Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Prepregnancy overweight and obesity and long-term risk of venous thromboembolism in women

Overweight and obesity rates have increased in recent decades, particularly among the younger population. The long-term consequences of obesity with respect to early venous thromboembolism (VTE) in women have not been established. The aim was to investigate the association between body mass index (BMI) in early pregnancy as a proxy for non-pregnant weight and long-term post-pregnancy risk of VTE in women. This registry-based prospective cohort study analysed data from the Swedish Medical Birth Registry, linked to the National Patient and the National Cause of Death Registries for information on post-pregnancy long-term risk of VTE. Cox proportional hazards model were used to determine the association between BMI at baseline and VTE events during follow-up starting 1 year after baseline. The mean age at registration was 27.5 (standard deviation, 4.9) years. During a median follow-up duration of 12 years (interquartile range, 6-21 years) starting 1 year after the first antenatal visit, 1765 and 2549 women had a deep vein thrombosis and/or pulmonary embolism. The risk of VTE linearly increased with increasing BMI. Compared to women with 20 ≤ BMI < 22.5 kg/m2, women with high normal weight, i.e. with a BMI of 22.5-25.0 kg/m2, had an adjusted hazard ratio (HR) of 1.30 (95% confidence interval [CI] 1.19-1.41), whereas those with a BMI of 30-35 kg/m2 and ≥ 35 kg/m2 (severe obesity) had an adjusted HR of 2.35 (95% CI 2.04-2.70) and 3.47 (95% CI 2.82-4.25, respectively. Using BMI in early pregnancy as a proxy for pre-pregnancy or non-pregnant BMI in young women, we found a significantly increased risk of post-pregnancy long-term risk of VTE even in those with high normal BMI, compared with lean women, whereas those with severe obesity had a markedly high risk.

Sex-related differences in long-term outcome of heart failure in low-risk patients with atrial fibrillation. A Swedish registry case-control study

Background

Knowledge about sex-related differences regarding long-term risk of heart failure (HF) among patients with atrial fibrillation (AF) is limited.

Aim

To evaluate the impact of sex on risks for new onset HF in patients with AF.

Methods

All patients from the Swedish National Patient Register, with a first-time diagnosis of AF between 1987 and 2018 were identified and compared with two matched controls without AF from the Total Population Register. Patients &lt;18 years, or any previous cardiovascular disease, diabetes mellitus and renal failure at the baseline were excluded.

Results

In total 227,811 patients and 452,712 controls were included; 44.5% were women. The mean age (SD) for men was 65.5 (15) vs. 72.7 (13) in women (p&lt;0.0001). The incidence rate for HF onset per 1000 person-years within one and five years after AF diagnosis was 77.3 (75.5–79.1) and 45.0 (44.3–45.7) in women vs. 66.5 (65.0–68.0) and 35.3 (34.8–35.9) in men, respectively. The incidence rate for HF onset increased with age in both patients with AF and controls, but was generally more pronounced in women. Women had 26% and 34% higher risk for HF onset, within five and thirty years, respectively. The highest risk for HF onset was found in women 18–34 years and 35–49 years of age, HR 24.64 (95%, confidence interval (CI) 7.59–80.0) and 8.09 (95%, CI 6.34–10.33) vs. 9.86 (95%, CI 6.81–14.27) and 6.52 (95%, CI 5.87–7.25) in equally old men. The mortality rate after HF was 42.3% and 33.1% in women and men with AF (p&lt;0.0001).

Conclusion

In this nationwide, register-based cohort study, when compared to matched controls we found that the risk for HF onset was higher in women with AF, particularly in reproductive age, highlighting great importance of further research for prevention of HF in young women with AF but without any other cardiovascular risk factors.

Funding Acknowledgement

Type of funding sources: None.

Obesity in adolescent men increases the risk of venous thromboembolism in adult life

BACKGROUND

As the population of obese and severely obese young adults grows, it is becoming increasingly important to recognize the long-term risks associated with adolescent obesity.

OBJECTIVES

This study aimed to determine the association between body mass index (BMI) in young men at enlistment for military service and later risk of venous thromboembolism (VTE).

