Overview and assessment of risk factors for pulmonary embolism

The genetic causal relationship between type 2 diabetes, glycemic traits and venous thromboembolism, deep vein thrombosis, pulmonary embolism: a two-sample Mendelian randomization study

OBJECTIVE

To investigate the genetic underpinnings of the association between type 2 diabetes (T2D), glycemic indicators such as fasting glucose (FG), fasting insulin (FI), and glycated hemoglobin (GH), and venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), thereby contributing novel insights to the scholarly discourse within this domain.

METHODS

Genome-wide association study (GWAS) summary data pertaining to exposures (T2D, FG, FI, GH) and outcomes (VTE, DVT, PE) were acquired from the IEU Open GWAS database, encompassing participants of European descent, including both male and female individuals. Two-sample Mendelian randomization (MR) analyses were conducted utilizing the TwoSampleMR and MRPRESSO packages within the R programming environment. The primary analytical approach employed was the random-effects inverse variance weighted (IVW) method. Heterogeneity was assessed via Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger. Horizontal pleiotropy was evaluated using the intercept test of MR Egger and MR pleiotropy residual sum and outlier (MR-PRESSO) analysis, with the latter also employed for outlier detection. Additionally, a "Leave one out" analysis was conducted to ascertain the influence of individual single nucleotide polymorphisms (SNPs) on MR results.

RESULTS

The random-effects IVW analysis revealed a negative genetic causal association between T2D) and VTE (P = 0.008, Odds Ratio [OR] 95% confidence interval [CI] = 0.896 [0.827-0.972]), as well as between FG and VTE (P = 0.002, OR 95% CI = 0.655 [0.503-0.853]), GH and VTE (P = 0.010, OR 95% CI = 0.604 [0.412-0.884]), and GH and DVT (P = 0.002, OR 95% CI = 0.413 [0.235-0.725]). Conversely, the random-effects IVW analysis did not detect a genetic causal relationship between FI and VTE (P > 0.05), nor between T2D, FG, or FI and DVT (P > 0.05), or between T2D, FG, FI, or GH and PE (P > 0.05). Both the Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger indicated no significant heterogeneity (P > 0.05). Moreover, the intercept tests of MR Egger and MR-PRESSO suggested the absence of horizontal pleiotropy (P > 0.05). MR-PRESSO analysis identified no outliers, while the "Leave one out" analysis underscored that the MR analysis was not influenced by any single SNP.

CONCLUSION

Our investigation revealed that T2D, FG, and GH exhibit negative genetic causal relationships with VTE at the genetic level, while GH demonstrates a negative genetic causal relationship with DVT at the genetic level. These findings furnish genetic-level evidence warranting further examination of VTE, DVT, and PE, thereby making a contribution to the advancement of related research domains.

Association of thrombopoietin-related drugs with thromboembolic events: Mendelian randomization and a real-world study

Background

Studies have shown conflicting results when using thrombopoietin-related drugs (TPORD) for thromboembolic events (TEEs). Our study aimed to explore the correlation between TPORDs and TEEs.

Method

Drug-targeted Mendelian randomization (MR) and multivariate MR (MVMR) analysis were used to explore the causal relationship between TPORDs and TEEs such as venous thromboembolism (VTE), deep vein thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI) and ischemic stroke (STR). At the same time, a real-world study was conducted by extracting adverse events (AEs) from the FDA Adverse Event Reporting System database included in AERSMine to further validate our findings.

Outcome

In drug-target MR, TPORDs were associated with VTE (OR = 1.193, 95% confidence interval (CI): 1.001-1.423, p = 0.049], DVT (OR = 1.321, 95% CI: 1.027-1.700, p = 0.030), MI (OR = 1.216, 95% CI: 1.010-1.464, p = 0.039), STR (OR = 1.224, 95% CI: 1.021-1.468, p = 0.029). VTE/DVT/STR remained stable in MVMR (VTE: OR = 1.3, 95% CI: 1.187-1.422, p < 0.001; DVT: OR = 1.465,95% CI:1.285-1.671, p < 0.001; STR: OR = 1.119, 95% CI: 1.018-1.229, p = 0.019) and real-world studies [lower bound of proportional reporting ratio (ROR) greater than 1]. The significance of myocardial infarction disappeared in MVMR (OR = 0.996, 95% CI: 0.894-1.109, p = 0.942) and in real-world studies (lower ROR lower than 1). There was no evidence of a causal relationship between TPORD and PE (OR = 1.244, 95% CI: 0.969-1.597, p = 0.087), but it generated a signal from a real-world study (lower bound of ROR greater than 1).

