databases was conducted for patients diagnosed with VTE. Cox proportional hazard models after propensity score matching were used to compare the risk of recurrent VTE and major bleeding. RESULTS There were no detected differences in recurrent VTE or major bleeding events between patients prescribed low versus full dose apixaban. CONCLUSION This study provides evidence that apixaban 2.5 mg twice daily is an alternative option for extended phase therapy for risk reduction of VTE recurrence compared to apixaban 5 mg twice daily.
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Affiliation(s)
- Christina E DeRemer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Eric A Dietrich
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Hye-Rim Kang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Pei-Lin Huang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
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38
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Lichtblau M, Piccari L, Ramjug S, Bokan A, Lechartier B, Jutant EM, Barata M, Garcia AR, Howard LS, Adir Y, Delcroix M, Jara-Palomares L, Bertoletti L, Sitbon O, Ulrich S, Vonk Noordegraaf A. ERS International Congress 2021: highlights from the Pulmonary Vascular Diseases Assembly. ERJ Open Res 2022; 8:00665-2021. [PMID: 35615412 PMCID: PMC9125041 DOI: 10.1183/23120541.00665-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/25/2022] [Indexed: 12/25/2022] Open
Abstract
This article aims to summarise the latest research presented at the virtual 2021 European Respiratory Society (ERS) International Congress in the field of pulmonary vascular disease. In light of the current guidelines and proceedings, knowledge gaps are addressed and the newest findings of the various forms of pulmonary hypertension as well as key points on pulmonary embolism are discussed. Despite the comprehensive coverage of the guidelines for pulmonary embolism at previous conferences, discussions about controversies in the diagnosis and treatment of this condition in specific cases were debated and are addressed in the first section of this article. We then report on an interesting pro–con debate about the current classification of pulmonary hypertension. We further report on presentations on Group 3 pulmonary hypertension, with research exploring pathogenesis, phenotyping, diagnosis and treatment; important contributions on the diagnosis of post-capillary pulmonary hypertension are also included. Finally, we summarise the latest evidence presented on pulmonary vascular disease and COVID-19 and a statement on the new imaging guidelines for pulmonary vascular disease from the Fleischner Society. This article summarises communications from #ERSCongress 2021 on pulmonary embolism diagnosis and treatment, PAH and CTEPH during the COVID-19 pandemic and beyond, novelties in post-capillary PH and in PH associated with respiratory diseaseshttps://bit.ly/3ASDO21
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Affiliation(s)
- Mona Lichtblau
- Dept of Pneumology, University Hospital Zürich, Zürich, Switzerland.,These authors contributed equally
| | - Lucilla Piccari
- Pulmonary Hypertension Unit, Dept of Pulmonary Medicine, Hospital del Mar, Barcelona, Spain.,These authors contributed equally
| | - Sheila Ramjug
- Dept of Respiratory Medicine, Manchester University NHS Foundation Trust, Wythenshawe, UK
| | - Aleksandar Bokan
- SLK Lungenklinik Loewenstein, Medical Clinic I: Pneumology, Respiratory Medicine and Intensive Medicine, Loewenstein, Germany
| | - Benoit Lechartier
- Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France.,Pulmonary Division, Lausanne University Hospital, Lausanne, Switzerland
| | - Etienne-Marie Jutant
- Université de Poitiers, CHU de Poitiers, Service de Pneumologie, Institut National de la Santé et de la Recherche Médicale CIC 1402, Poitiers, France
| | | | - Agustin Roberto Garcia
- Pulmonary Hypertension Unit, Dept of Pulmonary Medicine, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Luke S Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Yochai Adir
- Pulmonology Division, Lady Davis-Carmel Medical Center, Haifa, Israel.,Bruce and Ruth Rappaport Faculty of Medicine, The Technion, Haifa, Israel
| | - Marion Delcroix
- Clinical Dept of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Dept of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - Luis Jara-Palomares
- Medical Surgical Unit of Respiratory Diseases, Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocio, Seville, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Laurent Bertoletti
- CHU de St-Etienne, Service de Médecine Vasculaire et Thérapeutique; Institut National de la Santé et de la Recherche Médicale, UMR1059, Université Jean-Monnet; Institut National de la Santé et de la Recherche Médicale CIC-1408, CHU de Saint-Etienne; INNOVTE, CHU de Saint-Etienne, Saint-Etienne, France
| | - Olivier Sitbon
- Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France.,Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Unité Mixte de Recherche S999, Hôpital Marie Lannelongue-Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Silvia Ulrich