METHODS

Nationwide register-based prospective cohort study of men enlisting 1969 to 2005, followed through the Swedish National Patient and Cause of Death registries. We identified 1 639 838 men (mean age, 18.3 years) free of prior venous thromboembolism, of whom 29 342 were obese (BMI 30 to <35 kg m^-2 ) and 7236 severely obese (BMI ≥ 35 kg m^-2 ). The participants were followed until a first registered diagnosis of VTE.

RESULTS

During a median follow-up of 28 years (interquartile interval, 20 to 36 years), 11 395 cases of deep vein thrombosis and 7270 cases of pulmonary embolism were recorded. Compared with men with a BMI of 18.5 to <20 kg m^-2 , men with higher BMI in young adulthood showed an incrementally increasing risk of VTE that was moderately but significantly increased already at normal BMI levels. Adolescent obese men with a BMI of 30 to 35 kg m^-2 had an adjusted hazard ratio of 2.93 (95% confidence interval, 2.65 to 3.24) for VTE. Severely obese men with a BMI of ≥35 kg m^-2 had a hazard ratio of 4.95 (95% confidence interval, 4.16 to 5.90).

CONCLUSIONS

Men who were obese or severely obese in young adulthood had a marked increase in risk of VTE.

P3436T-wave inversion in middle age is associated with higher mortality risk compared to occurrence of a new T-wave inversion later in life

Background

Minor ECG abnormalities, such as T-wave inversions, are frequently seen in clinical practice in asymptomatic patients. Its prognostic role is incompletely studied. We have previously reported an association between T-wave inversion, and all-cause mortality during lifetime.

Purpose

To study the prognostic prediction of new-onset of T-wave inversion in ECG recorded at various ages, in a male random population-based cohort in lifetime follow up.

Methods

Subjects from a random longitudinal, prospective, population-based study: “The study of men born in 1913” (n=854) were examined at 50-years of age and re-examined at 60, 67, 75 and 80 years, including a 12-lead ECG recording, classified according to the Minnesota code. Participants were followed until death or year 2015 (48 years follow-up), and data were obtained through the Cause of Death Register. Unadjusted and adjusted Cox proportional hazards models, producing an overall hazard ratio (HR), and flexible parametric models for survival data by Royston and Parmar, producing continuous HR over studied time, were applied for prediction of time to all-cause death and cardiovascular disease (CVD) death by the incident negative T-wave.

Results

An increased risk of all-cause and CVD death associated with negative T-waves was evident at the majority of observational ages in unadjusted analyses. After adjustment for other conditions (smoking, physical activity level, BMI, systolic blood pressure (BP), hypertension, BP medication, s-cholesterol, hematocrit, Q/QS patterns, and ST-junction/segment depression), a negative T-wave at 50 years of age was significantly associated with all-cause and CVD death, [HR 1.46 (95% CI 1.06–2.01), p=0.021, and HR 1.58 (95% CI 1.06–2.36), p=0.025], respectively. However, the HR of 1.58 for CVD death interacted significantly with time (p=0.034), with greater risk in the years adjacent to observation than for later follow-up (Figure, right panel). The corresponding adjusted analyses of a newly diagnosed negative T-wave appearing at 60, 67 and 75 years were not statistically significant for either of the two outcomes. However, an incident negative T-wave at 80 years of age was shown to have numerically higher overall impact, but not statistically significant for all-cause death [HR 1.52 (95% CI 0.80–2.86), p=0.20], but for CVD death [HR 2.41 (95% CI 1.03–5.66), p=0.043], with no significant interaction with time.

Conclusion

In this population cohort, a first time registered negative T-wave at 50 years carried a considerably increased risk of mortality, specifically CVD mortality, which cannot be explained by other cardiovascular risk factors. The risk was greatest in middle age, and weakened with increasing age. Our findings warrant verification in other cohorts. If an independent risk indication of negative T-wave at middle age is confirmed it could be a valuable adjunct in screening and cardiovascular risk assessment.

