Obstetric venous thromboembolism: a one-year prospective study in a tertiary hospital in Egypt

Recommendations for prophylaxis of pregnancy‐related venous thromboembolism in carriers of inherited thrombophilia. Comment on the 2012 ACCP guidelines

Psoriasis is associated with a greater risk of incident venous thromboembolism: the Iowa Women's Health Study

Categorization of patients as having provoked or unprovoked venous thromboembolism: guidance from the SSC of ISTH

TV viewing and venous thromboembolism: Risk or red herring?

Addressing the burden of hospital‐related venous thromboembolism: the role of extended anticoagulant prophylaxis

Emergence of institutional antithrombotic protocols for coronavirus 2019

Venous-Thromboembolism in Elderly Patients with Acute Myeloid Leukemia

e19293 Background: VTE incidence varies based on factors such as tumor type, stage, and treatment. There is limited data on VTE incidence and risk factors in NSCLC pts receiving first-line therapies, including immune checkpoint inhibitors (ICIs) and targeted therapies (TTs). Methods: This is a single institution retrospective cohort study of adult NSCLC pts who received first-line treatment between July 2003 and July 2019. Treatments included chemotherapy (chemo) (platinums, taxanes, pemetrexed, gemcitabine, etoposide, bevacizumab), ICI (pembrolizumab, nivolumab, atezolizumab, durvalumab), chemo + ICI, or TT (erlotinib, gefitinib, afatinib, osimertinib, crizotinib, alectinib, ceritinib). Diagnosis codes (ICD 9/10 codes) confirmed VTE (deep vein thrombosis and/or pulmonary embolism) and presence of risk factors which are summarized in Table. Landmark VTE incidence was estimated from cumulative incidence curves for time to VTE, death as a competing risk. Time to VTE distributions were compared between groups with Gray’s tests. Univariable and multivariable competing risk analyses identified risk factors for time to VTE. Results: In 1,618 evaluable pts, the median age was 66 years, 53% were male, 79% White, 18% Black, 58% had adenocarcinoma, 32% squamous cell carcinoma, and 47% metastatic disease. 1178 received chemo, 172 ICIs, 157 chemo + ICI, and 111 TTs. 6-month VTE rates per arm were 5.3%, 7.0%, 7.2%, and 12.0% and 12-month rates were 8.9%, 8.1%, 11.7%, and 13.3%, respectively. Cumulative incidence of VTE was not significantly different between treatment groups (p = .27). Univariable and multivariable analyses are summarized in the Table below. Conclusions: Treatment type was not associated with VTE risk in first-line NSCLC, but rates were numerically highest in pts receiving TTs. Khorana risk score was significantly associated with VTE risk and may identify those likely to benefit from thromboprophylaxis. [Table: see text]

Arterial disease and venous thrombosis: are they related, and if so, what should we do about it?

Heart failure (HF) represents a major and growing public health problem because of its prevalence, incidence, morbidity, mortality, and economic costs. The prevalence of HF is 2% to 3% of the general population.1 Five million Americans are affected, with >550 000 cases diagnosed each year.2 The mortality rate from severe HF remains >60% within 5 years of diagnosis, and 50% of hospitalized patients with HF require readmission within 6 months of discharge. In the US estimated costs amount to > $35 billion per year.3 Although several therapies (eg, β-blockers, angiotensin-converting enzyme [ACE] inhibitors, and cardiac resynchronization therapy) have been proven effective in improving HF outcomes, many unanswered questions about optimal treatment remain. One area of ongoing uncertainty is the appropriate role for antithrombotic therapy in patients with HF. Observational data suggest that patients with HF have an increased venous thromboembolism (VTE) risk (deep venous thromboembolism [DVT], pulmonary embolism [PE], peripheral arterial thromboembolism, and stroke).4 These epidemiological findings are supported by multiple mechanisms that can contribute to a hypercoagulable state in patients with HF. Despite this increased risk of VTE, the role of antithrombotic therapy remains unclear. In this article, we provide an overview of epidemiology, pathophysiology, clinical trial data, and therapeutic recommendations for prevention of thromboembolism in HF. We searched PubMed for articles published between 1958 and 2010 using the following search terms: epidemiology of heart failure , thromboembolism and heart failure , thrombogenesis and heart failure , anticoagulation in heart failure , antiplatelet agent and heart failure , aspirin and heart failure , bleeding risk and anticoagulation , and aspirin and angiotensin-converting enzyme inhibitors . We also studied abstracts from national and international cardiovascular meetings to identify unpublished studies using the key words anticoagulation and dilated cardiomyopathy . Data from published observational studies and secondary …