- Dept of Pneumology, University Hospital Zürich, Zürich, Switzerland
| | - Anton Vonk Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Dept of Pulmonary Medicine, Amsterdam, The Netherlands
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39
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Assessment of Bleeding Risk in Hospitalized COVID-19 Patients: A Tertiary Hospital Experience during the Pandemic in a Predominant Minority Population-Bleeding Risk Factors in COVID-19 Patients. J Clin Med 2022; 11:jcm11102754. [PMID: 35628881 PMCID: PMC9145335 DOI: 10.3390/jcm11102754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/27/2022] [Accepted: 05/07/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction: In the wake of the SARS-CoV-2 (COVID-19) pandemic, our world has faced multiple challenges. Infection with this virus has commonly been associated with thrombotic events. However, little is known about bleeding risk and anticoagulation therapy. This study aims to determine factors that are associated with increased risk of bleeding in COVID-19 patients. Methods: A retrospective cohort study was conducted using the records of COVID-19 patients admitted during the COVID-19 pandemic from March 2020 through May 2020. Using patient charts, investigators manually collected data regarding patient characteristics and bleeding. Patients were included in the analysis if they had a confirmed COVID-19 PCR test, were older than 18 years of age and were admitted to the hospital. Patients who were pregnant or had incomplete charts were excluded from the study. ANOVA and logistic regression were used to determine the statistical significance of the data using SPSS version 27. Results: A total of 651 patients were included in the analysis out of 685 patients located in the database of COVID-19 infected patients during that time frame. The general characteristics of the patients were as follows: 54.2% were males; females 45.8% ages ranged from 28 to 83 years old (median age = 66 years old). There were 31 patients (4.9%) who required more than 1 unit of packed red blood cell (PRBC). A total of 16 (2.85%) patients had a documented gastrointestinal bleed (GIB), of which 8 received a total of 29 units of PRBC transfusions. The HAS-BLED score (without alcohol/drug due to inadequate charting) is calculated for patients who had a documented GI bleed and who received more than one unit of PRBC. It was noted that the higher the HAS-BLED score the greater the likelihood of having a GI bleed (p < 0.001). The HAS-BLED score (not including alcohol/drug) was also predictive for patients who received more than one unit of PRBC during their hospital stay (p < 0.001). Discussion: Using the HAS-BLED score without alcohol/drugs, patients with COVID-19 can be stratified in regard to their risk of GI bleeding and their risk of transfusion while in the hospital. When administering anticoagulation therapy, cautious monitoring should be carried out. Decisions regarding anticoagulant therapy should be based on individual patient characteristics.
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Reed-Guy L, Desai AS, Phillips RE, Croteau D, Albright K, O’Neill M, Brem S, O’Rourke DM, Amankulor NM, Bagley SJ. Risk of intracranial hemorrhage with direct oral anticoagulants vs low molecular weight heparin in glioblastoma: A retrospective cohort study. Neuro Oncol 2022; 24:2172-2179. [PMID: 35551405 PMCID: PMC9713497 DOI: 10.1093/neuonc/noac125] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Glioblastoma (GBM) is associated with a high incidence of venous thromboembolism (VTE), but there are little data to guide anticoagulation in patients with GBM, in whom the risks of VTE must be balanced against the risk of intracranial hemorrhage (ICH). METHODS We performed a single-institution retrospective cohort study of patients with GBM diagnosed with VTE from 2014 to 2021 who were treated with low molecular weight heparin (LMWH) or a direct oral anticoagulant (DOAC). The incidence of ICH was compared between the LMWH and DOAC groups. The primary outcome was clinically relevant ICH within the first 30 days of anticoagulation, defined as any ICH that was fatal, symptomatic, required surgical intervention, and/or led to cessation of anticoagulation. Secondary outcomes included clinically relevant ICH within 6 months, fatal ICH within 30 days and 6 months, and any bleeding within 30 days and 6 months. RESULTS One hundred twenty-one patients were identified in the cohort for 30-day outcome analyses (DOAC, n = 33; LMWH, n = 88). For 6-month outcome analyses, the cohort included only patients who were maintained on their initial anticoagulant (DOAC, n = 32; LMWH, n = 75). The incidence of clinically relevant ICH at 30 days was 0% in the DOAC group and 9% in the LMWH group (P = .11). The cumulative incidence of clinically relevant ICH at 6 months was 0% in the DOAC group and 24% in the LMWH group (P = .001), with 4 fatal ICHs in the LMWH group. CONCLUSIONS DOACs are associated with a lower incidence of clinically relevant ICH in patients with GBM-associated VTE compared to LMWH.
