PE Mortality Research Articles

The timing of death in acute pulmonary embolism patients regarding the mortality risk stratification at admission to the hospital

BackgroundThe management of patients with acute pulmonary embolism (aPE) depends on the severity of aPE. The timing of death in various aPE risk subgroups is only partially known. Methods1618 patients with an objectively established aPE diagnosis with computed tomography pulmonary angiography enrolled in the regional PE registry were included in the study. According to ESC criteria, patients were stratified at admission to the hospital in four risk strata. The timing of PE-related and non-PE-related deaths was analyzed regarding mortality risk. ResultsPE-related, and non-PE-related hospital death rates were 1.1 % and 1.5 % in low, 1.1 % and 4.8 % in intermediate-low, 8.1 % and 5.9 % in intermediate-high, and 27.7 % and 6.9 % in high-risk groups, respectively. The median time of PE-related and non-PE-related death across the PE mortality risk were: 4 (1.7–7.5) and 7.0 (4–14.7) days in low, 1.5 (1.0–9.5) and 11.5 (2.0–21.0) days in intermediate-low, 4.0 (2.0–9.0) and 9.0 (5.7–18.2) days in intermediate-high, 2.0 (1.0–4.75) and 7.0 (3.0–21.2) days in high-risk subgroups. 48.2 % and 17.1 % of patients who died in the high and intermediate-high risks died during the first hospital day. After the 6th hospitalization day, PE-related deaths were recorded in 43.9 % of deaths from intermediate-high and 17.9 % from high-risk subgroups. ConclusionPE-related mortality is prominent on the first hospitalization day in high and intermediate-high-risk PE. A substantial proportion of intermediate-high and high-risk patient's PE deaths occurred after the first 6 days of hospitalization.

Predicting Hospital Survival in Patients Admitted to ICU with Pulmonary Embolism.

The Pulmonary Embolism Severity Index (PESI) and simplified PESI (sPESI) predict mortality for patients with PE. We compared PESI/sPESI to the Acute Physiology and Chronic Health Evaluation IV (APACHE-IV) in predicting mortality in patients with PE admitted to the intensive care unit (ICU). Additionally, we assessed the performance of a novel ICU-sPESI score created by adding three clinical variables associated with acuity of PE presentation (intubation, confusion [altered mental status], use of vasoactive infusions) to sPESI. Using the eICU Collaborative Research Database from 2014 to 2015, we conducted a large retrospective cohort study of adult patients admitted to the ICU with a primary diagnosis of PE. We calculated APACHE-IV, PESI, sPESI, and ICU-sPESI scores and compared their performance for predicting in-hospital mortality using area under the receiver operating characteristic (AUROC) curve. Score thresholds for >99% negative predictive values (NPV) were calculated for each score. Survival was estimated using the Kaplan-Meier method. We included 1424 PE cases. In-hospital mortality was 6.3% [95% CI: 5.1%-7.6%]. AUROC for APACHE-IV, PESI, and sPESI were 0.870, 0.848, and 0.777, respectively. APACHE-IV and PESI outperformed sPESI (P < 0.01 for both comparisons), while APACHE-IV and PESI demonstrated similar performance (P = 0.322). The ICU-sPESI performance was similar to APACHE-IV and PESI (AUROC = 0.847; AUROC comparison: APACHE-IV vs ICU-sPESI: P = 0.396; PESI vs ICU-sPESI: P = 0.945). Hospital mortality for ICU-sPESI scores 0-2 was 1.1%, and for scores 3, 4, 5, 6, and ≥7 was 8.6%, 11.7%, 29.2%, 37.5%, and 76.9%, respectively. Score thresholds for >99% NPV were ≤48 for APACHE-IV, ≤115 for PESI, and 0 points for sPESI and ICU-sPESI. By accounting for severity of PE presentation, our newly proposed ICU-sPESI score provided improved PE mortality prediction compared to the original sPESI score and offered excellent discrimination of mortality risk.

