1
|
Maas DPMSM, Saes JL, Blijlevens NMA, Cnossen MH, den Exter PL, van der Heijden OWH, Kruis IC, Meijer K, Peters M, Schutgens REG, van Heerde WL, Nieuwenhuizen L, Schols SEM. High prevalence of heavy menstrual bleeding in women with rare bleeding disorders in the Netherlands: retrospective data from the RBiN study. J Thromb Haemost 2023; 21:2726-2734. [PMID: 37517479 DOI: 10.1016/j.jtha.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/22/2023] [Accepted: 07/05/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is associated with a reduced quality of life and limitations in social and physical functioning. Data on HMB in women with rare bleeding disorders (RBDs), including coagulation factor deficiencies and fibrinolytic disorders, are scarce. OBJECTIVES To analyze the prevalence, severity, and treatment of HMB in Dutch women with an RBD. METHODS The Rare Bleeding Disorders in the Netherlands (RBiN) study included 263 patients with an RBD from all 6 hemophilia treatment centers (October 2017-November 2019). In this analysis, data of 111 women aged ≥16 years were studied. According to the International Society on Thrombosis and Haemostasis bleeding assessment tool, HMB symptoms were scored from 0 (no/trivial) to 4 (severe symptoms requiring medical intervention). HMB was defined as a score ≥1. Age at RBD diagnosis was extracted from patient files. RESULTS HMB was reported by 80% of women (89/111) and was more prevalent in women with a fibrinolytic disorder (33/35; 94%) than in women with a coagulation factor deficiency (56/76; 74%) (P = .011). Of the 89 women with HMB, 82% (n = 73) ever required treatment. Multiple treatment modalities were frequently used, both in severe and mild deficiencies. Hormonal treatment was mostly used (n = 64; 88%), while antifibrinolytics were prescribed less frequently (n = 18; 25%). In women with HMB since menarche (n = 61; 69%), median age at RBD diagnosis was 28 years (IQR, 14-41). CONCLUSION HMB is common in women with RBDs. Women with mild deficiencies also frequently reported HMB. Only a minority of women were treated with hemostatic agents. A significant diagnostic delay was observed after the onset of HMB symptoms.
Collapse
Affiliation(s)
- Dominique P M S M Maas
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - Joline L Saes
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Ilmar C Kruis
- Netherlands Hemophilia Society, Nijkerk, the Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marjolein Peters
- Department of Pediatric Hematology, Amsterdam University Medical Centers, location Emma Children's Hospital, Amsterdam, the Netherlands
| | - Roger E G Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht and University Utrecht, Utrecht, The Netherlands
| | - Waander L van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, the Netherlands; Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Laurens Nieuwenhuizen
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, the Netherlands; Department of Hematology, Maxima Medical Center, Eindhoven, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, the Netherlands.
| |
Collapse
|
2
|
Klok FAE, den Exter PL, Bosma M, Eikenboom HCJJ. [Anti-Xa activity in LMWH treatment: when to assess and what to do with the result]. Ned Tijdschr Geneeskd 2023; 167:D7543. [PMID: 37493295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
The anti-factor Xa assay is designed to measure plasma low-molecular-weight heparin (LMWH) levels and to monitor heparin therapy. Notably, the results of anti-factor Xa testing cannot be used in the same way as the International Normalized Ratio (INR) is used to guide cumarin treatment: dose adjustments to remain in the therapeutic range have not been shown to be associated with better outcomes of care and lower rates of thrombotic and/or bleeding complications. The anti-factor Xa activity should therefore only be assessed in cases of considerable concern regarding an LWMH under- or overdosis. It is reasonable to lower the LMWH dose in case of a supratherapeutic anti-factor Xa activity. Increasing the LMWH dose in case of a subtherapeutic anti-factor Xa activity should however only be considered in case of morbid obesity or in the setting of breakthrough thrombosis in patients receiving therapeutic dosed LMWH, as long as the anti-factor Xa activity remains below the upper-level of the recommend range.
Collapse
Affiliation(s)
- F A Erik Klok
- LUMC, Leiden. Afd. Interne Geneeskunde
- Contact: F. A.(Erik) Klok
| | | | - Madeleen Bosma
- LUMC, Leiden. Afd. Afd. Klinische Chemie en Laboratoriumgeneeskunde
| | | |
Collapse
|
3
|
Romano LG, van Vulpen LF, den Exter PL, Heubel-Moenen FC, Hooijmeijer HL, Coppens M, Fijnvandraat K, Schols SE, Ypma PF, Smit C, Driessens MH, Rosendaal FR, van der Bom JG, Gouw SC, Kruip MJ. Desmopressin in nonsevere hemophilia A: patient perspectives on use and efficacy. Res Pract Thromb Haemost 2023; 7:100281. [PMID: 37601028 PMCID: PMC10439392 DOI: 10.1016/j.rpth.2023.100281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/22/2023] [Accepted: 06/01/2023] [Indexed: 08/22/2023] Open
Abstract
Background Desmopressin increases plasma factor VIII and von Willebrand factor levels in persons with nonsevere hemophilia A. Patients' perspectives on desmopressin are relevant to increase and optimize its suboptimal use. However, patients' views on desmopressin are not reported. Objectives To evaluate the perspectives of persons with nonsevere hemophilia A on desmopressin use, barriers for its use, side effects, and their knowledge about desmopressin's efficacy and side effects. Methods Persons with nonsevere hemophilia A were included in a cross-sectional, national, multicenter study. Questionnaires were filled out by adult patients and children aged ≥12 years themselves. Caretakers filled out questionnaires for children aged <12 years. Results In total, 706 persons with nonsevere hemophilia A were included (544 mild, 162 moderate, [age range, 0-88 years]). Of 508 patients, 234 (50%) patients reported previous desmopressin use. Desmopressin was considered as at least moderately effective in 171 of 187 (90%) patients. Intranasal administration was the modality of choice for 138 of 182 (76%) patients. Flushing was the most reported side effect in 54 of 206 (26%) adults and 7 of 22 (32%) children. The most frequently reported advantage and disadvantage were the convenience of intranasal, out-of-hospital administration by 56% (126/227) and side effects in 18% (41/227), respectively. Patients' self-perceived knowledge was unsatisfactory or unknown in 28% (63/225). Conclusion Overall, desmopressin was most often used intranasally and considered effective, with flushing as the most common side effect. The most mentioned advantage was the convenience of intranasal administration and disadvantage was side effects. More information and education on desmopressin could answer unmet needs in patients with current or future desmopressin treatment.
Collapse
Affiliation(s)
- Lorenzo G.R. Romano
- Department of Hematology, Hemophilia Treatment Center, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lize F.D. van Vulpen
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paul L. den Exter
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Helene L. Hooijmeijer
- Department of Pediatrics, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Amsterdam University Medical Center - Emma Children’s Hospital, University of Amsterdam, Amsterdam, The Netherlands
- Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Saskia E.M. Schols
- Department of Hematology, Radboud University Medical Center and Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
| | - Paula F. Ypma
- Department of Hematology, Haga Hospital, The Hague, The Netherlands
| | - Cees Smit
- Netherlands Hemophilia Patient Society (NVHP), Nijkerk, The Netherlands
| | | | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna G. van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Samantha C. Gouw
- Department of Pediatric Hematology, Amsterdam University Medical Center - Emma Children’s Hospital, University of Amsterdam, Amsterdam, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke J.H.A. Kruip
- Department of Hematology, Hemophilia Treatment Center, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
4
|
Veizaj D, den Exter PL, Bos MHA. Russell's viper venom: from diagnostic to bypassing agent for hemophilia? J Thromb Haemost 2023; 21:1429-1431. [PMID: 37179074 DOI: 10.1016/j.jtha.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Dejvid Veizaj
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Paul L den Exter
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Mettine H A Bos
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands.
| |
Collapse
|
5
|
Maas DPMSM, Saes JL, Blijlevens NMA, Cnossen MH, den Exter PL, van der Heijden OWH, Kruis IC, Meijer K, Peters M, Schutgens REG, van Heerde WL, Nieuwenhuizen L, Schols SEM. High prevalence of postpartum hemorrhage in women with rare bleeding disorders in the Netherlands: retrospective data from the RBiN study. J Thromb Haemost 2023; 21:499-512. [PMID: 36696205 DOI: 10.1016/j.jtha.2022.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/27/2022] [Accepted: 11/22/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Women with rare bleeding disorders (RBDs), including coagulation factor deficiencies and fibrinolytic disorders, may have a higher risk of postpartum hemorrhage (PPH). Information on this patient category is lacking in the existing PPH guidelines because data on PPH in patients with RBDs are scarce. OBJECTIVE To describe the prevalence of PPH in women with an RBD and evaluate the use of peripartum hemostatic prophylaxis. METHODS In the Rare Bleeding Disorders in the Netherlands (RBiN) study, patients with RBDs (n = 263) were included from all 6 Dutch hemophilia treatment centers. Patient-reported information on delivery, peripartum hemostatic prophylaxis, and occurrence of PPH was collected retrospectively. If available, information about the precise volume of postpartum blood loss was extracted from electronic patient files. PPH was defined as blood loss ≥500 mL (World Health Organization guideline). RESULTS A total of 244 pregnancies, including 193 livebirths, were reported by 85 women. A considerable proportion of these women experienced PPH, ranging from 30% in factor V deficiency to 100% in hyperfibrinolysis. Overall, PPH was reported in 44% of deliveries performed with and 53% of deliveries performed without administration of peripartum hemostatic prophylaxis. Blood loss was significantly higher in deliveries without administration of hemostatic prophylaxis (median 1000 mL) compared to deliveries with administration of prophylaxis (median 400 mL) (p = 0.011). Patients with relatively mild deficiencies also frequently experienced PPH when peripartum hemostatic prophylaxis was omitted. CONCLUSION PPH is common in rare coagulation factor deficiencies, both severe and mild, and fibrinolytic disorders, especially when peripartum prophylactic hemostatic treatment was not administered. The use of prophylactic hemostatic treatment was associated with less postpartum blood loss.