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Affiliation(s)
- Lauren Reed-Guy
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Arati S Desai
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Richard E Phillips
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Desiree Croteau
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Karen Albright
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Meghan O’Neill
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Steven Brem
- Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Donald M O’Rourke
- Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nduka M Amankulor
- Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stephen J Bagley
- Corresponding Author: Stephen J. Bagley, MD, MSCE, Perelman Center for Advanced Medicine, 10th Floor South Pavilion, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA ()
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Sylvester KW, Chen A, Lewin A, Fanikos J, Goldhaber SZ, Connors JM. Optimization of DOAC management services in a centralized anticoagulation clinic. Res Pract Thromb Haemost 2022; 6:e12696. [PMID: 35541695 PMCID: PMC9069544 DOI: 10.1002/rth2.12696] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/08/2022] [Accepted: 03/02/2022] [Indexed: 12/15/2022] Open
Abstract
Background In 2017, the Brigham and Women’s Hospital Anticoagulation Management Service (BWH AMS) expanded services to patients on direct oral anticoagulants (DOACs). We have since updated our DOAC management plan and adjusted the workflow of our clinic. Objectives This report describes how our DOAC management has evolved and describes key interventions made. Additionally, we report on the results of a survey completed by referring physicians that assessed perspectives regarding centralized DOAC management by BWH AMS pharmacists. Methods An analysis was completed of all patients referred to the BWH AMS and the number of interventions completed and documented in our anticoagulation management software. A survey with eight questions was sent to 110 referring physicians (selected based on referring to the AMS within the past 1.5 years). Results Over 4 years, 1622 patients on DOACs were referred to the BWH AMS, amounting to 3154 DOAC encounters. A total of 212 interventions for medication procurement, 171 dose adjustment interventions, and 603 coordinated procedure plans were completed. Of the 32 physicians who responded to the survey, many believed that the quality and safety of anticoagulation therapy was improved with BWH AMS management. Despite provider satisfaction with pharmacist‐led care in DOACs, physicians expressed concerns regarding the lack of provider awareness of the clinic and possible duplicative efforts. Conclusion We plan to evolve the DOAC clinic model to optimize its clinical and operational value and to improve our delivery of care using electronic tools to move toward a population management approach for DOAC management.
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Affiliation(s)
- Katelyn W. Sylvester
- Department of Pharmacy Services Brigham and Women’s Hospital Boston Massachusetts USA
| | - Alisia Chen
- Bouve College of Health Sciences Northeastern University Boston Massachusetts USA
| | - Andrea Lewin
- Department of Pharmacy Services Brigham and Women’s Hospital Boston Massachusetts USA
| | - John Fanikos
- Department of Pharmacy Services Brigham and Women’s Hospital Boston Massachusetts USA
| | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Jean M. Connors
- Division of Hematology Brigham and Women’s Hospital Boston Massachusetts USA
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Poénou G, Tolédano E, Helfer H, Plaisance L, Happe F, Versini E, Diab N, Djennaoui S, Mahé I. In Search of the Appropriate Anticoagulant-Associated Bleeding Risk Assessment Model for Cancer-Associated Thrombosis Patients. Cancers (Basel) 2022; 14:cancers14081937. [PMID: 35454844 PMCID: PMC9029420 DOI: 10.3390/cancers14081937] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Patients with venous thromboembolism events in the context of cancer should receive anticoagulants as long as the cancer is active. Therefore, a tailor-made anticoagulation strategy should rely on an individualized assessment of the risks of recurrent venous thromboembolism and anticoagulant-associated bleeding. No existing risk assessment model for anticoagulant-associated bleeding risk has been validated for cancer-associated thrombosis. To obtain a better risk assessment model to assess anticoagulant-associated bleeding risk in cancer-associated thrombosis patients, we deemed it necessary to answer questions related to how and when to assess anticoagulant-associated bleeding risk as well as what factors to assess for which patients. Abstract Patients with venous thromboembolism events (VTE) in the context of cancer should receive anticoagulants as long as the cancer is active. Therefore, a tailor-made anticoagulation strategy should rely on an individualized risk assessment model (RAM) of recurrent VTE and anticoagulant-associated bleeding. The aim of this review is to investigate the applicability of the currently available RAMs for anticoagulant-associated bleeding after VTE in the CAT population and to provide new insights on how we can succeed in developing a new anticoagulant-associated bleeding RAM for the current medical care of CAT patients. A systematic search for peer-reviewed publications was performed in PubMed. Studies, including systematic reviews, were eligible if they comprised patients with VTE and used a design for developing a prediction model, score, or other prognostic tools for anticoagulant-associated bleeding during anticoagulant treatment. Out of 15 RAMs, just the CAT-BLEED was developed for CAT patients and none of the presented RAMs developed for the VTE general population were externally validated in a population of CAT patients. The current review illustrates the limitations of the available RAMs for anticoagulant-associated bleeding in CAT patients. The development of a RAM for bleeding risk assessment in patients with CAT is warranted.