Acute pulmonary embolism in COVID-19 pandemic: prevalence and intrahospital outcome: a single center experience

Abstract Funding Acknowledgements Type of funding sources: None. Purpose We want to evaluate clinical, laboratory profiles and intra-hospital outcome in patients with acute PE treated in intensive care unit in the period of COVID-19 pandemic. Methods This is a single center, retrospective cohort study of patients with confirmed acute PE admitted in Intensive Cardiac Care Unit of a tertiary level university hospital between January and December 2020. Detailed history, risk factors, laboratory parameters and treatment strategy based on patient risk were assessed. All patients underwent 2-dimensional echocardiography, lower limb venous Doppler and CT pulmonary angiography (CTPA). sPESI score and intra-hospital outcomes were evaluated in all patients. Nasopharyngeal smear and real-time reverse transcriptase–polymerase chain reaction (RT-PCR) assay was performed in order to confirm COVID-19 infection. Results We studied 47 patients with acute PE treated in our ICU, with mean age 58.6 ± 19.4 years. Eight patients (17%) had massive PE (central thrombus) and 39 (83%) had sub massive PE (subsegmental thrombus) confirmed by CTPA. Six patients (12,7%) had history of deep vein thrombosis (DVT), 3 patients (6,3%) had history of prior PE, 4 patients (8,5%) were operated within 3 months, 7 patients (14,8%) had history of malignancy, 24 patient’s had increased body weight and obesity (51%). Twelve patients (25,5%) were tested for COVID 19 with real-time reverse transcriptase–polymerase chain reaction (RT-PCR) assay, and 3 come positive (12.5%). Eight patients were high risk with shock (17%), intermediate high risk were 29 patients (61.7%) and intermediate low risk were 10 patients (21.3%). sPESI score was &amp;gt;1 in all 47 patients. Abnormal RV function with PAH was found in 32 patients (68%). Five high risk, unstable patients died within 72 hours of admission, resulting in an overall ICU mortality rate of 10,6% and 62.5% mortality rate in patients with cardiogenic shock. Patients with PE and COVID-19 had significantly higher D-dimer and hs-Troponin I levels comparing to the patients with patients negative for COVID-19. Multivariate logistic regression analysis showed thrombolytic therapy OR 2.145 (95% CI: 1.105−4,512), D-Dimers &amp;gt;4.500 ng/ml OR 1.893 (95% CI: 0.932–3.241), high risk PE OR 3.98 (95% CI: 1.396−5.641) and acute renal failure OR 2.421 (95% CI: 1.105−4.762) as independent mortality predictors. Eight patients have been treated with fibrinolysis (t-PA), and 39 patients with Heparin therapy. 40 survived patients were discharged with NOAC treatment (95,2%). Conclusions Pulmonary embolism cardiology clinic ICU admission in the period of COVID-19 pandemic decreased, with increase of PE severity, patients risk and mortality rate. Thrombolytic therapy, D-Dimers &amp;gt;4.500 ng/ml, high risk PE and acute renal failure were independent mortality predictors. Thrombolysis was successful treatment for high risk patients with low bleeding risk.

Short-duration chemoprophylaxis might reduce incidence of deep vein thrombosis in Asian patients undergoing total knee arthroplasty

BackgroundVenous thromboembolism (VTE) is a serious complication that may occur after total knee arthroplasty (TKA), leading to the recommendation of routine chemoprophylaxis by international guidelines. This study aims to determine if short-duration chemoprophylaxis after TKA reduces the incidence of VTE in an Asian population.MethodsA retrospective study of 316 patients who underwent unilateral primary TKA between 1 January 2011 and 31 December 2013 was conducted. All patients received mechanical prophylaxis. One hundred seventeen patients (37%) received additional chemoprophylaxis, whereas 199 patients (63%) did not. A Doppler ultrasound (DUS) of both lower limbs was conducted for all patients within 6 days after surgery (median = 3 days) to assess for both proximal and distal DVT. Chemoprophylaxis in the form of enoxaparin (low molecular weight heparin; LMWH), aspirin, or heparin was administered until patients had a normal DUS, for a median duration of 4 days. Patients were followed up clinically for a minimum of 6 months to monitor for delayed or recurrent VTE and at least 2 years for patient-reported outcome measures.ResultsOverall, 24 patients (7.59%) developed deep vein thrombosis (DVT): three proximal and 21 distal DVTs. Twenty-three of the 24 patients were asymptomatic. Twenty of 199 patients (10.05%) with only mechanical prophylaxis developed DVT, whereas four of 117 patients (3.42%) with additional chemoprophylaxis developed DVT. Multivariate analysis showed that chemoprophylaxis use was associated with reduced incidence of DVT (odds ratio = 0.19, p value = 0.011). Other factors associated with increased DVT incidence include female gender (odds ratio = 5.45, p value = 0.034), positive history of cancer (odds ratio = 5.14, p value = 0.044), and increased length of stay in hospital (odds ratio = 1.19, p value < 0.001).ConclusionsOur study has shown that despite the low incidence of DVT in Asian patients undergoing TKA, short-duration chemoprophylaxis might be effective in reducing the incidence of DVT. However, most DVTs observed in our study were distal and may be of limited clinical significance. Further studies are needed to investigate the impact of chemoprophylaxis use on the incidence of PE and overall mortality rates among Asian patients.

