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Couturaud F, Meneveau N, Sevestre MA, Morange PE, Jimenez D. Duration of anticoagulation of venous thromboembolism. Presse Med 2024:104245. [PMID: 39244021 DOI: 10.1016/j.lpm.2024.104245] [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] [Indexed: 09/09/2024] Open
Abstract
Venous thromboembolism (VTE) is a common, serious condition that requires anticoagulation for at least three months to prevent recurrence and long-term complications. After this initial period, the decision to continue or stop anticoagulation depends on the balance between the risk of recurrent VTE and the risk of bleeding. Established guidelines suggest short-term anticoagulation for VTE caused by transient factors and indefinite anticoagulation for recurrent or cancer-associated VTE. However, for a first unprovoked VTE, decision-making remains challenging. Current predictive scores for recurrence and bleeding are not sufficiently reliable, and the safety and efficacy of reduced-dose anticoagulation remain unclear. In the future, precision and patient-centred medicine may improve treatment decisions in this area.
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Affiliation(s)
- Francis Couturaud
- CHU Brest, Département de Médecine Interne et Pneumologie, Brest, France; Univ_Brest, INSERM U1304-GETBO, CIC INSERM 1412, F29609 Brest; FCRIN INNOVTE network, Saint-Etienne, France.
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besançon, France;; EA3920, University of Franche-Comté, 25000 Besançon, France
| | | | - Pierre-Emmanuel Morange
- Aix-Marseille University, INSERM, INRAE, Centre de Recherche en CardioVasculaire et Nutrition, Laboratory of Haematology, CRB Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - David Jimenez
- Respiratory Department, Ramón y Cajal Hospital (IRICYS), Madrid, Spain; Medicine Department, Universidad de Alcalá (IRICYS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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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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Palareti G, Santagata D, De Ponti C, Ageno W, Prandoni P. Anticoagulation and compression therapy for proximal acute deep vein thrombosis. VASA 2024. [PMID: 39017921 DOI: 10.1024/0301-1526/a001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
The treatment of proximal deep vein thrombosis (DVT) of the lower limbs includes an initial management phase, covering the first 1 to 3 weeks, a primary treatment phase, lasting a minimum of 3 months, and a secondary treatment phase for those patients requiring continuing anticoagulation beyond the first 3 to 6 months. During the initial phase most patients with DVT can be managed as outpatients. Exclusion criteria for home treatment include high risk of bleeding, limb threatening DVT or other conditions requiring hospitalisation. Anticoagulant drugs represent the mainstay of treatment and include parenteral drugs such as unfractionated heparin or low molecular weight heparin, and oral drugs such as the vitamin K antagonists and the direct oral anticoagulants (DOACs). DOACs are currently recommended as the first line of treatment for proximal DVT of the lower limbs, with no preference for one DOAC over another. Factors to consider when choosing the anticoagulant strategy include, among others, renal and liver function, underlying diseases such as cancer or the antiphospholipid syndrome, and patient preferences. Indefinite duration of anticoagulation beyond the first 3 to 6 months is recommended for patients with unprovoked DVT and patients with permanent, chronic risk factors. Two DOACs, namely apixaban and rivaroxaban, can be administered at low doses for the secondary prevention of DVT. Elastic compression stockings (ECS) have been used for decades in patients with proximal DVT with the aim of counteracting the venous hypertension generated by the vascular disorder and reducing leg edema and to prevent the post-thrombotic syndrome.
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Affiliation(s)
| | - Davide Santagata
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
| | - Chiara De Ponti
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
| | - Walter Ageno
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
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4
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Andò G, Pelliccia F, Saia F, Tarantini G, Fraccaro C, D'Ascenzo F, Zimarino M, Di Marino M, Niccoli G, Porto I, Calabrò P, Gragnano F, De Rosa S, Piccolo R, Moscarella E, Fabris E, Montone RA, Spaccarotella C, Indolfi C, Sinagra G, Perrone Filardi P. Management of high and intermediate-high risk pulmonary embolism: A position paper of the Interventional Cardiology Working Group of the Italian Society of Cardiology. Int J Cardiol 2024; 400:131694. [PMID: 38160911 DOI: 10.1016/j.ijcard.2023.131694] [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: 12/10/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that remains a major global health concern. Noteworthy, patients with high- and intermediate-high-risk PE pose unique challenges because they often display clinical and hemodynamic instability, thus requiring rapid intervention to mitigate the risk of clinical deterioration and death. Importantly, recovery from PE is associated with long-term complications such as recurrences, bleeding with oral anticoagulant treatment, pulmonary hypertension, and psychological distress. Several novel strategies to improve risk factor characterization and management of patients with PE have recently been introduced. Accordingly, this position paper of the Working Group of Interventional Cardiology of the Italian Society of Cardiology deals with the landscape of high- and intermediate-high risk PE, with a focus on bridging the gap between the evolving standards of care and the current clinical practice. Specifically, the growing importance of catheter-directed therapies as part of the therapeutic armamentarium is highlighted. These interventions have been shown to be effective strategies in unstable patients since they offer, as compared with thrombolysis, faster and more effective restoration of hemodynamic stability with a consistent reduction in the risk of bleeding. Evolving standards of care underscore the need for continuous re-assessment of patient risk stratification. To this end, a multidisciplinary approach is paramount in refining selection criteria to deliver the most effective treatment to patients with unstable hemodynamics. In conclusion, the current management of unstable patients with PE should prioritize tailored treatment in a patient-oriented approach in which transcatheter therapies play a central role.
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Affiliation(s)
- Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, AOU Policlinico "Gaetano Martino", Messina, Italy
| | - Francesco Pelliccia
- Department of Cardiovascular Sciences, "La Sapienza" University, Rome, Italy.
| | - Francesco Saia
- Department of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Turin, Italy
| | - Marco Zimarino
- Department of Neuroscience, Imaging and Clinical Sciences, "Gabriele D'Annunzio" University of Chieti-Pescara, Chieti, Italy; Department of Cardiology, "SS. Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy
| | - Mario Di Marino
- Department of Neuroscience, Imaging and Clinical Sciences, "Gabriele D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Italo Porto
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties, University of Genoa, Genoa, Italy; Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV) IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Enrico Fabris
- Cardio-thoraco-vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carmen Spaccarotella
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Gianfranco Sinagra
- Cardio-thoraco-vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
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Vrotniakaite-Bajerciene K, Rütsche S, Calzavarini S, Quarroz C, Stalder O, Mean M, Righini M, Staub D, Beer JH, Frauchiger B, Osterwalder J, Kucher N, Matter CM, Husmann M, Banyai M, Aschwanden M, Mazzolai L, Hugli O, Rodondi N, Aujesky D, Angelillo-Scherrer A. Thrombin Generation Is Associated with Venous Thromboembolism Recurrence, but Not with Major Bleeding and Death in the Elderly: A Prospective Multicenter Cohort Study. J Clin Med 2023; 12:6050. [PMID: 37762997 PMCID: PMC10531633 DOI: 10.3390/jcm12186050] [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: 07/18/2023] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
It is currently unknown whether thrombin generation is associated with venous thromboembolism (VTE) recurrence, major bleeding, or mortality in the elderly. Therefore, our aim was to prospectively study the association between thrombin generation and VTE recurrence, major bleeding, and mortality in elderly patients with acute VTE. Consecutive patients aged ≥65 years with acute VTE were followed for 2 years, starting from 1 year after the index VTE. Primary outcomes were VTE recurrence, major bleeding, and mortality. Thrombin generation was assessed in 551 patients 1 year after the index VTE. At this time, 59% of the patients were still anticoagulated. Thrombin generation was discriminatory for VTE recurrence, but not for major bleeding and mortality in non-anticoagulated patients. Moreover, peak ratio (adjusted subhazard ratio 4.09, 95% CI, 1.12-14.92) and normalized peak ratio (adjusted subhazard ratio 2.18, 95% CI, 1.28-3.73) in the presence/absence of thrombomodulin were associated with VTE recurrence, but not with major bleeding and mortality after adjustment for potential confounding factors. In elderly patients, thrombin generation was associated with VTE recurrence, but not with major bleeding and/or mortality. Therefore, our study suggests the potential usefulness of thrombin generation measurement after anticoagulation completion for VTE to help identify among elderly patients those at higher risk of VTE recurrence.
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Affiliation(s)
- Kristina Vrotniakaite-Bajerciene
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Sereina Rütsche
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Sara Calzavarini
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Claudia Quarroz
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Odile Stalder
- Clinical Trials Unit (CTU) Bern, University of Bern, 3010 Bern, Switzerland;
| | - Marie Mean
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.M.); (N.R.); (D.A.)
- Department of Medicine, Lausanne University Hospital, Lausanne University, 1005 Lausanne, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital, 1205 Geneva, Switzerland;
| | - Daniel Staub
- Division of Angiology, Basel University Hospital, 4031 Basel, Switzerland; (D.S.); (M.A.)
| | - Juerg H. Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, 5404 Baden, Switzerland;
| | - Beat Frauchiger
- Department of Internal Medicine, Cantonal Hospital of Frauenfeld, 8501 Frauenfeld, Switzerland;
| | | | - Nils Kucher
- Clinic of Angiology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Christian M. Matter
- Department of Cardiology, University Heart Center, University Hospital Zurich, 8091 Zurich, Switzerland;
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, Zurich University Hospital and University of Zurich, 8091 Zurich, Switzerland
| | - Marc Husmann
- Center for Vascular Diseases, Zurich-Stadelhofen, Stadelhoferstrasse 8, 8001 Zurich, Switzerland;
| | - Martin Banyai
- Gefässpraxis Luzern Swiss AG, Pilatusstrasse 34, 6003 Lucerne, Switzerland;
| | - Markus Aschwanden
- Division of Angiology, Basel University Hospital, 4031 Basel, Switzerland; (D.S.); (M.A.)
| | - Lucia Mazzolai
- Service of Angiology, Lausanne University Hospital, Lausanne University, 1005 Lausanne, Switzerland;
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne University, 1005 Lausanne, Switzerland;
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.M.); (N.R.); (D.A.)
- Institute of Primary Health Care (BIHAM), University of Bern, 3010 Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.M.); (N.R.); (D.A.)
| | - Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
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Della Corte V, Riolo R, Scaglione S, Pecoraro R, Tuttolomondo A. The Role of Biomarkers, Metabolomics, and COVID-19 in Venous Thromboembolism-A Review of Literature. Int J Mol Sci 2023; 24:13411. [PMID: 37686216 PMCID: PMC10488048 DOI: 10.3390/ijms241713411] [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: 05/31/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
In recent years, the field of venous thromboembolism has undergone numerous innovations, starting from the recent discoveries on the role of biomarkers, passing through the role of metabolomics in expanding our knowledge on pathogenic mechanisms, which have opened up new therapeutic targets. A variety of studies have contributed to characterizing the metabolic phenotype that occurs in venous thromboembolism, identifying numerous pathways that are altered in this setting. Among these pathways are the metabolism of carnitine, tryptophan, purine, and fatty acids. Furthermore, new evidence has emerged with the recent COVID-19 pandemic. Hypercoagulability phenomena induced by this viral infection appear to be related to altered von Willebrand factor activity, alteration of the renin-angiotensin-aldosterone system, and dysregulation of both innate and adaptive immunity. This is the first literature review that brings together the most recent evidence regarding biomarkers, metabolomics, and COVID-19 in the field of venous thromboembolism, while also mentioning current therapeutic protocols.
