First Episode Of Venous Thromboembolism Research Articles

The dos, don'ts, and nuances of thrombophilia testing.

Considerable progress has been made in elucidating genetic and biologic risk factors for venous thromboembolism (VTE). Despite being able to identify heritable defects in a substantial proportion of patients with VTE, testing has not, in general, proven useful in management. Despite efforts to reduce inappropriate testing, it often falls to the hematologist to consult on patients having undergone thrombophilia testing. Through a series of cases, we discuss how D-dimer testing can be helpful in VTE recurrence risk stratification in younger women as well as how to approach patients with persistently elevated D-dimer levels in the absence of thrombosis. While elevated factor VIII coagulant activity levels are a significant risk factor for a first episode of VTE, its biologic basis is not fully understood, and studies have not shown it to be a useful predictor of recurrence. Abnormal results of genetic tests for methylene tetrahydrofolate reductase or plasminogen activator 1 promoter polymorphisms may be encountered, which carry little if any thrombotic risk and should never be ordered. We also discuss protein S deficiency, the most difficult of the hereditary thrombophilias to diagnose due to a wider "normal" range in the general population as compared with protein C, the presence of both free and bound forms in plasma, and the characteristics of the various assays in use. We also present a rare type of protein C deficiency that can be missed by functional assays using an amidolytic rather than a clotting end point.

Systematic search for the UBA1 mutation in men after a first episode of venous thromboembolism: A monocentric study

Systematic search for the UBA1 mutation in men after a first episode of venous thromboembolism: A monocentric study

Venous thromboembolism and mortality in a multiethnic population: a report from the Birmingham Black Country VTE registry (BBC-VTE Investigators)

Abstract Background Most epidemiological studies into venous thromboembolism (VTE) are based on the white Caucasian population and unrepresentative of VTE outcomes in non-white ethnicities. Purpose Our VTE registry aims to get an insight into the outcomes of VTE patients as applicable to a developed world population with a multi-ethnic background. This will guide clinicians to make appropriate decisions with regards to management and prognosis. Methods The Birmingham Black Country VTE Registry (BBC-VTE) is a multi-ethnic cohort of patients in the West Midlands region of the United Kingdom, who suffered a first episode of VTE. In this study we compared baseline characteristics, treatment patterns and outcomes, and secondly, compared these among the different ethnic groups in this region. Results Between the years 2012–2014 there was a total of 1615 patients (mean age 65.5; 53.1% female) admitted with a first episode of VTE of whom, 134 (8.3%) were Asian, 92 (5.7%) Black, and 1213 (75.1%) White. Asian patients were younger (mean age 54, SD 19.3) vs Black patients (59, SD 19.7) and White patients (68, SD 17.4); and were less often female (50.7% vs. 55.4% and 53.8%) for Black and White patients respectively. The initial VTE event was a DVT in 680 (42.1%) and a PE±DVT in 935 patients (57.9%). Below-knee and above-knee DVT occurred in 95 (5.9%) and 585 (36.2%) patients respectively. Recurrent DVT occurred in 3.2% of those with an initial below-knee DVT and 12.5% of those with an initial above-knee DVT. Recurrent PE was also more common in those with an initial above knee DVT (4.8%) compared to those with below-knee DVT (3.2%). After the initial VTE event, 1269 (78.6%) were started on long-term anticoagulation for the prevention of recurrent VTE. Of those, 65.1% stayed on anticoagulation for up to 6 months after the initial VTE event, and 34.9% continued for longer than 6 months, including those on lifelong anticoagulation. Bleeding and major bleeding occurred in 6.8% and 2.5% respectively in those on anticoagulation for 6 or less months, vs. 10.4% and 3.5% in those anticoagulated for longer than 6 months. The most common site of bleeding was gastrointestinal in 42.3% of all bleeds and this site was also responsible for 54.3% of major bleeds. From evaluating the odds ratio for VTE mortality (see Fig. 1), ethnicity did not have a significant impact. Older age; the presence of diabetes mellitus; history of malignancy; as well as admission laboratory results for C-reactive protein and neutrophil count were all significantly associated with higher odds of mortality in this patient cohort. Conclusion BBC-VTE is a contemporary multi-ethnic cohort of patients providing insights into the risk factors among multi-ethnic patients that have developed VTE. Ethnicity did not emerge as an independent risk for VTE mortality. Funding Acknowledgement Type of funding sources: None.