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Affiliation(s)
- Géraldine Poénou
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
- Correspondence:
| | - Emmanuel Tolédano
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
- Université de Paris Cité, 75006 Paris, France
| | - Hélène Helfer
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
| | - Ludovic Plaisance
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
| | - Florent Happe
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
| | - Edouard Versini
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
- Université de Paris Cité, 75006 Paris, France
| | - Nevine Diab
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
- Université de Paris Cité, 75006 Paris, France
| | - Sadji Djennaoui
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
| | - Isabelle Mahé
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
- Université de Paris Cité, 75006 Paris, France
- Unité Inserm UMR-S1140 Innovation Thérapeutique en Hémostase, 75006 Paris, France
- INNOVTE-FCRIN, CEDEX 2, 42055 Saint-Etienne, France
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Song M, Haymart B, Kong X, Ali M, Kaatz S, Kozlowski J, Krol G, Schaefer J, Froehlich JB, Barnes GD. Association of adding antiplatelet therapy to warfarin for management of venous thromboembolism with bleeding and other adverse events. Vasc Med 2022; 27:382-384. [DOI: 10.1177/1358863x221089333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Melinda Song
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Brian Haymart
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Xiaowen Kong
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mona Ali
- Department of Heart and Vascular Services, Beaumont Hospital, Royal Oak, MI, USA
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Jay Kozlowski
- Department of Cardiovascular Medicine, DMC Huron Valley-Sinai Hospital, Commerce, MI, USA
| | - Gregory Krol
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Jordan Schaefer
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - James B Froehlich
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
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May JE. Unexplained arterial thrombosis: approach to diagnosis and treatment. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:76-84. [PMID: 34889390 PMCID: PMC8791102 DOI: 10.1182/hematology.2021000235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Arterial thrombotic events in younger patients without a readily apparent etiology present significant diagnostic and management challenges. We present a structured approach to diagnosis with consideration of common causes, including atherosclerosis and embolism, as well as uncommon causes, including medications and substances, vascular and anatomic abnormalities, systemic disorders, and thrombophilias. We highlight areas of management that have evolved within the past 5 years, including the use of dual-pathway inhibition in atherosclerotic disease, antithrombotic therapy selection in embolic stroke of undetermined source and left ventricular thrombus, the role of closure of patent foramen ovale for secondary stroke prevention, and the thrombotic potential of coronavirus disease 2019 infection and vaccination. We conclude with a representative case to illustrate the application of the diagnostic framework and discuss the importance of consideration of bleeding risk and patient preference in determining the appropriate management plan.
