High Risk Of Venous Thromboembolism Research Articles

Clinical Efficacy and Safety of Novel Anticoagulants for the Management of Venous Thromboembolism in Patients with Cancer: A Systematic Review and Meta-Analysis.

Cancer patients face a four- to sevenfold higher risk of venous thromboembolism (VTE) than the general population. Novel oral anticoagulants (NOACs) provide convenient alternatives to traditional therapies. We performed a systematic literature search across PubMed, Embase, and the Cochrane Library, targeting studies that examined the use of NOACs in cancer-associated VTE. The search included randomized controlled trials (RCTs). Selected studies compared NOACs with low-molecular-weight heparin (LMWH) or vitamin K antagonists (VKA) in cancer patients diagnosed with VTE. A meta-analysis using a random-effects model was applied to estimate pooled effect sizes for outcomes. In this meta-analysis, we included 12 RCTs. Results showed NOACs were more effective than LMWH in preventing VTE recurrence (RR 0.66, 95% CI 0.52-0.83, p = 0.0004). Compared with VKAs, NOACs showed no significant difference (RR 0.63, 95% CI 0.34-1.15, p = 0.13). However, this finding is limited by the small patient sample. Major bleeding outcomes were similar between NOACs and LMWH/VKAs (RR 1.24, 95% CI 0.85-1.80, p = 0.28; RR 0.77, 95% CI 0.39-1.53, p = 0.46, respectively). Meta-regression analysis indicated a statistically significant positive correlation between mortality and major bleeding events when comparing NOACs with LMWH (p = 0.049). There was no significant difference in all-cause mortality between patients treated with NOACs and those treated with LMWH (RR 1.04, 95% CI 0.92-1.18, p = 0.54) or VKAs (RR 0.94, 95% CI 0.72-1.23, p = 0.65). Meta-analysis shows NOACs, especially factor Xa inhibitors, reduce VTE recurrence in cancer patients more effectively than LMWH. Comparison between NOACs and VKAs is inconclusive due to limited patient data. Further research is needed to assess NOACs' efficacy and safety against VKAs.

Clinical analysis of bleeding and thrombotic events in haematological-oncology patients with severe thrombocytopenia and a high risk of thrombosis

Background: Haematological patients with severe thrombocytopenia and high thrombotic risk face challenges related to balancing bleeding and thrombosis risks. This study investigated factors associated with bleeding and thrombosis in high-risk haematological oncology patients with severe thrombocytopenia not receiving anticoagulant therapy and characterized their clinical features when both events occurred. Methods: A total of 446 haematological oncology patients with Caprini scores ≥ 5 were included from July 2022 to June 2023 at Mianyang City Central Hospital. Those not receiving prophylactic anticoagulants due to an admission platelet count < 50 × 109/L were studied. Patients were categorized into bleeding/nonbleeding and thrombotic/nonthrombotic groups on the basis of hospital course. Relevant clinical data were collected, and univariate/multivariate logistic regression was used to analyse the influencing factors. The platelet count at admission was assessed via ROC curves for thrombosis prediction. Results: In the bleeding group, higher proportions of patients with leukaemia, myeloid tumours, lung infections, and a central venous catheter (CVC) with two lumens were observed, along with shorter catheter durations, lower initial and minimum platelet counts during hospitalization, and prolonged plasminogen times (all P < 0.05). The thrombotic group had a greater thrombosis history, initial platelet count, use of two venous catheter lumens, parenteral nutrition, sedation, and autologous haematopoietic stem cell transplantation (Auto-HSCT), with a lower leukaemia proportion (P < 0.05). Logistic regression identified lymphoma type and minimum platelet count as bleeding protective factors and the Charlson Comorbidity Index (CCI) score as an independent risk factor. Thrombosis history, two venous catheter lumens, and sedation were risk factors for thrombosis. The median platelet count was lower at bleeding and thrombosis than at admission (P = 0.007). The platelet count at admission had predictive value for thrombosis, especially severe thrombocytopenia, with an AUC of 0.735 (95% CI 0.613–0.858, P = 0.003) and a cut-off value of 42.5 × 109/L. Conclusions: For haematological neoplasm patients with a high risk of venous thromboembolism (VTE), severe thrombocytopenia and high CCI scores, risk prevention and control of bleeding take precedence over thrombosis prophylaxis. Prophylactic anticoagulation is still recommended for patients with lymphoma assessed at high risk for VTE and with platelet counts of at least 42.5 × 109/L.

Venous Thromboembolism in Outpatient Elective Foot and Ankle Procedure Patients Who Is at Risk?