Incidence and Predictors of Recurrence and Mortality Following First Venous Thromboembolism Among the Saudi Population: Single-Center Cohort Study.

BackgroundLittle is written about recurrence and mortality rates after a first episode of venous thromboembolism (VTE) among Saudi population.AimDetermine incidence rates and assess predictors of recurrence and mortality following the first VTE event.Patients and MethodsA total of 1124 patients aged ≥18 years with symptomatic VTE confirmed by imaging tests were evaluated. The incidence of VTE recurrence and mortality were assessed. The association between patient characteristics, and VTE recurrence and mortality was explored by estimating the hazard ratio (HR) and 95% confidence interval (CI). The difference between cancer-related, provoked and unprovoked VTE in terms of recurrence and mortality was explored using Kaplan–Meier curves.ResultsThe annual incidence rate of the first VTE was 1.7 per 1000 patients. Of 1124 patients with first VTE, 214 (19%) developed recurrent VTE, and 192 (17%) died with overall incidence rates of 15.8 per 100 person-years (95% CI, 13.8–18.0) and 10.0 per 100 person-years (95% CI, 8.7–11.5). Intensive care unit (ICU) admission (HR, 2.15; 95% CI, 1.67–3.10), presence of active cancer (HR, 2.97; 95% CI, 1.87–3.95), immobilization (HR, 2.52; 95% CI, 1.79–3.67), infection (HR, 2.32; 95% CI, 1.94–3.45), and pulmonary embolism ± deep venous thrombosis (HR, 2.22; 95% CI, 1.56–3.16) were found to be independent predictors of recurrent VTE. Recurrence carries a high hazard of mortality (HR, 5.21; 95% CI, 3.61–7.51). The estimated median time to VTE recurrence was lower in cancer-related VTE (18.7 months) compared with provoked (29.0 months) and unprovoked VTE (28.4 months). The estimated survival median time was lower in cancer-related VTE (21.8 months) compared with provoked (30.5 months) and unprovoked VTE (29.8 months).ConclusionImmobilization and presence of active cancer, infection, and PE ± DVT were significant predictors of recurrent VTE. Patients who developed recurrent VTE had a 5.2-fold higher hazard of mortality compared with patients with no VTE recurrence.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

The Birmingham and Black Country cohort of Venous Thromboembolism (BBC-VTE) registry: Rationale, design and preliminary results

The Birmingham Black Country Venous Thromboembolism registry (BBC-VTE) is a multi-ethnic cohort of patients who suffered a first episode of venous thromboembolism (VTE) and were admitted to various hospital sites across the West Midlands and Black Country regions in the United Kingdom. The BBC-VTE registry is a retrospective, observational cohort study which aims to collect data on outcomes including mortality, bleeding and VTE recurrence in this patient cohort. In addition, the comprehensive, structured data collected will allow us to conduct machine learning analyses for risk prediction in such patients and also to compare to previously derived mortality scores such as the PESI and the simplified PESI (sPESI).Our registry included 2183 patients admitted to hospital between the years 2012–14 and 2016–18 with a first episode of VTE and the mean follow up was 36 months. The cohort was ethnically diverse with 72.5% white Caucasian, 8.2% Asian (including South Asian), 6.7% black, and 11.7% of unknown/other ethnicity. Of those admitted during the collection period 56% had PE, 40% had DVT, with the rest presenting with both PE and DVT. Around 7% of patients went on to develop a bleeding episode and 36% died (all-cause mortality). Of the deaths, 10% of patients died within 30-days of admission (30-day mortality), with 16% dying within 90 days. In summary, this study investigates real-world outcomes of patients after the first index VTE event and attempts to bridge the gap in evidence for contemporary data in this population which will allow to construct more accurate risk prediction tools and management decisions.

Prediction of bleeding events using the VTE-BLEED risk score in patients with venous thromboembolism receiving anticoagulant therapy (Review).