Collapse
Affiliation(s)
- Dominique P M S M Maas
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Joline L Saes
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Ilmar C Kruis
- Netherlands Hemophilia Society, Nijkerk, The Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marjolein Peters
- Department of Pediatric Hematology, Amsterdam University Medical Centers, Location Emma Children's Hospital, Amsterdam, The Netherlands
| | - Roger E G Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht and University Utrecht, Utrecht, The Netherlands
| | - Waander L van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands; Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Laurens Nieuwenhuizen
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands; Department of Hematology, Maxima Medical Center, Eindhoven, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands.
| | | |
Collapse
|
6
|
Kortekaas KA, den Exter PL, Beeres SLMA, Palmen M, Jukema JW, Huisman MV, Tops LF. Systemic thrombolysis in the management of pump thrombosis in patients with left ventricular assist devices. Front Cardiovasc Med 2022; 9:969766. [PMID: 36312273 PMCID: PMC9606390 DOI: 10.3389/fcvm.2022.969766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/22/2022] [Indexed: 11/25/2022] Open
Abstract
Left ventricular assist device (LVAD) implantation as destination therapy (DT) is a valuable treatment option in patients with end-stage heart failure ineligible for heart transplant. However, this therapy can be complicated by life-threatening pump thrombosis (PT). This case series reports our single-center experience with a structured systemic thrombolysis protocol in case of PT. Consecutive patients undergoing DT LVAD (HVAD, Medtronic, Framingham, MA) implantation between 2010 and April 2021 at our institution were reviewed and those with PT identified. Clinical, laboratory and LVAD specific data were collected and analyzed retrospectively. All patients with PT were treated with systemic thrombolysis according to a structured bedside protocol. Treatment was defined successful if a patient was alive at 30 days follow-up and free of recurrent PT, stroke or device exchange. Fourteen out of 94 patients experienced a PT after LVAD implantation (11%). Systemic thrombolysis was successful in 10 of 14 patients (71%) at 30 days. Two patients died within 30 days due to a hemothorax and multi-organ failure. In three patients treatment was complicated by a major bleeding; twice a hemothorax (one fatal) and one right calf bleeding. No intracerebral hemorrhage was observed. Three patients experienced a thrombotic complication within 30 days; all recurrent PT. Eleven of the 14 DT patients were discharged home after a limited hospital stay after thrombolysis (average of 11 days). In conclusion, systemic thrombolysis may be a reasonable option for life-threatening PT in this vulnerable DT group in whom device exchange is often impossible due to comorbidity.
Collapse
Affiliation(s)
- Kirsten A. Kortekaas
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands,*Correspondence: Kirsten A. Kortekaas
| | - Paul L. den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | | | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Laurens F. Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
7
|
den Exter PL, Woller SC, Robert‐Ebadi H, Masias C, Morange P, Castelli D, Hansen J, Geersing G, Siegal DM, de Wit K, Klok FA. Management of bleeding risk in patients who receive anticoagulant therapy for venous thromboembolism: Communication from the ISTH SSC Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease. J Thromb Haemost 2022; 20:1910-1919. [PMID: 35735219 PMCID: PMC9545751 DOI: 10.1111/jth.15776] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022]
Abstract
Patients with acute venous thromboembolism (VTE) require anticoagulant therapy to prevent recurrent VTE and death, which exposes them to an inherent increased risk of bleeding. Identification of patients at high risk of bleeding, and mitigating this risk, is an essential component of the immediate and long-term therapeutic management of VTE. The bleeding risk can be estimated by either implicit judgment, weighing individual predictors (clinical variables or biomarkers), or by risk prediction tools developed for this purpose. Management of bleeding risk in clinical practice is, however, far from standardized. International guidelines are contradictory and lack clear and consistent guidance on the optimal management of bleeding risk. This report of the ISTH subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease summarizes the evidence on the prediction of bleeding in VTE patients. We systematically searched the literature and identified 34 original studies evaluating either predictors or risk prediction models for prediction of bleeding risk on anticoagulation in VTE patients. Based on this evidence, we provide recommendations for the standardized management of bleeding risk in VTE patients.
Collapse
Affiliation(s)
- Paul L. den Exter
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Scott C. Woller
- Department of MedicineIntermountain Medical CenterIntermountain HealthcareMurrayUtahUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Helia Robert‐Ebadi
- Division of Angiology and HemostasisGeneva University Hospitals and Faculty of MedicineGenevaSwitzerland
| | - Camila Masias
- Miami Cancer InstituteBaptist Health South Florida. Florida International University ‐ Herbert Wertheim College of MedicineMiamiFloridaUSA
| | - Pierre‐Emmanuel Morange
- Aix Marseille UnivINSERM 1263, INRAE 1260, C2VNMarseilleFrance
- Hematology DepartmentLa Timone University Hospital of MarseilleMarseilleFrance
| | | | - John‐Bjarne Hansen
- Thrombosis Research Center (TREC)Department of Clinical MedicineUiT – The Arctic University of Norway and University Hospital of North NorwayTromsøNorway
| | - Geert‐Jan Geersing
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Deborah M. Siegal
- Division of Hematology and ThromboembolismDepartment of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Kerstin de Wit
- Departments of Emergency Medicine and MedicineQueen's UniversityKingstonOntarioCanada
- Departments of Medicine and HEIMcMaster UniversityHamiltonOntarioCanada
| | - Frederikus A. Klok
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| |
Collapse
|
8
|
Woller SC, de Wit K, Robert-Ebadi H, Masias C, Klok FA, den Exter PL, Morange PE, Castelli D, Hansen JB. A systematic review of biomarkers among hospitalized patients with COVID-19 predictive of venous thromboembolism: A communication from the Predictive and Diagnostic Variables Scientific and Standardization Committee of the ISTH. Res Pract Thromb Haemost 2022; 6:e12786. [PMID: 36032214 PMCID: PMC9412137 DOI: 10.1002/rth2.12786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 12/15/2022] Open
Abstract
Background Thrombosis is reported to occur more often among patients with COVID‐19 than otherwise expected in the setting of viral pneumonia and sepsis. Systemic inflammatory biomarkers may be associated with venous thromboembolism (VTE) risk. The ISTH subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease aimed to report the evidence on prognostic biomarkers for VTE in hospitalized patients with COVID‐19. Methods Using a standardized Preferred Reporting Items for Systematic Reviews and Meta‐analysis methodology, we conducted a systematic literature review to identify studies reporting prognostic biomarkers for VTE among hospitalized patients with COVID‐19. Eligible studies included adults hospitalized with COVID‐19 and reported the prognostic associations between any biomarker measured on admission, and the subsequent diagnosis of deep vein thrombosis or pulmonary embolism. Two authors reviewed titles and abstracts, and three authors extracted study data and performed review of bias. Results were displayed descriptively. Meta‐analysis was not possible. Results From the initial 196 identified studies, full‐text review was performed for 72 studies. Admission D‐dimer levels were associated with VTE during hospitalization in five studies, and elevated platelet count was associated with VTE during hospitalization in one study. The risk of bias ranged from low to high for included studies. Overall, there was a paucity of high‐quality prognostic studies. Studies on other biomarkers did not meet the systematic review inclusion criteria. Conclusions Admission D‐dimer was associated with VTE diagnosis during hospitalization for COVID‐19; however, prospective validation of this finding is needed to identify optimal D‐dimer thresholds to guide VTE prophylaxis measures.
Collapse
Affiliation(s)
- Scott C Woller
- Department of Medicine Intermountain Medical Center, Intermountain Healthcare Murray Utah USA.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City Utah USA
| | - Kerstin de Wit
- Departments of Emergency Medicine and Medicine Queen's University Kingston Ontario Canada.,Departments of Medicine and HEI McMaster University Hamilton Ontario Canada
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Camila Masias
- Florida International University - Herbert Wertheim College of Medicine Miami Florida USA
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Paul L den Exter
- Department of Medicine - Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Pierre-Emmanuel Morange
- Aix Marseille Univ Marseille France.,Hematology Department La Timone University Hospital of Marseille Marseille France
| | - David Castelli
- Library Sciences Intermountain Healthcare Murray Utah USA
| | | |
Collapse
|
9
|
van der Heiden W, Koopman JJEB, Appelman-Dijkstra NM, den Exter PL. [Hyperkalemia due to low-molecular-weight heparin]. Ned Tijdschr Geneeskd 2022; 166:D6367. [PMID: 35736382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The cause of hyperkalemia is frequently iatrogenic. Patient's prescriptions should therefore be checked in the analysis of the hyperkalemia. Low-molecular-weight heparin is not often suspected to cause this. CASE DESCRIPTION A 64-year-old man, hospitalized because of a complicated clinical course of pancreatitis, developed an acute severe hyperkalemia. Further analysis was susceptive for hypoaldosteronism, which was confirmed with biochemical testing. The only drug that could cause hyperkalemia in this case was nadroparin, which was prescribed because of vena lienalis and a superior mesenteric vein thrombosis. A rechallenge with nadroparin showed a rapid rise in serum potassium, confirming our suspicion. CONCLUSION In the diagnostic work-up of hyperkalemia, hypoaldosteronism should be considered in patients using LMWH. In particular when other risk factors for hyperkalemia are present, monitoring of potassium could be advised in patients receiving these agents.