Venous thromboembolism (VTE) is a rare but potentially serious complication following elective foot and ankle (F&A) procedures. The absence of guidelines for thromboprophylaxis in elective procedures underscores the importance of identifying patients at risk. This study aimed to identify key risk factors of VTE in patients who underwent elective foot and ankle (F&A) operations. Data was collected from the IBM MarketScan Database (2009-2019) for patients >18 years old without prior VTE who underwent elective F&A procedures. Patients were divided into 3 groups based on region of operation (forefoot, mid/hindfoot, lower leg/ankle). VTE incidence (including deep vein thrombosis and/or pulmonary embolism) was recorded 30 and 90 days postprocedure. Risk factors for VTE were identified through multivariate logistic regression. Among the 301 256 patients who underwent elective F&A procedures, the overall 90-day incidence of VTE was 0.95%. The findings revealed that 31.9% of VTE incidents occurred within the first 2 weeks after operation, and 29.2% still occurred after 6 weeks. Analysis of the anatomical region of operation demonstrated that the lowest rate of 90-day VTE was amongst patients undergoing forefoot procedures (0.70%). There was a higher risk for VTE in patients undergoing midfoot/hindfoot procedures (1.22%, OR = 1.81) and lower leg/ankle procedures (1.76%, OR = 2.31). Additional risk factors for VTE included thrombophilia (4.02%, OR = 3.37), male sex (1.30%, OR = 1.47), increasing age (1.02% age 65+, OR = 1.41), and a high Charlson Comorbidity Index (1.12%, OR < 0.82 for scores <5). This study identifies the incidence and timing for VTE after elective F&A procedures. Furthermore, this study defines the risk factors associated with increased odds of VTE after elective F&A procedures. These findings are helpful in educating patients about a continued risk for VTE throughout the 90-day postoperative period and beyond. These results can also be utilized to stratify patients who need thromboprophylaxis based on the individual risk level. Level III: Retrospective cohort study.

Validation of risk assessment scores in predicting venous thromboembolism in patients with lung cancer receiving immune checkpoint inhibitors

IntroductionSeveral risk scores have been proposed to predict venous thromboembolism (VTE) in hospitalized patients. However, their predictive performances in lung cancer patients receiving immune checkpoint inhibitors (ICIs) is unclear. We aimed to validate and compare their performances of the Caprini, Padua and Khorana risk scores in lung cancer patients receiving ICIs.MethodsThis was a retrospective cohort study of patients with lung cancer treated with ICIs at West China Hospital between January 2018 and March 2022. The primary outcome was VTE during 12 months of follow-up from the first day of treatment with ICIs. The predictive performances of risk scores was determined using receiver operating characteristic (ROC) curve analysis.ResultsAmong the 1115 eligible patients with lung cancer who received ICIs, 105 patients (9.4%) experienced VTE during the 12-month follow-up period. There was a statistically significant difference in the cumulative incidence of VTE between the different risk levels as determined by Caprini and Padua scores (all P < 0.001). However, no significant difference was observed for the Khorana score (P = 0.488). The Caprini and Padua scores demonstrated good discriminative performances (AUC 0.743, 95% CI 0.688-0.799 for Caprini score; AUC 0.745, 95% CI 0.687‐0.803 for Padua score), which were significantly better than that of the Khorana score (AUC 0.553, 95% CI, 0.493‐0.613) (P < 0.05).ConclusionIn our study, the Caprini and Padua risk scores had better discriminative ability than the Khorana score to identify lung cancer patients treated with ICIs who were at high risk of VTE.

Primary Prevention of Cancer-Associated Thrombosis: Current Perspectives.

Over the past two decades, the incidence of cancer-associated thrombosis (CAT) has increased. It is nowadays a common and often serious complication among patients with cancer. Although medical thromboprophylaxis is recommended for most surgical and nonsurgical cancer patients, it has been infrequently used in ambulatory patients with cancer because of the burden of treatment and concerns about bleeding. However, various risk assessment scores are now available and randomized placebo-controlled trials have established the efficacy of low-molecular-weight heparin or the direct oral Xa inhibitors rivaroxaban and apixaban in ambulatory patients with cancer at high risk of venous thromboembolism (VTE). This review provides an overview of (1) primary thromboprophylaxis in the setting of hospitalized surgical and medical patients, (2) extended thromboprophylaxis after hospital discharge, (3) performance of risk assessment tools for CAT, and (4) primary thromboprophylaxis in ambulatory patients with cancer. The aim is to provide support to physicians in identifying ambulatory patients with cancer at high VTE risk who benefit most from medical thromboprophylaxis according to current recommendations from international guidelines.

