Occurrence Of Venous Thromboembolism Research Articles

The ICU-venous thromboembolism score and tumor grade can predict inhospital venous thromboembolism occurrence in critical patients with tumors

BackgroundVenous thromboembolism (VTE) is a threat to the prognosis of tumor patients, especially for critically ill patients. No uniform standard model of VTE risk for critically ill patients with tumors was formatted by now. We thus analyzed risk factors of VTE from the perspectives of patient, tumor, and treatment and assessed the predictive value of the ICU-VTE score, which consisted of six independent risk factors (central venous catheterization, 5 points; immobilization ≥ 4 days, 4 points; prior VTE, 4 points; mechanical ventilation, 2 points; lowest hemoglobin during hospitalization ≥ 90 g/L, 2 points; and baseline platelet count > 250,000/μL, 1 points).MethodsWe evaluated the data of tumor patients admitted to the intensive care unit of the Peking University Cancer Hospital between November 2011 and January 2022; 560 cases who received VTE-related screening during hospitalization were chosen for this retrospective study.ResultsThe inhospital VTE occurrence rate in our cohort was 55.7% (312/560), with a median interval from ICU admission to VTE diagnosis of 8.0 days. After the multivariate logistic regression analysis, several factors were proved to be significantly associated with inhospital VTE: age ≥ 65 years, high tumor grade (G3–4), medical diseases, fresh frozen plasma transfusion, and anticoagulant prophylaxis. The medium-high risk group according to the ICU-VTE score was positively correlated with VTE when compared with the low-risk group (9–18 points vs. 0–8 points; OR, 3.13; 95% CI, 2.01–4.85, P < 0.001). The AUC of the ICU-VTE scores according to the ROC curve was 0.714 (95% CI, 0.67–0.75, P < 0.001).ConclusionsThe ICU-VTE score, as well as tumor grade, might assist in the assessment of inhospital VTE risk for critically ill patients with tumors. The predictive accuracy might be improved when combining two of them; further follow-up researches are needed to confirm it.

1589P Chronological pattern of venous thromboembolism (VTE) occurrence impacts in survival of pancreatic ductal adenocarcinoma (PDAC)

VTE is considered one of the main causes of death and morbidity in cancer patients. Khorana score (KS) is the gold-standard to predict VTE risk in this population. PDAC is considered among the most prothrombotic malignancies. However, information about the timing of VTE diagnosis and its prognostic impact are currently scarce. All pancreatic cancer patients treated between 2019 and 2021 in Hospital General Universitario Gregorio Marañón, Madrid, Spain were analyzed. We reviewed the medical history of all patients to collect demographics, treatment characteristics and clinical outcomes. Patients were classified based on KS. Occurrence of VTE was evaluated from diagnosis through end of follow-up or death. A total of 197 patients (p) were included (Table, clinical characteristics ), 54 p (27.4%) were diagnosed with VTE. 14.5% (n=8) were deep vein thrombosis, 34.5% (n= 19) pulmonary embolism and 49.0% (n=27) visceral vein thrombosis. 36 p had metastatic disease (n=35, 66.6%), 12 locally advanced (22.2%) and 6 were resectable (11.1%). Most of them occurred in the first three months of diagnosis (74%, n=40). Early appearance of VTE (less than 3 months from cancer diagnosis) was associated with worse prognosis, median overall survival (mOS) VTE < 3 months 8.5 months (HR 1.65, 95% CI 1.11-2.46; p=0.014), mOS VTE >3 months 12.8 months (HR 0.78, 95% CI 0.39-1.54; p= 0.5) and mOS patients without VTE diagnosis 11.4 months (95% CI 10.1-15.4). 31.9% p were classified as high-risk and 64.9% as intermediate-risk based on KS. 35 p (27.3%) of the intermediate category developed a VTE and 19 (30.1%) in the high-risk category, showing no statistically significant association (chi2 test p-value = 0.9).Table: 1589PClinical characteristicsn=197 (100)Sex Female Male.98 (49.7) 99 (50.3)Age (years) < 65 ≥ 6569 (35.0) 128 (65.0)ECOG 0 1 2 329 (14.7) 134 (68.0) 27 (13.7) 7 (3.6)Disease status Resectable Locally advanced Metastasic41 (20.8) 54 (27.4) 102 (51.8)Tumor location Pancreatic head Body/tail region Unknown119 (60.4) 73 (37.1) 5 (2.5) Open table in a new tab Only early-onset VTE impacts in OS of PDAC patients, it may identify a more aggressive cancer phenotype. KS did not predict VTE in our population, being necessary better risk assessment models in clinical practice.