Acknowledgement/Funding

Sweden Heart-Lung Foundation, ALF Västra Götalandsregionen-Göteborgs Universitet

The early chain of care and risk of death in acute stroke in relation to the priority given at the dispatch centre: A multicentre observational study

BACKGROUND

The early chain of care is critical for stroke patients. The most important part is the so-called 'system delay' i.e. the delay time from call to the emergency medical services until a diagnosis is established (computer tomography).

AIM

The purpose of this study was to relate the initial priority level given by the dispatch centre to the early chain of care in acute stroke and to short-term and long-term mortality.

METHODS

All patients hospitalised with the first and the final diagnosis of acute stroke, 15 December 2010-15 April 2011, were recruited across nine hospitals, each hospital with a stroke care unit.

RESULTS

In all, 897 stroke patients were included. Priority at the dispatch centre: 54% received highest priority 1, 41% priority 2 and 5% priority 3. Median system delay from call to emergency medical services until diagnosis by computer tomography was 2 h and 52 min, 4 h and 49 min and 6 h and 33 min respectively in the three priority groups ( p<0.0001). There was a similarly strong association between priority level at the dispatch centre and system delay to arrival in a hospital ward, suspicion of stroke by the emergency medical services nurse as well as the physician on hospital admission and the proportion of patients given thrombolysis. Mortality during the subsequent 30 days was 22% among patients with priority 1 and 14% among patients with priority 2.

CONCLUSION

Patients given a lower priority level at the dispatch centre had the longest system delay. Although many of these patients died, the risk of death was highest among those given the highest priority.

Comparison of the university hospital and county hospitals in western Sweden to identify potential weak links in the early chain of care for acute stroke: results of an observational study

OBJECTIVE

To identify weak links in the early chain of care for acute stroke.

SETTING

9 emergency hospitals in western Sweden, each with a stroke unit, and the emergency medical services (EMS).

PARTICIPANTS

All patients hospitalised with a first and a final diagnosis of stroke-between 15 December 2010 and 15 April 2011. The university hospital in the city of Gothenburg was compared with 6 county hospitals. PRIMARY AND SECONDARY MEASURES: (1) The system delay, that is, median delay time from call to the EMS until diagnosis was designated as the primary end point. Secondary end points were: (2) the system delay time from call to the EMS until arrival in a hospital ward, (3) the use of the EMS, (4) priority at the dispatch centre and (5) suspicion of stroke by the EMS nurse.

RESULTS

In all, 1376 acute patients with stroke (median age 79 years; 49% women) were included. The median system delay from call to the EMS until (1) diagnosis (CT scan) and (2) arrival in a hospital ward was 3 h and 52 min and 4 h and 22 min, respectively. The system delay (1) was significantly shorter in county hospitals. (3) The study showed that 76% used the EMS (Gothenburg 71%; the county 79%; p<0.0001). (4) Priority 1 was given at the dispatch centre in 54% of cases. (5) Stroke was suspected in 65% of cases. A prenotification was sent in 32% (Gothenburg 52%; the county 20%; p<0.0001).

CONCLUSIONS

System delay is still long and only a small fraction of patients received thrombolysis. Three of four used the EMS (more frequent in the county). They were given the highest priority at the dispatch centre in half of the cases. Stroke was suspected in two-thirds of the cases, but a prenotification was seldom sent to the hospital.

Obesity and trends in cardiovascular risk factors over 40 years in Swedish men aged 50

OBJECTIVE

To study trends over 40 years in cardiovascular risk factors in normal weight, overweight and obese men, all aged 50 when examined. Design. Cross-sectional studies of five successive cohorts of men aged 50.

SETTING

City of Göteborg, Sweden.

SUBJECTS

Random population samples of altogether 3251 urban Swedish men born in 1913, 1923, 1933, 1943 and 1953.

MAIN OUTCOME MEASURES

Anthropometry, cardiovascular risk factors, rates of nonsmoking, normotension and serum cholesterol <5 mmol L(-1) over four decades.