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Affiliation(s)
- Vittoriano Della Corte
- Internal Medicine and Stroke Care Ward, Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialities (PROMISE) “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy
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Wu H, Tang Y, Zhang B, Klippel P, Jing Y, Yao J, Jiang X. Miniaturized Stacked Transducer for Intravascular Sonothrombolysis With Internal-Illumination Photoacoustic Imaging Guidance and Clot Characterization. IEEE Trans Biomed Eng 2023; 70:2279-2288. [PMID: 37022249 PMCID: PMC10399617 DOI: 10.1109/tbme.2023.3240725] [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] [Indexed: 02/04/2023]
Abstract
Thromboembolism in blood vessels can lead to stroke or heart attack and even sudden death unless brought under control. Sonothrombolysis enhanced by ultrasound contrast agents has shown promising outcome on effective treatment of thromboembolism. Intravascular sonothrombolysis was also reported recently with a potential for effective and safe treatment of deep thrombosis. Despite the promising treatment results, the treatment efficiency for clinical application may not be optimized due to the lack of imaging guidance and clot characterization during the thrombolysis procedure. In this paper, a miniaturized transducer was designed to have an 8-layer PZT-5A stacked with an aperture size of 1.4 × 1.4 mm2 and assembled in a customized two-lumen 10-Fr catheter for intravascular sonothrombolysis. The treatment process was monitored with internal-illumination photoacoustic tomography (II-PAT), a hybrid imaging modality that combines the rich contrast of optical absorption and the deep penetration of ultrasound detection. With intravascular light delivery using a thin optical fiber integrated with the intravascular catheter, II-PAT overcomes the penetration depth limited by strong optical attenuation of tissue. In-vitro PAT-guided sonothrombolysis experiments were carried out with synthetic blood clots embedded in tissue phantom. Clot position, shape, stiffness, and oxygenation level can be estimated by II-PAT at clinically relevant depth of ten centimeters. Our findings have demonstrated the feasibility of the proposed PAT-guided intravascular sonothrombolysis with real-time feedback during the treatment process.
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Eckelt J, Hobohm L, Merten MC, Pagel CF, Eggers AS, Lerchbaumer MH, Stangl K, Hasenfuß G, Konstantinides S, Schmidtmann I, Lankeit M, Ebner M. Long-term mortality in patients with pulmonary embolism: results in a single-center registry. Res Pract Thromb Haemost 2023; 7:100280. [PMID: 37601025 PMCID: PMC10439384 DOI: 10.1016/j.rpth.2023.100280] [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: 11/15/2022] [Revised: 04/03/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023] Open
Abstract
Background While numerous studies have investigated short-term outcomes after pulmonary embolism (PE), long-term mortality remains insufficiently studied. Objectives To investigate long-term outcomes in an unselected cohort of patients with PE. Methods A total of 896 consecutive patients with PE enrolled in a single-center registry between May 2005 and December 2017 were followed up for up to 14 years. The observed mortality rate was compared with the expected rate in the general population. Results The total follow-up time was 3908 patient-years (median, 3.1 years). The 1- and 5-year mortality rates were 19.7% (95% CI, 17.2%-22.4%) and 37.1% (95% CI, 33.6%-40.5%), respectively. The most frequent causes of death were cancer (28.5%), PE (19.4%), infections (13.9%), and cardiovascular events (11.6%). Late mortality (after >30 days) was more frequent than expected in the general population, a finding that was consistent in patients without cancer (the 5-year standardized mortality ratios were 2.77 [95% CI, 2.41-3.16] and 1.80 [95% CI, 1.50-2.14], respectively). Active cancer was the strongest risk factor for death between 30 days and 3 years (hazard ratio [HR], 6.51; 95% CI, 4.67-9.08) but was not associated with later mortality. Death after >3 years was predicted by age (HR, 1.86; 95% CI, 1.51-2.29 per decade), chronic heart failure (HR, 1.66; 95% CI, 1.02-2.70), and anemia (HR, 1.62; 95% CI, 1.09-2.41). Conclusion The risk of mortality in patients with PE remained elevated compared with that in the general population throughout the follow-up period. The main driver of long-term mortality during the first 3 years was cancer. After that, mortality was predicted by age, chronic heart failure, and anemia.
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Affiliation(s)
- Johannes Eckelt
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Marie C. Merten
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Charlotta F. Pagel
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Ann-Sophie Eggers
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Markus H. Lerchbaumer
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Radiology, Campus Charité Mitte (CCM), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Karl Stangl
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Göttingen, Göttingen, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Mainz, Germany
| | - Mareike Lankeit
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
| | - Matthias Ebner
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
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9
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Robin P, Le Pennec R, Eddy M, Sikora L, Le Roux PY, Carrier M, Couturaud F, Tromeur C, Planquette B, Sanchez O, Pesavento R, Filippi L, Rodger MA, Kovacs MJ, Mallick R, Salaun PY, Le Gal G. Residual pulmonary vascular obstruction and recurrence after acute pulmonary embolism: a systematic review and meta-analysis of individual participant data. J Thromb Haemost 2023; 21:1519-1528.e2. [PMID: 36740040 DOI: 10.1016/j.jtha.2023.01.030] [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: 09/30/2022] [Revised: 01/02/2023] [Accepted: 01/20/2023] [Indexed: 02/05/2023]
Abstract
We aimed to assess the relationship between residual pulmonary vascular obstruction (RPVO) on planar lung scan after completion of at least 3 months of anticoagulant therapy for acute pulmonary embolism (PE) and the risk of recurrent venous thromboembolism (VTE) or death due to PE one year after treatment discontinuation. The systematic review was registered with the International Prospective Registry of Systematic Reviews (PROSPERO: CRD42017081080). The primary outcome measure was to generate a pooled estimate of the rate of recurrent VTE at one year in patient with RPVO diagnosed on planar lung scan after discontinuation of at least 3 months of anticoagulant treatment for an acute PE. Individual data were obtained for 809 patients. RPVO (ie, obstruction >0%) was found in 407 patients (50.3%) after a median of 6.6 months of anticoagulant therapy for a first acute PE. Recurrent VTE or death due to PE occurred in 114 patients (14.1%), for an annual risk of 6.4% (95% confidence interval, 4.7%-8.6%). Out of the 114 recurrent events, 63 occurred within one year after discontinuation of anticoagulant therapy corresponding to a risk of 8.1% (6.4%-9.8%) at 1 year. The risk of recurrent VTE at one year was 5.8% (4.4-7.2) in participants with RPVO <5%, vs 11.7% (9.5-13.8) in participants with RPVO ≥5%. RPVO is a significant predictor of the risk of recurrent venous thromboembolism. However, the risk of recurrent events remains too high in patients without residual perfusion defect for it to be used as a stand-alone test to decide on anticoagulation discontinuation.
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Affiliation(s)
- Philippe Robin
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Romain Le Pennec
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Maggie Eddy
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Pierre-Yves Le Roux
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada
| | - Francis Couturaud
- Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France; Département de Médecine Interne et Pneumologie, Centre Hospitalier Régional Universitaire de Brest, Brest, France
| | - Cécile Tromeur
- Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France; Département de Médecine Interne et Pneumologie, Centre Hospitalier Régional Universitaire de Brest, Brest, France
| | - Benjamin Planquette
- Service de Pneumologie et Soins Intensifs, AP-HP, Hôpital Européen Georges Pompidou, Paris, France; Université de Paris, INSERM, UMRS 1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | - Olivier Sanchez
- Service de Pneumologie et Soins Intensifs, AP-HP, Hôpital Européen Georges Pompidou, Paris, France; Université de Paris, INSERM, UMRS 1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | | | - Lucia Filippi
- Division of General Medicine, Alto Vicentino Hospital, Santorso, Italy
| | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, QC, Canada
| | | | - Ranjeeta Mallick
- Ottawa Methods Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Pierre-Yves Salaun
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada; Centre d'Investigation Clinique, Centre Hospitalier Régional et Universitaire de Brest, Brest, France.
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10
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Schenker C, Stalder O, Méan M, Tritschler T, Righini M, Rodondi N, Aujesky D. Bleeding Risk in Elderly Patients with Venous Thromboembolism Who Would Have Been Excluded from Anticoagulation Trials. Thromb Haemost 2023; 123:427-437. [PMID: 36649737 DOI: 10.1055/s-0042-1760365] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Older patients with venous thromboembolism (VTE) are underrepresented in clinical anticoagulation trials. We examined to which extent elderly patients with VTE would be excluded from such trials and compared the bleeding risk between hypothetically excluded and enrolled patients. We studied 991 patients aged ≥65 years with acute VTE in a prospective multicenter cohort. We identified 12 landmark VTE oral anticoagulation trials from the eighth and updated ninth American College of Chest Physician Guidelines. For each trial, we abstracted the exclusion criteria and calculated the proportion of our study patients who would have been excluded from trial participation. We examined the association between five common exclusion criteria (hemodynamic instability, high bleeding risk, comorbidity, co-medication, and invasive treatments) and major bleeding (MB) within 36 months using competing risk regression, adjusting for age, sex, and periods of anticoagulation. A median of 31% (range: 20-52%) of our patients would have been excluded from participation in the landmark trials. Hemodynamic instability (sub-hazard ratio [SHR]: 2.2, 95% CI: 1.1-4.7), comorbidity (SHR: 1.5, 95% CI: 1.1-2.2), and co-medication (SHR: 1.5, 95% CI: 1.0-2.3) were associated with MB. Compared to eligible patients, those with ≥2 exclusion criteria had a twofold (SHR: 2.16, 95% CI: 1.38-3.39) increased risk of MB. Overall, about one-third of older patients would not be eligible for participation in guideline-defining VTE anticoagulation trials. The bleeding risk increases significantly with the number of exclusion criteria present. Thus, results from such trials may not be generalizable to older, multimorbid, and co-medicated patients.