Despite advancements, THA is still associated with risks, particularly venous thromboembolism (VTE). THA in patients with high-riding developmental dysplasia of the hip (DDH) could potentially be associated with an elevated risk of VTE. We conducted a study to evaluate whether patients with high-riding DDH undergoing THA and receiving aspirin have an increased risk of symptomatic VTE compared with patients undergoing primary THA for other diagnoses. Additionally, we investigated possible risk factors for VTE within this specific patient group. (1) Is the risk of symptomatic VTE (all deep vein thrombosis [DVT] plus pulmonary embolism, or proximal DVT plus pulmonary embolism) increased in patients undergoing THA for severe DDH, defined as Crowe type III or IV, compared with patients undergoing THA for other reasons when aspirin is used for prophylaxis? (2) In patients with severe DDH undergoing THA, are there specific identifiable risk factors associated with an increased risk of symptomatic VTE? Between June and November 2021, an arthroplasty surgeon performed 153 consecutive primary THAs on 146 patients across two arthroplasty centers. All patients except those with a history of prior VTE or those on chronic anticoagulation received aspirin as pharmacologic prophylaxis for VTE. No routine surveillance for VTE was used. To be eligible for this retrospective comparative study, a chart note documenting any signs or symptoms of symptomatic VTE had to be present at least 3 months postoperatively. Patients were excluded for the following reasons: they had a personal history of VTE (1% [2 of 146]), they were receiving ongoing anticoagulant therapy (2% [3 of 146]), they were out of the age criteria range (2% [3 of 146]), they had undergone same-setting bilateral THAs or the second side of staged bilateral THAs (3% [4 of 146]), or they were lost to follow-up within 90 days after surgery (0% [0]). After exclusions, 134 patients (134 hips) remained. Patients were divided into two groups based on their preoperative diagnosis: (1) high-riding DDH of Crowe type III or IV (35% [47 of 134] of hips) and (2) all other diagnoses, including primary or inflammatory arthritis, Crowe type I or II DDH, fracture, and osteonecrosis (65% [87 of 134] of hips). A comprehensive records review was conducted to determine the incidence of symptomatic VTE, including distal DVT, proximal DVT, or pulmonary embolism. Patients' demographics, surgical details, and outcomes were compared between the groups. The high-riding group had longer operations and a higher percentage of patients having general anesthesia, acetabular bone grafting, transfusions, or restricted weightbearing postoperatively. Univariable analysis was performed to compare the high-riding DDH group with the control group and to evaluate associations between potential risk factors and symptomatic VTE. Subsequently, multivariable logistic regression was conducted to identify independent risk factors among the variables identified in the univariable analysis. Patients undergoing THA for DDH had higher odds of experiencing symptomatic VTE compared with the control group (17% [8 of 47] versus 1% [1 of 87], OR 18 [95% confidence interval (CI) 2 to 146]; p = 0.001). After adjusting for confounding variables such as age, sex, American Society of Anesthesiologists grading, anesthesia type, operation duration, shortening osteotomy, shelf/impaction grafting, and blood transfusion, patients undergoing THA for high-riding DDH still had higher adjusted odds of symptomatic VTE compared with the other group (adjusted OR 67 [95% CI 3 to 151]; p = 0.008). When considering only proximal DVT or pulmonary embolism events (excluding distal DVT), the odds of experiencing a VTE event remained higher in patients with high-riding DDH compared with the other group (11% [5 of 47] versus 1% [1 of 87], OR 10 [95% CI 1 to 90]; p = 0.02). In patients undergoing THA for high-riding DDH, after controlling for potential confounding variables, limb lengthening was identified as the only factor associated with an increased likelihood of symptomatic VTE (median [range] lengthening 38 mm [25 to 60] versus 25 mm [15 to 50]; p = 0.002). Our findings showed that patients undergoing THA for high-riding developmental DDH and receiving aspirin for VTE prophylaxis had a higher likelihood of experiencing symptomatic VTE, including DVT and pulmonary embolism, compared with patients undergoing primary THA for other indications. Additionally, greater intraoperative limb lengthening in this group appeared to further increase the risk of VTE. While DDH may be a risk factor for symptomatic VTE after THA, this association could also be attributed to the increased complexity of the procedure in hips with high-riding DDH. Until larger studies with multivariable analyses of potential risk factors are conducted to clarify this issue, we recommend that surgeons consider using thromboprophylaxis agents more potent than aspirin for patients undergoing THA for high-riding DDH and remain particularly vigilant in the postoperative period for signs and symptoms of VTE. Level III, therapeutic study.