Efficacy and safety of direct oral anticoagulants for the treatment of cancer-associated venous thromboembolism: A systematic review and Bayesian network meta-analysis

IntroductionDirect oral anticoagulants (DOACs) could effectively prevent the occurrence of cancer-associated venous thromboembolism (CAVTE), which incidence rate was estimated to be 4–20%. But the efficacy and safety remain controversial between DOACs and low molecular weight heparin (LMWH). Materials and methodsPubMed, Cochrane Library, Embase, ClinicalTrials.gov databases for randomized controlled trials (RCTs) were systematically searched from inception to March 15, 2022. A random-effects model was used to report the odds ratio (OR) and 95% confidence interval (CI) for both direct and network meta-analyses. ResultsSeven studies were included totaling 3242 patients. A lower rate of recurrence VTE was noted in the DOACs compared with LMWH (OR 0.62, 95% CI 0.47–0.82, I2=0.0%). The aspect of major bleeding (MB) was similar (OR 1.30, 95% CI 0.77–2.18, I2=34.9%). When assessing clinically relevant nonmajor bleeding (CRNMB) (OR 1.61, 95% CI 1.17–2.22, I2=20.7%) and clinically relevant bleeding (CRB) (OR 1.39, 95% CI 1.11–1.74, I2=0.0%), a higher risk of events was observed in DOACs. In subgroup analyses, the MB of gastrointestinal and genitourinary malignancies had a higher rate in the DOACs. For ranking, apixaban ranked the first in prevention of VTE and reducing MB events. Edoxaban had the highest risk drug in MB. In terms of CRNMB and CRB, LMWH showed the lowest risk. ConclusionsCompared with LMWH, DOACs seemed to have a decreased risk of recurrence VTE while increasing CRNMB and CRB. DOACs and LMWH were equivalent to the aspect of MB, but DOACs had a higher MB risk in patients with gastrointestinal and genitourinary malignancies. Apixaban may be the lowest risk compared to the other DOACs in precaution of VTE and reducing bleeding events.

The Diagnostic Value of the Systemic Immune-Inflammation Index for Venous Thromboembolism in Lung Cancer Patients: A Retrospective Study

Background Venous thromboembolism (VTE) is considered a common complication in lung cancer patients. Despite its widespread use, the Khorana score performed moderately in predicting VTE risk. This study aimed to determine the diagnostic utility of the Systemic Immunoinflammatory Index (SII) and to create a novel nomogram for predicting VTE in patients with pulmonary carcinoma. Materials and Methods The data, like clinical features and laboratory indicators, of inpatients diagnosed with lung cancer from March 2019 to March 2020 were collected and analyzed. Univariate and multivariate logistic analyses were performed to confirm the risk factors and then construct a nomogram model. The calibration curve and clinical decision curve analysis (DCA) were used to assess the model's fitting performance. The receiver-operating characteristic (ROC) curve and the area under the ROC curve (AUC) were used to evaluate the diagnostic value of SII and the nomogram. Results This study enrolled 369 lung patients with a VTE morbidity rate of 23.33%. The patients with VTE had higher SII levels than the non-VTE group (1441.47 ± 146.28 vs. 626.76 ± 26.04, P < 0.001). SII is the stronger correlator for VTE among inflammatory markers, of which the optimal cut-off value was 851.51. Univariate and multivariate analysis revealed that the age, metastasis, antitumor treatment, hemoglobin<100 g/L, SII>851.51 × 109/L, and D-dimer>2 folds were independent risk factors for lung cancer-related VTE, and a new prediction nomogram model was constructed based on them. ROC curve analysis showed the AUC of the new model and Khorana score were 0.708 (0.643-0.772) and 0.600 (0.531-0.699). Conclusion The SII was a simple and valuable biomarker for VTE, and the new nomogram model based on it can accurately forecast the occurrence of VTE. They can be utilized in clinical practice to identify those at high risk of VTE in lung cancer patients.

229. Using machine learning (ML) models to predict risk of venous thromboembolism (VTE) following spine surgery

229. Using machine learning (ML) models to predict risk of venous thromboembolism (VTE) following spine surgery

Incidence of venous thromboembolism in patients with advanced staged ovarian cancer undergoing neoadjuvant chemotherapy (411)