Collapse
Affiliation(s)
| | | | | | - Paul L den Exter
- LUMC, Leiden. Afd. Interne Geneeskunde
- Contact: Paul L. den Exter
| |
Collapse
|
10
|
Maas DPMSM, Saes JL, Blijlevens NMA, Cnossen M, den Exter PL, Kruis IC, Meijer K, Nieuwenhuizen L, Peters M, Schutgens REG, van Heerde WL, Schols SEM. Treatment of patients with rare bleeding disorders in the Netherlands: Real-life data from the RBiN study. J Thromb Haemost 2022; 20:833-844. [PMID: 35038781 PMCID: PMC9305774 DOI: 10.1111/jth.15652] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Patients with rare inherited bleeding disorders (RBDs) exhibit hemorrhagic symptoms, varying in type and severity, often requiring only on-demand treatment. Prolonged bleeding after invasive procedures is common. Adequate peri-procedural therapy may reduce this bleeding risk. OBJECTIVE To describe general treatment plans of RBD patients and evaluate the use of peri-procedural hemostatic therapy. METHODS In the Rare Bleeding Disorders in the Netherlands (RBiN) study, RBD patients from all six Dutch Hemophilia Treatment Centers were included. General treatment plans were extracted from patient files. Patients with a dental or surgical procedure in their history were interviewed about use of peri-procedural treatment and bleeding complications. RESULTS Two-hundred sixty-three patients with a rare coagulation factor deficiency or fibrinolytic disorder were included. Eighty-four percent had a documented general treatment plan. General treatment plans of patients with the same RBD were heterogeneous, particularly in factor XI deficiency. Overall, 308 dental and 408 surgical procedures were reported. Bleeding occurred in 50% of dental and 53% of surgical procedures performed without hemostatic treatment and in 28% of dental and 19% of surgical procedures performed with hemostatic treatment. Not only patients with severe RBDs, but also patients with mild deficiencies, experienced increased bleeding without proper hemostatic treatment. CONCLUSION Large heterogeneity in general treatment plans of RBD patients was found. Bleeding after invasive procedures was reported frequently, both before and after RBD diagnosis, irrespective of factor activity levels and particularly when peri-procedural treatment was omitted. Improved guidelines should include uniform recommendations for most appropriate hemostatic products per RBD and emphasize the relevance of individual bleeding history.
Collapse
Affiliation(s)
- Dominique P. M. S. M. Maas
- Department of HematologyRadboud University Medical CenterNijmegenthe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐Maastrichtthe Netherlands
| | - Joline L. Saes
- Department of HematologyRadboud University Medical CenterNijmegenthe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐Maastrichtthe Netherlands
| | | | - Marjon H. Cnossen
- Department of Pediatric Hematology and OncologyErasmus MC‐Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Paul L. den Exter
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | | | - Karina Meijer
- Department of HematologyUniversity Medical Center GroningenGroningenthe Netherlands
| | - Laurens Nieuwenhuizen
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐Maastrichtthe Netherlands
- Department of HematologyMaxima Medical CenterEindhoventhe Netherlands
| | - Marjolein Peters
- Department of Pediatric HematologyAmsterdam University Medical CentersLocation Emma Children’s HospitalAmsterdamthe Netherlands
| | - Roger E. G. Schutgens
- Department of Benign Hematology, van CreveldkliniekUniversity Medical Center Utrecht and University UtrechtUtrechtthe Netherlands
| | - Waander L. van Heerde
- Department of HematologyRadboud University Medical CenterNijmegenthe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐Maastrichtthe Netherlands
- Enzyre BVNovio Tech CampusNijmegenthe Netherlands
| | - Saskia E. M. Schols
- Department of HematologyRadboud University Medical CenterNijmegenthe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐Maastrichtthe Netherlands
| | | |
Collapse
|
11
|
Becattini C, Maraziti G, Vinson DR, Ng ACC, den Exter PL, Côté B, Vanni S, Doukky R, Khemasuwan D, Weekes AJ, Soares TH, Ozsu S, Polo Friz H, Erol S, Agnelli G, Jiménez D. Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis. Eur Heart J 2021; 42:3190-3199. [PMID: 34179965 DOI: 10.1093/eurheartj/ehab329] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 01/01/2023] Open
Abstract
AIMS Patients with acute pulmonary embolism (PE) at low risk for short-term death are candidates for home treatment or short-hospital stay. We aimed at determining whether the assessment of right ventricle dysfunction (RVD) or elevated troponin improves identification of low-risk patients over clinical models alone. METHODS AND RESULTS Individual patient data meta-analysis of studies assessing the relationship between RVD or elevated troponin and short-term mortality in patients with acute PE at low risk for death based on clinical models (Pulmonary Embolism Severity Index, simplified Pulmonary Embolism Severity Index or Hestia). The primary study outcome was short-term death defined as death occurring in hospital or within 30 days. Individual data of 5010 low-risk patients from 18 studies were pooled. Short-term mortality was 0.7% [95% confidence interval (CI) 0.4-1.3]. RVD at echocardiography, computed tomography or B-type natriuretic peptide (BNP)/N-terminal pro BNP (NT-proBNP) was associated with increased risk for short-term death (1.5 vs. 0.3%; OR 4.81, 95% CI 1.98-11.68), death within 3 months (1.6 vs. 0.4%; OR 4.03, 95% CI 2.01-8.08), and PE-related death (1.1 vs. 0.04%; OR 22.9, 95% CI 2.89-181). Elevated troponin was associated with short-term death (OR 2.78, 95% CI 1.06-7.26) and death within 3 months (OR 3.68, 95% CI 1.75-7.74). CONCLUSION RVD assessed by echocardiography, computed tomography, or elevated BNP/NT-proBNP levels and increased troponin are associated with short-term death in patients with acute PE at low risk based on clinical models. RVD assessment, mainly by BNP/NT-proBNP or echocardiography, should be considered to improve identification of low-risk patients that may be candidates for outpatient management or short hospital stay.
Collapse
Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Ospedale Santa Maria della Misericordia, Via G. Dottori 1, 06129 Perugia, Italy
| | - Giorgio Maraziti
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Ospedale Santa Maria della Misericordia, Via G. Dottori 1, 06129 Perugia, Italy
| | - David R Vinson
- Department of Emergency Medicine, The Permanente Medical Group and the Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Austin C C Ng
- Cardiology Department, Concord Hospital, The University of Sydney, Concord, NSW, Australia
| | - Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Benoit Côté
- Département de Médecine Interne, Hôpital de l'Enfant-Jésus du CHU de Québec, Université Laval, Québec, Canada
| | - Simone Vanni
- Emergency Medicine Unit, Empoli, Azienda Usl Toscana Centro, Italy
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA
| | - Danai Khemasuwan
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Anthony J Weekes
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Thiago Horta Soares
- Internal Medicine Division, Rede Mater Dei de Saúde, Belo Horizonte, Minas Gerais, Brazil
| | - Savas Ozsu
- Department of Pulmonary Medicine, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Hernan Polo Friz
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Serhat Erol
- University of Ankara School of Medicine, Pulmonary Diseases Department, Ankara, Turkey
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Ospedale Santa Maria della Misericordia, Via G. Dottori 1, 06129 Perugia, Italy
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá (IRYCIS), Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
12
|
Braams NJ, Boon GJAM, de Man FS, van Es J, den Exter PL, Kroft LJM, Beenen LFM, Huisman MV, Nossent EJ, Boonstra A, Vonk Noordegraaf A, Ruigrok D, Klok FA, Bogaard HJ, Meijboom LJ. Evolution of CT findings after anticoagulant treatment for acute pulmonary embolism in patients with and without an ultimate diagnosis of chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 58:13993003.00699-2021. [PMID: 34112733 DOI: 10.1183/13993003.00699-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/13/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The pulmonary arterial morphology of patients with pulmonary embolism (PE) is diverse and it is unclear how the different vascular lesions evolve after initiation of anticoagulant treatment. A better understanding of the evolution of computed tomography pulmonary angiography (CTPA) findings after the start of anticoagulant treatment may help to better identify those PE patients prone to develop chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to assess the evolution of various thromboembolic lesions on CTPA over time after the initiation of adequate anticoagulant treatment in individual acute PE patients with and without an ultimate diagnosis of CTEPH. METHODS We analysed CTPA at diagnosis of acute PE (baseline) and at follow-up in 41 patients with CTEPH and 124 patients without an ultimate diagnosis of CTEPH, all receiving anticoagulant treatment. Central and segmental pulmonary arteries were scored by expert chest radiologists as normal or affected. Lesions were further subclassified as 1) central thrombus, 2) total thrombotic occlusion, 3) mural thrombus, 4) web or 5) tapered pulmonary artery. RESULTS Central thrombi resolved after anticoagulant treatment, while mural thrombi and total thrombotic occlusions either resolved or evolved into webs or tapered pulmonary arteries. Only patients with an ultimate diagnosis of CTEPH exhibited webs and tapered pulmonary arteries on the baseline scan. Moreover, such lesions always persisted after follow-up. CONCLUSIONS Webs and tapered pulmonary arteries at the time of PE diagnosis strongly indicate a state of chronic PE and should raise awareness for possible CTEPH, particularly in patients with persistent dyspnoea after anticoagulant treatment for acute PE.