Heritable Thrombophilia and Increased Risk for Venous Thromboembolism Despite Thromboprophylaxis After Pelvis or Acetabulum Fracture.

Individuals with pelvic and acetabular fractures are at high risk of venous thromboembolism (VTE). The purpose of this study was to determine whether serum markers for thrombophilia and rapid thromboelastography (r-TEG) values correlate with increased VTE risk among patients with pelvic and acetabular fractures. . Prospective observational study. Two urban academic level 1 trauma centers. Adult patients with isolated pelvis and/or acetabulum fractures (OTA/AO 61 and 62) treated surgically placed on a standardized VTE chemoprophylaxis regimen with enoxaparin over a 5-year period were included. Serum r-TEG, coagulation laboratory values, and markers for heritable thrombophilia were drawn postoperatively and after completion of a 6-week course of enoxaparin. The primary outcome was VTE event (either deep venous thrombosis or pulmonary embolism) diagnosed using a Duplex ultrasound, chest computed tomography angiogram, or lung ventilation-perfusion ordered based on clinical suspicion of a VTE event. Laboratory markers and values were then compared between patients who went on to have a VTE event and those who did not and patients with and without markers of thrombophilia. One hundred thirty-three adult patients with isolated operative pelvic and/or acetabular fractures were enrolled in this study. The average age of patients at time of injury was 48.3 years (range 18-91). Sixty-seven percent of patients in the study were (n = 90) males. Sixty-three percent of patients (n = 84) completed both clinical and laboratory follow-up. Forty-one percent of patients (n = 54) had 1 or more markers of heritable thrombophilia. Twelve percent (n = 10) of patients who completed follow-up were diagnosed with VTE. Age, sex, and smoking status were not associated with VTE. Patients who developed VTE had a higher body mass index (P = 0.04). Having more than 1 marker of heritable thrombophilia (P = 0.004) and an r-TEG mean amplitude greater than 72 mm postoperatively was positively associated with VTE (P = 0.02). Among patients treated surgically for isolated pelvic and acetabular fractures who received enoxaparin prophylaxis, the presence of more than 1 marker of heritable thrombophilia or r-TEG mean amplitude value greater than 72 mm postoperatively was associated with an increased risk of VTE. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preventable Hospital Admission-associated VTE: Thoughts on Thromboprophylaxis as Asians

AbstractPrevious studies surveying senior and junior doctors have shown that thromboprophylaxis was not commonly practiced in hospitalized medical patients in three public hospitals in Singapore. We, therefore, conducted an audit of our hospital's venous thromboembolism (VTE) clinic cases to study the proportion of preventable hospital admission-associated VTE (HAAVTE). All newly diagnosed VTE cases referred to our VTE clinic from March 2023 to December 2023 were reviewed, to identify those potentially associated with recent hospital admissions. We then reviewed the medical records of those cases to see if thromboprophylaxis was prescribed if indicated. HAAVTEs that had high VTE risk and did not receive appropriate thromboprophylaxis (pharmacological or mechanical) were considered preventable HAAVTE. Thirteen cases of HAAVTEs were identified, out of which only one was given the appropriate thromboprophylaxis. The proportion of preventable HAAVTE was 92.3%. Thromboprophylaxis is not widely practiced in our hospital. More effort is required to improve local thromboprophylaxis practice for hospitalized patients to reduce the burden of preventable HAAVTE.

Venous Thromboembolism Risk Assessment and Thromboprophylaxis Practice in Hospitalized Medical Patients: The Experience of a Singapore Teaching Hospital

AbstractDespite the availability of institutional guidelines, the practice of venous thromboembolism (VTE) risk assessment and thromboprophylaxis remains inadequate in Singapore. With hospital-associated VTE (HA-VTE) being a common cause of preventable mortality for medical patients, it is vital for prompt, appropriate prescription of thromboprophylaxis after VTE risk assessment. This study aimed to (1) assess the local practice of VTE risk assessment and prophylaxis according to institutional guidelines, (2) study the risk factors of potential preventable HA-VTE among hospitalized medical patients, and (3) improve the quality of care with respect to early prevention of HA-VTE. An audit was performed on daily new admissions to two general medical wards in a teaching hospital in Singapore (total capacity of 76 beds) over 2 weeks. Each new admission's medical records were reviewed to examine whether (1) VTE risk assessment was performed by the managing medical teams, (2) thromboprophylaxis was prescribed during admission in high VTE risk patients, and (3) any contraindications to pharmacological thromboprophylaxis for cases with high VTE risk but no pharmacological thromboprophylaxis prescribed was present. Only 1 out of 52 cases had VTE risk assessment performed. Thirty-one cases (59.1%) were identified to have high VTE risk using the Padua Prediction Score. However, only 1 out of the 31 cases (3.2%) had VTE prophylaxis prescribed. Adherence to local institutional guidelines remains poor despite increasing awareness of the importance of VTE risk assessment and prophylaxis in the prevention of associated morbidity and mortality. Certain patient profiles should prompt clinicians to perform VTE risk assessment.