<b>Objectives:</b> Venous thromboembolism (VTE) during neoadjuvant chemotherapy (NACT) treatment for epithelial ovarian cancer (EOC) can delay interval debulking surgery (IDS) and affect overall prognosis. Our primary objective was to determine the incidence and timing of VTEs in patients with advanced-stage EOC who received NACT. Our secondary aims were to identify specific risk factors that increase the risk of VTE and assess the rate of direct-acting oral anticoagulants (DOACs) use for VTE treatment. <b>Methods:</b> Our retrospective cohort study included patients with stage IIIC/IV EOC who received NACT followed by IDS between January 2, 2012, and April 30, 2018, at a single institution. Patients were identified from a prospectively maintained surgical database of clinical, surgical, and outcomes data collected from the medical record. Medical records were reviewed to ascertain a prior history of VTE or the date of a clinical diagnosis of VTE between the EOC diagnosis and up to 180 days after IDS. VTE was defined as a deep vein thrombosis and/or pulmonary embolism diagnosed by Doppler ultrasound or computed tomography angiogram, respectively. Associations of patient characteristics with the development of VTE between EOC diagnosis and IDS were evaluated univariately using logistic regression. <b>Results:</b> Of the 160 patients who met the study inclusion criteria, five patients had a remote history of VTE prior to EOC diagnosis, and four had a concurrent VTE at time of diagnosis and thus were excluded from the analyses. Among the remaining 151 patients (mean age: 65.7 years), there were 29 (19.2%) incident cases of VTE between EOC diagnosis and the first 180 days after IDS: nine (6.0%) between EOC diagnosis and start of NACT, 13 (8.6%) during NACT and before IDS, and seven (4.6%) occurred within 180 days after IDS (Figure). Among these 29 patients, ten (34.5%) received a DOAC, specifically apixaban and rivaroxaban, for VTE treatment without complications. We were unable to identify any statistically significant associations between the following factors and the occurrence of VTE between EOC diagnosis and IDS: age, body mass index, smoking status, American Society of Anesthesiologists (ASA) score (>3 vs <3: odds ratio [OR]: 2.3, 95% CI: 0.7-7.2), Khorana score, and clinical tumor histology (non-serous vs serous: OR: 2.9, 95% CI: 0.7-12.4), or stage (IV vs IIIC: OR: 1.5, 95% CI: 0.6-3.8). <b>Conclusions:</b> Of the patients with advanced EOC who underwent NACT, 14.6% experienced a possible preventable VTE between EOC diagnosis and IDS. VTE during NACT can significantly delay IDS and affect the overall prognosis. Our results raise the need for further research to determine the population of patients who would benefit from thromboprophylaxis during NACT. The use of DOAC may be safe in this patient population.

Association of D-dimer with short-term risk of venous thromboembolism in acutely ill medical patients: A systematic review and meta-analysis.

D-dimer, a marker of ongoing procoagulant activity, has been widely used for the diagnosis of venous thromboembolism (VTE). The prognostic significance of D-dimer in stratifying VTE risk for acutely ill medical patients has not been well-established. A literature search was performed to collect studies that compared the incidence of short-term VTE between acutely ill medical patients with elevated or nonelevated D-dimer levels. The cutoff of D-dimer was 0.5 μg/mL or otherwise defined by included studies. The study endpoint was any occurrence of VTE (inclusive of deep vein thrombosis [DVT], pulmonary embolism, or VTE-related death) within 90 days of hospital presentation. A meta-analytic approach was employed to estimate the odds ratio (OR) with 95% CI by fitting random-effects models using the generic inverse variance weighted approach. A total of 10 studies representing 31,119 acutely ill medical patients were included. Compared to those with nonelevated D-dimer levels, patients with elevated D-dimer had approximately threefold greater odds for short-term VTE within 90 days (OR, 3.28; 95% CI, 2.44 to 4.40; p < 0.0001). The association of elevated D-dimer with VTE composite (OR, 3.33; 95% CI, 2.20 to 5.02) and with DVT (OR, 3.26; 95% CI, 2.32 to 4.58) was comparable. The association was significant among patients who presented various acute medical illness (OR, 2.68; 95% CI, 2.01 to 3.58) and those who presented with acute stroke (OR, 3.25; 95% CI, 2.31 to 4.58). Elevation of D-dimer was predictive of the occurrence of VTE within 90 days among acutely ill medical patients.

Direct oral anticoagulant: Review article.

Venous thromboembolism (VTE) and atrial fibrillation (AF) is a major burden on the health care system. The average occurrence of venous thromboembolism annually is around 108 per 100,000 person-year. DOACs have transformed treatment of coagulation disorder, and now, it is the leading treatment for stroke prevention in AF and VTE prophylaxis and treatment. For more many years, oral vitamin K antagonists (VKAs) were the drug of choice in managing VTE. VKAs treatment is safe and effective if therapeutic international normalized ratio (INR) maintained on the target. However, achieving a stable, therapeutic international normalized ratio (INR) can be difficult and challenging in the context of drug and food interactions and liver disorder, resulting in undertreatment which increases the risk of thromboembolism or overtreatment which might cause bleeding. Herein, we provide an overview of DOACs indications, use in specific comorbidities, monitoring parameters, perioperative management, and reversal agents.