Collapse
Affiliation(s)
- Natalia J Braams
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gudula J A M Boon
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frances S de Man
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Josien van Es
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul L den Exter
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Dept of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ludo F M Beenen
- Dept of Radiology, Amsterdam UMC, AMC, Amsterdam, The Netherlands
| | - Menno V Huisman
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther J Nossent
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anco Boonstra
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dieuwertje Ruigrok
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Harm Jan Bogaard
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands .,H.J. Bogaard and L.J. Meijboom are co-last authors and contributed equally to this work
| | - Lilian J Meijboom
- Dept of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,H.J. Bogaard and L.J. Meijboom are co-last authors and contributed equally to this work
| |
Collapse
|
13
|
den Exter PL, Kroft LJM, Gonsalves C, Le Gal G, Schaefer-Prokop CM, Carrier M, Huisman MV, Klok FA. Establishing diagnostic criteria and treatment of subsegmental pulmonary embolism: A Delphi analysis of experts. Res Pract Thromb Haemost 2020; 4:1251-1261. [PMID: 33313465 PMCID: PMC7695556 DOI: 10.1002/rth2.12422] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/25/2020] [Accepted: 07/04/2020] [Indexed: 12/27/2022] Open
Abstract
Background Improved imaging techniques have increased the incidence of subsegmental pulmonary embolism (ssPE). Indirect evidence is suggesting that ssPE may represent a more benign presentation of venous thromboembolism not necessarily requiring anticoagulant treatment. However, correctly diagnosing ssPE is challenging with reported low interobserver agreement, partly due to the lack of widely accepted diagnostic criteria. Objectives We sought to derive uniform diagnostic criteria for ssPE, guided by expert consensus. Methods Based on an extensive literature review and expert opinion of a Delphi steering committee, two surveys including statements regarding diagnostic criteria and management options for ssPE were established. These surveys were conducted electronically among two panels, respectively: expert thoracic radiologists and clinical venous thromboembolism specialists. The Delphi method was used to achieve consensus after multiple survey rounds. Consensus was defined as a level of agreement >70%. Results Twenty‐nine of 40 invited radiologists (73%) and 40 of 51 clinicians (78%) participated. Following two survey rounds by the expert radiologists, consensus was achieved on 15 of 16 statements, including on the established diagnostic criteria for ssPE (96% agreement): a contrast defect in a subsegmental artery, that is, the first arterial branch division of any segmental artery independent of artery diameter, visible in at least two subsequent axial slices, using a computed tomography scanner with a desired maximum collimator width of ≤1 mm. These criteria were approved by 83% of the clinical venous thromboembolism (VTE) specialists. The clinical expert panel favored anticoagulant treatment in case of prior VTE, antiphospholipid syndrome, pregnancy, cancer, and proximal deep vein thrombosis. Conclusion The results of this analysis provide standard radiological criteria for ssPE that may be applicable in both clinical trials and practice.
Collapse
Affiliation(s)
- Paul L den Exter
- Department of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Lucia J M Kroft
- Department of Radiology Leiden University Medical Center Leiden The Netherlands
| | - Carol Gonsalves
- Department of Medicine Ottawa Hospital Research Institute at the University of Ottawa Ontario Canada
| | - Gregoire Le Gal
- Department of Medicine Ottawa Hospital Research Institute at the University of Ottawa Ontario Canada
| | - Cornelia M Schaefer-Prokop
- Diagnostic Image Analysis Group Department of Radiology and Nuclear Medicine Radboud University Medical Center Nijmegen The Netherlands.,Department of Radiology Meander Medisch Centrum Amersfoort The Netherlands
| | - Marc Carrier
- Department of Medicine Ottawa Hospital Research Institute at the University of Ottawa Ontario Canada
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| |
Collapse
|
14
|
Hendriks SV, Klok FA, den Exter PL, Eijsvogel M, Faber LM, Hofstee HMA, Iglesias Del Sol A, Kroft LJM, Mairuhu ATA, Huisman MV. Right Ventricle-to-Left Ventricle Diameter Ratio Measurement Seems to Have No Role in Low-Risk Patients with Pulmonary Embolism Treated at Home Triaged by Hestia Criteria. Am J Respir Crit Care Med 2020; 202:138-141. [PMID: 32203673 DOI: 10.1164/rccm.202002-0267le] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Stephan V Hendriks
- Leiden University Medical CenterLeiden, the Netherlands.,Haga Teaching HospitalThe Hague, the Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Hendriks SV, den Exter PL, Zondag W, Brouwer R, Eijsvogel M, Grootenboers MJ, Faber LM, Heller-Baan R, Hofstee HMA, Iglesias del Sol A, Kruip MJHA, Mairuhu ATA, Melissant CF, Peltenburg HG, van de Ree MA, Serné EH, Huisman MV, Klok FA. Reasons for Hospitalization of Patients with Acute Pulmonary Embolism Based on the Hestia Decision Rule. Thromb Haemost 2020; 120:1217-1220. [DOI: 10.1055/s-0040-1713170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Background The Hestia criteria can be used to select pulmonary embolism (PE) patients for outpatient treatment. The subjective Hestia criterion “medical/social reason for admission” allows the treating physician to consider any patient-specific circumstances in the final management decision. It is unknown how often and why this criterion is scored.
Methods This is a patient-level post hoc analysis of the combined Hestia and Vesta studies. The main outcomes were the frequency of all scored Hestia items in hospitalized patients and the explicit reason for scoring the subjective criterion. Hemodynamic parameters and computed tomography-assessed right ventricular (RV)/left ventricular (LV) ratio of those only awarded with the subjective criterion were compared with patients treated at home.
Results From the 1,166 patients screened, data were available for all 600 who were hospitalized. Most were hospitalized to receive oxygen therapy (45%); 227 (38%) were only awarded with the subjective criterion, of whom 51 because of “intermediate to intermediate-high risk PE.” Compared with patients with intermediate risk PE (RV/LV ratio > 1.0) treated at home (179/566, 32%), hospitalized patients with only the subjective criterion had a higher mean RV/LV ratio (mean difference +0.30, 95% confidence interval [CI] 0.19–0.41) and a higher heart rate (+18/min, 95% CI 10–25). No relevant differences were observed for other hemodynamic parameters.
Conclusion The most frequent reason for hospital admission was oxygen therapy. In the decision to award the subjective criterion as sole argument for admission, the severity of the RV overload and resulting hemodynamic response of the patient was taken into account rather than just abnormal RV/LV ratio.
Collapse
Affiliation(s)
- Stephan V. Hendriks
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Paul L. den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy Zondag
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf Brouwer
- Department of Internal Medicine, Reinier de Graaff Gasthuis, Delft, The Netherlands
| | - Michiel Eijsvogel
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Laura M. Faber
- Department of Pulmonary Medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - Roxanne Heller-Baan
- Department of Pulmonary Medicine, Ikazia Hospital, Rotterdam, The Netherlands
| | - Herman M. A. Hofstee
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Marieke J. H. A. Kruip
- Department of Haematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Albert T. A. Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | | | - Henny G. Peltenburg
- Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
| | | | - Erik H. Serné
- Department of Internal Medicine, VU Medical Center, Amsterdam, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | |
Collapse
|
16
|
den Exter PL, Beeres SLMA, Eikenboom J, Klok FA, Huisman MV. Anticoagulant treatment and bleeding complications in patients with left ventricular assist devices. Expert Rev Cardiovasc Ther 2020; 18:363-372. [PMID: 32449431 DOI: 10.1080/14779072.2020.1773803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The treatment options for advanced heart failure patients drastically changed with the introduction of left ventricular assist devices (LVADs), either as bridge to transplant or as destination therapy for patients ineligible for transplant. Despite major benefits in terms of survival, functional status and quality of life, managing patients with LVADs comes with several challenges. The most significant challenge is balancing between the risks of thrombotic and bleeding complications. AREAS COVERED The present review describes the pathophysiological mechanisms explaining the alterations in the hemostatic profile of LVAD patients, and summarizes current evidence to guide clinical decision making with regard to anticoagulant treatment and management of bleeding complications. EXPERT OPINION LVAD patients require life-long anticoagulant therapy to reduce the risk of pump thrombosis. However, exposing LVAD patients to anticoagulant therapy, in combination with common acquired coagulopathies after LVAD implantation such as acquired von Willebrand syndrome, comes with high risks of bleeding. There is a need for randomized controlled trials in LVAD patients to determine the optimal antithrombotic regimen and find the most effective balance between thrombotic and bleeding complications. In addition, strategies to specifically target the acquired von Willebrand syndrome and its associated angiodysplasias need to be evaluated in the LVAD population.