Aspirin Is Associated With Reduced Rates of Venous Thromboembolism in Older Patients With Cancer.

Older patients with cancer are at high risk of developing venous thromboembolism (VTE) and bleeding. Aspirin may decrease VTE in the general population without significant bleeding. Here, we examined whether aspirin is associated with reduced rates of VTE in older patients with cancer. Using the National Inpatient Sample 2016, we retrospectively identified a cohort of patients with cancer ≥65 years old who received aspirin and a similar cohort who did not receive aspirin (n = 31 654, each). The cohorts were matched for age, sex, race, patient demographics, insurance, hospital demographics, and 9 comorbidities (smoking, obesity, hypertension, hyperlipidemia, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, congestive heart failure, and history of deep venous thrombosis [DVT]/pulmonary embolism [PE]). Primary outcomes were discharge diagnosis of acute PE or acute DVT. Secondary outcomes were inhospital mortality, bleeding, length of hospital stay (LOS), and total hospitalization cost. The aspirin group, compared with the nonaspirin group, had a significantly lower incidence of acute PE (matched, 2.1% vs 2.6%, P < .001), acute DVT (matched, 2.3% vs 3.2%, P < .001), and inhospital mortality (matched 4.0% vs 6.5%, P < .001); shorter LOS (matched, 5.29 ± 5.01 vs 6.20 ± 6.56 days, P < .001); and lower total costs (matched, US$14 700 ± 15 031 vs US$16 363 ± 20 219, P < .001). The primary and secondary outcomes were similar before and after propensity matching. We found no increase in bleeding in the aspirin group compared to the nonaspirin group: gastrointestinal bleeding (matched, 3.8% vs 4.0%, P= .168), hematuria (matched, 3.5% vs 3.7%, P = .102), hemoptysis (matched, 0.9% vs 0.9%, P = .532), and hemorrhagic stroke (matched, 0.8% vs 0.8%, P = .443). In subgroup analyses, aspirin was associated with decreased inhospital mortality, mostly in patients with lung, colon, pancreatic, prostate, breast cancer, lymphoma, and leukemia. Among older patients with cancer, aspirin was associated with lower VTE incidence and overall inhospital mortality without significantly increased bleeding.

Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity.

Pelvic exenteration (PE) provides a potentially curative option for advanced or recurrent malignancy confined to the pelvis. A clear (R0) resection margin is the strongest prognostic factor predicting long-term survival, driving most technical advances in PE surgery. The aim of this cohort study was to describe changing trends in extent of resection, postoperative complications, mortality and overall survival after PE surgery. Consecutive patients who underwent PE for advanced or recurrent pelvic malignancy at a single institution in Sydney, Australia, were identified. The cohort was divided into three groups based on time periods reflecting annual surgical volume: 1994-2006 (20 or fewer procedures per year), 2007-2013 (21-50 procedures per year) and 2014-2017 (over 50 procedures per year). Primary outcomes were extent of resection, postoperative complications, 60-day mortality and 3-year overall survival. Secondary outcomes were patient characteristics, receipt of neoadjuvant therapy and duration of hospital stay. There were increases over time in rates of lateral and posterior compartment resections (P < 0·001), and bony pelvis (P = 0·002) and neurovascular (P < 0·001) excision. For patients undergoing reconstruction, the proportion receiving vertical rectus abdominus myocutaneous flaps increased significantly (P = 0·005). Rates of wound infection, dehiscence, and abdominal and pelvic collections increased over the study interval. Short-term mortality decreased, and 1- and 3-year survival rates improved. Technical and surgical advancements have led to more complex PE resections, with R0 and mortality rates improving with higher annual volume. There were associated increases in intraoperative blood loss and postoperative morbidity.