Haemost 2014; 112: 692-699. Historically, hospital-related venous thromboembolism (VTE) has been thought to mainly occur in surgical patients (1). Several phase III randomised controlled trials (RCTs) have investigated benefits and harms of pharmacologic thromboprophylaxis in this setting (1). Subsequently, acutely ill hospitalised medical patients have been recognised to be at increased risk of VTE, with approximately 75% of all VTE-related deaths diagnosed in autopsy studies occurring in non-surgical patients (2). Based on such compelling evidence, a number of RCTs have been carried out which consistently shown the clinical benefit of pharmacologic thromboprophylaxis also in medical inpatients (3, 4). Conversely, 3 phase III RCTs, i.e. EXCLAIM, ADOPT, and MAGELLAN studies, have subsequently failed to support the extended use of thromboprohylaxis beyond the first two weeks of treatment in this setting due to an excess in bleeding rates (5-7). The results of these trials have raised again concerns on the true clinical benefit of anticoagulant prophylaxis in a population that is mainly represented by fragile, elderly patients (8). The widespread existence of these concerns is confirmed by the fact that despite high-quality evidence supporting in-hospital prophylaxis and recommendations from international guidelines, thromboprophylaxis in acutely ill medical inpatients remains substantially underused (9-11). Appropriate patient selection remains a major issue and a number of pitfalls in proposed strategies have been identified. First, the group-specific thromboembolic risk assessment used in the RCTs, that is based on the diagnosis of admission, does not sufficiently take into account the heterogeneity of medical diseases and the role of concomitant patient-specific risk factors; second, immobilisation per se does not represent a sufficient condition for recommending pharmacologic thromboprophylaxis; third, patient bleeding risk has not been adequately addressed and, therefore, used for patient selection (12). The 9th edition of the American College of Chest Physicians (ACCP) guidelines for the first time introduced a new approach to patient selection, based on the application of risk assessment models (RAM) (3). The concept behind RAMs is that VTE risk factors are generally cumulative and the majority of patients hospitalised in medical wards harbour more than one risk factor. The proposed RAM to assess VTE risk for the medical population was the PADUA score, which combines patient specific risk factors (e.g. advanced age, obesity, known thrombophilia, previous VTE) and disease specific risk factors (e.g. cancer, heart failure, respiratory failure, reduced mobility) (13). Although there was no validated RAM to assess the individual risk of bleeding, the guidelines panel proposed to consider the IMPROVE bleeding risk score, yet acknowledging this score is complex and not validated, and therefore suggesting to consider patients to have an excessive risk of bleeding if they had multiple risk factors or one risk factor with the strongest association with bleeding (14). Unfortunately, none of available RAM has been extensively and adequately validated till recently (15). Indeed, the model performance in validation studies is often worse than in development studies (12). In this issue of Thrombosis and Haemostasis, Mahan et al. published the first external validation of any appropriately evidence-derived RAM in acutely ill medical patients (16). They used a large database of 41,486 inpatients from three acute care hospitals to validate the IMPROVE RAM. The seven included VTE risk factors and the assigned points can be summarised by the acronym Im1P3A1C2T2-I1LL2: Immobilisation ≥ 7 days, Previous VTE, Age > 60 years, Cancer, known Thrombophilia, Intensive care / coronary care unit stay, Lower Limb paralysis. In the derivation cohort, a score of 0 to 1 placed patients at low risk of symptomatic VTE (less than 1%), a score of 2 to 3 at moderate VTE risk (1 to 2%), and a score of 4 or more at high VTE risk (> 4.8%) (17). In this study, the incidence of VTE was 0.20% (95% confidence interval [CI] 0.18-0.22), 1.04% (95% CI 0.88-1.25) and 4.15% (95% CI 2.79-8.12) in the low, moderate, and high VTE risk groups, respectively (16). The proportion of patients classified at low, moderate and high VTE risk was 63.3%, 31.1%, and 5.5%, respectively. As the receiver-operating curve was 0.77, we may conclude that another step forward for the correct stratification of VTE risk in medical inpatients has been made. We are only at the beginning of a new era in VTE prevention. As correctly acknowledged by the authors, this external validation study demonstrates a level 2 of evidence for the validation of a RAM, according to McGinn scale (18). An impact analysis remains necessary in order to reach a level 1 of evidence and to use a RAM in a wide variety of settings with confidence that its use can change clinical behaviour and improve patient outcomes. Concomitantly, it is important to perform Invited Editorial Focus