Venous thromboembolism (VTE) is a major healthcare problem due to its high incidence, significant mortality rate from pulmonary embolism, high recurrence rate and morbidity from long-term complications. After a first episode of VTE all patients must receive anticoagulant treatment for 3 months. Further anticoagulation is recommended in patients without transient risk factors for VTE or patients with active cancer, if they are not at a high risk for bleeding. The VTE-BLEED risk score was created with the purpose of enabling a better stratification of the bleeding risk during stable anticoagulation after a first VTE. Currently, it is the most validated risk score in VTE settings (selected and non-selected cohorts). It has a good prediction power for major bleeding events in patients receiving any of the currently available classes of oral anticoagulants, and it can identify patients at risk of intracranial and fatal bleeding events. The aim of our review was to highlight the strengths of the VTE-BLEED risk score, to acknowledge its weak points and to properly position its use in current medical practice.

Clinical features and management of venous thromboembolism in patients with Behçet's syndrome: a single-center case-control study.

Almost one third of patients with Behçet's syndrome (BS) display vascular involvement. However, data regarding the prevalence and management of venous thromboembolism (VTE) in BS are scanty. We assessed the differential characteristics between patients with and without VTE and the factors associated with VTE incidence. A case-control study in a cohort of patients with BSwas performed. 57 patients were included (56.1% women) with a mean follow-up of 10.56 (± 10.7) years. Mean age at diagnosis of BS and diagnosis of the first VTE episode was 34.7 (± 12.1) and 31.2 (± 8.9) years, respectively. Erythema nodosum (OR 4.6, CI 95% 1.2-18.1) and fever (OR 8.2, CI 95% 1.6-42.1) were associated with a higher risk of VTE. 26 episodes of VTE were registered in 12/57 (21%) patients. 83.3% of patients were not diagnosed with BS when the first episode of VTE occurred and, among them, the episode of VTE led to the diagnosis of BS in 40% of cases. Half of patients had at least one VTE recurrence. The absence of immunosuppressive treatment was associated with a higher risk of developing a first episode of VTE (OR 20 CI 95% 19.2-166.6). All patients were treated with anticoagulation and 75% were treated with immunosuppressants after the first VTE event. The diagnosis of VTE usually precedes that of BS, with a high frequency of VTE recurrence. Erythema nodosum and fever were associated with a higher risk of VTE, while the immunosuppressants showed a protective role for the development of VTE.

Venous thromboembolism 2011\u20132018 in Stockholm: a demographic study

Venous thromboembolism (VTE) is an important cause of morbidity and mortality in Western countries. The incidence rate of VTE is estimated at 1–2 cases per 1000 annually. This study was a population-based cohort study of previously treatment naïve patients with a first occurrence of venous thromboembolism (VTE), using data from the administrative health data register of the Stockholm Region 2011–2018. Data on anticoagulant treatment was taken from the Swedish Prescribed Drug Register. We also analyzed all VTE events between 2011 and 2018. Altogether 14,849 naïve incident VTE cases were identified. In 2011 the majority of patients with a first episode of VTE were prescribed warfarin versus non-vitamin K antagonist oral anticoagulants (NOACs), 1144 versus 5. In contrast in 2018, the majority of patients were treated with NOACs, 1049 versus 59 treated with warfarin. Treatment with low molecular weight heparin only decreased from 814 to 683 patients. The frequency of all VTE events in the population increased over time from 1.88/1000 to 1.93/1000 (p = 0.072), and PE diagnoses increased from 0.69/1000 to 0.76/1000 (p = 0.003). In conclusion, during 2011–2018 there has been a shift of prescription of warfarin to a clear predominance of NOACs in the treatment of VTE in the Stockholm Region, in line with current recommendations. In the clinical situation, treatment has been simplified as monitoring of warfarin has decreased substantially. PE events increased during the time period in the population even if the increase was rather modest, while all VTE events did not increase significantly.

The Effect of Antipsychotic Treatment on Recurrent Venous Thromboembolic Disease: A Cohort Study.