Does tranexamic acid alter the risk of thromboembolism following primary total knee arthroplasty with sequential earlier anticoagulation? A large, single center, prospective cohort study of consecutive cases

IntroductionIn order to decrease the blood loss and transfusion requirement, tranexamic acid (TXA) has attracted the public’s attention in total knee arthroplasty (TKA). However, the safety profile of TXA hindered its wide adoption. And the balance of anti-coagulation sequential anti-fibrinolysis has not yet been explored. This large, single center, prospective cohort study of consecutive cases aimed to investigate the epidemiology of vascular occlusive events associated with TXA and introduce our preliminary results of novel thromboprophylaxis. Materials and methodsWe prospectively collected patients’ data of our institution through National Health Database. The primary outcome was the incidence of venous thromboembolism and mortality within 30days following primary TKA. Subgroup analysis was performed on the basis of TXA administration methods. ResultsDuring 2012 to 2014, a total of 2532 unilateral TKA procedures were conducted in our institution, 2222 with TXA, 310 without TXA. The total occurrence of vascular occlusive events was statistically significantly higher (17.55% Vs 9.35%, p<0.001) in the TXA group but this finding was confined to the calf veins, with the main difference being the incidence in the calf muscular veins (13.68% Vs 6.77%, p=0.001). Statistical difference was not detected neither in the incidence of symptomatic DVT nor asymptomatic DVT. No episode of symptomatic PE and all-cause mortality within 30days occurred postoperatively. Subgroup analysis revealed no significant difference with regard to the incidence of DVT (p>0.05). ConclusionThis study confirmed that the incidence of postoperative VTE was unchanged when TXA was administered in primary unilateral TKA. And our study further indicated that earlier anticoagulation should be adopted to keep the balance between anti-fibrinolysis and anti-coagulation after administering TXA.

Bedside intravascular ultrasound-guided inferior vena cava filter placement in medical-surgical intensive care critically-ill patients

Introduction and objectivePulmonary Embolism (PE) is a potentially life-threatening complication of critical illness. Prophylactic inferior vena cava filter (IVC) placement offers a protection rate of 99% against fatal PE. Transportation of critically ill patients from the intensive care unit to the interventional radiology suit is a potential risk and cumbersome. Bedside IVC filter placement offers protection against fatal PE without added risk of transportation. Transabdominal ultrasound visualization of the IVC can be difficult because of patient body habitus or recent abdominal surgeries. Intravascular Ultrasound (IVUS) is an appealing imaging guidance that does not have this limitation. We are aiming at evaluation the safety and outcome of bedside IVUS-guided Günther Tulip filter placement in the intensive care units patients. ResultsThe single venous access technique via the femoral vein was used. Filter placement was successful in 95% of cases (35/37). In two earlier cases filters misplaced at the right iliocaval confluence were fluoroscopically repositioned in the infrarenal IVC. Neither PE nor PE-related mortality was recorded. Renal impairment was seen in 35% of cases (n=13/37). The body mass index calculation in 27 patients revealed obesity in 67% of the patients. ConclusionsBedside IVUS-guided filter placement in medical-surgical critically ill patient in intensive care unit is a feasible, safe and reliable technique for IVC interruption. IVUS may be the most appropriate tool to guide filter insertion in obese patient.

Pulmonary embolism severity index and simplified pulmonary embolism severity index risk scores are useful to predict mortality in Japanese patients with pulmonary embolism.

The Pulmonary Embolism Severity Index (PESI) and simplified PESI (sPESI) have not been fully evaluated in Japan, so the present study aimed to evaluate these risk stratification models in the prediction of mortality of affected patients in Japan. We retrospectively analysed 302 PE patients (63.9±17.2 years of age; 42.4% male) from January 2011 to December 2012 using data from the Tokyo CCU Network. The areas under the receiver-operating characteristic curves were 0.92 (95% confidence interval (CI): 0.88-0.97) for the PESI and 0.88 (95% CI: 0.77-0.98) for the sPESI. Both scores can be used to predict PE mortality in Japan.