The Incidence of Venous Thromboembolism in Dengue Viral Infections: A Systematic Review

BACKGROUND Dengue infection has become a major public health problem with significant socioeconomic burden to the increasing geographical extension, number of cases, and severity of the disease. One of the neglected complications in dengue is venous thromboembolism (VTE) which could also be as fatal is often overlooked in the overall management of dengue. OBJECTIVE This study aimed to provide a perspective on the incidence of thromboembolism in patients with dengue infection. METHODS The search strategy was conducted through PubMed and LinkSpringer. About 182 articles were retrieved using ‘vein thrombosis’ and ‘dengue’ keywords. Further, screening was carried out and resulted in 15 articles. In the end, five articles were included. To be eligible, the articles should be published from 2011-2121 and published in English. RESULTS This review found that VTE can occur in dengue patients of all ages, genders, and severities. VTE is more common in dengue shock syndrome patient rather than dengue haemorrhagic fever or least likely in dengue fever. Administering Anticoagulants is still the preferred option in managing VTE in dengue patients with caution of the thrombocyte count of patients. CONCLUSIONS The likeliness of VTE occurrence is linear with the severity of the dengue infection and the patient’s length of stay in hospitals. Preventive measures could be taken to prevent VTE in high-risk dengue patients, thus it is important to do risk scoring in high-risk patients. Thrombocytopenia must be taken into account when realizing said preventive measure, i.e., administering anticoagulant as prophylaxis.

Correlation of Platelet Function with Postpartum Hemorrhage and Venous Thromboembolism in Patients with Gestational Hypertension Complicated with Diabetes.

Objective This study was aimed at investigating the correlation of platelet function with postpartum hemorrhage and venous thromboembolism (VTE) in gestational hypertension patients with diabetes mellitus. Methods A total of 93 patients with gestational hypertension complicated with diabetes treated from March 2020 to June 2021 were selected as the research group, and 56 healthy pregnant women during the same period were selected as the control group. Platelet function-related indicators (platelet count (PLT), platelet volume distribution width (PDW), and mean platelet volume (MPV)) were compared between the two groups. The patients were divided into a severe group (n = 13), mild group (n = 28), and nonbleeding group (n = 52) according to the severity of postpartum hemorrhage, and the value of combined detection of platelet function-related indicators on the severity of postpartum hemorrhage was evaluated and analyzed. According to the occurrence of VTE, the patients were divided into a VTE group and non-VTE group to analyze the predictive value of combined detection of platelet function-related indicators for VTE occurrence in patients. Results The PLT value of the study group was lower than that of the control group, while the PDW and MPV values were higher than those of the control group (all P < 0.05). The PLT value increased with the aggravation of postpartum hemorrhage, while the PDW and MPV values decreased with the aggravation of postpartum hemorrhage among the three groups with different severities of postpartum hemorrhage (all P < 0.05). The area under the curve (AUC) of PLT, PDW, and MPV combination to evaluate the severity of postpartum hemorrhage in patients with gestational hypertension combined with diabetes was greater than that of PLT alone and PDW alone (both P < 0.05). The PLT value was negatively correlated with the severity of postpartum hemorrhage, while PDW and MPV values were positively correlated with the severity of postpartum hemorrhage (both P < 0.05). According to the occurrence of VTE, patients were divided into the VTE group (n = 10) and non-VTE group (n = 83). The PLT value of the VTE group was higher than that of the non-VTE group, while the PDW and MPV values were lower than those of the non-VTE group (all P < 0.05). The AUC of PLT, PDW, and MPV combination to predict the occurrence of VTE in patients with gestational hypertension combined with diabetes was greater than that of each index alone (all P < 0.05). Conclusion Patients with gestational hypertension complicated with diabetes had abnormal platelet function, and the platelet function was related to postpartum hemorrhage and VTE.

High-dose versus low-dose venous thromboprophylaxis in hospitalized patients with COVID-19: a systematic review and meta-analysis.

BackgroundHospitalized COVID-19 patients are at high risk of venous thromboembolism (VTE). Standard doses of anticoagulant prophylaxis may not be sufficiently effective for the prevention of VTE. The objective of this systematic-review and meta-analysis was to compare the efficacy and safety of high-dose versus low-dose thromboprophylaxis in hospitalized patients with COVID-19.Material and methodsMEDLINE and EMBASE were searched up to October 2021 for randomized clinical trials (RCTs) comparing high-dose with low-dose thromboprophylaxis in hospitalized adult patients with COVID-19. The primary efficacy outcome was the occurrence of VTE and the primary safety outcome was major bleeding.ResultsA total of 5470 patients from 9 RCTs were included. Four trials included critically ill patients, four non-critically ill patients, and one included both. VTE occurred in 2.9% of patients on high-dose and in 5.7% of patients on low-dose thromboprophylaxis (relative risk [RR] 0.53; 95% confidence intervals [CIs], 0.41–0.69; I2 = 0%; number needed to treat for an additional beneficial outcome, 22). Major bleeding occurred in 2.5% and 1.4% of patients, respectively (RR 1.78; 95% CI, 1.20–2.66; I2 = 0%; number needed to treat for an additional harmful outcome, 100). All-cause mortality did not differ between groups (RR 0.97; 95% CI, 0.75–1.26; I2 = 47%). The risk of VTE was significantly reduced by high-dose thromboprophylaxis in non-critically ill (RR 0.54; 95% CI, 0.35–0.86; I2 = 0%), but not in critically ill patients (RR 0.69; 95% CI, 0.39–1.21; I2 = 36%).DiscussionIn hospitalized patients with COVID-19, high-dose thromboprophylaxis is more effective than low-dose for the prevention of VTE but increases the risk of major bleeding.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11739-022-03004-x.