Collapse
Affiliation(s)
- Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
| | - Saskia L M A Beeres
- Department of Cardiology, Leiden University Medical Center , Leiden, The Netherlands
| | - Jeroen Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
| |
Collapse
|
17
|
Klok FA, den Exter PL, Huisman MV, Eikenboom J. [Dealing with COVID-19-associated coagulopathy]. Ned Tijdschr Geneeskd 2020; 164:D5031. [PMID: 32395964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
COVID-19 is associated with a high prevalence of activation of the coagulation cascade. It has been suggested that this so-called COVID-19-associated coagulopathy is predictive of a poor outcome and of mortality. Consensus documents on how to manage patients with COVID-19-associated coagulopathy are based on the limited number of mainly retrospective studies that is currently available, and for this reason the recommendations are not always consistent with one another. In this article, we review the first studies into COVID-19-associated coagulopathy and give the most important do's and don'ts for diagnostics and the daily management of coagulopathy and the prevention of complications in patients with, or with strongly-suspected, COVID-19 in Dutch clinical practice.
Collapse
Affiliation(s)
- Frederikus A Klok
- Leids Universitair Medisch Centrum, afd. Trombose en Hemostase, Leiden
- Contact: Frederikus A. Klok
| | - Paul L den Exter
- Leids Universitair Medisch Centrum, afd. Trombose en Hemostase, Leiden
| | - Menno V Huisman
- Leids Universitair Medisch Centrum, afd. Trombose en Hemostase, Leiden
| | - Jeroen Eikenboom
- Leids Universitair Medisch Centrum, afd. Trombose en Hemostase, Leiden
| |
Collapse
|
18
|
Hendriks SV, Lankeit M, den Exter PL, Zondag W, Brouwer R, Eijsvogel M, Grootenboers MJ, Faber LM, Heller-Baan R, Hofstee HMA, Iglesias Del Sol A, Mairuhu ATA, Melissant CF, Peltenburg HG, van de Ree MA, Serné EH, Konstantinides S, Klok FA, Huisman MV. Uncertain Value of High-sensitive Troponin T for Selecting Patients With Acute Pulmonary Embolism for Outpatient Treatment by Hestia Criteria. Acad Emerg Med 2020; 27:1043-1046. [PMID: 32163216 PMCID: PMC7687260 DOI: 10.1111/acem.13943] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Stephan V Hendriks
- From the, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,the, Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - Mareike Lankeit
- the, Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,the, Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany
| | - Paul L den Exter
- From the, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy Zondag
- From the, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf Brouwer
- the, Department of Internal Medicine, Reinier de Graaff Gasthuis, Delft, The Netherlands
| | - Michiel Eijsvogel
- the, Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Laura M Faber
- the, Department of Pulmonary medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
| | | | - Herman M A Hofstee
- the, Department of Internal Medicine, Haaglanden MC, The Hague, The Netherlands
| | | | - Albert T A Mairuhu
- the, Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | | | - Henny G Peltenburg
- the, Department of Internal Medicine, Groene hart Hospital, Gouda, The Netherlands
| | - Marcel A van de Ree
- the, Department of Internal Medicine, Diakonessenhuis, Utrecht, The Netherlands
| | - Erik H Serné
- and the, Department of Internal Medicine, VU Medical Center, Amsterdam, The Netherlands
| | - Stavros Konstantinides
- the, Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Frederikus A Klok
- From the, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,the, Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Menno V Huisman
- From the, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | |
Collapse
|
19
|
den Exter PL, Huisman MV. Direct oral anticoagulants and obesity: one size fits all? Lancet Haematol 2019; 6:e341-e342. [PMID: 31133410 DOI: 10.1016/s2352-3026(19)30092-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 05/07/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Postbus 9600, 2300 RC, The Netherlands.
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Postbus 9600, 2300 RC, The Netherlands
| |
Collapse
|
20
|
van der Pol LM, Bistervels IM, van Mens TE, van der Hulle T, Beenen LFM, den Exter PL, Kroft LJM, Mairuhu ATA, Middeldorp S, van Werkhoven JM, Ten Wolde M, Huisman MV, Klok FA. Lower prevalence of subsegmental pulmonary embolism after application of the YEARS diagnostic algorithm. Br J Haematol 2018; 183:629-635. [PMID: 30198551 PMCID: PMC6282699 DOI: 10.1111/bjh.15556] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/29/2018] [Indexed: 12/11/2022]
Abstract
The rate of identified isolated subsegmental pulmonary embolism (ssPE) has doubled with advances in computed tomography pulmonary angiography (CTPA) technology, but its clinical relevance is debated. The YEARS diagnostic algorithm was shown to safely reduce the number of required CTPAs in the diagnostic management of PE. We hypothesized that the higher threshold for performing CTPA in YEARS was associated with a lower prevalence of ssPE compared to the conventional diagnostic algorithm. We compared 2291 consecutive patients with suspected PE managed according to YEARS to 3306 consecutive control patients managed according to the Wells score for the prevalence of isolated ssPE. In the YEARS cohort, 52% were managed without CTPA, 12% had pulmonary embolism (PE) of which 10% were isolated ssPE, and the 3‐month diagnostic failure rate was 0·35%. In the control cohort, 32% were managed without CTPA, 20% had PE of which 16% were isolated ssPE, and the 3‐month failure rate was 0·73%. The isolated ssPE prevalence was significantly lower in YEARS (absolute difference 6·2% (95% confidence interval [CI] 1·4–10), Odds Ratio 0·58 (95% CI 0·37–0·90). In conclusion, YEARS is associated with a lower prevalence of isolated ssPE, due to reduction in CTPAs by the higher D‐dimer threshold. This was however not associated with a higher risk of recurrent VTE during follow‐up.
Collapse
Affiliation(s)
- Liselotte M van der Pol
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Ingrid M Bistervels
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands.,Department of Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Thijs E van Mens
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Tom van der Hulle
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Paul L den Exter
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| |
Collapse
|
21
|
Crobach MJT, Dolsma A, Donker ML, Eijsvogel M, Faber LM, Hofstee HMA, Kaasjager KAH, Kruip MJHA, Labots G, Melissant CF, Sikkens MSG, Huisman MV, Zondag W, den Exter PL. Comparison of two methods for selection of out of hospital treatment in patients with acute pulmonary embolism. Thromb Haemost 2017; 109:47-52. [DOI: 10.1160/th12-07-0466] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 10/08/2012] [Indexed: 11/05/2022]
Abstract
SummaryThe aim of this study is to compare the performance of two clinical decision rules to select patients with acute pulmonary embolism (PE) for outpatient treatment: the Hestia criteria and the simplified Pulmonary Embolism Severity Index (sPESI). From 2008 to 2010, 468 patients with PE were triaged with the Hestia criteria for outpatient treatment: 247 PE patients were treated at home and 221 were treated as inpatients. The outcome of interest was all-cause 30-day mortality. In a post-hoc fashion, the sPESI items were scored and patients were classified according to the sPESI in low and high risk groups. Of the 247 patients treated at home, 189 (77%) patients were classified as low risk according to the sPESI and 58 patients (23%) as high risk. In total, 11 patients died during the first month; two patients treated at home and nine patients treated in-hospital. None of the patients treated at home died of fatal PE. Both the Hestia criteria and sPESI selected >50% of patients as low risk, with good sensitivity and negative predictive values for 30-day mortality: 82% and 99% for the Hestia criteria and 91% and 100% for the sPESI, respectively. The Hestia criteria and the sPESI classified different patients eligible for out-patient treatment, with similar low risks for 30-day mortality. This study suggests that the Hestia criteria may identify a proportion of high risk sPESI patiennts who can be safely treated at home, this however requires further validation.
Collapse
|
22
|
Kroft LJM, Erkens PMG, Douma RA, Mos ICM, Jonkers G, Hovens MMC, Durian MF, Cate HT, Beenen LFM, Kamphuisen PW, Huisman MV, den Exter PL, van Es J. Thromboembolic resolution assessed by CT pulmonary angiography after treatment for acute pulmonary embolism. Thromb Haemost 2017; 114:26-34. [DOI: 10.1160/th14-10-0842] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/13/2015] [Indexed: 11/05/2022]
Abstract
SummaryThe systematic assessment of residual thromboembolic obstruction after treatment for acute pulmonary embolism (PE) has been under-studied. This assessment is of potential clinical importance, should clinically suspected recurrent PE occur, or as tool for risk stratification of cardiopulmonary complications or recurrent venous thromboembolism (VTE). This study aimed to assess the rate of PE resolution and its implications for clinical outcome. In this prospective, multi-center cohort study, 157 patients with acute PE diagnosed by CT pulmonary angiography (CTPA) underwent follow-up CTPA-imaging after six months of anticoagulant treatment. Two expert thoracic radiologists independently assessed the presence of residual thromboembolic obstruction. The degree of obstruction at baseline and follow-up was calculated using the Qanadli obstruction index. All patients were followed-up for 2.5 years. At baseline, the median obstruction index was 27.5 %. After six months of treatment, complete PE resolution had occurred in 84.1 % of the patients (95 % confidence interval (CI): 77.4–89.4 %). The median obstruction index of the 25 patients with residual thrombotic obstruction was 5.0 %. During follow-up, 16 (10.2 %) patients experienced recurrent VTE. The presence of residual thromboembolic obstruction was not associated with recurrent VTE (adjusted hazard ratio: 0.92; 95 % CI: 0.2–4.1). This study indicates that the incidence of residual thrombotic obstruction following treatment for PE is considerably lower than currently anticipated. These findings, combined with the absence of a correlation between residual thrombotic obstruction and recurrent VTE, do not support the routine use of follow-up CTPA-imaging in patients treated for acute PE.