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Affiliation(s)
- Jori E. May
- Department of Medicine, Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
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Klok FA, Ageno W, Ay C, Bäck M, Barco S, Bertoletti L, Becattini C, Carlsen J, Delcroix M, van Es N, Huisman MV, Jara-Palomares L, Konstantinides S, Lang I, Meyer G, Ní Áinle F, Rosenkranz S, Pruszczyk P. Optimal follow-up after acute pulmonary embolism: a position paper of the European Society of Cardiology Working Group on Pulmonary Circulation and Right Ventricular Function, in collaboration with the European Society of Cardiology Working Group on Atherosclerosis and Vascular Biology, endorsed by the European Respiratory Society. Eur Heart J 2021; 43:183-189. [PMID: 34875048 PMCID: PMC8790766 DOI: 10.1093/eurheartj/ehab816] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/22/2021] [Accepted: 11/12/2021] [Indexed: 12/11/2022] Open
Abstract
This position paper provides a comprehensive guide for optimal follow-up of patients with acute pulmonary embolism (PE), covering multiple relevant aspects of patient counselling. It serves as a practical guide to treating patients with acute PE complementary to the formal 2019 European Society of Cardiology guidelines developed with the European Respiratory Society. We propose a holistic approach considering the whole spectrum of serious adverse events that patients with acute PE may encounter on the short and long run. We underline the relevance of assessment of modifiable risk factors for bleeding, of acquired thrombophilia and limited cancer screening (unprovoked PE) as well as a dedicated surveillance for the potential development of chronic thromboembolic pulmonary hypertension as part of routine practice; routine testing for genetic thrombophilia should be avoided. We advocate the use of outcome measures for functional outcome and quality of life to quantify the impact of the PE diagnosis and identify patients with the post-PE syndrome early. Counselling patients on maintaining a healthy lifestyle mitigates the risk of the post-PE syndrome and improves cardiovascular prognosis. Therefore, we consider it important to discuss when and how to resume sporting activities soon after diagnosing PE. Additional patient-relevant topics that require Focused counselling are travel and birth control.
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Affiliation(s)
- Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands.,Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.,I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Magnus Bäck
- Center for Molecular Medicine and Department of Cardiology, Karolinska University Hospital, Solna, Sweden, Stockholm.,INSERM U1116, Université de Lorraine, Centre Hospitalier Régional Universitaire de Nancy, Vandoeuvre les Nancy, France
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne 42055, France.,INSERM, UMR1059, Université Jean-Monnet, Saint-Etienne 42055, France.,INSERM, CIC-1408, CHU de Saint-Etienne, Saint-Etienne 42055, France.,INNOVTE, CHU de Saint-Etienne, Saint-Etienne 42055, France
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marion Delcroix
- Clinical Dept. of Respiratory Diseases, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium.,BREATHE, Dept CHROMETA, KU Leuven, Leuven, Belgium
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Luis Jara-Palomares
- Medical Surgical Unit of Respiratory Diseases, Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocio, Seville, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Greece
| | - Irene Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Guy Meyer
- Respiratory Medicine Department, Hôpital Européen Georges Pompidou, Aphp, Paris, France.,Université Paris Descartes, Paris 75006, France
| | - Fionnuala Ní Áinle
- Dept. of Hematology, Mater University Hospital and Rotunda Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Stephan Rosenkranz
- Dept. of Cardiology, Heart Center at the University of Cologne, Germany.,Cologne Cardiovascular Research Center (CCRC), University of Cologne, Köln 50937, Germany
| | - Piotr Pruszczyk
- Dept. of Internal Medicine and Cardiology Medical University of Warsaw, Lindley St 4, Warsaw 00-005, Poland
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Bertoletti L. Initial Anticoagulant Treatment of Pulmonary Embolism: How Can We Better Predict Bleeding in the Early Days Rather Than the Early Months? Chest 2021; 160:1596-1598. [PMID: 34743843 DOI: 10.1016/j.chest.2021.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France; INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France; INSERM, CIC-1408, Saint-Etienne, France; F-CRIN INNOVTE Network, Saint-Etienne, France.
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[Chinese guidelines for diagnosis, prevention and treatment of thrombophilia (2021)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:881-888. [PMID: 35045648 PMCID: PMC8763586 DOI: 10.3760/cma.j.issn.0253-2727.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep vein thrombosis (DVT), is encountered commonly. Acute PE may present as a high-risk cardiovascular emergency, and acute DVT can cause acute and chronic vascular complications. The goal of this review is to ensure that cardiologists are comfortable managing VTE-including risk stratification, anticoagulation therapy, and familiarity with primary reperfusion therapy. Clinical assessment and determination of degree of right ventricular dysfunction are critical in initial risk stratification of PE and determination of parenteral versus oral anticoagulation therapy. Direct oral anticoagulants have emerged as preferred first-line oral anticoagulation strategy in VTE scenarios.
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Affiliation(s)
- Abby M Pribish
- Department of Medicine, Division of ADM-Housestaff, Beth Israel Deaconess Medical Center, Harvard Medical School, Deac 311, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 4th Floor, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Alec A Schmaier
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 4th Floor, 375 Longwood Avenue, Boston, MA 02215, USA.