Development and validation of a nomogram to assess postoperative venous thromboembolism risk in patients with stage IA non-small cell lung cancer.

Venous thromboembolism (VTE) is a common postoperative complication in patients with lung cancer that seriously affects prognosis and quality of life. At present, the detection rate of patients with early-stage lung cancer is increasing, but there are few studies on the risk factors for postoperative venous thromboembolism (VTE) in patients with stage IA non-small cell lung cancer (NSCLC). This study aimed to establish a nomogram for predicting the probability of postoperative VTE risk in patients with stage IA NSCLC. The clinical data of 452 patients with stage IA NSCLC from January 2017 to January 2022 in our center were retrospectively analyzed and randomly divided into a training set and a validation set at a ratio of 7:3. Independent risk factors were identified by univariate and multivariate logistic regression analyses, and a nomogram was established based on the results and internally validated. The predictive power of the nomogram was evaluated by receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis (DCA). The nomogram prediction model included three risk factors: age, preoperative D-dimer, and intermuscular vein dilatation. The areas under the ROC curve of this predictive model were 0.832 (95% CI: 0.732-0.924) and 0.791 (95% CI: 0.668-0.930) in the training and validation sets, respectively, showing good discriminative power. In addition, the probability of postoperative VTE occurrence predicted by the nomogram was consistent with the actual occurrence probability. In the decision curve, the nomogram model had a better net clinical benefit at a threshold probability of 5%-90%. This study is the first to develop a nomogram for predicting the risk of postoperative VTE in patients with stage IA NSCLC; this nomogram can accurately and intuitively evaluate the probability of VTE in these patients and help clinicians make decisions on prevention and treatment.

Assessment of thromboembolism risk in COVID-19 patients with cardiovascular disease risk factors: Analysis of a Japanese Nationwide Registry

IntroductionPatients with COVID-19 and cardiovascular disease risk factors (CVDRF) have been reported to develop coagulation abnormalities frequently. However, there are limitations in conventional predictive models for the occurrence of thromboembolism in patients with COVID-19 and CVDRF. MethodsAmong data on 1518 hospitalized patients with COVID-19 registered with CLAVIS-COVID, a Japanese nationwide cohort study, 693 patients with CVDRF were subjected to least absolute shrinkage and selection operator (LASSO) analysis; a method of shrinking coefficients for reducing variance and minimizing bias to increase predictive accuracy. LASSO analysis was performed to identify risk factors for systemic thromboembolic events; occurrence of arterial and venous thromboembolism during the index hospitalization as the primary endpoint. ResultsLASSO analysis identified a prior systemic thromboembolism, male sex, hypoxygenemia requiring invasive mechanical ventilation support, C-reactive protein levels and D-dimer levels at admission, and congestion on chest X-ray at admission as potential risk factors for the primary endpoint. The developed risk model consisting of these risk factors showed good discriminative performance (AUC-ROC: 0.83, 95 % confidence interval [CI]: 0.77–0.90), which was significantly better than that shown by D-dimer (AUC-ROC: 0.70, 95 % CI: 0.60–0.80) (p < 0.001). Furthermore, systemic embolic events were independently associated with in-hospital mortality (adjusted odds ratio: 3.29; 95 % CI: 1.31–8.00). ConclusionsSix parameters readily available at the time of admission were identified as risk factors for thromboembolic events, and these may be capable of stratifying the risk of in-hospital thromboembolic events, which are associated with in-hospital mortality, in patients with COVID-19 and CVDRF.

Standard Fixed Enoxaparin Dosing for Venous Thromboembolism Prophylaxis Leads to Low Peak Anti-Factor Xa Levels in Both Head and Neck and Breast Free Flap Patients.