Venous thromboembolism (VTE) represents a major cause of morbidity and mortality worldwide. Antipsychotic treatment is associated with an increased risk of thromboembolic disease, an effect that seems to be constant across the spectrum of distinct agents. This study sought to delineate the effect of new antipsychotic use on the risk of recurrent thromboembolic events after a first episode of either deep venous thrombosis or pulmonary embolism. This cohort study, conducted between January 2010 and June 2017, was based on a prospectively collected database of adult patients with VTE. The main exposure was the new onset of antipsychotic treatment after having a first episode of venous thromboembolic disease. The primary outcome was defined as recurrent VTE, either deep venous thrombosis or pulmonary embolism, during long-term follow-up. The composite of all-cause mortality and recurrent VTE served as the secondary outcome. An inverse probability weighted multivariable Cox proportional hazards model was fitted to adjust for measured confounding and competing risks. One thousand one hundred three patients were included in the present analysis, of whom 136 were identified as new users of antipsychotic agents. A total of 67% of patients were currently treated with full-dose anticoagulation at baseline. No association was found between the new use of antipsychotic agents and recurrent VTE during follow-up (adjusted hazard ratio (HR) = 1.08; 95% CI, 0.38-3.08). However, the use of these agents was associated with a 63% increased risk of recurrent VTE or all-cause mortality (adjusted HR = 1.63; 95% CI, 1.26-2.10). The use of antipsychotic agents among patients with a first episode of VTE and full-dose anticoagulation was not associated with an increased risk of recurrent thromboembolic events. However, antipsychotic treatment was associated with a higher risk of both VTE and all-cause mortality. Further studies are warranted to confirm these findings.

Association of Short-Term Mortality of Venous Thromboembolism with Family History of Venous Thromboembolism and Charlson Comorbidity Index.

Studies on short-term prognosis of venous thromboembolism (VTE) that take family history of VTE and Charlson Comorbidity Index (CCI) into account are sparse. The aim was to investigate the importance of family history of VTE and CCI for short-term mortality after a first episode of VTE. Using Swedish medical databases, we conducted a 90-day nationwide cohort study of 41,700 Swedish born patients with a first-time VTE (July 2005-August 2012). Patients diagnosed with VTE and prescribed anticoagulant treatment were included. Mortality hazard ratios (HRs) with 95% confidence intervals (CIs) were determined with Cox regression. Patients with first-degree (sibling/parent) family history of VTE (n = 11,405, 27.4%) had significantly lower CCI than those without family history. Independent risk factors for 90-day mortality in the adjusted model were: female sex (HR = 1.19, 95% CI: 1.09-1.29), increasing age (HR = 1.02, 95% CI: 1.01-1.02 per year), pulmonary embolism (HR = 1.21, 95% CI: 1.11-1.32) or combined pulmonary embolism and deep venous thrombosis (HR = 1.60, 95% CI: 1.27-2.01) compared with deep venous thrombosis, CCI = 1 (HR = 2.93, 95% CI: 2.32-3.72), CCI = 2 (HR = 8.65, 95% CI: 7.16-10.46) or CCI = 3 (HR = 22.25, 95% CI: 18.73-26.44) compared with CCI = 0. Having one or two or more affected first-degree relatives with VTE was associated with lower mortality, HR = 0.83 (95% CI: 0.74-0.92) and HR = 0.65 (95% CI: 0.51-0.85), respectively. The mortality rate was 0.70% in patients with a CCI of zero. In receiver operating characteristic (ROC) analysis, the area under the ROC curve for CCI was 0.84 (0.83-0.95). Family history of VTE is associated with lower mortality while CCI is a strong predictor for short-term mortality in VTE. Co-morbidities are important for risk assessment of VTE.

Venous Thromboembolism (VTE) Education Preferences Amongst Physicians and Patients: A Qualitative Needs Assessment