Role of physical activity and sedentary behavior in venous thromboembolism: a systematic review and dose-response meta-analysis

Increasing studies have investigated the link between physical activity (PA) and sedentary behavior with venous thromboembolism (VTE) but the existing findings are not consistent and the independent relationship is uncertain. This meta-analysis aimed to comprehensively assess the shape of dose-response relationship between PA and sedentary behavior with VTE and further explore whether the relationship is independent after mutual adjustment. We systematically searched PubMed, Embase and Web of Science from inception to August 1, 2024. PA exposures were converted into MET-h/wk. Categorical meta-analyses and a cubic spline model were performed to evaluate the association between PA, sedentary behavior and VTE. Twenty-five articles including 31 studies were included. A curvilinear dose-response relationship between PA and VTE was observed, with steeper gradients even at lower PA levels. After adjustment for sedentary behavior, higher level of PA was independently associated with a reduced VTE risk (OR = 0.83, 95%CI:0.77–0.89). Based on population attributable fraction analyses, 2.37% (95%CI: 1.90-2.85%) of incident VTE could have been prevented if all adults had achieved half the PA minimum recommended level. A linear dose-response relationship between sedentary behavior and VTE risk was found, and there was a 2% higher risk of VTE (OR = 1.02, 95%CI: 1.00-1.03) for 1 h increment of sedentary behavior per day. After adjustment for PA, sedentary behavior was independently associated with an increased VTE risk (OR = 1.19, 95CI%:1.01–1.39). Our analyses demonstrated PA and sedentary time were indeed independently associated with the risk of VTE after mutually adjusting for sedentary time or PA, highlighting a unique perspective on their individual contributions. Further studies assessing the effects of different combinations of PA and sedentary time for assessing joint effects on VTE are needed.

Risk profile and thromboprophylaxis practices among patients undergoing laparotomy at Moi teaching and referral hospital

Background: Venous thromboembolism (VTE) significantly causes hospital mortality worldwide, with abdominal surgery a risk factor. Venous thromboprophylaxis can reduce VTE risk, but has adverse effects. Local research on risk profile and practice helps individualize thromboprophylaxis and develop local protocols. Methods: A prospective study was conducted at Moi teaching and referral hospital (MTRH) on adult laparotomy patients. The minimal sample size was 325 patients, using consecutive sampling. DVT was assessed using Well's score perioperatively, 2 weeks and 4 weeks postoperatively. A lower limb Doppler ultrasonography was performed on patients with a score of 2 or greater to rule out DVT. Results: The mean age of study participants was 38 years, with a 1.5:1 male-to-female ratio. Infection in the abdomen was the main reason for laparotomy. All procedures were open, and 75.4% of individuals had high or moderate VTE risk. Within 72 hours, 82.7% of patients were mobilized. Chemoprophylaxis was limited to enoxaparin post-op. Enoxaparin duration was unstandardized, and MTRH VTE risk categorization chart use was not reported. 3% of individuals received chemoprophylaxis against ACCP guidelines and 12% received enoxaparin despite contraindications. Only 13% and 24% of intermediate and high-risk patients got chemoprophylaxis. No mechanical prophylaxis was used. Symptomatic DVT was 6.8%. Advanced age, Caprini score, and enoxaparin prescription increased symptomatic DVT risk. Conclusions: Despite increased laparotomies for intra-abdominal infection and middle-aged patients, VTE is common in MTRH patients. Poor VTE risk stratification and MTRH protocol failure led to improper thromboprophylaxis. Prescribers should employ MTRH VTE regimen for proper prophylaxis. Providing prescribers with thromboprophylaxis choices to customize prescriptions.

Impact of an emergency department nurse training intervention on the adequacy of thromboprophylaxis for venous thromboembolism: the PROTESU III study.