Time trends in pulmonary embolism mortality in France, 2000-2010

BackgroundPulmonary Embolism (PE) is a potentially fatal complication of venous thrombosis. Recent and comprehensive estimates of PE incidence and mortality are scarce. Moreover, while contemporary mortality trends of PE would enable the evaluation of prevention and quality of care, such data are lacking. The aim of this study was to provide nationwide estimations of PE mortality and time trends in France between 2000 and 2010. MethodsMortality data were obtained from the French Epidemiology Center on medical causes of death. Mortality rates were calculated with PE as an underlying or one of multiple causes of death. The annual percentage changes were assessed using a Poisson regression model. Age-standardized PE mortality rates were also assessed. ResultsIn 2010, the overall age-adjusted PE mortality rate was 21.0 per 100000. This rate was 30% higher in men than in women and decreased by 3% per year between 2000 and 2010. Over this period, PE mortality declined in men and women over 55years but only slightly decreased in patients younger than 55. Cancer, obesity, osteopathies and complications of surgery were often coded as the underlying causes of death when PE was an associated cause of death recorded on certificate. DiscussionThis study is the first to provide a contemporary and exhaustive nationwide estimation of PE mortality and time trends in France. The observed decrease in PE mortality between 2000 and 2010 is encouraging, but further efforts in prevention are needed to ensure that this reduction is widespread in all age groups.

Endovascular Stent Graft Exclusion of Thoracic Arteriovenous Malformation in a Patient With Cobb Syndrome

this study was to quantitatively weigh the risks and benefits of IVC filter retrieval using formal decision analysis. Methods: A Markov state-transition model was used to simulate two clinical scenarios: to leave a previously placed IVC filter or to retrieve it. Analysis was performed over the lifetime of the individual, and outcomes were expressed in quality-adjusted life years (QALYs). The base case is a 60-year-old man with a filter placed within 3 months who no longer requires mechanical thromboprophylaxis. Potential events included PE, filter complications, and death from all other causes during each cycle. Tolls were used to incorporate the disutility of short-term treatment for PE and/or filter complications. For the base-case and sensitivity analyses, we used utilities and probabilities derived from the literature. Results: In the base-case scenario, leaving the filter in place was preferred to filter retrieval, yielding 22.3 vs 21.9 QALYs. One-way sensitivity analysis demonstrated that filter retrieval might be preferable if the utility of living with a filter is <0.98. For all probabilities of retrieval and PE mortality, leaving the filter in place is preferred. Conclusions: Leaving a previously placed IVC filter provides a 0.4 QALY benefit over retrieving the filter for the average patient. This decision is sensitive to the utility of living with the IVC filter and underlying PE risk.

PS180. Open Surgical Reconstruction for Benign Superior Vena Cava Syndrome

(PE) when anticoagulation is contraindicated or ineffective. Technical advances now allow catheter-based filter retrieval. Many believe the benefits of retrieval are selfevident, yet retrieval carries an inherent complication risk and cost. The purpose of this study was to quantitatively weigh the risks and benefits of IVC filter retrieval using formal decision analysis. Methods: A Markov state-transition model was used to simulate two clinical scenarios: to leave a previously placed IVC filter or to retrieve it. Analysis was performed over the lifetime of the individual and outcomes were expressed in quality-adjusted life-years (QALYs). The base case is a 60-year-old man with a filter placed #3 months who no longer requires mechanical thromboprophylaxis. Potential events included PE, filter complications, and death from all other causes during each cycle. Tolls were used to incorporate the disutility of short-term treatment for PE and/or filter complications. For the base case and sensitivity analyses, we used utilities and probabilities derived from the literature. Results: In the base-case scenario, leaving the filter in place was preferred to filter retrieval, yielding 22.3 vs 21.9 QALYs. One-way sensitivity analysis demonstrated that filter retrieval may be preferable if the utility of living with a filter is <0.98. For all probabilities of retrieval and PE mortality, leaving the filter in place is preferred. Conclusions: Leaving a previously placed IVC filter provides a 0.4 QALY benefit over retrieving the filter for the average patient. This decision is sensitive to the utility of living with the IVC filter and underlying PE risk.