RESULTS

Over 40 years, there was a net increase in body mass index (BMI) from 24.8 (SD = 3.2) to 26.4 (3.7) kg m(-2) (P < 0.0001), with an increase in the prevalence of obesity (BMI >or= 30 kg m(-2)) from 6.0% in 1963 to 13.8% in 2003. Favourable trends with respect to smoking, blood pressure and serum cholesterol were observed similarly amongst normal weight, overweight and obese men. In 1963, 24% of obese men were normotensive compared to 45% in 2003, and 6% had serum cholesterol <5 mmol L(-1) compared to 34% in 2003. Compared with obese men in 1963, men who were obese in 2003 had an odds ratio (OR) of 3.39 being a nonsmoker [95% confidence interval (CI): 1.56 to 7.36], 2.67 of being normotensive (1.23 to 5.83) and having serum cholesterol <5 mmol L(-1) of 8.30 (2.37 to 29.0). However, optimal risk factor status - no smoking, normotension and total serum cholesterol <5 mmol L(-1)- was still present in less than one in six men in 2003, similar across BMI categories.

CONCLUSIONS

Obese Swedish men who are now in their fifties have much lower levels of other risk factors compared with obese men 40 years ago. This could contribute to explain why coronary heart disease death rates still are falling despite increasing rates of obesity.

High fruit intake may reduce mortality among middle-aged and elderly men. The Study of Men Born in 1913

OBJECTIVE

A number of long-term population-based studies have tried to study fruit and vegetable consumption in relation to cardiovascular disease, cancer and total mortality. Few of these studies are based on randomly selected population samples. The aim of the study was to investigate the long-term effect of fruit and vegetable consumption on mortality, cardiovascular disease, cardiovascular death, cancer morbidity and cancer death among middle-aged and elderly men.

DESIGN

Prospective cohort study.

SETTING

General community. The Study of Men Born in 1913.

SUBJECTS

792 men at age 54 who participated in a screening examination in 1967.

MAIN OUTCOME MEASURES

A food frequency questionnaire was used to obtain information of the dietary habits in 730 of the men (92%). All men were followed up with repeated examinations until the age of 80.

RESULTS

Cardiovascular as well as total mortality was significantly lower among men with high fruit consumption in univariate analysis. There was no correlation between fruit or vegetable consumption in relation to cancer incidence, cancer death and cardiovascular disease. In multivariate survival analysis where smoking, cholesterol and hypertension were taken into account, there was a significantly lower mortality among men with a high fruit consumption during 16 y follow up until the age of 70 (P=0.042), but this finding was no longer statistically significant during 26 y follow-up at the age of 80 (P=0.051).

CONCLUSIONS

Daily fruit consumption seems to have positive effect on long-term survival independently of other traditional cardiovascular risk factors like smoking, hypertension and cholesterol.

SPONSORSHIP

This study was supported by grants from the Swedish Medical Research Council (K98-274-06276-17) King Gustav V and Queen Victoria's Foundation, and the Göteborg University.

Recurrent venous thromboembolism after deep vein thrombosis: incidence and risk factors

BACKGROUND

The recurrence rate after deep vein thrombosis (DVT) is high and the risk factors for recurrent thromboembolic events have only been investigated on a small scale.

OBJECTIVES

To estimate the cumulative incidence of recurrent venous thromboembolic events after a first or a second DVT and to identify possible risk factors for recurrent venous thromboembolism.

METHODS

We prospectively followed up 738 consecutive patients with an objectively verified symptomatic DVT for 3.7 to 8.8 years. Medical records and death certificates for all patients were reviewed during follow-up and recurrent DVT and pulmonary embolism were registered.

RESULTS

The 5-year cumulative incidence of recurrent venous thromboembolic events was 21.5% (95% confidence interval [CI], 17.7%-25.4%) after a first DVT and 27.9% (95% CI, 19.7%-36.1%) after a second DVT. The 5-year cumulative incidence of fatal pulmonary embolism was 2.6% (95% CI, 1.1%-4.1%) after a first DVT. Proximal DVT (relative risk [RR], 2.40; 95% CI, 1.48-3.88; P<.001), cancer (RR, 1.97; 95% CI, 1.20-3.23; P<.001), and history of a venous thromboembolism (RR, 1.71; 95% CI, 1.16-2.52; P<.01) predicted an independently increased risk of recurrent events in multivariate survival analysis. Postoperative DVT (RR, 0.27; 95% CI, 0.13-0.55; P<.001) and a long duration of oral anticoagulation therapy (RR, 0.95; 95% CI, 0.92-0.98; P<.01) involved a smaller risk of recurrent events. Sex, age, initial antithrombotic therapy, or immobilization did not affect the risk of a recurrent event.