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Affiliation(s)
- Carla Schenker
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Marie Méan
- Division of Internal Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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11
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Khan F, Thavorn K, Coyle D, van Katwyk S, Tritschler T, Hutton B, Le Gal G, Rodger M, Fergusson D. Protocol for a modelling study to assess the clinical and cost-effectiveness of indefinite anticoagulant therapy for first unprovoked venous thromboembolism. BMJ Open 2023; 13:e053927. [PMID: 36609323 PMCID: PMC9827190 DOI: 10.1136/bmjopen-2021-053927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Deciding whether to stop or extend anticoagulant therapy indefinitely after completing at least 3 months of initial treatment for a first unprovoked venous thromboembolism (VTE) remains a challenge for clinicians, patients and policy makers. Guidelines suggest an indefinite duration of anticoagulant therapy in these patients, yet its benefits, harms and costs have not been formally assessed. The aim of this proposed modelling study is to assess the differences in clinical benefits, harms and costs of stopping versus continuing anticoagulant therapy indefinitely for a first unprovoked VTE. METHODS AND ANALYSIS We will develop a probabilistic Markov model, adopting a 1-month cycle length and a lifetime horizon, to estimate life-years, quality-adjusted life-years, costs and the incremental cost-effectiveness ratios for a simulated population of patients with a first unprovoked VTE who will receive indefinite duration of anticoagulant therapy versus a population who will not receive extended treatment after completing 3 months of initial anticoagulant therapy. The economic evaluation will adopt a third-party payer perspective relating to a Canadian publicly funded healthcare system. Estimates for the probability of relevant clinical events will be informed by systematic reviews and meta-analyses, while costs and utility values will be obtained from published Canadian sources. Stratified analyses based on sex, age and site of initial VTE will also be performed to identify subgroups of patients with a first unprovoked VTE in whom continuing anticoagulant therapy indefinitely might prove to be clinically beneficial and cost-effective over stopping treatment. We will also conduct sensitivity and scenario analyses to assess robustness of study findings to changes in individual or groups of key parameters. ETHICS AND DISSEMINATION Ethical approval is not applicable for this study. The results will be disseminated through presentations at relevant conferences and in a manuscript that will be submitted to a peer-reviewed journal.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Sasha van Katwyk
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Tobias Tritschler
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of General Internal Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gregoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Québec, Canada
| | - Dean Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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12
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Li D, Liu Y, Song Y, Wen A. Antithrombotic therapy for secondary prevention of unprovoked venous thromboembolism: a systematic review and network meta-analysis of randomized controlled trials. Ann Med 2022; 54:253-261. [PMID: 35023788 PMCID: PMC8759723 DOI: 10.1080/07853890.2022.2026002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Extended antithrombotic treatment is recommended for secondary prevention of unprovoked venous thromboembolism (VTE), however, there is no consensus on which antithrombotic strategy is preferable. AIM To compare the efficacy and safety of different antithrombotic strategies for secondary prevention unprovoked VTE. METHODS Cochrane Central Register of Controlled Trials, Embase, and MEDLINE were systematically searched from inception to 22 July 2020 for randomized controlled trials (RCTs) that compared the efficacy and/or safety of extended antithrombotic strategies including aspirin, warfarin and direct oral anticoagulants (DOACs) for secondary prevention of unprovoked VTE. The primary outcome was risk of major bleeding and the secondary outcomes were risks of recurrent VTE and all-cause death. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using pairwise and network meta-analysis with random effect. Possible ranking of extended antithrombotic strategies was plotted using the surface under the cumulative ranking curve and mean ranks. RESULTS Seventeen RCTs met the inclusion criteria, and meta-analysis results showed that warfarin was associated with significantly higher risk of major bleeding than placebo/observation (OR 2.71, 95% CI 1.32-5.55) or apixaban (OR 10.65, 95% CI 1.06-107.13). Apixaban and low-apixaban were the top two strategies according to the ranking of major bleeding. Warfarin (OR 0.25, 95%CI 0.13-0.49), rivaroxaban (OR 0.18, 95%CI 0.03-0.90), apixaban (OR 0.18, 95%CI 0.04-0.85) and low-apixaban (OR 0.18, 95%CI 0.04-0.82) were related to significantly lower risk than placebo/observation; edoxaban was non-inferior to warfarin on the risk of recurrent VTE. Furthermore, apixaban was linked with significantly lower risk of all-cause death than placebo/observation (OR 0.29, 95% CI 0.09-0.88). CONCLUSION Apixaban showed superiority to other antithrombotic strategies on major bleeding and all-cause death for secondary prevention of unprovoked VTE. Further studies are warranted owing to the limited number of studies and positive cases.Key messagesAll antithrombotic strategies including warfarin, DOACs and aspirin were superior to placebo/observation on recurrent VTE for secondary prevention of unprovoked VTE.Apixaban demonstrated lower risk of major bleeding than warfarin, and lower risk of all-cause death than placebo/observation.Further research about the efficacy and safety of antithrombotic treatments for secondary prevention of unprovoked VTE is warranted.
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Affiliation(s)
- Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yi Liu
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yao Song
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Aiping Wen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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13
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Muacevic A, Adler JR, TA V, Pandurangan N, Shinde V. "The Great Masquerader": An Interesting Case Series of Pulmonary Thromboembolism. Cureus 2022; 14:e32330. [PMID: 36632266 PMCID: PMC9828400 DOI: 10.7759/cureus.32330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
Venous thromboembolism (VTE) encompasses pulmonary embolism (PE) and deep vein thrombosis (DVT). The clinical manifestations of pulmonary embolism are highly variable and non-specific. We report five cases of pulmonary embolism, each with a unique clinical profile and degree of severity. The clinical, electrocardiographic, and radiologic findings of each patient are described in this case series along with the appropriate therapy based on hemodynamic stability. It is crucial to distinguish between hemodynamically stable and unstable pulmonary embolism and treatment should be started right away to reduce morbidity and mortality secondary to obstructive shock.
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14
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Liu Z, Tan J, Deng Y, Hua L, Guo T. Clinical and Safety Outcomes Associated with Extended Treatment of Venous Thromboembolism: A Network Meta-Analysis. J Cardiovasc Dev Dis 2022; 9:jcdd9120414. [PMID: 36547411 PMCID: PMC9781418 DOI: 10.3390/jcdd9120414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Many anticoagulant strategies are available for the extended treatment of venous thromboembolism, yet little guidance exists regarding which drug is most effective and safe. AIM A network meta-analysis was performed to resolve this uncertainty. METHODS We searched the medical literature through June 2022 for randomized controlled trials (RCTs) evaluating the efficacy and safety of anticoagulants for adults with VTE compared with other anticoagulants or a placebo. RESULTS We identified 13 eligible RCTs in 12 articles. All pooled hazard ratios (HR) and 95% credible intervals (CrI) mentioned below, except that for aspirin, were calculated by comparison with standard-intensity warfarin. Novel oral anticoagulants (NOACs) were not inferior to standard-intensity warfarin in preventing recurrence, and edoxaban was ranked first among the NOACs (HR, 0.99; 95% CrI, 0.70-1.39). All the NOACs, except rivaroxaban, were superior to standard-intensity warfarin in preventing bleeding events. Apixaban was ranked first and was considered to be safer than other NOACs for control of both major bleeding (HR = 0.07, 95% CrI: 0.01-0.37) and clinically relevant non-major bleeding (CRNMB, HR = 0.30, 95% CrI: 0.13-0.67). Edoxaban was ranked second among the NOACs for control of major bleeding (HR = 0.44, 95% CI: 0.21-0.88), and dabigatran was ranked second among the NOACs for control of CRNMB (HR = 0.54, 95% CrI: 0.4-0.73). CONCLUSIONS There existed no statistically significant differences in recurrence between NOACs and standard-intensity warfarin, and NOACs were associated with a lower risk of bleeding events. Edoxaban effectively prevented VTE recurrence and major bleeding, and apixaban was the best anticoagulant for controlling bleeding events.
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Affiliation(s)
| | | | | | - Lu Hua
- Correspondence: (L.H.); (T.G.)
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15
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Sonne-Holm E, Kjærgaard J, Bang LE, Køber L, Fosbøl E, Carlsen J, Winther-Jensen M. Educational differences in mortality but not in risk of recurrence following first-time pulmonary embolism: A Danish nationwide register-based study. Thromb Res 2022; 219:22-29. [PMID: 36088711 DOI: 10.1016/j.thromres.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/11/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Emilie Sonne-Holm
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark.
| | - Jesper Kjærgaard
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Lia E Bang
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Emil Fosbøl
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Jørn Carlsen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Matilde Winther-Jensen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark; Department of Data, Biostatistics and Pharmacoepidemiology, Centre for Clinical Research and Prevention, Copenhagen University hospital Bispebjerg and Frederiksberg Hospital, Denmark
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16
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17
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Tang Y, Wu H, Klippel P, Zhang B, Huang HYS, Jing Y, Jiang X, Yao J. Deep thrombosis characterization using photoacoustic imaging with intravascular light delivery. Biomed Eng Lett 2022; 12:135-145. [PMID: 35529341 PMCID: PMC9046522 DOI: 10.1007/s13534-022-00216-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 11/28/2022] Open
Abstract
Venous thromboembolism (VTE) is a condition in which blood clots form within the deep veins of the leg or pelvis to cause deep vein thrombosis. The optimal treatment of VTE is determined by thrombus properties such as the age, size, and chemical composition of the blood clots. The thrombus properties can be readily evaluated by using photoacoustic computed tomography (PACT), a hybrid imaging modality that combines the rich contrast of optical imaging and deep penetration of ultrasound imaging. With inherent sensitivity to endogenous chromophores such as hemoglobin, multispectral PACT can provide composition information and oxygenation level in the clots. However, conventional PACT of clots relies on external light illumination, which provides limited penetration depth due to strong optical scattering of intervening tissue. In our study, this depth limitation is overcome by using intravascular light delivery with a thin optical fiber. To demonstrate in vitro blood clot characterization, clots with different acuteness and oxygenation levels were placed underneath ten-centimeter-thick chicken breast tissue and imaged using multiple wavelengths. Acoustic frequency analysis was performed on the received PA channel signals, and oxygenation level was estimated using multispectral linear spectral unmixing. The results show that, with intravascular light delivery, clot oxygenation level can be accurately measured, and the clot age can thus be estimated. In addition, we found that retracted and unretracted clots had different acoustic frequency spectrum. While unretracted clots had stronger high frequency components, retracted clots had much higher low frequency components due to densely packed red blood cells. The PACT characterization of the clots was consistent with the histology results and mechanical tests.
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Affiliation(s)
- Yuqi Tang
- Department of Biomedical Engineering, Duke University, Durham, NC USA
| | - Huaiyu Wu
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC USA
| | - Paul Klippel
- Graduate Program in Acoustics and Department of Biomedical Engineering, Pennsylvania State University, University Park, PA USA
| | - Bohua Zhang
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC USA
| | - Hsiao-Ying Shadow Huang
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC USA
| | - Yun Jing
- Graduate Program in Acoustics and Department of Biomedical Engineering, Pennsylvania State University, University Park, PA USA
| | - Xiaoning Jiang
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC USA
| | - Junjie Yao
- Department of Biomedical Engineering, Duke University, Durham, NC USA
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18
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Marques Antunes M, Alves M, Pinto FJ, Agnelli G, Caldeira D. The high-risk bleeding category of different scores in patients with venous thromboembolism: Systematic review and meta-analysis. Eur J Intern Med 2021; 94:45-55. [PMID: 34732296 DOI: 10.1016/j.ejim.2021.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND In patients with venous thromboembolism (VTE), bleeding risk should be carefully assessed but none of the available risk scores is currently recommended. The aim of this study was to systematically evaluate the performance of bleeding scores in patients with VTE focusing on high-risk patients. METHODS Longitudinal studies were searched in Medline and Cochrane Library, as well as reviews and references of retrieved articles. Studies were identified, data were extracted, and reporting quality was evaluated. We determined the sensitivity, specificity, positive likelihood ratio (LR+), and diagnostic odds ratio (DOR) of the 'high risk' category of each bleeding score. Random effects meta-analysis was performed in order to derive the central estimates and 95% confidence intervals (95% CI). RESULTS Twenty-one studies and ten bleeding scores fulfilled the inclusion criteria. VTE-BLEED showed the highest sensitivity but the second-lowest specificity (Se 76%; Sp 61%), followed by ACCP (Se 59%; Sp 57%). The remaining scores had high specificity (> 80%) but a low sensitivity (< 20%). HEMORR2HAGES and Niewenhuis score showed the best performance regarding LR+ that was 2.67 and 5.91, respectively. Regarding DOR, the Niewenhuis score and VTE-BLEED were the best performers with 9.04; 95% CI 3.87-21.09 and 4.94 95% CI 2.66-9.09, respectively. In a cohort with patients predominantly treated with direct oral anticoagulants (DOACs), VTE-BLEED had the highest sensitivity (Se 77%; Sp 60%). CONCLUSIONS Overall, the majority of the risk scores showed a moderate ability to forecast major bleeding events, with the VTE-BLEED as the most sensitive in patients treated with DOACs.
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Affiliation(s)
- Miguel Marques Antunes
- Cardiovascular Center of the University of Lisbon (CCUL), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisbon 1649-028, Portugal; Centro Hospitalar Universitário Lisboa Central, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal
| | - Mariana Alves
- Serviço de Medicina III, Hospital Pulido Valente, CHULN, Lisbon, Portugal
| | - Fausto J Pinto
- Cardiovascular Center of the University of Lisbon (CCUL), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisbon 1649-028, Portugal; Serviço de Cardiologia, Hospital Universitário de Santa Maria, CHULN, CAML, Av. Prof. Egas Moniz, Lisbon 1649-028, Portugal
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Daniel Caldeira
- Cardiovascular Center of the University of Lisbon (CCUL), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisbon 1649-028, Portugal; Serviço de Cardiologia, Hospital Universitário de Santa Maria, CHULN, CAML, Av. Prof. Egas Moniz, Lisbon 1649-028, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal; Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal..
