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Nair V, Singh S, Ashraf MZ, Yanamandra U, Sharma V, Prabhakar A, Ahmad R, Chatterjee T, Behera V, Guleria V, Patrikar S, Gupta S, Vishnoi MG, Rigvardhan, Kalshetty K, Sharma P, Bajaj N, Khaling TD, Wankhede TS, Bhattachar S, Datta R, Ganguli LP. Epidemiology and pathophysiology of vascular thrombosis in acclimatized lowlanders at high altitude: A prospective longitudinal study. Lancet Reg Health Southeast Asia 2022; 3:100016. [PMID: 37384264 PMCID: PMC10306047 DOI: 10.1016/j.lansea.2022.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Previous literature suggests that thrombosis is more common in lowlanders sojourning at high altitude (HA) compared to near-sea-level. Though the pathophysiology is partly understood, little is known of its epidemiology. To elucidate this, an observational prospective longitudinal study was conducted in healthy soldiers sojourning for months at HA. METHODS A total of 960 healthy male subjects were screened in the plains, of which 750 ascended, to altitudes above 15,000ft (4,472m). Clinical examination, haemogram, coagulogram, markers of inflammation and endothelial dysfunction, were studied at three time points during ascent and descent. The diagnosis of thrombosis was confirmed radiologically in all cases where a thrombotic event was suspected clinically. Subjects developing thrombosis at HA were labelled as Index Cases (ICs) and compared to a nested cohort of the healthy subjects (comparison group,(CG)) matched for altitude of stay. FINDINGS Twelve and three subjects, developed venous (incidence: 5,926/105 person-years) and arterial (incidence: 1,482/105 person-years) thrombosis at HA, respectively. The ICs had enhanced coagulation (FVIIa: p<0.001; FXa: p<0.001) and decreased levels of natural anticoagulants (thrombomodulin, p=0.016; tissue factor pathway inhibitor [TFPI]: p<0.001) and a trend to dampened fibrinolysis (tissue plasminogen activator tPA; p=0.078) compared to CG. ICs also exhibited statistically significant increase in the levels of endothelial dysfunction and inflammation markers (vascular cell adhesion molecule-1[VCAM-1], intercellular adhesion molecule-1 [ICAM-1], vascular endothelial growth factor receptor 3 [VEGFR-3], P-Selectin, CD40 ligand, soluble C-reactive protein and myeloperoxidase: p<0.001). INTERPRETATION The incidence of thrombosis in healthy subjects at HA was higher than that reported in literature at near sea-level. This was associated with inflammation, endothelial dysfunction, a prothrombotic state and dampened fibrinolysis. FUNDING Research grants from the Armed Forces Medical Research Committee, Office of the Director General of Armed Forces Medical Services (DGAFMS) & Defence Research and Development Organization (DRDO), Ministry of Defence, India.
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Affiliation(s)
- Velu Nair
- Department of the Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
- Director General Medical Services (Army), India
- Comprehensive Blood & Cancer Center (CBCC), Gandhinagar, Gujarat, India
| | - Surinderpal Singh
- Department of Physiology, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Physiology, Army College of Medical Sciences, New Delhi, India
| | - Mohammad Zahid Ashraf
- Defense Institute of Physiology & Allied Science (DIPAS), New Delhi, India
- Department of Biotechnology, Jamia Millia Islamia, New Delhi, India
| | - Uday Yanamandra
- Department of the Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
- 153 General Hospital, Leh, India
| | - Vivek Sharma
- Department of Imaging & Radiodiagnosis, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Radiology, Bharati Vidyapeeth Hospital & Medical College, Pune, Maharashtra, India
| | - Amit Prabhakar
- Defense Institute of Physiology & Allied Science (DIPAS), New Delhi, India
- Cardiovascular Research Institute (CVRI), University of California, San Francisco, USA
| | - Rehan Ahmad
- Department of Clinical Haematology and Centre for Stem Cell Therapy and Research, Army Hospital (Research and Referral), New Delhi, India
- Luchkee Health Pvt Ltd Vasant Kunj, New Delhi, India
| | - Tathagata Chatterjee
- Department of Laboratory Sciences and Molecular Medicine, Army Hospital (Research & Referral), New Delhi, India
- Department of Haematology and Stem Cell Transplant, ESIC Med College and Hospital, Faridabad, Haryana, India
| | - Vineet Behera
- Department of the Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Internal Medicine, INHS Asvini, Colaba, Mumbai, India
| | - Vivek Guleria
- Department of the Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Cardiology, Army Hospital (Research & Referral), New Delhi, India
| | - Seema Patrikar
- Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
| | - Shivi Gupta
- 403 Field Hospital, C/o 56 APO, India
- Indian Field Hospital, UN Mission, Malakal 71111, South Sudan
| | - Madan Gopal Vishnoi
- 403 Field Hospital, C/o 56 APO, India
- Department of Nuclear Medicine, Command Hospital (Eastern Command), Kolkata, India
| | - Rigvardhan
- Defense Institute of Physiology & Allied Science (DIPAS), New Delhi, India
| | - Kiran Kalshetty
- Regimental Medical Officer, 20 Grenadiers c/o 56 APO, India
- Department of Anaesthesiology, 305 Field Hospital, C/o 99 APO, India
| | - Prafull Sharma
- Department of the Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Cardiology, Military Hospital, Jalandhar, Punjab, India
| | - Nitin Bajaj
- Department of Internal Medicine, Command Hospital (Western Command), Chandimandir, Haryana, India
- Department of Cardiology, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Thyelnai D. Khaling
- Department of Physiology, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Physiology, Institute of Aerospace Medicine, Bangalore, Karnataka, India
| | - Tanaji Sitaram Wankhede
- Department of Physiology, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Sports Medicine, Armed Forces Medical College, Pune, Maharashtra, India
| | - Srinivasa Bhattachar
- Department of Physiology, Institute of Aerospace Medicine, Bangalore, Karnataka, India
- High Altitude Medical Research Centre, Leh, Ladakh, India
| | - Rajat Datta
- Department of Cardiology, Army Hospital (Research & Referral), New Delhi, India
- Director General Armed Forces Medical Services, New Delhi, India
| | - Late Prosenjit Ganguli
- Department of Clinical Haematology and Centre for Stem Cell Therapy and Research, Army Hospital (Research and Referral), New Delhi, India
- Department of Pathology, Command Hospital (Eastern Command), Kolkata, India
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