Introduction: Venous thromboembolism (VTE) is the leading cause of preventable deaths in hospitalized patients. Prior studies have demonstrated that increasing patient education about VTE increases medication adherence. Thus, standardizing VTE education is an important priority in optimizing patient care. In this regard, online education offers unique advantages as it can be accessed by patients anywhere and anytime. However, an effective VTE educational tool remains elusive as little research has been done to determine what information patients should know or how such information can be delivered most effectively. We performed a qualitative study of hematologists and VTE patients to understand these issues, with the goal of utilizing this information to create an online educational tool for VTE that addresses the needs of both clinicians and patients.Methods: We conducted semi-structured interviews with physicians in the Section of Hematology at Yale School of Medicine (YSM) and VTE patients in the outpatient Benign Hematology Clinic at Yale Cancer Hospital. Adult patients with a pulmonary embolism or deep venous thrombosis, who were on or off anticoagulation, and who were seen in the outpatient clinic either as new patients or for follow-up visits were all included. Providers were asked about what strategies work best when communicating to patients and important aspects of VTE they felt patients should know. Patients were asked about their understanding of VTE and how an educational tool would best address their concerns. All interviews were audio recorded and transcribed. Data were analyzed with grounded theory, and each transcript was double-coded until thematic saturation was achieved.Results: Five physicians participated in the study: one with a focus in benign hematology, three with a focus in benign and malignant hematology, and one who had been a private practice hematology/oncology provider and then transitioned into a clinical appointment on the YSM Hematology faculty. Qualitative analysis from the physician interviews revealed important themes. In particular, physicians believed that an online resource for VTE should: 1) provide visual animation to facilitate conceptual understanding; 2) be readily accessible and as concise as possible; and 3) follow a standardized format that addresses classification of VTE (provoked vs. unprovoked), signs and symptoms of VTE, treatment options, and long-term management.Eight patients were interviewed for the study, 4 with a first episode of VTE and 4 with recurrent VTE. Of these, 7 were on anticoagulation and 1 was not. Most patients indicated that their major source of online health education was through websites - most notably “WebMD.” Patients identified websites as helpful in providing background information, but felt that websites were limited in their ability to provide personalized patient-based recommendations. Many also found website text lengthy and felt that concepts could be better conveyed if explained visually in a concise manner.Conclusion: Based on the physician and patient interviews, an optimal online educational tool about VTE should address the pathophysiology, natural history, management, recurrence risk, and prevention of VTE, in a concise and personalized manner, utilizing visual stimuli. We plan on synthesizing this information to create a 5-10 minute animated video about VTE that addresses all of these issues; we then hope to study the efficacy of the video through a randomized control trial. DisclosuresNo relevant conflicts of interest to declare.

Antipsychotic drugs and the risk of recurrent venous thromboembolism: A prospective cohort study

BackgroundNumerous studies have suggested that antipsychotic drugs are associated with an increased risk for a first episode of venous thromboembolism (VTE). However, after anticoagulation discontinuation, the impact of antipsychotic drugs on the risk of recurrent VTE (rVTE) remains unknown. ObjectiveTo estimate the risk of rVTE in association with antipsychotic drugs. MethodsBetween May 2000 and December 2012, we included all consecutive patients with a first unprovoked symptomatic VTE and who discontinued anticoagulation. During follow-up, exposure to antipsychotic drugs was systematically assessed. ResultsA total of 736 patients with a first unprovoked symptomatic VTE were followed-up during a median period of 27.0 months (interquartile range (IQR) 6.2–60.0). Patients' median age was 66.0 years (IQR 49.0–76.0), 404 (54.9%) were men, and 61 (8.3%) were exposed to antipsychotics during follow-up. The incidence rate of r VTE was 12.1% person-year (95% CI 7.2–20.5) in antipsychotics users compared with 8.3% person-year (95% CI 7.1–9.8) in non-users (p = 0.20). Multivariate analysis showed a significant increased risk of recurrence associated with antipsychotic exposure (adjusted hazard ratio 1.9, 95% CI 1.1–3.3). ConclusionsIn this cohort study, exposure to antipsychotic drugs was found to be associated with an increased risk of rVTE among patients with a previous first unprovoked symptomatic VTE and who discontinued anticoagulation. Larger studies are needed to confirm and further explore this association.

Evaluation of Expression Level of Apolipoprotein M as a Diagnostic Marker for Primary Venous Thromboembolism.

Recently, decreased levels of apolipoprotein M (ApoM) were shown to be associated with higher risk of recurrent venous thromboembolism (VTE) in male patients. However, the role of ApoM in primary VTE is unknown. We aimed in our study to analyze the plasma levels of ApoM in patients with VTE in order to evaluate the diagnostic importance of ApoM in primary VTE. A total of 357 patients with suspected first episode of VTE were recruited prospectively in the SCORE study. Plasma samples from 307 patients were available for quantifying the plasma levels of ApoM in patients with VTE using sandwich enzyme-linked immunosorbent assay method. Among the whole population, plasma levels (mean [standard deviation]) of ApoM were not significantly different between patients with VTE (0.72 [0.20]) and non-VTE patients (0.72 [0.16]), P = .99. Similarly, in regression analyses, no significant association of ApoM plasma levels with the risk of VTE was found on univariate (odds ratio [OR] =1.0, 95% confidence interval [CI] 0.21-4.84, P = .99) and multivariate analysis (OR = 1.25, 95% CI = 0.19-8.34, P = .819) after adjusting for age, body mass index, and smoking. Moreover, results did not differ significantly after stratification of data according to sex ( P > .05). In this study, our results do not suggest a diagnostic role for ApoM plasma levels in patients with primary VTE. Moreover, the current study suggests that role of ApoM as a risk factor may differ for primary VTE and recurrent VTE in male patients.