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19
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Porembskaya OY, Kravchuk VN, Lobastov KV, Kuzmina-Krutetskaya SR, Laberko LA, Chesnokov MS, Velikanova KE, Saiganov SA. [Pulmonary artery thrombosis: strategy of anticoagulation]. Khirurgiia (Mosk) 2021:76-82. [PMID: 34786919 DOI: 10.17116/hirurgia202111176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This review is devoted to the management of primary artery thrombosis (PAT). This disease was always considered only as a part of other venous thromboembolic events, in particular isolated pulmonary embolism (PE). Various studies show that PAT can develop as an independent event without concomitant damage to extra-vessels. PAT is characterized by own typical signs as primary and recurrent event that can determine special strategies of treatment. However, there are no studies devoted to this problem. We can only make some assumptions about PAT anticoagulation (AC) considering data on isolated PE comprising PAT. These data are available in PADIS-PE, ASPIRE, EINSTEIN-PE, Hokusai-VTE studies underlying modern guidelines of various societies. In the absence of studies on PAT AC these guidelines should regulate PAT AC approaches. AC is recommended in all cases of PE except isolated subsegmental PAT in ambulatory patients. Duration of AC depends on risk factors (major or minor). Anticoagulation for PAT following chronic inflammatory diseases is still disputable.
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Affiliation(s)
- O Ya Porembskaya
- Mechnikov North-Western State Medical University, St. Petersburg, Russia.,Institute of Experimental Medicine, St. Petersburg, Russia
| | - V N Kravchuk
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - K V Lobastov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - L A Laberko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M Sh Chesnokov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - K E Velikanova
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - S A Saiganov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
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20
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Khan F, Rahman A, Tritschler T, Carrier M, Kearon C, Weitz JI, Schulman S, Couturaud F, Becattini C, Agnelli G, Brighton T, Lensing AW, Pinede L, Parpia S, Geersing GJ, Takada T, Bradbury C, Andreozzi GM, Palareti G, Prandoni P, Buller HR, Mallick R, Hutton B, Thavorn K, Le Gal G, Rodger M, Fergusson DA. Long-term risk of major bleeding after discontinuing anticoagulation for unprovoked venous thromboembolism: a systematic review and meta-analysis. Thromb Haemost 2021; 122:1186-1197. [PMID: 34753191 DOI: 10.1055/a-1690-8728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The long-term risk of major bleeding after discontinuing anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. OBJECTIVES To determine the incidence of major bleeding up to 5 years after discontinuing anticoagulation for a first unprovoked VTE. METHODS We searched MEDLINE, EMBASE, and Cochrane CENTRAL (from inception to January 2021) to identify relevant randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding after discontinuing anticoagulation in patients with a first unprovoked VTE who had completed ≥3 months of initial treatment. Unpublished data on major bleeding events and person-years were obtained from authors of included studies to calculate study-level incidence rates. Random-effects meta-analysis was used to pool results across studies. RESULTS Of 1123 records identified by the search, 20 studies (17 RCTs) and 8740 patients were included in the analysis. During 13 011 person-years of follow-up after discontinuing anticoagulation, the pooled incidence of major bleeding (n=41) and fatal bleeding (n=7) per 100 person-years was 0.35 (95% confidence interval [CI], 0.20-0.54) and 0.09 (95% CI, 0.05-0.15). The 5-year cumulative incidence of major bleeding was of 1.0% (95% CI, 0.4%-2.4%). The case-fatality rate of major bleeding after discontinuing anticoagulation was 19.9% (95% CI, 10.6%-31.1%). CONCLUSIONS Patients with a first unprovoked VTE have a non-trivial risk of major bleeding once anticoagulants are discontinued. Estimates from this study can help clinicians counsel patients about the incremental risk of major bleeding with extended anticoagulation to guide decision making about treatment duration for unprovoked VTE.
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Affiliation(s)
- Faizan Khan
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Tobias Tritschler
- Department of General Internal Medicine, Bern University Hospital, Bern, Switzerland
| | - Marc Carrier
- Department of Medicine. University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada.,The Thrombosis and Atherosclerosis Research Institute, Hamilton, Canada
| | | | - Francis Couturaud
- Department of internal medicine and chest diseases, Brest University Hospital Centre, Brest, France
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine,Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine,Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Timothy Brighton
- Prince of Wales Hospital and Community Health Services, Randwick, Australia
| | | | - Laurent Pinede
- Infirmerie Protestante de Lyon, Caluire et Cuire, France
| | | | | | | | - Charlotte Bradbury
- University of Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland
| | | | | | | | - H R Buller
- Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | | | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kednapa Thavorn
- ICES @uOttawa, University of Ottawa Faculty of Medicine, Ottawa, Canada
| | - Grégoire Le Gal
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa, Canada.,Université de Bretagne Occidentale, Brest, France.,INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, Saint Etienne, France
| | - Marc Rodger
- Medicine, McGill University, Montreal, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada
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21
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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, Shi M, Thavorn K, Hutton B, Le Gal G, Rodger M, Fergusson D. Long-term risk of recurrent venous thromboembolism among patients receiving extended oral anticoagulant therapy for first unprovoked venous thromboembolism: A systematic review and meta-analysis. J Thromb Haemost 2021; 19:2801-2813. [PMID: 34379859 DOI: 10.1111/jth.15491] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The long-term risk for recurrent venous thromboembolism (VTE) during extended anticoagulation for a first unprovoked VTE is uncertain. OBJECTIVES To determine the incidence of recurrent VTE during extended anticoagulation of up to 5 years in patients with a first unprovoked VTE. METHODS MEDLINE, EMBASE, and the Cochrane CENTRAL were searched to identify randomized trials and prospective cohort studies reporting recurrent VTE among patients with a first unprovoked VTE who were to receive anticoagulation for a minimum of six additional months after completing ≥3 months of initial treatment. Unpublished data on number of recurrent VTE and person-years, obtained from authors of included studies, were used to calculate study-level incidence rate, and random-effects meta-analysis was used to pool results. RESULTS Twenty-six studies and 15 603 patients were included in the analysis. During 11 631 person-years of follow-up, the incidence of recurrent VTE and fatal pulmonary embolism per 100 person-years was 1.41 (95% CI, 1.03-1.84) and 0.09 (0.04-0.16), with 5-year cumulative incidences of 7.1% (3.0%-13.2%) and 1.2% (0.4%-4.6%), respectively. The incidence of recurrent VTE was 1.08 (95% CI, 0.77-1.44) with direct oral anticoagulants and 1.55 (1.01-2.20) with vitamin K antagonists. The case-fatality rate of recurrent VTE was 4.9% (95% CI, 2.2%-8.7%). CONCLUSIONS In patients with a first unprovoked VTE, the long-term risk of recurrent VTE during extended anticoagulation is low but not negligible. Thus, clinicians and patients should be aware of this risk and take appropriate and timely action in case of suspicion of recurrent VTE. Estimates from this study can be used to advise patients on what to expect while receiving extended anticoagulation, and estimate the net clinical benefit of extended treatment to guide long-term management of unprovoked VTE.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Miriam Kimpton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Philip S Wells
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, OK, USA
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Brest University Hospital, Brest, France
| | | | | | | | - Paul A Kyrle
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sabine Eichinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Lisbeth Eischer
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Benilde Cosmi
- Department of Specialty, Diagnostic and Experimental Medicine, Division of Angiology and Blood Coagulation, S. Orsola Malpighi University Hospital, Bologna, Italy
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Letizia Marconi
- Department of Surgical, Medical and Molecular Pathology, and Critical Care, University of Pisa, Pisa, Italy
| | - Antonio Palla
- Department of Surgical, Medical and Molecular Pathology, and Critical Care, University of Pisa, Pisa, Italy
| | - Sergio Siragusa
- Department Pro.Mi.Se., University of Palermo, Palermo, Italy
| | | | - Sameer Parpia
- Departments of Oncology, and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | | | - Minggao Shi
- Daiichi-Sankyo Pharma Development, Basking Ridge, NJ, USA
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gregoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Marc Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Dean Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
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22
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Hobohm L, Lankeit M. [Pulmonary Embolism]. Pneumologie 2021; 75:800-818. [PMID: 34662916 DOI: 10.1055/a-1029-9937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pulmonary embolism (PE) is a life-threatening disease and the third most frequent cardiovascular cause of death after stroke and myocardial infarction. The annual incidence is increasing (in Germany from 85 cases per 100000 population in the year 2005 to 109 cases per 100000 population in the year 2015). The individual risk for PE-related complications and death increases with the number of comorbidities and severity of right ventricular dysfunction. Using clinical, laboratory and imaging parameters, patients with PE can be stratified to four risk classes (high, intermediate-high, intermediate-low and low risk). This risk stratification has concrete therapeutic consequences ranging from out-of-hospital treatment of low-risk patients to reperfusion treatment of (intermediate)-high-risk patients. For haemodynamically unstable patients, treatment decision should preferably be made in interdisciplinary "Pulmonary Embolism Response Teams" (PERT). Due to their comparable efficacy and preferable safety profile compared to vitamin-K antagonists (VKAs), non-vitamin K-dependent oral anticoagulants (NOACs) are increasingly considered the treatment of choice for initial and prolonged anticoagulation of patients with pulmonary embolism. Use of low molecular weight heparins (LMWHs) is recommended for PE patients with cancer; however, recent studies indicate that treatment with factor Xa-inhibitors may be effective and safe (in patients without gastrointestinal cancer). Only prolonged anticoagulation (in reduced dosage) will ensure reduction of VTE recurrence and should thus be considered for all patients with unprovoked events.
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23
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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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24
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Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545-e608. [PMID: 34352278 DOI: 10.1016/j.chest.2021.07.055] [Citation(s) in RCA: 368] [Impact Index Per Article: 122.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/11/2021] [Accepted: 07/08/2021] [Indexed: 01/06/2023] Open
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25
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Stolberg S, Mudawi D, Dean K, Cheng A, Barraclough R. Investigation and management of pulmonary embolism 1: a probability-based approach. Br J Hosp Med (Lond) 2021; 82:1-16. [PMID: 34338014 DOI: 10.12968/hmed.2021.0286a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary embolism remains a common and potentially deadly disease, despite advances in diagnostic imaging, treatment and prevention. Managing pulmonary embolism requires a multifactorial approach involving risk stratification, determining appropriate diagnostics and selecting individualised therapy. This article reviews the pathophysiology, risk factors, clinical presentation, diagnostic evaluation and therapeutic management and early outpatient management of pulmonary embolism. The second part summarises pulmonary embolism in the setting of pregnancy, COVID-19, recurrent disease and chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Stephanie Stolberg
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
| | - Dalia Mudawi
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
| | - Katrina Dean
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
| | - Andrew Cheng
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
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26
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Wang L, Shu T, Wang W, Chen H, Feng P, Xiang R, Huang W. Association of statin use and the risk of recurrent pulmonary embolism in real-world Chinese population. Pulm Circ 2021; 11:20458940211035006. [PMID: 34377437 PMCID: PMC8327238 DOI: 10.1177/20458940211035006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 07/02/2021] [Indexed: 11/26/2022] Open
Abstract
Background Previous studies have suggested that statins exert protective effects against venous thromboembolism. However, few randomized studies have explicitly concentrated on patients with pulmonary embolism. Thus far, evidence of the effect of statins on the pulmonary embolism recurrence in China remains lacking. Methods A retrospective analysis was conducted utilizing our University database. Patients with an International Coding of Diseases-defined diagnosis of pulmonary embolism from 1 January 2017 to 31 December 2019 were included. The patients were divided into two groups, namely, with statin or without statin treatment. Propensity score matching was applied to balance the covariates between the comparison groups. Univariate analysis and multivariable logistic regression were performed to analyze the association between statin use and pulmonary embolism recurrence. Results A total of 365 patients diagnosed with pulmonary embolism were included in the research. Pulmonary embolism recurrence accounted for 15.1% of the patients and was observed during the entire study period. In the initial population, no significant difference in recurrence was observed between the groups with and without statins treatment (statin 15.6% vs. non-statin 14.9%, p = 0.860). After propensity score matching, multivariate logistic regression analysis revealed that the odds ratio of pulmonary embolism recurrence in the statin users was 0.489 (95% confidence interval 0.190–1.258, p = 0.138). Conclusions Our study provides no support for the use of statins as an adjunctive therapy in patients with pulmonary embolism at the initiated time of diagnosis or as a prophylactical plan when anticoagulation is discontinued attempting to reduce the risk of recurrence.