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Khan F, Tritschler T, Kimpton M, Wells PS, Kearon C, Weitz JI, Büller HR, Raskob GE, Ageno W, Couturaud F, Prandoni P, Palareti G, Legnani C, Kyrle PA, Eichinger S, Eischer L, Becattini C, Agnelli G, Vedovati MC, Geersing GJ, Takada T, Cosmi B, Aujesky D, Marconi L, Palla A, Siragusa S, Bradbury CA, Parpia S, Mallick R, Lensing AWA, Gebel M, Grosso MA, Thavorn K, Hutton B, Le Gal G, Fergusson DA, Rodger MA. Long-Term Risk for Major Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism : A Systematic Review and Meta-analysis. Ann Intern Med 2021; 174:1420-1429. [PMID: 34516270 DOI: 10.7326/m21-1094] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The long-term risk for major bleeding in patients receiving extended (beyond the initial 3 to 6 months) anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. PURPOSE To determine the incidence of major bleeding during extended anticoagulation of up to 5 years among patients with a first unprovoked VTE, overall, and in clinically important subgroups. DATA SOURCES MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to 23 July 2021. STUDY SELECTION Randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding among patients with a first unprovoked VTE who were to receive oral anticoagulation for a minimum of 6 additional months after completing at least 3 months of initial anticoagulant treatment. DATA EXTRACTION Two reviewers independently abstracted data and assessed study quality. Unpublished data required for analyses were obtained from authors of included studies. DATA SYNTHESIS Among the 14 RCTs and 13 cohort studies included in the analysis, 9982 patients received a vitamin K antagonist (VKA) and 7220 received a direct oral anticoagulant (DOAC). The incidence of major bleeding per 100 person-years was 1.74 events (95% CI, 1.34 to 2.20 events) with VKAs and 1.12 events (CI, 0.72 to 1.62 events) with DOACs. The 5-year cumulative incidence of major bleeding with VKAs was 6.3% (CI, 3.6% to 10.0%). Among patients receiving either a VKA or a DOAC, the incidence of major bleeding was statistically significantly higher among those who were older than 65 years or had creatinine clearance less than 50 mL/min, a history of bleeding, concomitant use of antiplatelet therapy, or a hemoglobin level less than 100 g/L. The case-fatality rate of major bleeding was 8.3% (CI, 5.1% to 12.2%) with VKAs and 9.7% (CI, 3.2% to 19.2%) with DOACs. LIMITATION Data were insufficient to estimate incidence of major bleeding beyond 1 year of extended anticoagulation with DOACs. CONCLUSION In patients with a first unprovoked VTE, the long-term risks and consequences of anticoagulant-related major bleeding are considerable. This information will help inform patient prognosis and guide decision making about treatment duration for unprovoked VTE. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research. (PROSPERO: CRD42019128597).
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Affiliation(s)
- Faizan Khan
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Tobias Tritschler
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T., D.A.)
| | - Miriam Kimpton
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Philip S Wells
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Clive Kearon
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (C.K., J.I.W.)
| | - Jeffrey I Weitz
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (C.K., J.I.W.)
| | - Harry R Büller
- Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (H.R.B.)
| | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, Oklahoma (G.E.R.)
| | | | | | - Paolo Prandoni
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Gualtiero Palareti
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Cristina Legnani
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Paul A Kyrle
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | - Sabine Eichinger
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | - Lisbeth Eischer
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | | | | | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (G.G., T.T.)
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (G.G., T.T.)
| | - Benilde Cosmi
- Sant'Orsola-Malpighi University Hospital, Bologna, Italy (B.C.)
| | - Drahomir Aujesky
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T., D.A.)
| | | | | | | | | | - Sameer Parpia
- McMaster University, Hamilton, Ontario, Canada (S.P.)
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (R.M.)
| | | | | | | | - Kednapa Thavorn
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Brian Hutton
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Gregoire Le Gal
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Dean A Fergusson
- University of Ottawa, Ottawa Hospital Research Institute, and The Ottawa Hospital, Ottawa, Ontario, Canada (D.A.F.)
| | - Marc A Rodger
- Ottawa Hospital Research Institute, Ottawa, Ontario, and McGill University, Montreal, Quebec, Canada (M.A.R.)