CONCLUSIONS

The recurrence rate after a symptomatic DVT is high. Patients with proximal DVT, diagnosed cancer, short duration of oral anticoagulation therapy, or a history of thromboembolic events had a higher risk of recurrent events, while patients with postoperative DVT had a lower recurrence rate. This knowledge could help identify patients who might benefit most from prolonged prophylactic treatment in various risk situations.

Smoking and abdominal obesity: risk factors for venous thromboembolism among middle-aged men: "the study of men born in 1913"

BACKGROUND

Risk factors for deep vein thrombosis and pulmonary embolism are mostly derived from case-control studies of hospitalized patients, and there are few long-term population-based studies.

OBJECTIVE

To study the long-term risk factors for deep vein thrombosis and pulmonary embolism among middle-aged men.

DESIGN

A prospective cohort study.

SETTING

General community, "The Study of Men Born in 1913."

SUBJECTS

A random population sample of 855 men, all aged 50 years at baseline.

MAIN OUTCOME MEASURES

Eight-hundred fifty-five men participated in a screening examination in 1963 at the age of 50 years, and 792 of these men were reexamined in 1967 at the age of 54. All the men were followed up with periodic examinations until the age of 80. Objective methods were used to ascertain a diagnosis of deep vein thrombosis or pulmonary embolism.

RESULTS

Waist circumference (P=.004) and smoking (P = .02) predicted a venous thromboembolic event in multivariate survival analysis. Men in the highest decile of waist circumference (> or =100 cm) had an adjusted relative risk of 3.92 (95% confidence interval, 2.10-7.29; P<.001) compared with men with a waist circumference of less than 100 cm. For men who smoked 15 g of tobacco (15 cigarettes) a day or more, the adjusted relative risk was 2.82 (95% confidence interval, 1.30-6.13; P= .009) compared with nonsmokers.

CONCLUSIONS

Smoking and abdominal obesity were independent risk factors for venous thromboembolic events during follow-up. In addition to the prevention of smoking and obesity, a more aggressive strategy regarding the use of prophylactic agents among smokers and obese patients, in various risk situations, may be justified.

Prevalence of APC resistance and its relationship to arterial and venous thromboembolism in a general population sample of elderly Swedish men: The Study of Men Born in 1913

BACKGROUND

Most studies of hereditary resistance to activated protein C (APC resistance) as a risk factor for venous thromboembolism are derived from case-control studies of hospitalized patients, whilst the importance of this condition in the general population has been only sparsely investigated.

OBJECTIVE

To study the prevalence of APC resistance and its relationship to morbidity and mortality in a general population sample of elderly men.

DESIGN

Cross-sectional and prospective follow-up study.

SETTING

General community: The Study of Men Born in 1913.

SUBJECTS

A random population sample of 404 men, all 75 years of age.

MAIN OUTCOME MEASURES

Four hundred and four men participated in a screening examination in 1988. The APC ratio was analysed in 382 of them. All the men were followed up for 5 years. Medical records were reviewed for all the men with a history of deep vein thrombosis, pulmonary embolism, myocardial infarction or stroke.

RESULTS

Twenty-five men (6.5%) were found to have APC resistance. The incidence of venous thromboembolism, myocardial infarction or stroke did not differ between men with or without APC resistance, either retrospectively or during follow-up. Only two men experienced a deep vein thrombosis before the age of 80 and there was no case of pulmonary embolism. Mortality during 5 years of follow-up did not differ between men with and without APC resistance.