Conclusion

This study suggests that TPORDs may be associated with an increased risk of TEEs, particularly AEs leading to VTE/DVT/STR. In addition, the relationship between TPORDs and PE/MI is debatable and requires more research.

Influence of steep Trendelenburg position on postoperative complications: a systematic review and meta-analysis

Intraoperative physiologic changes related to the steep Trendelenburg position have been investigated with the widespread adoption of robot-assisted pelvic surgery (RAPS). However, the impact of the steep Trendelenburg position on postoperative complications remains unclear. We conducted a meta-analysis to compare RAPS to laparoscopic/open pelvic surgery with regards to the rates of venous thromboembolism (VTE), cardiac, and cerebrovascular complications. Meta-regression was performed to evaluate the influence of confounding risk factors. Ten randomized controlled trials (RCTs) and 47 non-randomized controlled studies (NRSs), with a total of 380,125 patients, were included. Although RAPS was associated with a decreased risk of VTE and cardiac complications compared to laparoscopic/open pelvic surgery in NRSs [risk ratio (RR), 0.59; 95% CI 0.51–0.72, p < 0.001 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively], these differences were not confirmed in RCTs (RR 0.92; 95% CI 0.52–1.62, p = 0.77 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively). In subgroup analyses of laparoscopic surgery, there was no significant difference in the risk of VTE and cardiac complications in both RCTs and NRSs. In the meta-regression, none of the risk factors were found to be associated with heterogeneity. Furthermore, no significant difference was observed in cerebrovascular complications between RAPS and laparoscopic/open pelvic surgery. Our meta-analysis suggests that the steep Trendelenburg position does not seem to affect postoperative complications and, therefore, can be considered safe with regard to the risk of VTE, cardiac, and cerebrovascular complications. However, proper individualized preventive measures should still be implemented during all surgeries including RAPS to warrant patient safety.

State-of-Art in the Age Determination of Venous Thromboembolism: A Systematic Review

Venous thromboembolism (VTE), consisting of deep vein thrombosis (DVT) and pulmonary embolism (PE), requires a forensic age determination to ascertain their causal relationship with recent events, such as trauma or medical treatment. The main objective of this systematic review is to identify the current state-of-the-art immunohistochemical methods for age determination of fatal VTE. A literature search was performed through different databases, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Within the study, we have selected only cases represented by deceased patients for DVT and/or PTE in which thromboembolic material was collected during an autoptic examination and then subjected to a histological and an immunohistochemical investigation. Studies based on animal models were not included. We assessed bias risk. A database-based search produced a total of 19 articles. After excluding duplicate items from the selection, 14 articles were reviewed. Ten articles were excluded because they did not meet the inclusion criteria. The results have pointed out 4 studies that were included in the present analysis for a total of 157 samples of DVT and 171 PTE samples. These were analyzed using traditional histological and immunohistochemical techniques. The results must be interpreted with a critical eye because of their heterogeneity in terms of time, geography, and study design. The present review highlights the importance of associating specific immunohistochemical markers with a histological analysis for the timing of DVT/PTE fatal events. Further future experiences will hopefully endorse actual knowledge on the subject to increase the accuracy in the assessment of thrombus-embolus age.

In situ Pulmonary Artery Thrombosis: A Previously Overlooked Disease

Pulmonary thromboembolism (PTE) is the third leading cause of death in cardiovascular diseases. PTE is believed to be caused by thrombi detached from deep veins of lower extremities. The thrombi travel with systemic circulation to the lung and block pulmonary arteries, leading to sudden disruption of hemodynamics and blood gas exchange. However, this concept has recently been challenged by accumulating evidence demonstrating that de novo thrombosis may be formed in pulmonary arteries without deep venous thrombosis. On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH), a subtype of pulmonary hypertension, could have different pathogenesis than traditional PTE. Therefore, this article summarized and compared the risk factors, the common and specific pathogenic mechanisms underlying PTE, in situ pulmonary artery thrombosis, and CTEPH at molecular and cellular levels, and suggested the therapeutic strategies to these diseases, aiming to facilitate understanding of pathogenesis, differential diagnosis, and precision therapeutics of the three pulmonary artery thrombotic diseases.