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Mathonier C, Meneveau N, Besutti M, Ecarnot F, Falvo N, Guillon B, Schiele F, Chopard R. Available Bleeding Scoring Systems Poorly Predict Major Bleeding in the Acute Phase of Pulmonary Embolism. J Clin Med 2021; 10:jcm10163615. [PMID: 34441911 PMCID: PMC8396851 DOI: 10.3390/jcm10163615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/29/2021] [Accepted: 08/10/2021] [Indexed: 11/18/2022] Open
Abstract
We aimed to compare six available bleeding scores, in a real-life cohort, for prediction of major bleeding in the early phase of pulmonary embolism (PE). We recorded in-hospital characteristics of 2754 PE patients in a prospective observational multicenter cohort contributing 18,028 person-days follow-up. The VTE-BLEED (Venous Thrombo-Embolism Bleed), RIETE (Registro informatizado de la enfermedad tromboembólica en España; Computerized Registry of Patients with Venous Thromboembolism), ORBIT (Outcomes Registry for Better Informed Treatment), HEMORR2HAGES (Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk and Stroke), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, Drugs/Alcohol) scores were assessed at baseline. International Society on Thrombosis and Haemostasis (ISTH)-defined bleeding events were independently adjudicated. Accuracy of the overall original 3-level and newly defined optimal 2-level outcome of the scores were evaluated and compared. We observed 82 first early major bleedings (3.0% (95% CI, 2.4–3.7)). The predictive power of bleeding scores was poor (Harrel’s C-index from 0.57 to 0.69). The RIETE score had numerically higher model fit and discrimination capacity but without reaching statistical significance versus the ORBIT, HEMORR2HAGES, and ATRIA scores. The VTE-BLEED and HAS-BLED scores had significantly lower C-index, integrated discrimination improvement, and net reclassification improvement compared to the others. The rate of observed early major bleeding in score-defined low-risk patients was high, between 15% and 34%. Current available scoring systems have insufficient accuracy to predict early major bleeding in patients with acute PE. The development of acute-PE-specific risk scores is needed to optimally target bleeding prevention strategies.
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Affiliation(s)
- Camille Mathonier
- Department of Cardiology, University Hospital Jean Minjoz, 25000 Besançon, France; (C.M.); (N.M.); (M.B.); (F.E.); (B.G.); (F.S.)
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, 25000 Besançon, France; (C.M.); (N.M.); (M.B.); (F.E.); (B.G.); (F.S.)
- EA3920, University of Burgundy Franche-Comté, 25000 Besançon, France
- F-CRIN, INNOVTE Network, CHU de Saint-Étienne-CIC 1408, Hôpital Nord-Médecine Vasculaire et Thérapeutique, CEDEX 2, 42055 Saint-Etienne, France
| | - Matthieu Besutti
- Department of Cardiology, University Hospital Jean Minjoz, 25000 Besançon, France; (C.M.); (N.M.); (M.B.); (F.E.); (B.G.); (F.S.)
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Jean Minjoz, 25000 Besançon, France; (C.M.); (N.M.); (M.B.); (F.E.); (B.G.); (F.S.)
- EA3920, University of Burgundy Franche-Comté, 25000 Besançon, France
| | - Nicolas Falvo
- Department of Vascular Medicine, University Hospital of Dijon, 21079 Dijon, France;
| | - Benoit Guillon
- Department of Cardiology, University Hospital Jean Minjoz, 25000 Besançon, France; (C.M.); (N.M.); (M.B.); (F.E.); (B.G.); (F.S.)
- EA3920, University of Burgundy Franche-Comté, 25000 Besançon, France
| | - François Schiele
- Department of Cardiology, University Hospital Jean Minjoz, 25000 Besançon, France; (C.M.); (N.M.); (M.B.); (F.E.); (B.G.); (F.S.)
- EA3920, University of Burgundy Franche-Comté, 25000 Besançon, France
| | - Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, 25000 Besançon, France; (C.M.); (N.M.); (M.B.); (F.E.); (B.G.); (F.S.)
- EA3920, University of Burgundy Franche-Comté, 25000 Besançon, France
- F-CRIN, INNOVTE Network, CHU de Saint-Étienne-CIC 1408, Hôpital Nord-Médecine Vasculaire et Thérapeutique, CEDEX 2, 42055 Saint-Etienne, France
- Correspondence:
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