CONCLUSION

The prevalence of APC resistance was 6.5% in this study of Swedish men. Although the size of the population sample is somewhat small, the study shows that, amongst elderly men, the association between APC resistance and venous thromboembolic disease was weak and men with this hereditary condition did not have any increase in morbidity or mortality compared with men without APC resistance.

Pharmacokinetics and pharmacodynamics of melagatran, a novel synthetic LMW thrombin inhibitor, in patients with acute DVT

Forty-eight patients with acute proximal deep vein thrombosis (DVT) were randomised to intravenous infusions for 4 to 6 days with melagatran, a novel synthetic low molecular weight thrombin inhibitor, or unfractionated heparin adjusted by the activated partial thromboplastin time (APTT). The aim of the study was to investigate the pharmacokinetics, pharmacodynamics and the safety of melagatran therapy at three different doses. Steady-state plasma concentrations were rapidly achieved and maintained throughout the infusion period. The mean plasma concentrations in the low, medium and high dose groups were 0.17, 0.31 and 0.53 micromol/l, respectively. The prolongation of APTT was stable during the melagatran infusions and correlated to the plasma concentration. Phlebographically verified regression of thrombus size measured as decrease in Marder score was seen after 4 to 6 days in 8 of 12 patients, 6 of 12 patients and 5 of 11 patients in the low, medium and high dose groups of melagatran and in 5 of the heparin-treated patients. In the low dose group with melagatran, thrombus extension was seen in one patient. At the dose levels studied, melagatran was well tolerated with no clinically significant bleeding problems, suggesting that melagatran could safely be given to patients suffering from DVT.

Bundle-branch block in a general male population: the study of men born 1913

BACKGROUND

Interest in bundle-branch block has focused primarily on its role as a predictor of mortality and coexisting cardiovascular diseases. Previous studies of prevalence, correlation to cardiovascular disease, and mortality have produced conflicting results.

METHODS AND RESULTS

We studied a random-sampled population of 855 men who were 50 years old in 1963 and followed them up for 30 years with repeated examinations. Men who developed bundle-branch block were studied with regard to cumulative incidence, relationship with cardiovascular disease/risk factors, and survival. The prevalence of bundle-branch block increases from 1% at age 50 years to 17% at age 80 years, resulting in a cumulative incidence of 18%. No significant relationship with ischemic heart disease or mortality was found. Men who would develop bundle-branch block had a bigger heart volume at age 50 years and developed diabetes mellitus and congestive heart disease during follow-up more often than control subjects.

CONCLUSIONS

Bundle-branch block correlates strongly to age and is common in elderly men. Our results support the theory that bundle-branch block is a marker of a slowly progressing degenerative disease that also affects the myocardium.

[Pulmonary embolism remains an overlooked diagnosis. Proposed strategy in suspected cases]

The problem of misdiagnosed pulmonary embolism (PE) is reviewed in the light of the introduction of new diagnostic methods such as spiral tomography (helical scanning). Despite new diagnostic methods, the frequency of misdiagnosed PE will not be reduced unless PE is suspected at the right juncture. PE should always be suspected in the presence of 'pulmonary syndromes' and venous thromboembolic risk factors. A strategy for the management of cases of suspected PE is proposed in the article: 1, recognition of the presence of cardiopulmonary disease, 2, determination of the clinical probability of PE; 3, confirmation (or exclusion) of PE; 4, determination of its severity and prognosis; and 5, choice of treatment. A two-part algorithm for use in patients with stable or unstable haemodynamics is also presented.

Deep vein thrombosis and pulmonary embolism in the general population. 'The Study of Men Born in 1913'

BACKGROUND

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common public health problems. Still, little is known about the epidemiology and the natural history of venous thromboembolism.

METHODS

In the Study of Men Born in 1913, 855 men were followed up prospectively from the age of 50 years to the age of 80 years. Several cross-sectional samples, also of men born in 1913, were studied at the ages of 50, 54, 60, 67, 75, and 80 years. Objective methods were used to ascertain a diagnosis of DVT or PE, and all were confirmed by hospital records or autopsy reports. The follow-up rate in the longitudinal study was 98.2%.