Venous thromboembolism (VTE) is a serious complication, particularly in cancer patients undergoing free flap reconstruction. Subcutaneous enoxaparin is the conventional prophylaxis for VTE prevention, and serum anti-factor Xa (afXa) levels are being increasingly used to monitor enoxaparin activity. In this study, free flap patients receiving standard enoxaparin prophylaxis were prospectively followed to investigate postoperative afXa levels and 90-day VTE and bleeding-related complications. Patients undergoing free tissue transfer during an 8-month period were identified and prospectively followed. Patients received standard fixed enoxaparin dosing at 30 mg twice daily in head and neck (H&N) and 40 mg daily in breast reconstructions. Target peak prophylactic afXa range was 0.2 to 0.5 IU/mL. The primary outcome was the occurrence of 90-day postoperative VTE- and bleeding-related events. Independent predictors of afXa level and VTE incidence were analyzed for patients that met the inclusion criteria. Seventy-eight patients were prospectively followed. Four (5.1%) were diagnosed with VTE, and six (7.7%) experienced bleeding-related complications. The mean afXa levels in both VTE patients and bleeding patients were subprophylactic (0.13 ± 0.09 and 0.11 ± 0.07 IU/mL, respectively). Forty-six patients (21 breast, 25 H&N) had valid postoperative peak steady-state afXa levels. Among these, 15 (33%) patients achieved the target prophylactic range: 5 (33%) H&N and 10 (67%) breast patients. The mean afXa level for H&N patients was significantly lower than for breast patients (p = 0.0021). Patient total body weight was the sole negative predictor of afXa level (R 2 = 0.47, p < 0.0001). Standard fixed enoxaparin dosing for postoperative VTE prophylaxis does not achieve target afXa levels for the majority of our free flap patients. H&N patients appear to be a particularly high-risk group that may require a more personalized and aggressive approach. Total body weight is the sole negative predictor of afXa level, supporting a role for weight-based enoxaparin dosing.

Prevalence of Venous Thromboembolism in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: An Indian Perspective

Chronic obstructive pulmonary disease (COPD) will be the third leading cause of death by 2020. Recent studies reveal that pulmonary embolism (PE) may be a trigger of acute deterioration in patients with COPD. Patients with COPD have approximately twice the risk of PE than those without COPD. The primary objective was to assess the prevalence of venous thromboembolism (VTE) in patients with acute exacerbation of COPD (AE-COPD) in India. We conducted this prospective study on patients admitted for AE-COPD in a tertiary care hospital in Mumbai, India. We considered the prevalence of deep venous thrombosis (DVT) to reflect the occurrence of VTE. The screening tool used was a colour Doppler of the bilateral lower limbs. One hundred patients enrolled, were in stage II to stage IV COPD; 9% had DVT. Eight of these nine patients had unilateral DVT. Two patients had developed PE and died. Our results show a lower prevalence of unsuspected DVT in Indian patients admitted for AE-COPD. Future prospective, randomised studies are needed to confirm the findings of the present study and to determine whether a systematic evaluation for VTE is justified in these patients, and hence, be recommended.

P-206 Association between primary tumor site of colorectal cancer and RAS/BRAF mutational status with venous thromboembolism: A retrospective-prospective cohort study from 3 Croatian oncology centers

Right-sided colorectal cancer (RCRC) is associated with several negative clinicopathological and molecular features and also with worse survival than left-sided colorectal cancer (LCRC). A recent study has shown an association between RCRC and increased incidence of venous thromboembolism (VTE). However, the role of RAS/BRAF mutations considering the risk of VTE in metastatic colorectal cancer (mCRC) remains unclear. The aim of our study was to examine impact of tumor sidedness and RAS/BRAF status regarding VTE occurrence in a cohort of patients with mCRC. We conducted a multicenter, combined retrospective-prospective, observational study, with 234 patients (n=234) and known KRAS/NRAS/BRAF status who were treated with first-line chemotherapy with or without biological therapy for mCRC in three Croatian oncologic centers (General Hospital of Šibenik-Knin County, General Hospital Zadar and General Hospital Dubrovnik) from June 2013 to March 2020. Considering prospective arm of the study 40 patients with informed consent were enrolled with minimum follow-up of 1 year. The primary endpoint was incidence of VTE and its association with location of the primary tumor and RAS/BRAF status. VTE was defined as deep venous thrombosis and/or pulmonary embolism occurred 6 months before or at any time after the diagnosis of mCRC. Numerical data were described by the median and the interquartile range (IQR). Categorical variables were tested by Chi-square test and by Fisher's exact test. The normality of the distribution was tested by the Shapiro-Wilk test. Differences between two independent groups were tested by Mann-Whitney's U test. Logistic regression analysis was used to analyze the independent factors associated with VTE. All P values were two-sided. The level of significance was set at Alpha of 0.05. The median follow-up time was 21 months (IQR13-33). Of 234 patients included in analysis 26% had RCRC and 74% had LCRC. KRAS, NRAS and BRAF mutations were detected in 50%, 3% and 5% of patients, respectively. KRAS/NRAS mutations were more common in RCRC than in LCRC (62% vs 50% p=0.001) and the same finding has been noticed with BRAF mutations (12% vs 2% p =0.001). A total of 56 (24%) patients experienced VTE. The incidence was 43% in RCRC patients and 17.3% in LCRC patients (p < 0.001). According to mutational status, incidence was 48.2% in KRAS/NRAS-mutated patients, 10.7% in BRAF-mutated patients and 41% in KRAS/NRAS/BRAF wilde type patients. The results of logistic regression adjustment for known predictors of VTE including Khorana score, use of bevacizumab or anti-EGFR therapy and chemotherapy confirmed that RCRC was significant predictor of VTE (OR=4.7; 95% CI 1.74 – 12.57). However KRAS/NRAS/BRAF mutations were not associated with VTE (OR =0.86; 95% CI 0.11-6.59). In our study, primary tumor sidedness has been associated with VTE in patients with mCRC. Our results have not confirmed an association between biomarker status (KRAS, NRAS and BRAF) and an increased risk of VTE in mCRC patients.