Gender Differences in Cancer-associated Venous Thromboembolism.

Venous thromboembolism (VTE) is a commonly diagnosed multifactorial condition with significant morbidity and mortality, occurring in up to 20% of cancer patients. Indeed, patients with cancer are in a higher pro-thrombotic state due to alterations in their haemostatic- coagulative system, stasis and blood flow slowdown, endothelial dysfunction, vascular inflammation and platelet activation. Moreover, several cancer-dependent factors can sum up to trigger a first episode of VTE or to cause its recurrence in the course of anticoagulant treatment. Such a pro-thrombotic condition is further worsened by additional favoring risks such as immobilization, infection, surgery, or insertion of a central venous catheter, and anti-cancer therapy. Furthermore, in the secondary prevention setting, the anticoagulant therapy is accompanied by a high incidence of bleeding complications. Given the above, understanding and identifying the factors associated with the incidence and clinical outcome of VTE in cancer patients might be of great value in the prevention and management of VTEattributable complications, including death. Differences associated to gender on cancerrelated VTEs are not yet fully defined; many of the studies that addressed the question have been biased by erroneous/non homogeneous inclusion criteria. In the present review, we analyzed the potential differences in VTEs occurrence in cancer patients, by reporting the most significant findings in the recent literature. The identification of a differential clinical approach according to patient sex, might prompt the design of personalized treatment options tailored and optimized according to algorithms for oncological VTE prevention.

Long-term quality of life and postthrombotic syndrome in women after an episode of venous thromboembolism.

Objectives To evaluate health-related quality of life after venous thromboembolism. Methods We conducted a cohort study, TEHS follow-up, including 1040 women with a first episode of venous thromboembolism and 994 women unexposed to venous thromboembolism. Patients were recruited from the "Thrombo Embolism Hormonal Study" (TEHS), a Swedish nation-wide case-control study on risk factors for venous thromboembolism in women 18-64 years of age. Quality of life was measured using SF-36 and VEINES-QoL/VEINES-Sym. Results On average there were no difference in mean SF-36 summary scales scores between exposed and unexposed women. Twenty percent of exposed women developed postthrombotic syndrome during follow-up. Women with postthrombotic syndrome had severely impaired quality of life with lower scores on all scales. Other predictors of low quality of life after venous thromboembolism were age, obesity, physical inactivity, and recurrent venous thromboembolism. Conclusion Long-term quality of life after venous thromboembolism in women was severely impaired among those developing postthrombotic syndrome, while quality of life in women not developing postthrombotic syndrome was similar to a control population.

Recurrence and mortality after first venous thromboembolism in a large population‐based cohort

Background Previous reports on recurrence and mortality rates after a first episode of venous thromboembolism (VTE) vary considerably. Advances in the management and treatment of VTE during the last 15 years may have influenced the rates of clinical outcomes. Aim To estimate the rates of recurrence and mortality after a first VTE in patients recruited from a large population-based cohort. Method From the Tromsø study, patients (n = 710) with a first, symptomatic, objectively confirmed VTE were included and followed in the period 1994-2012. Recurrent episodes of VTE were identified from multiple sources and carefully validated by review of medical records. Incidence rates and cumulative incidence rates with 95% confidence intervals (CIs) of VTE recurrence and mortality were calculated. Results The mean age of the patients was 68 years (range 28-102 years), and 166 (23.4%) had cancer at the time of first VTE. There were 114 VTE recurrences and 333 deaths during a median study period of 7.7 years (range 0.04-18.2 years). The risk of recurrence was highest during the first year. The overall 1-year recurrence rate was 7.8 (95% CI 5.8-10.6) per 100 person-years (PY), whereas the recurrence rate in the remaining follow-up period (1-18 years) was 3.0 (95% CI 2.4-3.8) per 100 PY. The overall 1-year all-cause mortality rate was 29.9 (95% CI 25.7-34.8) per 100 PY, and in those without cancer the corresponding rate was 23.6 (95% CI 17.8-31.3) per 100 PY. Conclusion Despite advances in VTE management, the rates of adverse events remained fairly high, particularly in the first year following a first VTE.