Objectives. To assess the impact of training for emergency department (ED) nurses on adequate thromboprophylaxis for patients admitted to hospital from the ED for medical conditions. Methods. Multicenter quasiexperimental pre-post study of an ED nurse training intervention in 8 hospitals. Patients were recruited from January 2022 through May 2023 in 3 phases: before nurse training, in the first month after training, and in the sixth month after training. Included were patients attended in the ED for medical conditions. Adequate thromboprophylaxis was defined as 1) use of prophylactic drugs in patients at high risk for venousthromboembolism according to the Padua Prediction Score (PPS), and 2) nonuse in patients at low risk. We compared the percentage of adequate prophylaxis in the first phase to the percentages in the second and third phases. Results. A total of 928 patients were included (326 in phase 1, 295 in phase 2, and 307 in phase 3). PPS scores indicated that 238 (73%) of the patients were at high risk in phase 1 vs 189 (64.1%, P = .016) in phase 2 and 207 (67.4%, P = .125) in phase 3. A total of 187 patients (57.4%, 95% CI, 51.8%-62.8%) were adequatelythromboprophylaxed in phase 1 vs 178 (60.%, 95% CI, 54.5%-66%) in phase 2 (absolute difference in proportions, 3.0% (95% CI, -4.8% to 10.6%; P = .462)]. In phase 3, 166 patients (54.1%, 95% CI, 48.3%-59.7%) received adequate prophylaxis (difference, -3.3% (95% CI, -11.0% to 4.4%; P = .405). Conclusions. A training intervention for ED nurses, implemented as an isolated strategy, had no impact on the adequacy of thromboprophylaxis in patients admitted from the ED for medical conditions.

A new simplified risk assessment model enhances postoperative prophylaxis of venous thromboembolism in Chinese adult patients with inguinal hernia (CHAT-3): a prospective, multicenter, randomized controlled trial.

Venous thromboembolism (VTE) significantly affects the prognosis of surgical patients with inguinal hernia. The complex Caprini score, commonly used for postoperative VTE risk assessment, poses practical challenges for surgeons in clinical settings. The CHAT-3 trial, a prospective, multicenter, randomized controlled trial, compared a simple three-factor model to assess VTE risk against routine practices in postinguinal hernia surgery (IHS) patients. The patients were randomly assigned (1:1) to the intervention or control arm. The intervention group used the three-factor model to identify patients at moderate or high risk of VTE for subsequent prophylaxis according to clinical guidelines. Both groups were followed for 4 weeks, with randomization implemented using computer-generated sequences. The primary outcome measured was the rate of VTE prophylaxis. Secondary outcomes included time spent on VTE risk assessment (surgeon self-reported), postoperative D-dimer trends, perioperative VTE occurrence, bleeding events, and the net clinical benefit. Of the 1109 participants, 508 in the experimental group and 601 in the control group completed follow-up. The three-factor model showed higher VTE prophylaxis rates in all patients (pharmacologic prophylaxis: 26.2 vs. 6.00%, P <0.001) and particularly in those at high risk (pharmacologic prophylaxis: 57.3 vs. 9.50%, P <0.001). The experimental group significantly reduced VTE risk assessment time compared to the Caprini score (1.39±0.55min vs. 5.73±1.35min, P <0.001). The experimental group had lower D-dimer levels (0.26±0.73mg/l vs. 0.35±0.55mg/l, P =0.028). In the experimental group, the patients did not experience an increased risk of VTE (0 vs. 1.66%, P =0.268) and bleeding (1.18 vs. 0.67%, P =0.558) compared to the controls. There was no significant difference in net clinical benefit, which combined VTE and bleeding events, between the experimental and control groups (1.18 vs. 0.83%, P =0.559). Applying the simple three-factor model in perioperative VTE management could quickly identify the patient with a high risk of VTE and improve the prophylaxis rate of perioperative VTE.

Multiple myeloma: retrospective assessment of routine thromboprophylaxis and utility of thrombotic risk scores

BackgroundThe high risk of venous thromboembolism (VTE) in multiple myeloma (MM) warrants primary thromboprophylaxis for most patients. Myeloma-specific thrombotic risk scores (TRSs), such as IMPEDE-VTE, SAVED, and PRISM, were developed to improve risk assessment and guide antithrombotic strategies. Their performance is variable and has not yet been tested in Latin America. ObjectivesWe aimed to assess the use of primary thromboprophylaxis, the incidence of VTE and bleeding events, and the effectiveness of TRSs in patients with newly diagnosed MM. MethodsThis was a retrospective, single-center study. Cumulative VTE rates and TRS performance were analyzed using survival and receiver operating characteristic curves. ResultsThe study included 250 newly diagnosed MM patients; the vast majority (98.6%) received aspirin as thromboprophylaxis. VTE occurred in 8% within the initial 6 months, increasing to 14.8% over a median follow-up of 19 months. High rates of major bleeding (4.8%) and clinically relevant nonmajor bleeding (4.4%) events were documented. A minimal proportion (0.8%, 0.5%, and 1.2%) of patients were classified as low risk by IMPEDE-VTE, PRISM, and SAVED scores, respectively. Only IMPEDE-VTE exhibited a trend for distinguishing between intermediate-risk (7.14%) and high-risk (13.2%) groups (P = .09). PRISM and SAVED scores showed limited utility. VTE did not impact survival. ConclusionAspirin as primary thromboprophylaxis carries an unacceptable risk of VTE and bleeding in patients at intermediate or high thrombotic risk. The IMPEDE-VTE score performed best, although without reaching statistical significance. We confirm that VTE does not portend poor overall survival in MM.