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Affiliation(s)
- Lu Wang
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tingting Shu
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wuwan Wang
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huaqiao Chen
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Panpan Feng
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Xiang
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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27
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Yamashita Y, Amano H, Morimoto T, Kadota K, Hata R, Matsushita K, Osakada K, Sano A, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Inoko M, Tada T, Chen PM, Murata K, Tsuyuki Y, Nishimoto Y, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Kato T, Ono K, Kimura T. Risk factors of thrombotic recurrence and major bleeding in patients with intermediate-risk for recurrence of venous thromboembolism. J Thromb Thrombolysis 2021; 53:182-190. [PMID: 34228248 DOI: 10.1007/s11239-021-02520-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 02/02/2023]
Abstract
Prolonged anticoagulation therapy is recommended for patients with intermediate-risk for recurrence of venous thromboembolism (VTE). The current study aimed to identify risk factors of VTE recurrence and major bleeding in intermediate-risk patients. The COMMAND VTE Registry is a multicenter registry enrolled consecutive 3027 patients with acute symptomatic VTE among 29 centers in Japan. The current study population consisted of 1703 patients with intermediate-risk for recurrence. The primary outcome measure was recurrent VTE during the entire follow-up period, and the secondary outcome measures were recurrent VTE and major bleeding during anticoagulation therapy. In the multivariable Cox regression model for recurrent VTE incorporating the status of anticoagulation therapy as a time-updated covariate, off-anticoagulation therapy was strongly associated with an increased risk for recurrent VTE (HR 9.42, 95% CI 5.97-14.86). During anticoagulation therapy, the independent risk factor for recurrent VTE was thrombophilia (HR 3.58, 95% CI 1.56-7.50), while the independent risk factors for major bleeding were age ≥ 75 years (HR 2.04, 95% CI 1.36-3.07), men (HR 1.52, 95% CI 1.02-2.27), history of major bleeding (HR 3.48, 95% CI 1.82-6.14) and thrombocytopenia (HR 3.73, 95% CI 2.04-6.37). Among VTE patients with intermediate-risk for recurrence, discontinuation of anticoagulation therapy was a very strong independent risk factor of recurrence during the entire follow-up period. The independent risk factors of recurrent VTE and those of major bleeding during anticoagulation therapy were different: thrombophilia for recurrent VTE, and advanced age, men, history of major bleeding, and thrombocytopenia for major bleeding. CLINICAL TRIAL REGISTRATION: Unique identifier: UMIN000021132. COMMAND VTE Registry: http://www.umin.ac.jp/ctr/index.htm .
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hidewo Amano
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Reo Hata
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazuki Matsushita
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kohei Osakada
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Arata Sano
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Moriaki Inoko
- Cardiovascular Center, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Faculty of Medicine, Kinki University, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
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28
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Hodeib H, Youssef A, Allam AA, Selim A, Tawfik MA, Abosamak MF, Esam A, Abd Elghafar MS, Samir S, ELshora OA. Genetic Risk Profiling Associated with Recurrent Unprovoked Venous Thromboembolism. Genes (Basel) 2021; 12:874. [PMID: 34200207 PMCID: PMC8230078 DOI: 10.3390/genes12060874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and/or pulmonary embolism (PE), is a common, acute, multifactorial disease with a five-years cumulative incidence of recurrence of approximately 25%. Actually, no single genetic defect can predict the risk of recurrence of VTE. Therefore, individual genetic risk profiling could be useful for the prediction of VTE recurrence. AIM OF THE STUDY To assess the combined effect of the common prothrombotic genotypes on the risk of recurrence of VTE in recently diagnosed unprovoked VTE patients. PATIENTS AND METHODS This population based, prospective follow-up study was carried out from January 2015 to December 2020 in (internal medicine, cardiovascular medicine and anesthesia and ICU departments, Tanta University Hospital, Egypt) on 224 recently diagnosed unprovoked VTE patients. Whole blood was collected by standard venipuncture at the time of admission prior to the beginning of anticoagulant therapy. Genomic DNA was extracted and was genotyped for the 5-SNPs Genetic risk score (GRS), previously validated for first venous thrombosis (FVL rs6025, PTM rs1799963, ABO rs8176719, FGG rs2066865 and FXI rs2036914). RESULTS The main important finding in the present study was that patients having ≥3 risk alleles were associated with higher risk of VTE recurrence compared to those having ≤2 risk alleles (the reference group) (HR 2.5, 95% CI 1.48-4.21) (p = 0.001). Patients with GRS ≥ 3 had a significantly shorter time recurrence free survival (43.07 months) compared to the low risk group of patients with GRS (0-2) (p < 0.001). CONCLUSION GRS model could be an effective and useful model in risk stratification of VTE patients, and genetic risk profiling of VTE patients could be used for the prediction of recurrence of VTE.
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Affiliation(s)
- Hossam Hodeib
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (H.H.); (A.Y.); (O.A.E.)
| | - Amira Youssef
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (H.H.); (A.Y.); (O.A.E.)
| | - Alzahraa A. Allam
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (A.A.A.); (A.S.)
| | - Amal Selim
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (A.A.A.); (A.S.)
| | - Mohamed A. Tawfik
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (A.A.A.); (A.S.)
| | - Mohammed F. Abosamak
- Anesthesia/ICU Department, Faculty of Medicine, Tanta University Hospital, Tanta 31512, Egypt; (M.F.A.); (A.E.); (M.S.A.E.)
| | - Ahmed Esam
- Anesthesia/ICU Department, Faculty of Medicine, Tanta University Hospital, Tanta 31512, Egypt; (M.F.A.); (A.E.); (M.S.A.E.)
| | - Mohamed S. Abd Elghafar
- Anesthesia/ICU Department, Faculty of Medicine, Tanta University Hospital, Tanta 31512, Egypt; (M.F.A.); (A.E.); (M.S.A.E.)
| | - Sameh Samir
- Cardiovascular Medicine Department, Faculty of Medicine, Tanta University, Tanta 31511, Egypt;
| | - Ola A. ELshora
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta 31512, Egypt; (H.H.); (A.Y.); (O.A.E.)
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Zhu YJ, Zhou YP, Wei YP, Xu XQ, Yan XX, Liu C, Zhu XJ, Liu ZY, Sun K, Hua L, Jiang X, Jing ZC. Association Between Anticoagulation Outcomes and Venous Thromboembolism History in Chronic Thromboembolic Pulmonary Hypertension. Front Cardiovasc Med 2021; 8:628284. [PMID: 34095244 PMCID: PMC8175786 DOI: 10.3389/fcvm.2021.628284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The association between anticoagulation outcomes and prior history of venous thromboembolism (VTE) in chronic thromboembolic pulmonary hypertension (CTEPH) has not been established. This study aimed to compare the efficacy and safety of anticoagulation treatment in CTEPH patients with and without prior history of VTE. Methods: A total of 333 CTEPH patients prescribed anticoagulants were retrospectively included from May 2013 to April 2019. The clinical characteristics were collected at their first admission. Incidental recurrent VTE and clinically relevant bleeding were recorded during follow-up. The Cox proportional regression models were used to identify potential factors associated with recurrent VTE and clinically relevant bleeding. Results: Seventy patients (21%) without a prior history of VTE did not experience recurrent VTE during anticoagulation. Compared to CTEPH patients without a prior history of VTE, those with a prior history of VTE had an increased risk of recurrent VTE [2.27/100 person-year vs. 0/100 person-year; hazard ratio (HR), 8.92; 95% confidence interval (CI), 1.18–1142.00; P = 0.029] but a similar risk of clinically relevant bleeding (3.90/100 person-year vs. 4.59/100 person-year; HR, 0.83; 95% CI, 0.38–1.78; P = 0.623). Multivariate Cox analyses suggested that a prior history of VTE and interruption of anticoagulation treatments were significantly associated with an increased risk of recurrent VTE, while anemia and glucocorticoid use were significantly associated with a higher risk of clinically relevant bleeding. Conclusions: This study is the first to reveal that a prior history of VTE significantly increases the risk of recurrent VTE in CTEPH patients during anticoagulation treatment. This finding should be further evaluated in prospective studies.
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Affiliation(s)
- Yong-Jian Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Ping Zhou
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yun-Peng Wei
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Qi Xu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Xin Yan
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Jie Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Yi Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Sun
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Hua
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Jiang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Cheng Jing
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Mavromanoli AC, Barco S, Konstantinides SV. Antithrombotics and new interventions for venous thromboembolism: Exploring possibilities beyond factor IIa and factor Xa inhibition. Res Pract Thromb Haemost 2021; 5:S2475-0379(22)01378-4. [PMID: 34027284 PMCID: PMC8130658 DOI: 10.1002/rth2.12509] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/19/2021] [Accepted: 03/04/2021] [Indexed: 12/17/2022] Open
Abstract
Direct oral anti-activated factor X and antithrombin agents have largely replaced vitamin K antagonists as the standard of care in treatment of venous thromboembolism. However, gaps in efficacy and safety persist, notably in end-stage renal disease, implantable heart valves or assist devices, extracorporeal support of the circulation, and antiphospholipid syndrome. Inhibition of coagulation factor XI (FXI) emerges as a promising new therapeutic target. Antisense oligonucleotides offer potential advantages as a prophylactic or therapeutic modality, with one dose-finding trial in orthopedic surgery already published. In addition, monoclonal antibodies blocking activation and/or activity of activated factor XI are investigated, as are small-molecule inhibitors with rapid offset of action. Further potential targets include upstream components of the contact pathway such as factor XII, polyphosphates, or kallikrein. Finally, catheter-directed, pharmacomechanical antithrombotic strategies have been developed for high- and intermediate-risk pulmonary embolism, and large randomized trials aiming to validate their efficacy, safety, and prognostic impact are about to start.
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Affiliation(s)
- Anna C. Mavromanoli
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
- Clinic of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
- Department of CardiologyDemocritus University of ThraceAlexandroupolisGreece
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31
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2116] [Impact Index Per Article: 705.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv 2021; 5:927-974. [PMID: 33570602 PMCID: PMC7903232 DOI: 10.1182/bloodadvances.2020003442] [Citation(s) in RCA: 415] [Impact Index Per Article: 138.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. RESULTS Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. CONCLUSIONS Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.
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Affiliation(s)
- Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH
| | - Andrew D Leavitt
- Department of Laboratory Medicine and
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Oncology, BC Cancer, Vancouver site, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- American University of Beirut (AUB) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Center, American University of Beirut, Beirut, Lebanon; and
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
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Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Cuker A, Hutten BA, Jaff MR, Manja V, Schulman S, Thurston C, Vedantham S, Verhamme P, Witt DM, D Florez I, Izcovich A, Nieuwlaat R, Ross S, J Schünemann H, Wiercioch W, Zhang Y, Zhang Y. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv 2020; 4:4693-4738. [PMID: 33007077 PMCID: PMC7556153 DOI: 10.1182/bloodadvances.2020001830] [Citation(s) in RCA: 604] [Impact Index Per Article: 151.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000 each year, corresponding to ∼300 000 to 600 000 events in the United States annually. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 28 recommendations for the initial management of VTE, primary treatment, secondary prevention, and treatment of recurrent VTE events. CONCLUSIONS Strong recommendations include the use of thrombolytic therapy for patients with PE and hemodynamic compromise, use of an international normalized ratio (INR) range of 2.0 to 3.0 over a lower INR range for patients with VTE who use a vitamin K antagonist (VKA) for secondary prevention, and use of indefinite anticoagulation for patients with recurrent unprovoked VTE. Conditional recommendations include the preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications and a preference for direct oral anticoagulants over VKA for primary treatment of VTE.