Collapse
|
23
|
den Exter PL, Klok FA, Huisman MV. Reply: N-Terminal Pro–Brain Natriuretic Peptide Trial Design. Am J Respir Crit Care Med 2017; 196:531-532. [DOI: 10.1164/rccm.201701-0252le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
24
|
van der Hulle T, van Es N, den Exter PL, van Es J, Mos ICM, Douma RA, Kruip MJHA, Hovens MMC, Ten Wolde M, Nijkeuter M, Ten Cate H, Kamphuisen PW, Büller HR, Huisman MV, Klok FA. Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability? A patient-level meta-analysis. Thromb Haemost 2017; 117:1622-1629. [PMID: 28569924 DOI: 10.1160/th17-02-0076] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/20/2017] [Indexed: 12/21/2022]
Abstract
A normal computed tomography pulmonary angiography (CTPA) remains a controversial criterion for ruling out acute pulmonary embolism (PE) in patients with a likely clinical probability. We set out to determine the risk of VTE and fatal PE after a normal CTPA in this patient category and compare these risk to those after a normal pulmonary angiogram of 1.7 % (95 %CI 1.0-2.7 %) and 0.3 % (95 %CI 0.02-0.7 %). A patient-level meta-analysis from 4 prospective diagnostic management studies that sequentially applied the Wells rule, D-dimer tests and CTPA to consecutive patients with clinically suspected acute PE. The primary outcome was the 3-month VTE incidence after a normal CTPA. A total of 6,148 patients were included with an overall PE prevalence of 24 %. The 3-month VTE incidence in all 4,421 patients in whom PE was excluded at baseline was 1.2 % (95 %CI 0.48-2.6) and the risk of fatal PE was 0.11 % (95 %CI 0.02-0.70). In patients with a likely clinical probability the 3-month incidences of VTE and fatal PE were 2.0 % (95 %CI 1.0-4.1 %) and 0.48 % (95 %CI 0.20-1.1 %) after a normal CTPA. The 3-month incidence of VTE was 6.3 % (95 %CI 3.0-12) in patients with a Wells rule >6 points. In conclusion, this study suggests that a normal CTPA may be considered as a valid diagnostic criterion to rule out PE in the majority of patients with a likely clinical probability, although the risk of VTE is higher in subgroups such as patients with a Wells rule >6 points for which a closer follow-up should be considered.
Collapse
Affiliation(s)
- Tom van der Hulle
- Tom van der Hulle, MD, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, P.O Box 9600, 2300 RC, Leiden, the Netherlands, Tel.: + 31 71 526 8132, Fax: +31 71 526 6868, E-mail:
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
den Exter PL, Zondag W, Klok FA, Brouwer RE, Dolsma J, Eijsvogel M, Faber LM, van Gerwen M, Grootenboers MJ, Heller-Baan R, Hovens MM, Jonkers GJPM, van Kralingen KW, Melissant CF, Peltenburg H, Post JP, van de Ree MA, Vlasveld LT(T, de Vreede MJ, Huisman MV. Efficacy and Safety of Outpatient Treatment Based on the Hestia Clinical Decision Rule with or without N-Terminal Pro–Brain Natriuretic Peptide Testing in Patients with Acute Pulmonary Embolism. A Randomized Clinical Trial. Am J Respir Crit Care Med 2016; 194:998-1006. [DOI: 10.1164/rccm.201512-2494oc] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
26
|
van Es N, van der Hulle T, van Es J, den Exter PL, Douma RA, Goekoop RJ, Mos ICM, Galipienzo J, Kamphuisen PW, Huisman MV, Klok FA, Büller HR, Bossuyt PM. Wells Rule and d-Dimer Testing to Rule Out Pulmonary Embolism: A Systematic Review and Individual-Patient Data Meta-analysis. Ann Intern Med 2016; 165:253-61. [PMID: 27182696 DOI: 10.7326/m16-0031] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The performance of different diagnostic strategies for pulmonary embolism (PE) in patient subgroups is unclear. PURPOSE To evaluate and compare the efficiency and safety of the Wells rule with fixed or age-adjusted d-dimer testing overall and in inpatients and persons with cancer, chronic obstructive pulmonary disease, previous venous thromboembolism, delayed presentation, and age 75 years or older. DATA SOURCES MEDLINE and EMBASE from 1 January 1988 to 13 February 2016. STUDY SELECTION 6 prospective studies in which the diagnostic management of PE was guided by the dichotomized Wells rule and quantitative d-dimer testing. DATA EXTRACTION Individual data of 7268 patients; risk of bias assessed by 2 investigators with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool. DATA SYNTHESIS The proportion of patients in whom imaging could be withheld based on a "PE-unlikely" Wells score and a negative d-dimer test result (efficiency) was estimated using fixed (≤500 µg/L) and age-adjusted (age × 10 µg/L in patients aged >50 years) d-dimer thresholds; their 3-month incidence of symptomatic venous thromboembolism (failure rate) was also estimated. Overall, efficiency increased from 28% to 33% when the age-adjusted (instead of the fixed) d-dimer threshold was applied. This increase was more prominent in elderly patients (12%) but less so in inpatients (2.6%). The failure rate of age-adjusted d-dimer testing was less than 3% in all examined subgroups. LIMITATION Post hoc analysis, between-study differences in patient characteristics, use of various d-dimer assays, and limited statistical power to assess failure rate. CONCLUSION Age-adjusted d-dimer testing is associated with a 5% absolute increase in the proportion of patients with suspected PE in whom imaging can be safely withheld compared with fixed d-dimer testing. This strategy seems safe across different high-risk subgroups, but its efficiency varies. PRIMARY FUNDING SOURCE None.
Collapse
|
27
|
Kooiman J, den Exter PL, Kilicsoy I, Cannegieter SC, Eikenboom J, Huisman MV, Klok FA, Versteeg HH. Association between micro particle-tissue factor activity, factor VIII activity and recurrent VTE in patients with acute pulmonary embolism. J Thromb Thrombolysis 2016; 40:323-30. [PMID: 25665657 PMCID: PMC4546691 DOI: 10.1007/s11239-015-1180-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Studies on the association between microparticle expressing tissue factor (MP-TF) activity, FVIII activity (FVIII:C) and recurrent VTE yielded inconclusive results. We studied these associations in patients diagnosed with acute pulmonary embolism. Plasma levels of MP-TF and FVIII activity were measured in 277 patients with a first and 72 patients with a recurrent VTE. All patients were categorized based on the quintiles of MP-TF and FVIII activity in those with a single VTE. For both markers, odds ratios (ORs) for recurrent VTE were computed using patients in the lowest quintile as a reference group. No association was observed between MP-TF activity and recurrent VTE, with an OR of 1.4 (95 % CI 0.7–2.9) in the highest quintile of MP-TF activity. Compared with the reference group, patients in the highest quintile of FVIII:C were at increased risk of recurrent VTE, OR 4.2 (95 % CI 1.4–12.2). MP-TF activity was not associated with recurrent VTE whereas high FVIII:C levels were associated with a 4-fold increased risk of VTE recurrence. Future prospective studies are necessary to explore the potential of FVIII:C as a tool for risk stratification, either by itself or in combination with other pro-thrombotic markers.
Collapse
Affiliation(s)
- Judith Kooiman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, C7-Q, P.O. Box 9600, 2300 RC, Leiden, The Netherlands,
| | | | | | | | | | | | | | | |
Collapse
|
28
|
van der Hulle T, den Exter PL, van den Hoven P, van der Hoeven JJ, van der Meer FJM, Eikenboom J, Huisman MV, Klok FA. Cohort Study on the Management of Cancer-Associated Venous Thromboembolism Aimed at the Safety of Stopping Anticoagulant Therapy in Patients Cured of Cancer. Chest 2016; 149:1245-51. [PMID: 26836911 DOI: 10.1016/j.chest.2015.10.069] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/11/2015] [Accepted: 10/15/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND After diagnosis of cancer-associated VTE, guidelines recommend considering the continuation of anticoagulant treatment until the patient is cured of cancer, although the safety of stopping anticoagulant treatment after the patient is cured has never been evaluated. METHODS We conducted a cohort study in consecutive patients in whom cancer-associated VTE was diagnosed at the Leiden University Medical Center between January 2001 and January 2010 and monitored for the effect of cancer treatment, occurrence of recurrent VTE, major hemorrhage, and death. RESULTS Of the 358 patients with cancer-associated VTE, anticoagulant treatment was continued until the death of 207 patients. In another 12 patients anticoagulant treatment was continued because of an alternative indication despite their being cured of cancer. Anticoagulant treatment was stopped in 50 patients for reasons other than major hemorrhage despite active cancer, in 21 patients after major hemorrhage, and in 68 patients after they had been cured of cancer. Among these 68 patients, 10 patients received a diagnosis of symptomatic recurrent VTE during a cumulative follow-up of 311 years, resulting in an incidence rate of 3.2 per 100 patient-years (95% CI, 1.5-5.9). Seven of these 10 patients with recurrent VTE experienced a cancer relapse during follow-up. For the 50 patients who stopped anticoagulant treatment despite active cancer the recurrent VTE incidence rate was 19 per 100 patient-years (11 events during 59 years of follow-up; 95% CI, 9.3-33). CONCLUSIONS Our data support the recommendation to stop anticoagulant treatment of cancer-associated VTE in patients cured of cancer. A cancer relapse seems to be a strong risk factor for recurrent symptomatic VTE.