What Constitutes High Risk for Venous Thromboembolism? Comparing Approaches to Determining an Appropriate Threshold.

Guidelines recommend pharmacological venous thromboembolism (VTE) prophylaxis only for high-risk patients, but the probability of VTE considered "high-risk" is not specified. Our objective was to define an appropriate probability threshold (or range) for VTE risk stratification and corresponding prophylaxis in medical inpatients. Patients were adults admitted to any of 10 Cleveland Clinic Health System hospitals between December 2020 and August 2021 (N = 41,036). Hospital medicine physicians and internal medicine residents from included hospitals were surveyed between June and November 2023 (N = 214). We compared five approaches to determining a threshold: decision analysis, maximizing the sensitivity and specificity of a logistic regression model, deriving a probability from a point-based model, surveying physicians' understanding of VTE risk, and deriving a probability from physician behavior. For each approach, we determined the probability threshold above which a patient would be considered high-risk for VTE. We applied each threshold to the Cleveland Clinic VTE risk assessment model (CCM) and calculated the percentage of the 41,036 patients in our cohort who would be considered eligible for prophylaxis due to their high-risk status. We compared these hypothetical prophylaxis rates with physicians' observed prophylaxis rates. The different approaches yielded thresholds ranging from 0.3% to 5.4%, corresponding inversely with hypothetical prophylaxis rates of 0.2% to 75%. Multiple thresholds clustered between 0.52% to 0.55%, suggesting an average hypothetical prophylaxis rate of approximately 30%, whereas physicians' observed prophylaxis rates ranged from 48% to 76%. Multiple approaches to determining a probability threshold for VTE prophylaxis converged to suggest an optimal threshold of approximately 0.5%. Other approaches yielded extreme thresholds that are unrealistic for clinical practice. Physicians prescribed prophylaxis much more frequently than the suggested rate of 30%, indicating opportunity to reduce unnecessary prophylaxis. To aid in these efforts, guidelines should explicitly quantify high-risk.

The Efficacy and Safety of DOACs in Inherited Antithrombin Deficiency: A Cohort Study from a Tertiary Referral Center.

Individuals with inherited antithrombin deficiency (IATD) have a high risk of venous thromboembolism (VTE). Most VTEs are managed with direct oral anticoagulants (DOACs), but the utility of DOACs in antithrombin deficiency (ATD) is unreported. Patients with IATD treated with DOAC were identified from our institutions' IATD registry. We assessed patients' characteristics, ATD type, and initial VTE characteristics, thrombosis recurrence and bleeding rates. Thirty-three patients received DOACs for 73 (38.5-111.5) months (median (interquartile range)). Prior to taking DOACs, 12 (36%) patients had VTE recurrence: these occurred after anticoagulation was ceased (4), nonadherence to VKA prior to DOAC use (3), or during heparin use in pregnancy (5). There were no VTE recurrences on standard-dose DOAC, except in a noncompliant patient receiving dabigatran. There was one recurrence with compliant DOAC use-a patient receiving rivaroxaban 10 mg. Six (18%) patients experienced clinically relevant bleeding, which was predominantly menorrhagia (5/6). One major bleeding event, intracranial hemorrhage, occurred in a patient receiving full-dose rivaroxaban who had refractory hypertension (0.5 events/100 patient-years). In this cohort, compliant DOAC users had an overall VTE recurrence rate of 0.5/100 patient-years, whereas with low-dose DOACs the event rate was 3.5/100 patient-years. Standard-dose DOACs appear efficacious and relatively safe in IATD.