Long-term strategies in patients with unprovoked venous thromboembolism

SummaryOnce anticoagulation is stopped, the risk of recurrent venous thromboembolism (VTE) over years approaches 40 % of all patients with a first episode of VTE. The risk is twice as high in patients with unprovoked VTE than in those with minor (either transient or persistent) risk factors of thrombosis. Although the latest international guidelines suggest indefinite anticoagulation for most patients with a first episode of unprovoked VTE, strategies that incorporate the assessment of residual vein thrombosis and D-dimer have the potential to identify a substantial proportion of subjects in whom anticoagulation can be safely discontinued. For those patients in whom anticoagulation cannot be discontinued, new opportunities are offered by the availability of low-dose anti-Xa compounds, which have been found to possess an extremely favorable benefit/risk profile.

Family history of venous thromboembolism and mortality after venous thromboembolism: a Swedish population-based cohort study

Studies on whether family history (FH) of venous thromboembolism (VTE) affects long-term mortality after VTE are missing. The aim of this study was to determine whether FH of VTE affects long-term mortality after a first episode of VTE. Using Swedish medical databases, we conducted a 30-year nationwide cohort study of 49,159 adult Swedish born patients included in the multi-generation register (born 1932 or later) with a first-time VTE (1981–2010). Using Cox regression, we assessed mortality Hazard ratios (HRs) with 95% confidence intervals (CIs). Totally 10,093 (20.5%) patients with VTE had a first-degree FH of VTE (parent/sibling). Patients without FH of VTE had significantly more VTE provoking risk factors and comorbidities than those with FH. The mortality HR the first 10-years after first time VTE was decreased for those with FH of VTE compared to for those without FH: crude HR 0.807, 95% CI 0.771–0.845 and adjusted HR 0.864, 95% CI 0.826–0.905. After 10-years of follow-up there was no significant effect of FH of VTE on mortality: crude HR = 1.018, 95% CI 0.905–1.145 and adjusted HR = 0.995, 95% CI 0.884–1.119. Cancer-associated mortality was more common in those without FH the first 10 years (56.9 vs. 53.4%, p = 0.002). After 10 years there were no difference in cancer-associated mortality (4.9 vs. 5.6%, p = 0.604). The results suggest that patients with FH of VTE have lower thrombotic threshold and need less provoking factors and comorbidities. They have also slightly lower total and cancer mortality the first 10 years after VTE.

Utility of thrombophilia testing in patients with venous thrombo-embolism

Clinical practice of thrombophilia testing those with venous thrombo-embolism (VTE) in public hospitals may not be consistent with the international guidelines. This study aims to assess whether practice of thrombophilia testing in two public hospitals are consistent with international guidelines, and to assess whether certain groups of patients were more likely to benefit from testing. A retrospective audit on patients who presented to two Queensland public hospitals from August 2011 to September 2012 with VTE. Data were collected on demographics, yield of the test, and whether the result of the test changed the duration of anticoagulation. Group analysis was performed to identify patients who were more likely to yield positive results. Of the 152 patients, 49% were tested for thrombophilia, of whom 31% returned a positive result. 38% of patients with provoked VTE were tested for thrombophilia, inconsistent with guideline recommendations. In 1.2% of cases there were documented changes to duration of anticoagulation with positive results. The rates of positive results were 45% in unprovoked VTE cases compared with 29% in provoked VTE cases (P=0.054). The rates of positive results were 52% in recurrent VTE cases compared with 27% in those cases with first episode of VTE (P=0.007). The practice of thrombophilia testing in public hospitals was frequently inconsistent with guidelines, and did not significantly influence clinical decisions. There was higher yield of testing in patients with recurrent episodes of VTE and possibly in patients with unprovoked VTE.