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Affiliation(s)
- Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University, Durham NC
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insurbria, Varese, Italy
| | - Rebecca Beyth
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation Service, Kaiser Permanente, Aurora, CO
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Veena Manja
- University of California Davis, Sacramento, CA
- Veterans Affairs Northern California Health Care System, Mather, CA
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Suresh Vedantham
- Division of Diagnostic Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Peter Verhamme
- KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Ivan D Florez
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ariel Izcovich
- Internal Medicine Department, German Hospital, Buenos Aires, Argentina; and
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Stephanie Ross
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Konstantinides S, Meyer G. Management of acute pulmonary embolism 2019: what is new in the updated European guidelines? Intern Emerg Med 2020; 15:957-966. [PMID: 32458205 PMCID: PMC7467952 DOI: 10.1007/s11739-020-02340-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 04/08/2020] [Indexed: 12/11/2022]
Abstract
Pulmonary embolism (PE) is the third most frequent acute cardiovascular syndrome. Annual PE incidence and PE-related mortality rates rise exponentially with age, and consequently, the disease burden imposed by PE on the society continues to rise as the population ages worldwide. Recently published landmark trials provided the basis for new or changed recommendations included in the 2019 update of the European Society of Cardiology Guidelines (developed in cooperation with the European Respiratory Society). Refinements in diagnostic algorithms were proposed and validated, increasing the specificity of pre-test clinical probability and D-dimer testing, and thus helping to avoid unnecessary pulmonary angiograms. Improved diagnostic strategies were also successfully tested in pregnant women with suspected PE. Non-vitamin K antagonist oral anticoagulants (NOACs) are now the preferred agents for treating the majority of patients with PE, both in the acute phase (with or without a brief lead-in period of parenteral heparin or fondaparinux) and over the long term. Primary reperfusion is reserved for haemodynamically unstable patients. Besides, the 2019 Guidelines endorse multidisciplinary teams for coordinating the acute-phase management of high-risk and (in selected cases) intermediate-risk PE. For normotensive patients, physicians are advised to include the assessment of the right ventricle on top of clinical severity scores in further risk stratification, especially if early discharge of the patient is envisaged. Further important updates include guidance (1) on extended anticoagulation after PE, taking into account the improved safety profile of NOACs; and (2) on the overall care and follow-up of patients who have suffered PE, with the aim to prevent, detect and treat late sequelae of venous thromboembolism.
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Affiliation(s)
- Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Langenbeckstrasse 1, Bldg. 403, 55131 Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Komotini, Greece
| | - Guy Meyer
- Respiratory Medicine Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Université Paris Descartes, 75006 Paris, France
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35
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Becattini C, Cimini LA. Long term use of anticoagulant therapy for patients with pulmonary embolism. Expert Rev Hematol 2020; 13:709-718. [DOI: 10.1080/17474086.2020.1770589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
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Pompilio G, Integlia D, Raffetto J, Palareti G. Comparative Efficacy and Safety of Sulodexide and Other Extended Anticoagulation Treatments for Prevention of Recurrent Venous Thromboembolism: A Bayesian Network Meta-analysis. TH OPEN 2020; 4:e80-e93. [PMID: 32355907 PMCID: PMC7188513 DOI: 10.1055/s-0040-1709731] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/12/2020] [Indexed: 02/07/2023] Open
Abstract
Objective This network meta-analysis (NMA) assesses the clinical comparative efficacy and safety of sulodexide versus direct-acting oral anticoagulants (DOACs), vitamin K antagonist (VKA), and aspirin in patients with an unprovoked venous thromboembolism (VTE). Methods We conducted a literature search in MEDLINE, Embase, and Cochrane Library using both randomized controlled trials (RCTs) and observational studies. Reduction in recurrent deep venous thrombosis (r-DVT), pulmonary embolism (PE), major bleeding (MB), clinically relevant nonmajor bleeding (CRNMB) were the primary efficacy and safety outcomes. Other secondary end points were also included. We performed a fixed, random effects, and hierarchical models Bayesian NMA for each outcome. Results We identified 18 RCTs and seven observational studies. Random models showed sulodexide is the best treatment compared with DOACs, VKA, and aspirin at reducing the risk of CRNMB, for preventing death from any cause, and VTE/PE/myocardial infarction (MI)/stroke with 0.47, 0.81, and 0.65 probabilities, respectively. In the random model sulodexide was the best treatment for reducing the risk of MB with a 0.50 probability and hierarchical model that confirmed favorable results. Random and hierarchical models showed sulodexide and DOACs to be the best treatments for reducing PE risk. Sulodexide was more effective than aspirin for reducing r-DVT with 0.12 and less of 0.0001 probabilities, respectively. Conclusion Sulodexide is more effective for reducing MB and CRNMB, for preventing deaths from any cause, and from VTE/PE/MI/stroke, than other treatments, for both random and hierarchical models. Sulodexide showed to be more effective than aspirin in reducing the risk of r-DVT and PE. Sulodexide's reduction in bleeding while protecting from recurrent DVT risk makes this therapeutic option an important alternative for extended anticoagulation treatment.
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Affiliation(s)
| | | | - Joseph Raffetto
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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Antagonists of Vitamin K-Popular Coumarin Drugs and New Synthetic and Natural Coumarin Derivatives. Molecules 2020; 25:molecules25061465. [PMID: 32213944 PMCID: PMC7146486 DOI: 10.3390/molecules25061465] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 12/24/2022] Open
Abstract
Many natural coumarins and their chemically synthesized analogs and derivatives exert diverse properties, such as anticancer, antioxidant, anti-inflammatory, or anticoagulant, with the latter being of the utmost importance. The widely used warfarin, acenocoumarol, and phenprocoumon exert anticoagulant properties by inhibiting the vitamin K epoxide reductase complex. In this interdisciplinary review, we present biochemical principles of the coagulation processes and possible methods for their tuning based on the use of coumarins. We also summarize chemical methods of synthesis of coumarins and discuss structures and properties of those that have been used for a long time, as well as newly synthesized compounds. Brief information on the clinical use of coumarins and other anticoagulant drugs is given, including the severe effects of overdosing and methods for reversing their action.
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38
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Wang W, Su Y, Wu C, Sun Y, Dai N, Chen W, Zhang J, Xu Y, Brindis RG, Xu D, Li J. Optimal duration of Vitamin K antagonists anticoagulant therapy after venous thromboembolism: a systematic review and network meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2020; 20:53. [PMID: 32013892 PMCID: PMC6998293 DOI: 10.1186/s12872-020-01345-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/16/2020] [Indexed: 12/21/2022] Open
Abstract
Background The optimal duration of oral anticoagulant therapy for patients with venous thromboembolism (VTE) remains highly uncertain in clinical practice. It is essential to accurately assess the effect of anticoagulant therapy in reducing recurrent VTE against the risk of inducing major bleeding. Methods Randomized controlled trials were identified by searching PubMed, Web of Science, Embase, and the Cochrane library, reporting rates of recurrent VTE and major bleeding in patients taking Vitamin K Antagonists (VKA) with VTE and comparing different durations. Results Eleven RCTs with 3109 participants utilizing varied durations were included in the meta-analysis. Longer VKA therapy was associated with significantly lower rates of VTE recurrence compared with shorter duration of VKA therapy (OR 0.75, 95%CI 0.57–0.99), with significant difference noted in major bleeding risk (OR 2.31, 95%CI 1.17–4.56). During anticoagulation duration, patients treated by 6-month VKA had higher risk of major bleeding compared with 3-month VKA regimen (OR 33.45, 95%CI 2.00–559.67). Conclusions Regimen longer than 6 months did not show statistical elevation of major bleeding risk. VKA treatment strongly reduces the risk of recurrent VTE during anticoagulation therapy. The absolute risk of recurrent VTE declines over time while the risk for major bleeding after 6 months’ treatment did not demonstrate a continuous significant increase with extended duration of VKA therapy.
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Affiliation(s)
- Wei Wang
- Key Laboratory of Arrhythmias of the Ministry of Education, Shanghai East Hospital, Tongji University School of Medicine, Tongji University, Shanghai, 200120, People's Republic of China.,Institute of Clinical Epidemiology and Evidence-based Medicine, Tongji University School of Medicine, 1239 Siping Road, Shanghai, 200092, China
| | - Yang Su
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 1239 Siping Road, Shanghai, 200092, China
| | - Chunyan Wu
- Key Laboratory of Arrhythmias of the Ministry of Education, Shanghai East Hospital, Tongji University School of Medicine, Tongji University, Shanghai, 200120, People's Republic of China.,Institute of Clinical Epidemiology and Evidence-based Medicine, Tongji University School of Medicine, 1239 Siping Road, Shanghai, 200092, China
| | - Yuxi Sun
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 1239 Siping Road, Shanghai, 200092, China
| | - Neng Dai
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 1239 Siping Road, Shanghai, 200092, China
| | - Wei Chen
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 1239 Siping Road, Shanghai, 200092, China
| | - Jie Zhang
- Key Laboratory of Arrhythmias of the Ministry of Education, Shanghai East Hospital, Tongji University School of Medicine, Tongji University, Shanghai, 200120, People's Republic of China.,Institute of Clinical Epidemiology and Evidence-based Medicine, Tongji University School of Medicine, 1239 Siping Road, Shanghai, 200092, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 1239 Siping Road, Shanghai, 200092, China
| | - Ralph G Brindis
- Department of Medicine & the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Dachun Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 1239 Siping Road, Shanghai, 200092, China.
| | - Jue Li
- Key Laboratory of Arrhythmias of the Ministry of Education, Shanghai East Hospital, Tongji University School of Medicine, Tongji University, Shanghai, 200120, People's Republic of China. .,Institute of Clinical Epidemiology and Evidence-based Medicine, Tongji University School of Medicine, 1239 Siping Road, Shanghai, 200092, China.
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Slabbynck H, Clukers J, Galdermans D. Should oral anticoagulation be discontinued after 3 months in the setting of a first high-risk pulmonary embolism secondary to a major transient/reversible risk factor? Eur Respir J 2020; 55:55/1/1902028. [DOI: 10.1183/13993003.02028-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/27/2019] [Indexed: 11/05/2022]
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Bradbury C, Fletcher K, Sun Y, Heneghan C, Gardiner C, Roalfe A, Hardy P, McCahon D, Heritage G, Shackleford H, Hobbs FR, Fitzmaurice D. A randomised controlled trial of extended anticoagulation treatment versus standard treatment for the prevention of recurrent venous thromboembolism (VTE) and post-thrombotic syndrome in patients being treated for a first episode of unprovoked VTE (the ExACT study). Br J Haematol 2019; 188:962-975. [PMID: 31713863 DOI: 10.1111/bjh.16275] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/06/2019] [Indexed: 12/19/2022]
Abstract
Venous thromboembolism (VTE) is prevalent and impactful, with a risk of death, morbidity and recurrence. Post-thrombotic syndrome (PTS) is a common consequence and associated with impaired quality of life (QoL). The ExACT study was a non-blinded, prospective, multicentred randomised controlled trial comparing extended versus limited duration anticoagulation following a first unprovoked VTE (proximal deep vein thrombosis or pulmonary embolism). Adults were eligible if they had completed ≥3 months anticoagulation (remaining anticoagulated). The primary outcome was time to first recurrent VTE from randomisation. The secondary outcomes included PTS severity, bleeding, QoL and D-dimers. Two-hundred and eighty-one patients were recruited, randomised and followed up for 24 months (mean age 63, male:female 2:1). There was a significant reduction in recurrent VTE for patients receiving extended anticoagulation [2·75 vs. 13·54 events/100 patient years, adjusted hazard ratio (aHR) 0·20 (95% confidence interval (CI): 0·09 to 0·46, P < 0·001)] with a non-significant increase in major bleeding [3·54 vs. 1·18 events/100 patient years, aHR 2·99 (95% CI: 0·81-11·05, P = 0·10)]. Outcomes of PTS and QoL were no different between groups. D-dimer results (on anticoagulation) did not predict VTE recurrence. In conclusion, extended anticoagulation reduced VTE recurrence but did not reduce PTS or improve QoL and was associated with a non-significant increase in bleeding. Results also suggest very limited clinical utility of D-dimer testing on anticoagulated patients.