Examining postpartum anticoagulation practices: An international survey of healthcare providers

BackgroundThe risk of venous thromboembolism (VTE) is 15 to 35-fold higher in the postpartum period compared to non-pregnant individuals. Clinical practice guidelines recommend the use of postpartum thromboprophylaxis with low molecular weight heparin (LMWH) for 6 weeks in individuals at high risk of developing VTE. However, a marked reduction in the risk of VTE risk occurs beyond the third week of the postpartum period. ObjectiveWe sought to characterize practice patterns of clinicians who manage postpartum individuals at high risk of VTE. MethodsWe conducted a cross-sectional study using a self-administered electronic questionnaire. The survey explored the use of postpartum thromboprophylaxis in high-risk individuals. Descriptive statistics were used to summarize survey responses. ResultsOf the 113 participants that responded to the initial invitation, 78 completed the survey (Europe (53.9 %); North America (23.2 %); Australia and New Zealand (19.0 %)). For individuals with a prior unprovoked or provoked deep venous thrombosis or pulmonary embolism, cerebral vein thrombosis and splanchnic vein thrombosis, 97.4 %, 93.5 %, 91.0 % and 88.5 % of the respondents recommended six weeks of postpartum thromboprophylaxis using LMWH, respectively. The recommendation for 6 weeks of thromboprophylaxis in patients with sickle cell disease and obstetric APS was comparatively lower (70.5 and 78.2 % respectively). Respondents with higher practice volumes and more years of experience in clinical practice were more likely to recommend a shorter duration of thromboprophylaxis. ConclusionOur study highlights the variability in clinician recommendations and the acceptability of treatment durations for postpartum thromboprophylaxis in high-risk conditions. Prospective studies are needed to determine optimal duration and establish evidence-based management.

Comparative Analysis of Muscle Activity and Circulatory Dynamics: A Crossover Study Using Leg Exercise Apparatus and Ergometer.

Background and Objectives: Bedridden patients are at a high risk of venous thromboembolism (VTE). Passive devices such as elastic compression stockings and intermittent pneumatic compression are common. Leg exercise apparatus (LEX) is an active device designed to prevent VTE by effectively contracting the soleus muscle and is therefore expected to be effective in preventing disuse of the lower limbs. However, few studies have been conducted on the kinematic properties of LEX. Therefore, this study aimed to compare the exercise characteristics of LEX with those of an ergometer, which is commonly used as a lower-limb exercise device, and examine its effect on the two domains of muscle activity and circulatory dynamics. Materials and Methods: This study used a crossover design in which each participant performed both exercises to evaluate the exercise characteristics of each device. Fifteen healthy adults performed exercises with LEX and an ergometer (Terasu Erugo, SDG Co., Ltd., Tokyo, Japan) for 5 min each and rested for 10 min after each exercise. Muscle activity was measured using surface electromyography (Clinical DTS, Noraxon, Scottsdale, AZ, USA), and circulatory dynamics were recorded using a non-invasive impedance cardiac output meter (Physioflow Enduro, Manatec Biomedical, Paris, France). The primary outcome was the mean percentage of maximum voluntary contraction (%MVC) of the soleus muscle during exercise. Results: The mean %MVC of the soleus muscle was significantly higher in the LEX group, whereas no significant differences were observed across the periods and sequences. Heart rate, stroke volume, and cardiac output increased during exercise and decreased thereafter; however, the differences between the devices were not significant. Conclusions: LEX may not only have a higher thromboprophylaxis effect, but also a higher effect on preventing muscle atrophy as a lower-extremity exercise device. Additionally, LEX could potentially be used safely in patients who need to be monitored for changes in circulatory dynamics.

TXA combined with whole blood transfusion in trauma patients does not increase the risk of VTE but shock index does

