Upper Extremity Deep Vein Thrombosis - Incidence, Risk Factors, and Management. The Worcester Venous Thromboembolism Study.

Abstract

Background: Recent observations suggest that upper extremity deep vein thrombosis (DVT) has become more common over the last few decades. However the prevalence of this disorder within the community has not been established. The purpose of this study was to compare the occurrence rate, risk factor profile, management strategies, and hospital outcomes in patients with upper versus lower extremity DVT in a cohort of all Worcester residents diagnosed with venous thromboembolism (VTE) in 1999.Methods: The medical records of all residents from the Worcester, MA statistical metropolitan area (2000 census=478,000) diagnosed with ICD-9 codes consistent with possible DVT and/or pulmonary embolism at all 11 Worcester hospitals during the years 1999, 2001, and 2003 are being reviewed by trained data abstractors. Validation of each case of VTE is performed using prespecified criteria.Results: A total of 483 cases have been validated as acute DVT events - this represents all cases of DVT occurring in residents of the Worcester SMSA in 1999. For purposes of this analysis we have excluded 4 patients with both upper and lower extremity DVT. Upper extremity DVT was diagnosed in 68 (14.2%) of patients versus 411 (85.8%) cases of lower extremity DVT. Patients with upper extremity DVT were younger, more likely to be Hispanic, more likely to have renal disease and more likely to have had a recent central venous catheter, infection, surgery, ICU stay, or chemotherapy than patients with lower extremity DVT. They were less likely to have had a prior DVT or to have developed their current DVT as an outpatient. Although less likely to be treated with heparin, LMWH, or warfarin they were more likely to suffer major bleeding complications. Recurrence rates of VTE during hospitalization were very low in both groups.Conclusions: Patients with upper extremity DVT comprise a small but clinically important proportion of all patients with DVT in the community setting. Their risk profiles differs from patients with lower extremity DVT suggesting strategies for DVT prophylaxis and treatment for this group may need to be tailored.Characteristics of Patients with Upper versus Lower Extremity DVTUpper extremity (n=68)Lower extremity (n=417)P valueDemographicsMean Age, yrs59.366.5<0.001Male (%)51.545NSRace (%)<0.05White86.691.6Black1.53.2Hispanic9.02.0VTE Setting (%)<0.001Community53.876.2Hospital Acquired46.223.8Risk Factors (%)Recent Central Venous Catheter61.811.9<0.001Recent Infection48.532.4<0.01Recent Surgery47.828.1<0.001Cancer44.132.60.06Recent Immobility38.247.0NSRecent chemotherapy259.5<0.001Renal disease23.51.7<0.0001Recent ICU discharge23.515.10.07Recent CHF19.116.6NSPrevious DVT3.018.7<0.01Anticoagulant prophylaxis (%)During hospital admission (n=125)76.771.6NSDuring recent prior hospital admission (n=188)73.754.7<0.05During recent surgery (n=146)62.555.3NSHospital therapy - treatment doses (%)Any heparin/LMWH66.282<0.01Warfarin at discharge53.171.2<0.01Hospital Outcomes (%)Length of stay (mean, d)11.26.8<0.01Major bleeding11.84.9<0.05Recurrent DVT1.51.0NSRecurrent PE00.2NSHospital Mortality4.54.1NS*Recent = < 3 months