Collapse
Affiliation(s)
- Tom van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Pim van den Hoven
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Felix J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
29
|
Jiménez D, Resano S, Otero R, Jurkojc C, Portillo AK, Ruiz-Artacho P, Corres J, Vicente A, den Exter PL, Huisman MV, Moores L, Yusen RD. Computerised clinical decision support for suspected PE: Table 1. Thorax 2015; 70:909-11. [DOI: 10.1136/thoraxjnl-2014-206689] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 01/14/2015] [Indexed: 11/03/2022]
|
30
|
Fabiá Valls MJ, van der Hulle T, den Exter PL, Mos ICM, Huisman MV, Klok FA. Performance of a diagnostic algorithm based on a prediction rule, D-dimer and CT-scan for pulmonary embolism in patients with previous venous thromboembolism. A systematic review and meta-analysis. Thromb Haemost 2014; 113:406-13. [PMID: 25373512 DOI: 10.1160/th14-06-0488] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 08/15/2014] [Indexed: 11/05/2022]
Abstract
Diagnostic management of suspected pulmonary embolism (PE) in patients with a history of venous thromboembolism (VTE) is complicated due to persistent abnormal D-dimer levels, residual embolic obstruction and higher clinical prediction rule (CPR) scores. We aimed to evaluate the safety and efficiency of the standard diagnostic algorithm consisting of a CPR, D-dimer test and computed tomography pulmonary angiography (CTPA) in this specific patient category. We performed a systematic literature search for prospective studies evaluating a diagnostic algorithm in consecutive patients with clinically suspected PE and a history of VTE. The VTE incidence rates during three-month follow-up and the number of indicated CTPAs were pooled using random effect models. Four studies concerning 1,286 patients were included with a pooled baseline PE prevalence of 36 % (95 % confidence interval [CI] 30-42). In only 217 patients (15 %; 95 %CI 11-20) PE could be excluded without CTPA. The three-month VTE incidence rate was 0.8 % (95 %CI 0.06-2.4) in patients managed without CTPA, 1.6 % (95 %CI 0.3-4.0) in patients in whom PE was excluded by CTPA and 1.4 % (95 %CI 0.6-2.7) overall. In the pooled studies, PE was safely excluded in patients with a history of VTE based on a CPR followed by a D-dimer test and/or CTPA, although the efficiency of the algorithm is relatively low compared to patients without a history of VTE.
Collapse
Affiliation(s)
| | - Tom van der Hulle
- Tom van der Hulle, MD, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, P. O. Box 9600, 2300 RC, Leiden, The Netherlands, Tel: +31 71 526 8132, Fax: +31 71 526 6868, E-mail:
| | | | | | | | | |
Collapse
|
31
|
van der Hulle T, Tan M, den Exter PL, van Roosmalen MJG, van der Meer FJM, Eikenboom J, Huisman MV, Klok FA. Recurrence risk after anticoagulant treatment of limited duration for late, second venous thromboembolism. Haematologica 2014; 100:188-93. [PMID: 25261098 DOI: 10.3324/haematol.2014.112896] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Patients with a second venous thromboembolism generally receive anticoagulant treatment indefinitely, although it is known that the recurrence risk diminishes over time while the risk of hemorrhage persists with continued anticoagulation and increases with age. Based on these arguments and limited evidence for indefinitely prolonged treatment, the Dutch guidelines recommend considering treatment of a limited duration (i.e. 12 months) for a 'late' second venous thromboembolism, defined by a second venous thromboembolism diagnosed more than 1 year after discontinuing treatment for a first event. It is hypothesized that the risk of continued anticoagulation might outweigh the benefits in such circumstances. We evaluated this management in daily practice. Since 2003, limited duration of treatment was systematically considered at our hospital in consecutive patients, in whom we determined the recurrence risk. Of 131 patients with late second venous thromboembolism, 77 were treated for a limited duration, of whom 26 developed a symptomatic third venous thromboembolism thereafter during a cumulative follow-up of 277 years, resulting in an incidence rate of 9.4/100 patient-years (95% confidence interval: 6.1-14). The incidence rates in patients with unprovoked and provoked venous thromboembolism were 12/100 patient-years (95% confidence interval: 7.4-19) and 5.6/100 patient-years (95% confidence interval: 2.2-12), respectively [adjusted hazard ratio 2.8 (95% confidence interval: 1.1-7.2)]. The recurrence risk after treatment of limited duration for 'late' second venous thromboembolism exceeded the risk of hemorrhage associated with extended anticoagulation. Most patients may, therefore, be better served by treatment of indefinite duration, although the risk-benefit ratio of extended anticoagulation should be weighed for every patient.
Collapse
Affiliation(s)
- Tom van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Melanie Tan
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Mark J G van Roosmalen
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Felix J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Jeroen Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| |
Collapse
|
32
|
van der Hulle T, den Exter PL, Mos ICM, Kamphuisen PW, Hovens MMC, Kruip MJHA, van Es J, ten Cate H, Huisman MV, Klok FA. Optimization of the diagnostic management of clinically suspected pulmonary embolism in hospitalized patients. Br J Haematol 2014; 167:681-6. [DOI: 10.1111/bjh.13090] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 07/09/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Tom van der Hulle
- Department of Thrombosis and Haemostasis; LUMC; Leiden The Netherlands
| | - Paul L. den Exter
- Department of Thrombosis and Haemostasis; LUMC; Leiden The Netherlands
| | - Inge C. M. Mos
- Department of Thrombosis and Haemostasis; LUMC; Leiden The Netherlands
| | - Pieter W. Kamphuisen
- Department of Vascular Medicine; University Medical Centre Groningen; Groningen The Netherlands
| | | | | | - Josien van Es
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - Hugo ten Cate
- Department of Internal Medicine and Cardiovascular Research Institute Maastricht; Maastricht University Medical Centre; Maastricht The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Haemostasis; LUMC; Leiden The Netherlands
| | | |
Collapse
|
33
|
|
34
|
den Exter PL, van den Hoven P, van der Hulle T, Mos ICM, Douma RA, van Es J, Huisman MV, Klok FA. Performance of the revised Geneva score in patients with a delayed suspicion of pulmonary embolism. Eur Respir J 2014; 43:1801-4. [PMID: 24525436 DOI: 10.1183/09031936.00214113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Paul L den Exter
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden Both authors contributed equally
| | - Pim van den Hoven
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden Both authors contributed equally
| | - Tom van der Hulle
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden
| | - Inge C M Mos
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden
| | - Renée A Douma
- Dept of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Josien van Es
- Dept of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Menno V Huisman
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden
| | - Frederikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden
| |
Collapse
|
35
|
van Es J, den Exter PL, Kaptein AA, Andela CD, Erkens PMG, Klok FA, Douma RA, Mos ICM, Cohn DM, Kamphuisen PW, Huisman MV, Middeldorp S. Quality of life after pulmonary embolism as assessed with SF-36 and PEmb-QoL. Thromb Res 2013; 132:500-5. [PMID: 24090607 DOI: 10.1016/j.thromres.2013.06.016] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 06/12/2013] [Accepted: 06/16/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Although quality of life (QoL) is recognized as an important indicator of the course of a disease, it has rarely been addressed in studies evaluating the outcome of care for patients with pulmonary embolism (PE). This study primarily aimed to evaluate the QoL of patients with acute PE in comparison to population norms and to patients with other cardiopulmonary diseases, using a generic QoL questionnaire. Secondary, the impact of time period from diagnosis and clinical patient characteristics on QoL was assessed, using a disease-specific questionnaire. METHODS QoL was assessed in 109 consecutive out-patients with a history of objectively confirmed acute PE (mean age 60.4 ± 15.0 years, 56 females), using the generic Short Form-36 (SF-36) and the disease specific Pulmonary Embolism Quality of Life questionnaire (PEmb-QoL). The score of the SF-36 were compared with scores of the general Dutch population and reference populations with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), a history of acute myocardial infarction (AMI), derived from the literature. Scores on the SF-35 and PEmb-QoL were used to evaluate QoL in the short-term and long-term clinical course of patients with acute PE. In addition, we examined correlations between PEmb-QoL scores and clinical patient characteristics. RESULTS Compared to scores of the general Dutch population, scores of PE patients were worse on several subscales of the SF-36 (social functioning, role emotional, general health (P<0.001), role physical and vitality (P<0.05)). Compared to patients with COPD and CHF, patients with PE scored higher (=better) on all subscales of the SF-36 (P ≤ 0.004) and had scores comparable with patients with AMI the previous year. Comparing intermediately assessed QoL with QoL assessed in long-term follow-up, PE patients scored worse on SF-36 subscales: physical functioning, social functioning, vitality (P<0.05), and on the PEmb-QoL subscales: emotional complaints and limitations in ADL (P ≤ 0.03). Clinical characteristics did not correlate with QoL as measured by PEmb-QoL. CONCLUSION Our study demonstrated an impaired QoL in patients after treatment of PE. The results of this study provided more knowledge about QoL in patients treated for PE.