IntroductionPrevious studies have demonstrated the benefits of tranexamic acid (TXA) administration in combination with packed red blood cell (PRBC) transfusion in trauma patients without increasing the risk of venous thromboembolism (VTE). However, the effect of TXA in combination with whole blood (WB) has not been studied. Injury, abbreviated injury severity scores (ISS and AIS) and the need for blood transfusions are historically associated with VTE. The objective of this study was to determine the relationship between VTE and the combination of TXA administration and transfusion of PRBCs vs. WB. MethodsOur institutional trauma registry was queried for trauma patients between 2015 and 2022 who received either WB ​+ ​TXA or PRBC ​+ ​TXA either prehospital or within 4 ​h of arrival. Multivariate analysis was utilized to determine independent risk factors for VTE, which were defined as either a deep vein thrombosis (DVT) or a pulmonary embolism (PE). Model covariates included age, mechanism of injury (MOI), ISS, lower extremity AIS, comorbid conditions, and shock index (SI). Additional outcomes analyzed were hospital length of stay (LOS), ICU LOS, and ventilator days. ResultsThree hundred and five patients had complete data and were included in the analysis. Of those, 251 received WB ​+ ​TXA and 54 received PRBC ​+ ​TXA. A total of 34 patients were found to have VTE event (11.1 ​%); 28 (11.2 ​%) and 6 (11.1 ​%) from the WB ​+ ​TXA and PRBC ​+ ​TXA groups, respectively. An elevated pre-hospital SI was independently associated with increased VTE rate (OR 1.85, 95 ​% CI 1.07–3.20). WB transfusion, TXA administration, ISS, and MOI did not influence the rate of VTE. ConclusionThese data demonstrate that the combination of WB ​+ ​TXA administered to trauma patients has no higher risk of VTE than patients who receive PRBC ​+ ​TXA, a comparison that has not been studied clinically to date. Despite the pro thrombotic state enhanced by TXA and the decreased dilutional coagulopathy seen in WB resuscitation, there was no increased risk of VTE compared to TXA ​+ ​PRBC. There is no evidence that TXA combined with whole blood transfusion is associated with an increased risk of VTE. However, higher pre-hospital SI was associated with an elevated rate of VTE. These clinical features provide insight into patients who may be at an increased risk of developing VTE and may benefit from targeted prevention strategies.

Evaluation of a Risk Screening Checklist for Venous Thromboembolism Prophylaxis in a Women and Newborn Hospital.

The venous thromboembolism (VTE) risk screening forms were developed to allow for recording identified risk factors for VTE including thrombophilia, history of VTE, postpartum hemorrhage, and cesarean delivery, and documentation of specific actions taken to mitigate these risks and reduce complications due to VTE. Compliance with hospital guidelines in assessing VTE risk and appropriate prescribing of thromboprophylaxis was evaluated prior to the introduction of VTE risk screening forms (March 2022). Efficacy of the new VTE risk screening forms was also assessed (April 2023). Patient discharge summaries and patient medical records including medication charts were used to review the documentation of VTE risk assessments and details of thromboprophylaxis prescribing. Of 74 postnatal patients, 37.8% had VTE risk assessment documented prior to the introduction of VTE risk screening forms. Of 37 patients identified to be at moderate to high risk of VTE requiring pharmacological prophylaxis, 70.3% (n = 26) were appropriately prescribed pharmacological prophylaxis. After the risk screening forms were introduced, a total of 67 antenatal, postnatal, and gynecologic patients were studied. Of these, 32.8% (n = 22) of patients had all required fields completed appropriately. When using the forms, 26.9% (n = 7) of postnatal and 88% (n = 22) of gynecological patients were rated as medium or high risk, and all received medical review within 24 hours. Pharmacological prophylaxis was indicated in 88% (n = 22) of gynecological, 43.8% (n = 7) of antenatal, and 38.5% (n = 10) of postnatal patients, and all were appropriately prescribed. The guideline review and introduction of VTE risk screening forms was valuable to provide guidance in the risk assessment for VTE and to identify patients requiring prophylaxis.

Does preperitoneal packing increase venous thromboembolim risk among trauma patients? A prospective multicenter analysis across 17 level I trauma centers.

Pelvic fractures are associated with a high risk of venous thromboembolism (VTE). Among treatment options, including pelvic angioembolization (PA), preperitoneal pelvic packing (PPP), and pelvic open reduction internal fixation (ORIF), PPP has been postulated as a VTE risk factor. We aimed to characterize the risk of VTE among pelvic fracture patients receiving PPP, PA or ORIF. We used observational data from a 17-site Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group, a US level I trauma center collaborative working to identify factors associated with posttraumatic VTE, deep venous thrombosis, pulmonary embolism, or pulmonary thrombosis. The CLOTT criteria included age 18 to 40 years with at least one independent VTE risk factor. We compared outcomes of PPP, PA, and pelvic ORIF to reference of no pelvic intervention. Our primary outcome was VTE. A competing risk analysis was performed. Among 1,387 pelvic fracture patients, VTE incidence was 5.6%. The ORIF patients were most likely to develop VTE (24.7%), while VTE incidence for PPP was 9.0% and 2.6% for PA. After multivariate, risk-competing analysis, none of the three treatment interventions for pelvic fractures were significantly associated with VTE. Initiation of VTE prophylaxis in the first 24 hours of admission independently halved VTE incidence (hazard ratio, 0.55; confidence interval, 0.33-0.91). Pelvic fracture interventions do not appear to be independent risk factors for VTE in our study. Initiation of VTE pharmacoprophylaxis within the first 24 hours of admission remains critical to significantly decreasing VTE formation in this high-risk population. Therapeutic Study; Level III.