Risk factors for obstetric venous thromboembolism (VTE), a leading cause of maternal mortality in the United States, are increasing on a population basis. This review provides the obstetrician with an update of current issues related to obstetric VTE risk, prophylaxis, outcomes, anaesthesia considerations and future research opportunities. Obstetric VTE affects approximately 1 per 1000 pregnancies and accounts consistently for 9-10% of maternal deaths in the United States. In industrialized countries, risk factors for VTE, including overweight/obesity, caesarean delivery and obstetrical complications such postpartum haemorrhage and infection continue to increase. VTE prophylaxis is central to reducing maternal mortality. However, recommendations for prophylaxis from leadership societies vary widely. In the UK, maternal mortality risk from VTE has decreased significantly in the setting of broader heparin prophylaxis. In the United States where mechanical VTE prophylaxis is used more commonly, mortality risk has remained constant. Obstetric VTE is a leading cause of maternal mortality in the United States. The incidence of risk factors for obstetric VTE continues to increase. Currently, recommendations for obstetric VTE prophylaxis vary substantially. Opportunities for research in this area exist to optimize prophylaxis and improve maternal outcomes.

Background: Venous thromboembolism (VTE) is a major healthcare problem that has resulted in a significant increase in mortality, morbidity, and healthcare cost. Our knowledge of the incidence and risk factors of VTE differs among various ethnic backgrounds and nationalities, therefore, there is a need to explore the incidence of VTE and to understand the role of risk factors that require a pooled analysis. The aim of this review is to assess the incidence and risk factors of venous thromboembolism (VTE) in hospitalized patients. Methods: We searched PubMed, Embase, Scopus and Web of Sciences databases from 2015 to 2022, to identify studies reporting the incidence and risk factor of VTE among hospitalized patients. Descriptive statistics were described to present the results. Results: We identified 17 studies comprising 17703 participants, and only 1132 (6.4%) of them developed VTE. 12 studies were retrospectives, while 5 studies were prospective. The majority of participants 9573 (54%) were female, while 8130 (4645.9%) were male. 13 (76%) studies reported a low incidence of VTE, while 2 (12%%) studies concluded high incidence and 2 (12%) studies reported moderate incidence of VTE. 12 (70%) studies revealed low risk factors associated with VTE, while 3 (18%) studies found high risk factors associated with VTE and 2 (12%) studies described moderate risk factors related to VTE. Conclusions: Despite universal thromboprophylaxis, medical and surgical ill patients continue to be at risk for VTE. Incidence of VTE among hospitalized patients was low and associated with several risk factors. All patients need to undertake dynamic and constant risk assessment for VTE with laboratory monitoring, associated medications, invasive procedures, and previous medical history considered, particularly for severe and critically ill patients. We strongly urge clinicians to be conscious of VTE risk factors and highlight on optimizing patients' comorbidities before admission to the hospital.

Venous thromboembolism in cancer clinical trials: recommendation for standardized reporting and analysis