Collapse
Affiliation(s)
- Josien van Es
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, the Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
den Exter PL, van Es J, Erkens PMG, van Roosmalen MJG, van den Hoven P, Hovens MMC, Kamphuisen PW, Klok FA, Huisman MV. Impact of delay in clinical presentation on the diagnostic management and prognosis of patients with suspected pulmonary embolism. Am J Respir Crit Care Med 2013; 187:1369-73. [PMID: 23590273 DOI: 10.1164/rccm.201212-2219oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
RATIONALE The nonspecific clinical presentation of pulmonary embolism (PE) frequently leads to delay in its diagnosis. OBJECTIVES This study aimed to assess the impact of delay in presentation on the diagnostic management and clinical outcome of patients with suspected PE. METHODS In 4,044 consecutive patients with suspected PE, patients presenting more than 7 days from the onset of symptoms were contrasted with those presenting within 7 days as regards the safety of excluding PE on the basis of a clinical decision rule combined with D-dimer testing. Patients were followed for 3 months to assess the rates of recurrent venous thromboembolism and mortality. MEASUREMENTS AND MAIN RESULTS A delayed presentation (presentation >7 d) was present in 754 (18.6%) of the patients. The failure rate of an unlikely clinical probability and normal D-dimer test was 0.5% (95% confidence interval [CI], 0.01-2.7) for patients with and 0.5% (95% CI, 0.2-1.2) for those without diagnostic delay. D-dimer testing yielded a sensitivity of 99% (95% CI, 96-99%) and 98% (95% CI, 97-99%) in these groups, respectively. Patients with PE with diagnostic delay more frequently had centrally located PE (41% vs. 26%; P < 0.001). The cumulative rates of recurrent venous thromboembolism (4.6% vs. 2.7%; P = 0.14) and mortality (7.6% vs. 6.6%; P = 0.31) were not different for patients with and without delayed presentation. CONCLUSIONS PE can be safely excluded based on a clinical decision rule and D-dimer testing in patients with a delayed clinical presentation. A delayed presentation for patients who survived acute PE was associated with a more central PE location, although this did not affect the clinical outcome at 3 months.
Collapse
Affiliation(s)
- Paul L den Exter
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
den Exter PL, Gómez V, Jiménez D, Trujillo-Santos J, Muriel A, Huisman MV, Monreal M. A clinical prognostic model for the identification of low-risk patients with acute symptomatic pulmonary embolism and active cancer. Chest 2013; 143:138-145. [PMID: 22814859 DOI: 10.1378/chest.12-0964] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Physicians need a specific risk-stratification tool to facilitate safe and cost-effective approaches to the management of patients with cancer and acute pulmonary embolism (PE). The objective of this study was to develop a simple risk score for predicting 30-day mortality in patients with PE and cancer by using measures readily obtained at the time of PE diagnosis. METHODS Investigators randomly allocated 1,556 consecutive patients with cancer and acute PE from the international multicenter Registro Informatizado de la Enfermedad TromboEmbólica to derivation (67%) and internal validation (33%) samples. The external validation cohort for this study consisted of 261 patients with cancer and acute PE. Investigators compared 30-day all-cause mortality and nonfatal adverse medical outcomes across the derivation and two validation samples. RESULTS In the derivation sample, multivariable analyses produced the risk score, which contained six variables: age > 80 years, heart rate ≥ 110/min, systolic BP < 100 mm Hg, body weight < 60 kg, recent immobility, and presence of metastases. In the internal validation cohort (n = 508), the 22.2% of patients (113 of 508) classified as low risk by the prognostic model had a 30-day mortality of 4.4% (95% CI, 0.6%-8.2%) compared with 29.9% (95% CI, 25.4%-34.4%) in the high-risk group. In the external validation cohort, the 18% of patients (47 of 261) classified as low risk by the prognostic model had a 30-day mortality of 0%, compared with 19.6% (95% CI, 14.3%-25.0%) in the high-risk group. CONCLUSIONS The developed clinical prediction rule accurately identifies low-risk patients with cancer and acute PE.
Collapse
Affiliation(s)
| | - Vicente Gómez
- Medicine Department, Ramón y Cajal Hospital, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain.
| | | | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | | | - Manuel Monreal
- Medicine Department, Germans Trias I Pujol Hospital, Badalona, Barcelona, Spain
| | | |
Collapse
|
38
|
Abstract
The signs and symptoms of patients with pulmonary embolism (PE) form a wide spectrum and considerably overlap with other cardiopulmonary diseases. Timely recognizing of this disease therefore remains challenging, but is of vital importance to avoid PE-related morbidity and mortality. To aid and standardize the initial diagnostic approach of patients with suspected PE, clinical probability rules have been developed and simplified for use in clinical practice. It has been demonstrated by clinical outcome studies that it is safe and of high clinical utility to exclude PE on the basis of an unlikely clinical probability and a normal D-dimer test result. For the remaining patients with suspected PE, imaging tests are required. The introduction of multi-detector computed tomographic pulmonary angiography (MD-CTA) has significantly improved the detection of PE, and this test is now regarded as the imaging test of first choice. This review will focus on recent advances and pitfalls that remain in the diagnostic work-up of patients with suspected acute PE.
Collapse
Affiliation(s)
- Paul L den Exter
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | | | | |
Collapse
|
39
|
den Exter PL, Hooijer J, Dekkers OM, Huisman MV. Reply to C.L. O'Connell et al. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.37.5469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - José Hooijer
- Leiden University Medical Center, Leiden, the Netherlands
| | | | | |
Collapse
|
40
|
den Exter PL, Hooijer J, Dekkers OM, Huisman MV. Risk of recurrent venous thromboembolism and mortality in patients with cancer incidentally diagnosed with pulmonary embolism: a comparison with symptomatic patients. J Clin Oncol 2011; 29:2405-9. [PMID: 21555690 DOI: 10.1200/jco.2010.34.0984] [Citation(s) in RCA: 187] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE The routine use of modern computed tomography scanners has led to an increased detection of incidental pulmonary embolism (PE), in particular in patients with cancer. The clinical relevance of these incidental findings is unknown. PATIENTS AND METHODS In this retrospective cohort study, oncology patients in whom PE was objectively proven between 2004 and 2010 and anticoagulant treatment was started, were included. Fifty-one patients with incidental PE and 144 with symptomatic PE were observed for 1 year to compare the risks of recurrent venous thromboembolism (VTE), bleeding complications, and mortality. Kaplan-Meier and Cox survival analyses were performed. RESULTS Incidental and symptomatic patients did not differ with respect to mean age, sex, cancer type and stage, and risk factors for VTE. As a result from evolving treatment guidelines, approximately half of the patients in both groups received long-term treatment with vitamin K antagonists in stead of currently recommended low-molecular-weight heparin. The 12-month cumulative incidence of recurrent VTE was 13.3% in the incidental group versus 16.9% in the symptomatic group (P = .77). Notably, 20% VTE events recurred after premature termination of anticoagulant therapy. The risk of major bleeding complications was also comparable in the two groups (12.5% for incidental patients and 8.6% for symptomatic patients; P = .5). The respective 12-month mortality risks were 52.9% and 53.3% (P = .7). CONCLUSION Our findings suggest that oncology patients diagnosed with and treated for incidental PE, have similar high rates of recurrent VTE, bleeding complications, and mortality, as compared with oncology patients who develop symptomatic PE.
Collapse
|
41
|
den Exter PL, Hornstra BJ, Vree R. [Phyllodes tumour: a rare, rapidly growing breast tumour]. Ned Tijdschr Geneeskd 2009; 153:A981. [PMID: 20015419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A 40-year-old woman presented at the breast outpatient clinic with a giant tumour of her left breast. The size, rapid growth and radiological characteristics of the lesion led us to suspect a phyllodes tumour. A histological examination of a needle biopsy confirmed this diagnosis. An additional CT scan revealed no signs of metastases. We performed a mastectomy during which a tumour measuring 48 x 33 x 25 cm was resected. Histological examination revealed a borderline phyllodes tumour. Phyllodes tumours are rare fibroepithelial neoplasms of the breast and pre-operatively these are often difficult to differentiate from fibroadenomas. Phyllodes tumours have a variable clinical course with the ability to metastasize and a propensity to recur locally. Complete excision with wide margins is essential to prevent local recurrence. In our case, the surgical margins were limited and our patient was therefore treated with postoperative radiation therapy.
Collapse
|