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Affiliation(s)
- Charlotte Bradbury
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Kate Fletcher
- Institute of Applied Health Research, The University of Birmingham, Birmingham, UK
| | - Yongzhong Sun
- Institute of Applied Health Research, The University of Birmingham, Birmingham, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Chris Gardiner
- Haemostasis Research Unit (HRU), Department of Haematology, University College London, London, UK
| | - Andrea Roalfe
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Pollyanna Hardy
- Institute of Applied Health Research, The University of Birmingham, Birmingham, UK
| | - Debbie McCahon
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gail Heritage
- Institute of Applied Health Research, The University of Birmingham, Birmingham, UK
| | - Helen Shackleford
- Institute of Applied Health Research, The University of Birmingham, Birmingham, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - David Fitzmaurice
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
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Couturaud F, Girard P, Laporte S, Sanchez O. [What duration of anticoagulant treatment for PE/proximal DVT?]. Rev Mal Respir 2019; 38 Suppl 1:e99-e112. [PMID: 31711819 DOI: 10.1016/j.rmr.2019.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- F Couturaud
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; EA3878-GETBO, CIC Inserm1412, département de médecine interne et pneumologie, centre hospitalo-universitaire de Brest, université de Bretagne occidentale, 29200 Brest, France
| | - P Girard
- Institut du thorax-Curie-Montsouris, l'institut mutualiste Montsouris, 75014 Paris, France
| | - S Laporte
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; SAINBOIS U1059 équipe DVH, Unité de recherche clinique, Inserm, innovation, pharmacologie, CHU de Saint-Étienne, université Jean-Monnet, université de Lyon, hôpital du Nord, 42000 Saint-Étienne, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Service de pneumologie et soins intensifs, université de Paris, AH-HP, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Innovations thérapeutiques en hémostase, Inserm UMRS 1140, 75006 Paris, France.
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Folkerts K, Broughton J, Sheikh U, Mckaig S. Cost-effectiveness of rivaroxaban versus apixaban for the initial treatment of venous thromboembolism and extended prevention of recurrences in the UK. J Med Econ 2019; 22:1179-1191. [PMID: 31433687 DOI: 10.1080/13696998.2019.1658589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Aim: To evaluate the relative cost-effectiveness of using rivaroxaban vs apixaban for the initial treatment plus extended prevention of venous thromboembolism (VTE) in the UK. Extended prevention was assessed using a 10-mg rivaroxaban dose, as the 20-mg dose has already been evaluated. Methods: A Markov model compared the health outcomes and costs of treating VTE patient cohorts with either rivaroxaban (15 mg twice daily for 3 weeks, followed by 20 mg once daily for 6 months, then extended prevention with 10 mg once daily) or apixaban (10 mg twice daily for 1 week, followed by 5 mg twice daily for 6 months, then extended prevention with 2.5 mg twice daily) over a lifetime horizon. The model included an initial acute treatment and prevention phase (0-6 months) and an extended prevention phase (6-18 months). Efficacy and safety data were derived from two network meta-analyses. Reference treatment comparators were derived from the EINSTEIN-Pooled study and EINSTEIN-CHOICE trial. Healthcare costs and utility data were derived from published literature. Results: The rivaroxaban regimen was associated with increased quality-adjusted life years (QALYs) and slightly lower total costs compared with apixaban over a lifetime horizon. Deterministic and probabilistic sensitivity analyses demonstrated that rivaroxaban remained a cost-effective alternative to apixaban over a wide range of parameters. Incremental cost-effectiveness ratio estimates were below the £20,000 per QALY threshold in 74.1% of 2,000 model simulations. Scenario analyses further supported that rivaroxaban is a cost-effective alternative to apixaban. Limitations: Clinical and safety inputs were derived from network meta-analysis, which are subject to inherent limitations whereby small differences between study designs may severely impact efficacy and safety outcomes. Furthermore, these inputs were based on data from clinical trials, which may not reflect real-world data. Conclusions: Rivaroxaban was associated with a slightly lower total cost and increased QALYs compared with apixaban for VTE management in the UK over a lifetime horizon.
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Áinle FN, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Respir J 2019; 54:13993003.01647-2019. [DOI: 10.1183/13993003.01647-2019] [Citation(s) in RCA: 509] [Impact Index Per Article: 101.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Becattini C, Giustozzi M, Cerdà P, Cimini LA, Riera-Mestre A, Agnelli G. Risk of recurrent venous thromboembolism after acute pulmonary embolism: Role of residual pulmonary obstruction and persistent right ventricular dysfunction. A meta-analysis. J Thromb Haemost 2019; 17:1217-1228. [PMID: 31063646 DOI: 10.1111/jth.14477] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/01/2019] [Indexed: 08/31/2023]
Abstract
Essentials Debated is the role of residual pulmonary obstruction (RPO) in predicting venous thromboembolism. Whether right ventricular dysfunction (RVD) predicts recurrent venous thromboembolism is unknown. 15 studies on RPO and 4 on RVD and venous thromboembolism were included in this meta-analysis. RPO is a predictor of recurrent venous thromboembolism when assessed by perfusion lung scan. RVD after acute pulmonary embolism is not associated with recurrent venous thromboembolism. BACKGROUND There is conflicting evidence regarding the role of residual pulmonary obstruction (RPO) or persistent right ventricular dysfunction (RVD) after pulmonary embolism (PE) as a predictor of recurrent venous thromboembolism (VTE). The aim of this study was to assess whether RPO or persistent RVD after PE is associated with recurrent VTE. METHODS MEDLINE and EMBASE were searched through December 2018. Studies reporting on (a) RPO either on computed tomography (CT) angiography or perfusion lung scan, or RVD on echocardiography or CT angiography, after therapeutic anticoagulation for the acute PE, and (b) recurrent VTE, were included in this meta-analysis. RESULTS RPO was associated with an increased risk of recurrent VTE (16 studies; 3472 patients; odds ratio [OR] 2.22; 95% confidence interval [CI] 1.61-3.05; I2 = 26%); the association was statistically significant for lung scan-detected RPO (11 studies; 2916 patients; OR 2.21; 95% CI 1.63-3.01) but not for CT angiography-detected RPO (five studies; 556 patients; OR 2.56; 95% CI 0.82-7.94). No significant association was found between persistent RVD and recurrent VTE (four studies; 852 patients; OR 1.62; 95% CI 0.63-4.17). CONCLUSIONS RPO is a predictor of recurrent VTE after a first acute PE, mainly when assessed by perfusion lung scan.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Michela Giustozzi
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Pau Cerdà
- Internal Medicine, Hospital Universitari Bellvitge-IDIBELL, Barcelona, Spain
| | - Ludovica A Cimini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Antoni Riera-Mestre
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
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Khan F, Rahman A, Carrier M, Kearon C, Weitz JI, Schulman S, Couturaud F, Eichinger S, Kyrle PA, Becattini C, Agnelli G, Brighton TA, Lensing AWA, Prins MH, Sabri E, Hutton B, Pinede L, Cushman M, Palareti G, Wells GA, Prandoni P, Büller HR, Rodger MA. Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis. BMJ 2019; 366:l4363. [PMID: 31340984 PMCID: PMC6651066 DOI: 10.1136/bmj.l4363] [Citation(s) in RCA: 155] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To determine the rate of a first recurrent venous thromboembolism (VTE) event after discontinuation of anticoagulant treatment in patients with a first episode of unprovoked VTE, and the cumulative incidence for recurrent VTE up to 10 years. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, and the Cochrane Central Register of Controlled Trials (from inception to 15 March 2019). STUDY SELECTION Randomised controlled trials and prospective cohort studies reporting symptomatic recurrent VTE after discontinuation of anticoagulant treatment in patients with a first unprovoked VTE event who had completed at least three months of treatment. DATA EXTRACTION AND SYNTHESIS Two investigators independently screened studies, extracted data, and appraised risk of bias. Data clarifications were sought from authors of eligible studies. Recurrent VTE events and person years of follow-up after discontinuation of anticoagulant treatment were used to calculate rates for individual studies, and data were pooled using random effects meta-analysis. Sex and site of initial VTE were investigated as potential sources of between study heterogeneity. RESULTS 18 studies involving 7515 patients were included in the analysis. The pooled rate of recurrent VTE per 100 person years after discontinuation of anticoagulant treatment was 10.3 events (95% confidence interval 8.6 to 12.1) in the first year, 6.3 (5.1 to 7.7) in the second year, 3.8 events/year (95% confidence interval 3.2 to 4.5) in years 3-5, and 3.1 events/year (1.7 to 4.9) in years 6-10. The cumulative incidence for recurrent VTE was 16% (95% confidence interval 13% to 19%) at 2 years, 25% (21% to 29%) at 5 years, and 36% (28% to 45%) at 10 years. The pooled rate of recurrent VTE per 100 person years in the first year was 11.9 events (9.6 to 14.4) for men and 8.9 events (6.8 to 11.3) for women, with a cumulative incidence for recurrent VTE of 41% (28% to 56%) and 29% (20% to 38%), respectively, at 10 years. Compared to patients with isolated pulmonary embolism, the rate of recurrent VTE was higher in patients with proximal deep vein thrombosis (rate ratio 1.4, 95% confidence interval 1.1 to 1.7) and in patients with pulmonary embolism plus deep vein thrombosis (1.5, 1.1 to 1.9). In patients with distal deep vein thrombosis, the pooled rate of recurrent VTE per 100 person years was 1.9 events (95% confidence interval 0.5 to 4.3) in the first year after anticoagulation had stopped. The case fatality rate for recurrent VTE was 4% (95% confidence interval 2% to 6%). CONCLUSIONS In patients with a first episode of unprovoked VTE who completed at least three months of anticoagulant treatment, the risk of recurrent VTE was 10% in the first year after treatment, 16% at two years, 25% at five years, and 36% at 10 years, with 4% of recurrent VTE events resulting in death. These estimates should inform clinical practice guidelines, enhance confidence in counselling patients of their prognosis, and help guide decision making about long term management of unprovoked VTE. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017056309.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alvi Rahman
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Marc Carrier
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Ottawa Blood Disease Centre, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University, and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Sam Schulman
- Department of Medicine, McMaster University, and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Brest University Hospital, Brest, France
| | - Sabine Eichinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Paul A Kyrle
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | | | | | - Martin H Prins
- Department of Epidemiology and Technology Assessment, University of Maastricht, Maastricht, Netherlands
| | - Elham Sabri
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Laurent Pinede
- Department of Internal Medicine, Infirmerie Protestante, Caluire-Lyon, France
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | | | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Marc A Rodger
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Ottawa Blood Disease Centre, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
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Legnani C, Martinelli I, Palareti G, Ciavarella A, Poli D, Ageno W, Testa S, Mastroiacovo D, Ciammaichella M, Bucherini E, Mumoli N, Cosmi B. D-dimer levels during and after anticoagulation withdrawal in patients with venous thromboembolism treated with non-vitamin K anticoagulants. PLoS One 2019; 14:e0219751. [PMID: 31310608 PMCID: PMC6634858 DOI: 10.1371/journal.pone.0219751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 07/01/2019] [Indexed: 11/18/2022] Open
Abstract
Background D-dimer levels measured during and after vitamin K antagonist withdrawal may be used in clinical practice to assess the individual risk of recurrent venous thromboembolism. Currently, direct oral anticoagulants (DOACs) are frequently used in venous thromboembolism treatment; however, their pharmacokinetics and pharmacodynamics characteristics are completely different than vitamin K antagonists. The present study aimed at comparing the results of D-dimer levels during and after anticoagulation withdrawal in patients with venous thromboembolism treated with DOACs or warfarin. Material and methods D-dimer levels were measured in 527 patients (“cases”) during DOACs treatment (T0) and after 15 (T15), 30 (T30), 60 (T60) and 90 (T90) days after their discontinuation and in 527 patients (“controls”) enrolled in the DULCIS study (all treated with warfarin), matched for sex, age (+/-3 y), type of D-dimer assay and site of venous thromboembolism. Both cases and controls received anticoagulant treatment after a first venous thromboembolism event that was unprovoked or associated with weak risk factors. Results The rate of positive D-dimer results was significantly higher in cases than in controls at T0 (10.8% vs 5.1%, p = 0.002) and at T30 (18.8% vs 11.8%, p = 0.019), as well as at the other time-points, though not statistically significant. Conclusion D-dimer levels during and after stopping an anticoagulant treatment for a venous thromboembolism episode differ between patients treated with a DOAC than in those treated with warfarin. Specifically designed prospective studies are warranted to reassess the use of D-dimer as predictor of the risk of recurrent venous thromboembolism in patients treated with DOACs.