Impact of CT venography added to CT pulmonary angiography for the detection of deep venous thrombosis and relevant incidental CT findings

OBJECTIVES

To assess the additional diagnostic value of CT venography (CTV) simultaneously performed with CT pulmonary angiography (CTPA) in the context of thromboembolic disease for the detection of deep venous thrombosis (DVT) and other relevant incidental CT findings.

MATERIALS AND METHODS

Retrospectively and consecutively, we included all patients referred to our emergency department within the last 24 months for suspected pulmonary embolism (PE) who underwent CTPA combined with CTV. Two radiologists blinded to clinical information and results independently analysed CTV images in the context of DVT of the lower extremities and other, unsuspected abdominal/pelvic findings. These latter were classified as relevant with therapeutic consequences or irrelevant. One radiologist reviewed patient clinical records. Inter-observer agreement for DVT detection was calculated.

RESULTS

Of 696 patients, 119 had PE (17.1%) and 54 had DVT (7.8%), 16 (2.3%) of them without concomitant PE. Inter-observer agreement between the two readers was substantial (kappa = 0.78). CTV examinations led to diagnosis of relevant incidental abdominal/pelvic findings in 40 (5.7%) patients, including 11 with new malignant tumours, and 8 with progressive metastatic disease. The evaluated clinical and biological risk factors were not significantly associated with the presence of relevant incidental findings. CTV changed therapeutic management in 29 patients (4.3%): 15 had DVTs without PE, and 14 had abdominal/pelvic findings with therapeutic consequences.

CONCLUSION

CTV simultaneously performed with CTPA offers limited incremental value for detecting DVT. It may reveal other relevant findings leading to therapeutic changes, but the low rate does not justify screening patients with suspected PE.

To Scope or Not to Scope? The Safety of Upper Endoscopy in the Setting of Pulmonary Embolism

OBJECTIVES

We aimed to describe the frequency of upper endoscopy and associated outcomes in subjects hospitalized with upper GI bleeding (UGIB) and pulmonary embolism (PE).

METHODS

We performed a cross-sectional study using the Nationwide Inpatient Sample from 2007 to 2014. The association between upper endoscopy and in-hospital mortality was evaluated using propensity score matching.

RESULTS

A total of 44,412 subjects had a coexistent PE and UGIB. 63.5% had an inpatient upper endoscopy with a lower likelihood of in-hospital death and a shorter length of stay.

CONCLUSIONS

A substantial proportion of inpatients with PE and UGIB undergo endoscopy with a relatively lowmortality rate.

Histological criteria for age determination of fatal venous thromboembolism

In clinical and forensic practice, fatal thromboembolism is a major problem, particularly in a patient with no pre-existing risk factors. Out of a recent case, we discuss here the criteria for age determination of venous thrombi in a 46-year-old female with concomitant deep vein thrombosis in the common femoral left vein and in the right heart and fatal pulmonary embolism. At autopsy, histopathology and immunohistochemistry evidenced the different composition of thrombi in different sites and permitted to define the different timing. We discuss and review the histopathological criteria for age estimation of venous thrombi starting from the case and in relation to the acquired and inherited thrombophilic risk factors. The appropriateness of clinical management is also discussed.

Medical Management of Pulmonary Embolism: Beyond Anticoagulation

Pulmonary embolism (PE) is a common medical condition that carries significant morbidity and mortality. Although diagnosis, anticoagulation, and interventional clot-burden reduction strategies represent the focus of clinical research and care in PE, appropriate risk stratification and supportive care are crucial to ensure good outcomes. In this chapter, we will discuss the medical management of PE from the time of presentation to discharge, focusing on the critical care of acute right ventricular failure, anticoagulation of special patient populations, and appropriate follow-up testing after acute PE.