Analysis of influencing factors of community-acquired pneumonia with deep venous thrombosis in elderly communities

Community-acquired pneumonia (CAP) is one of the common infectious diseases that threaten human health, venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE), is a global health care problem. Acute infection and age ≥70 years are important risk factors for VTE in internal medicine inpatients. There is increasing evidence that acute infectious diseases caused by bacterial and viral infections can induce coagulation, platelet (PLT) activation and inhibit the activity of anticoagulant factors. However, there is no consensus on whether patients with CAP suffer from DVT. Finding out the clinical characteristics and risk factors of DVT in elderly patients with CAP is helpful for early identification of high-risk patients with VTE and timely prevention, which can significantly reduce the occurrence of VTE in hospitals. Data was collected from 505 patients with CAP aged ≥70 years old hospitalized in the Department of Respiratory and Critical Care Medicine. 133 patients with DVT were selected as the DVT group. DVT score and risk grading were performed for all patients using Padua. Fifty-seven cases were diagnosed as having severe pneumonia, including 50 cases diagnosed as having septic shock. Padua, D-dimer, between the DVT group and the control group, the severe pneumonia group and the non-severe pneumonia group, and the severe pneumonia DVT group and the control group were compared. (I) The incidence of DVT with severe pneumonia was much higher than with non-severe pneumonia (P<0.001). The incidence of DVT in patients with septic shock and non-septic shock was 74.0% (37/50) and 28.6% (2/7) respectively (P=0.0154). (II) There were significant differences in Padua scores between the DVT group and the control group and between the severe pneumonia group and non-severe pneumonia group (P<0.001). (III) There were significant differences in D-dimer level between the DVT group and the control group and between the severe pneumonia group and the non-severe pneumonia group (P<0.001). (IV) Regression analysis indicated the central venous catheter (CVC), D-dimer value, and Padua score were significantly correlated with thrombosis (P=0.042, <0.001, 0.043). Severe pneumonia in elderly patients and septic shock may be complicated by DVT, and central venous catheterization and D-dimer are closely related to thrombosis.

Venous or arterial thrombosis and deaths among COVID-19 cases: a European network cohort study

BackgroundThere are few data on the incidence of thrombosis among COVID-19 cases, with most research concentrated on hospitalised patients. We aimed to estimate the incidence of venous thromboembolism, arterial thromboembolism, and death among COVID-19 cases and to assess the impact of these events on the risks of hospitalisation and death.MethodsWe conducted a distributed network cohort study using primary care records from the Netherlands, Italy, Spain, and the UK, and outpatient specialist records from Germany. The Spanish database was linked to hospital admissions. Participants were followed up from the date of a diagnosis of COVID-19 or positive RT-PCR test for SARS-CoV-2 (index date) for 90 days. The primary study outcomes were venous thromboembolic events, arterial thromboembolic events, and death, all over the 90 days from the index date. We estimated cumulative incidences for the study outcomes. Multistate models were used to calculate adjusted hazard ratios (HRs) for the association between venous thromboembolism or arterial thromboembolism occurrence and risks of hospitalisation or COVID-19 fatality.FindingsOverall, 909 473 COVID-19 cases and 32 329 patients hospitalised with COVID-19 on or after Sept 1, 2020, were studied. The latest index dates across the databases ranged from Jan 30, 2021, to July 31, 2021. Cumulative 90-day incidence of venous thromboembolism ranged from 0·2% to 0·8% among COVID-19 cases, and up to 4·5% for those hospitalised. For arterial thromboembolism, estimates ranged from 0·1% to 0·8% among COVID-19 cases, increasing to 3·1% among those hospitalised. Case fatality ranged from 1·1% to 2·0% among patients with COVID-19, rising to 14·6% for hospitalised patients. The occurrence of venous thromboembolism in patients with COVID-19 was associated with an increased risk of death (adjusted HRs 4·42 [3·07–6·36] for those not hospitalised and 1·63 [1·39–1·90] for those hospitalised), as was the occurrence of arterial thromboembolism (3·16 [2·65–3·75] and 1·93 [1·57–2·37]).InterpretationRisks of venous thromboembolism and arterial thromboembolism were up to 1% among COVID-19 cases, and increased with age, among males, and in those who were hospitalised. Their occurrence was associated with excess mortality, underlying the importance of developing effective treatment strategies that reduce their frequency.FundingEuropean Medicines Agency.