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Affiliation(s)
| | - Ida Martinelli
- Fondazione Ca’ Granda (Istituto di Ricovero e Cura a Carattere Scientifico) - Ospedale Maggiore Policlinico - A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
| | | | - Alessandro Ciavarella
- Fondazione Ca’ Granda (Istituto di Ricovero e Cura a Carattere Scientifico) - Ospedale Maggiore Policlinico - A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
| | - Daniela Poli
- Malattie Aterotrombotiche - Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Walter Ageno
- Degenza Breve Internistica e Centro Trombosi ed Emostasi - Azienda Socio Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi - Laboratorio Analisi chimico-cliniche e microbiologiche - Azienda Socio Sanitaria Territoriale di Cremona, Cremona, Italy
| | - Daniela Mastroiacovo
- Unità Operativa Semplice Dipartimentale di Angiologia e Diagnostica Vascolare - Ospedale Civile S.S. Filippo e Nicola, Avezzano, L’Aquila, Italy
| | - Maurizio Ciammaichella
- Unità Operativa Complessa di Medicina d’Urgenza - Azienda Ospedaliera S. Giovanni Addolorata, Roma, Italy
| | - Eugenio Bucherini
- Struttura Semplice Dipartimentale - Medicina Vascolare – Angiologia – Ospedale Civile Faenza, Faenza, Ravenna, Italy
| | - Nicola Mumoli
- Unità Operativa Complessa di Medicina Interna - Ospedale Fornaroli, Magenta, Milan, Italy
| | - Benilde Cosmi
- Unità Operativa Angiologia e Malattie della Coagulazione - Azienda Ospedaliero Universitaria di Bologna - Policlinico S. Orsola - Malpighi, Bologna, Italy
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Mai V, Guay CA, Perreault L, Bonnet S, Bertoletti L, Lacasse Y, Jardel S, Lega JC, Provencher S. Extended Anticoagulation for VTE. Chest 2019; 155:1199-1216. [DOI: 10.1016/j.chest.2019.02.402] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/27/2019] [Accepted: 02/19/2019] [Indexed: 12/19/2022] Open
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Direct oral anticoagulants for extended treatment of venous thromboembolism: insights from the EINSTEIN CHOICE study. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2019; 18:49-57. [PMID: 31184579 DOI: 10.2450/2019.0265-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/15/2019] [Indexed: 01/08/2023]
Abstract
The risk of recurrence of venous thromboembolism (VTE) persists after interruption of the initial anticoagulation therapy. New evidence shows that direct oral anticoagulants are effective for extended treatment of VTE and may reduce the risk of all-cause mortality. The optimal duration of anticoagulation after VTE is, however, controversial and complicated by the need for individualised assessment and balance between thrombosis and bleeding risks. Three direct oral anticoagulants (rivaroxaban, apixaban and dabigatran) have been studied for extended treatment of VTE. Dabigatran was shown to be safer than vitamin K antagonists and similarly effective for the prevention of recurrent VTE. Dabigatran, apixaban and rivaroxaban resulted in significant decreases in the rate of recurrent symptomatic VTE when compared to placebo, without a statistically significant difference in the risk of major bleeding. The latest guidelines of the American College of Chest Physicians suggest the use of low-dose aspirin to prevent VTE recurrence in patients who want to stop anticoagulation. In the randomised, double-blind, phase 3 EINSTEIN CHOICE trial, once-daily rivaroxaban at doses of 20 mg or 10 mg and 100 mg of aspirin were compared in VTE patients for whom there was clinical equipoise for extended anticoagulation. Either a treatment dose (20 mg) or a prophylactic dose (10 mg) of rivaroxaban significantly reduced the risk of VTE recurrence without a significant increase in bleeding risk compared with aspirin. The EINSTEIN CHOICE trial included patients with provoked or unprovoked VTE. Patients with VTE provoked by minor persistent or minor transient risk factors enrolled in this trial had not-negligible VTE recurrence rates. These new findings on extended therapy suggest the possibility of anticoagulation regimens at intensities tailored to the patients' risk profiles and VTE characteristics, with a shift of the risk-benefit balance in favour of extended treatment.
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49
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Extended anticoagulation for the secondary prevention of venous thromboembolic events: An updated network meta-analysis. PLoS One 2019; 14:e0214134. [PMID: 30933993 PMCID: PMC6443183 DOI: 10.1371/journal.pone.0214134] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/07/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Extended treatment is preconized in a significant proportion of patients with unprovoked venous thromboembolism (VTE). However, limited direct/indirect comparisons are available to appropriately weight the benefit/risk ratio of the diverse treatments available. We aimed to compare the rate of symptomatic recurrent VTE and major bleeding (MB), the net clinical benefit (VTE+MB) and death on vitamin-K antagonist (VKA), direct oral anticoagulants (DOAC) and antiplatelet drugs for extended anticoagulation. METHODS A systematic literature search through September 2018 identified randomized trials studying these pharmacologic therapies for extended anticoagulation following VTE. Treatment effects were calculated using network meta-analysis with frequentist fixed-effects model. RESULTS 18 trials (18,221 patients) were included in the analysis. All treatments reduced the risk of recurrence compared to placebo/observation. Nonetheless, VKA (RR 0.22; 95%CI 0.13-0.39) and DOAC (RRs ranging from 0.25-0.32; 95%CI ranging from 0.13-0.52) were more effective than aspirin, whereas low-dose VKA was less effective than standard-dose VKA (RR 2.47; 95%CI 1.34-4.55). The efficacy of DOAC was globally comparable to standard-adjusted dose VKA. Low- (RR 3.13; 95%CI 1.37-7.16) and standard-dose (RR 3.23; 95%CI 1.16-8.99) VKA also increased the risk of MB, which was not the case for any DOAC. Low-dose VKA and low-dose DOAC had similar effects on MB compared to standard-doses. Although there was a trend for reduced MB and enhanced net clinical benefit for DOAC compared to VKA, this was not statistically significant. The specific anticoagulant therapies had no significant effects on deaths. CONCLUSION Standard-dose VKA and low/standard-dose DOAC share similar effects on VTE recurrence and MB, whereas aspirin and low-dose VKA were associated with lower benefit/risk ratio.
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Schnegg‐Kaufmann A, Calzavarini S, Limacher A, Mean M, Righini M, Staub D, Beer J, Frauchiger B, Osterwalder J, Kucher N, Matter CM, Husmann M, Banyai M, Aschwanden M, Mazzolai L, Hugli O, Nagler M, Daskalakis M, Rodondi N, Aujesky D, Angelillo‐Scherrer A. A high Gas6 level in plasma predicts venous thromboembolism recurrence, major bleeding and mortality in the elderly: a prospective multicenter cohort study. J Thromb Haemost 2019; 17:306-318. [PMID: 30570809 PMCID: PMC6850608 DOI: 10.1111/jth.14365] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Indexed: 12/29/2022]
Abstract
Essentials Predictive ability of pro-hemostatic Gas6 for recurrent venous thromboembolism (VTE) is unknown. We measured Gas6 levels in 864 patients with VTE over 3 years. High Gas6 (> 157%) at diagnosis is associated with VTE recurrence, major bleeding and mortality. Gas6 plasma levels measured 12 months after the index VTE are discriminatory for VTE recurrence. SUMMARY: Background Growth arrest-specific gene 6 (Gas6) is a prohemostatic protein with an unknown predictive ability for recurrent venous thromboembolism (VTE). In the elderly, VTE results in higher mortality but does not have a higher rate of recurrence than in younger patients. Consequently, anticoagulation management in the elderly is challenging. Objective To prospectively investigate the performance of Gas6 in predicting VTE recurrence, major bleeding and mortality in the elderly. Methods Consecutive patients aged ≥ 65 years with acute VTE were followed for a period of 3 years. Primary outcomes were symptomatic VTE recurrence, major bleeding, and mortality. Plasma Gas6 was measured with ELISA. Results Gas6 levels were measured in 864 patients at the time of the index VTE (T1) and, in 70% of them, also 12 months later (T2). The Gas6 level at T1 was discriminatory for VTE recurrence (C-statistic, 0.56; 95% confidence interval [CI] 0.51-0.62), major bleeding (0.60, 95% CI 0.55-0.65) and mortality (0.69, 95% CI 0.65-0.73) up to 36 months. VTE recurrence up to 24 months after T2 was discriminated by the Gas6 level at T2 (0.62, 95% CI 0.54-0.71). High Gas6 levels (> 157%) and continuous Gas6 levels at T1 were associated with VTE recurrence up to 6 months and 12 months, respectively. Conclusions In elderly patients, a high Gas6 level is associated with higher risks of VTE recurrence, major bleeding, and death. These findings support further studies to assess the performance of Gas6 in adjusting the length of anticoagulation.
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Affiliation(s)
- Annatina Schnegg‐Kaufmann
- Department of Hematology and Central Hematology Laboratory, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Sara Calzavarini
- Department of Hematology and Central Hematology Laboratory, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Andreas Limacher
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Marie Mean
- Department of General Internal Medicine, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department of MedicineLausanne University HospitalLausanneSwitzerland
| | - Marc Righini
- Division of Angiology and HemostasisGeneva University HospitalGenevaSwitzerland
| | - Daniel Staub
- Division of AngiologyBasel University HospitalBaselSwitzerland
| | - Juerg‐Hans Beer
- Department of Internal MedicineCantonal Hospital of BadenBadenSwitzerland
| | - Beat Frauchiger
- Department of Internal MedicineCantonal Hospital of FrauenfeldFrauenfeldSwitzerland
| | | | - Nils Kucher
- University Clinic of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Christian M. Matter
- Center for Molecular CardiologyUniversity of Zurich, and Clinic for CardiologyUniversity Heart CenterZurich University HospitalZurichSwitzerland
| | - Marc Husmann
- University Clinic of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Martin Banyai
- Division of AngiologyCantonal Hospital of LucerneLucerneSwitzerland
| | | | - Lucia Mazzolai
- Service of AngiologyLausanne University HospitalLausanneSwitzerland
| | - Oliver Hugli
- Emergency DepartmentLausanne University HospitalLausanneSwitzerland
| | - Michael Nagler
- Department of Hematology and Central Hematology Laboratory, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Michael Daskalakis
- Department of Hematology and Central Hematology Laboratory, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernBernSwitzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, InselspitalBern University HospitalUniversity of BernBernSwitzerland
| | - Anne Angelillo‐Scherrer
- Department of Hematology and Central Hematology Laboratory, InselspitalBern University HospitalUniversity of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
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