RESULTS

In the longitudinal study, the incidence of DVT was 182 per 100,000 observation-years. Corresponding incidence rates were 98 for nonfatal PE, 107 for fatal PE, and 387 for all thromboembolic events. The cumulative probability for a venous thromboembolic event at different ages was estimated to be 0.5% by the age of 50 years and 10.7% by the age of 80 years. In the cross-sectional studies, a history of confirmed venous thromboembolism was found in 0.5% of the men at age 50 years, 0.9% at age 54 years, 1.3% at age 60 years, 2.0% at age 67 years, 4.5% at age 75 years, and 3.8% at age 80 years.

CONCLUSIONS

The results indicate a high incidence of DVT and PE in the general population. The incidence of thromboembolic events increases with age. The rate of fatal PE seems to be higher than estimated before, and PE constitutes almost 5% of all deaths during follow-up.

Subcutaneous recombinant hirudin (HBW 023) versus intravenous sodium heparin in treatment of established acute deep vein thrombosis of the legs: a multicentre prospective dose-ranging randomized trial. International Multicentre Hirudin Study Group

The aim of this multicentre, prospective, randomised, dose-ranging study was to compare the safety and efficacy of subcutaneous recombinant hirudin (HBW 023) against intravenous sodium heparin in acute lower limb deep venous thrombosis (DVT). Patients were randomized to treatment with either HBW 023 or heparin for 5 +/- 1 days. HBW 023 was given according to body-weight in three dose groups. Thromboembolic disease was assessed by phlebography and ventilation/perfusion (V/Q) scanning on Day 1 and Day 5 +/- 1. One hundred and fifty-five patients were enrolled, of these 121 were evaluable for efficacy analysis. Significantly fewer patients on HBW 023 developed new V/Q abnormalities during the treatment period, (p = 0.006). There was no difference between the groups in thrombus extension or regression, major bleeding complications or serious adverse events. There were significantly fewer findings of new V/Q mismatch after treatment with HBW 023, and anticoagulant control was superior in these patients.

Can laboratory testing improve screening strategies for deep vein thrombosis at an emergency unit?

OBJECTIVES

To study various markers of blood coagulation and fibrinolysis in relation to the extension of deep vein thrombosis (DVT), and to compare the diagnostic usefulness of these markers as screening tests for excluding DVT.

DESIGN

A clinical study of patients admitted to an emergency unit.

SETTING

Ostra Hospital, Göteborg, Sweden.

SUBJECTS

One hundred and five patients with a clinical suspicion of DVT.

MAIN OUTCOME MEASURES

Phlebography was used as the reference method for a diagnosis of DVT. Small distal thromboses as well as large proximal thromboses were included. Plasma D-dimer as well as other markers of coagulation and fibrinolysis were analysed.

RESULTS

Twenty-eight proximal and 20 distal DVTs were found. Plasma D-dimers (one ELISA and two latex assays), fibrin monomer, prothrombin fragment 1 + 2 (F1+2), thrombin-antithrombin III complex (TAT) and the t-PA-PAI-1 complex were all significantly correlated to the extension of DVT, whilst fibronectin, tissue-type plasminogen activator (t-PA), single-chain urokinase-type plasminogen activator (scru-PA) and plasminogen activator inhibitor 1 (PAI-1) were not. The sensitivity was 94% for the D-dimer ELISA and one of the latex methods (latex-B), at a specificity of 60% and 68%, respectively. The negative predictive value was 92% for ELISA and 93% for latex-B, and both assays showed a negative predictive value of 100% for proximal DVTs. Fibrin monomer, F1+2, TAT, D-dimer (latex-S) and the t-PA-PAI-1 complex all showed lower negative predictive values (88, 84, 79, 78 and 65% respectively).

CONCLUSIONS

Sensitivity and negative predictive values for a latex assay (D-dimer latex-B) was similar to that of a D-dimer ELISA: With a sensitivity of 94% (100% for proximal DVTs) such a latex assay may be included in a screening strategy for DVT at an emergency unit. However, the safety of such an approach has to be tested in other prospective studies.