D-Dimer Values and Venous Thromboembolism in Patients With COVID-19 in Japan - From the CLOT-COVID Study.

Background: To date, there are no large-scale data on the association between D-dimer levels at admission and the occurrence of venous thromboembolism (VTE) in Japanese patients with coronavirus disease 2019 (COVID-19).Methods and Results: The CLOT-COVID study was a retrospective, multicenter cohort study enrolling consecutive hospitalized patients with COVID-19 across 16 centers in Japan from April 2021 to September 2021. Among 2,894 enrolled patients, 2,771 (96%) had D-dimer levels measured at admission. Patients were divided into 3 groups based on tertiles of D-dimer levels at admission (1st tertile, D-dimer ≤0.5 μg/mL, n=949; 2nd tertile, D-dimer 0.51–1.09 μg/mL, n=894; 3rd tertile, D-dimer ≥1.1 μg/mL, n=928). The higher the tertile group, the more severe the COVID-19 status at admission. The incidence of VTE during hospitalization was highest in the 3rd tertile group (1st tertile, 0.3%; 2nd tertile, 0.3%; 3rd tertile, 3.6%; P<0.001). Even after adjusting for confounders in the multivariable logistic regression model, the higher D-dimer levels in the 3rd tertile (≥1.1 μg/mL) were independently associated with a higher risk of VTE during hospitalization (adjusted odds ratio 4.83 [95% confidence interval 1.93–12.11; P<0.001]; reference=1st tertile).Conclusions: Higher D-dimer levels at admission were associated with a higher risk of VTE events during hospitalization in Japanese patients with COVID-19. This could be helpful in determining patient-specific anticoagulation management strategies for COVID-19 in Japan.

Venous thromboembolism in cancer surgery: A report from the nationwide readmissions database

BackgroundThe present study characterized the incidence of venous thromboembolism in a contemporary cohort of surgical oncology patients and its association with index hospitalization and postdischarge outcomes. MethodsAdults undergoing 7 major thoracic and abdominal cancer resections were identified in the 2016–2019 Nationwide Readmissions Database. Multivariable models stratified by operative subtype were developed to evaluate the association of venous thromboembolism with outcomes of interest. ResultsOf an estimated 436,368 patients, venous thromboembolism was identified in 9,811 (2.2%) patients during index hospitalization. Esophageal (4.1%) and gastric (4.1%) resections exhibited the highest rates of venous thromboembolism, whereas pulmonary resection (1.0%) the lowest. Following adjustment, cancer resection type demonstrated the strongest association with venous thromboembolism development among all factors analyzed (adjusted odds ratio: 3.13, 95% confidence interval: 2.60–3.78). Diagnosis of venous thromboembolism was associated with increased mortality (10.2%, 95% confidence interval: 9.4–11.1 vs 1.7, 95% confidence interval: 1.6–1.7) and prolonged index hospital stay (19.5 days, 95% confidence interval: 19.1–20.0 vs 7.5, 95% confidence interval: 7.4–7.5). Of patients who survived index hospitalization, venous thromboembolism occurrence was associated with increased risk of nonhome discharge (56.4%, 95% confidence interval: 54.7–58.0 vs 14.4, 95% confidence interval: 14.2–14.7) and readmission (30.0%, 95% confidence interval: 28.5–31.1 vs 16.9, 95% confidence interval: 16.7–17.1). Additionally, venous thromboembolism substantially increased index hospitalization ($40,000, 95% confidence interval: $38,000–$42,000) and readmission costs ($3,200, 95% confidence interval: $1,700–$4,700). ConclusionRates of venous thromboembolism remain high in surgical oncology patients, with cancer resection type as a major predictor of venous thromboembolism incidence. Venous thromboembolism was associated with inferior clinical and financial outcomes that extended beyond discharge. These findings underscore the importance of continued vigilance and procedure-specific prophylaxis measures.