Trends of Pulmonary Embolism Before and After Kidney Transplantation in Black Versus White Patients

BackgroundPulmonary embolism (PE) is an important cause of in-hospital mortality and is common in renal transplantation and maintenance dialysis patients. PE incidence is higher among patients who are black; however, differences in trends of incidence and outcomes of PE by race among patients on dialysis and after renal transplantation is not well known. MethodsIn this observational study, the incidences of PE hospitalizations and mortality were studied in those with renal transplant, on maintenance dialysis, and in general population. Incidences were compared across racial groups. Renal transplantation status as a predictor of mortality was also examined. ResultsThe incidences of PE in general population, dialysis, and renal transplant groups were 70.5, 518.8, and 158.8 per 100,000 population, respectively. Incidence was higher in blacks across all groups. The age-adjusted incidence of PE admissions increased over time in all groups with greater increase in blacks in non-transplant groups (the slope in dialysis for blacks was 112.1 versus that for whites at 49.4; P = .001; the slope in general population for blacks was 9.3 versus 3.4 for whites; P = .003). The mortality rate in general population was not significantly different than renal transplant group (3.4% versus 1.9%, P = .2); however, was lower than 6.8% seen in dialysis group (P < .001). The mortality rate was not different between whites and blacks. Maintenance dialysis was an independent predictor of mortality (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.62–2.32). ConclusionsPE in those with renal transplant is more common than in general population but less common than those on maintenance dialysis. The mortality rate for PE hospitalizations is equivocal between renal transplant and general population but higher for patients on dialysis. The incidence of PE hospitalizations is not only higher among blacks, but is increasing disproportionately in this group among those who are on maintenance dialysis and within general population.

Trends in Same-Day Bilateral Total Knee Arthroplasty

Between 2000 and 2009 demographics, comorbidity, complications, and 30-day mortality following same-day BTKA (SBTKA) in two high-volume institutions were obtained. Two 5-year periods were created to facilitate trend analysis. The percentage of SBTKA decreased by 36.2% in the latter period. A decline in mean age reflected mainly by a 50% decrease in patients >75years was observed. The average LOS decreased (5.7 vs. 4.5days). Overall, selected patients were healthier in the second period. The prevalence of CAD and obesity decreased, whereas hypercholesteremia increased. The overall complication rate decreased by 55.5%; reduction in cardiac adverse events and acute posthemorrhagic anemia was observed. The rate of PE and 30-day mortality was unchanged with time. A need for more selective preoperative screening for potential candidates of SBTKAs is indicated.

The Incidence and Mortality of Thromboembolic Events in Lumbar Spine Surgery

Retrospective database analysis. A population-based database was analyzed to identify the incidence, risk factors, and mortality associated with thromboembolic events after lumbar spine surgery. Pulmonary embolism (PE) and deep vein thrombosis (DVT) are potential complications that may occur after orthopedic procedures. The incidence of these complications is not well characterized after lumbar spine surgery. Data from the Nationwide Inpatient Sample was obtained from 2002-2009. Patients undergoing lumbar decompression (LD), or lumbar fusion (LF) for degenerative conditions were identified. Acute PE and DVT incidences and mortality rates were calculated. Comorbidities were calculated using a modified Charlson Comorbidity Index. Statistical analysis was performed using the Student t test for discrete variables and χ test for categorical data. Logistic regression was used to identify independent predictors of thromboembolic events. A P value of less than or equal to 0.0005 was used to denote statistical significance. A total 578,457 LDs and LFs were identified from 2002-2009. DVT incidences were 2.4 and 4.3 per 1000 cases in the LD and LF groups, respectively. PE incidences were 1.0 and 2.6 per 1000 cases in the LD and LF groups, respectively. Patients who had undergone LF with thromboembolic events were younger, had fewer comorbidities, and incurred greater costs than patients who had undergone LD. Statistically significant predictors of DVT were pulmonary circulation disorders, coagulopathy, fluid/electrolyte disorders, anemia, obesity, teaching hospital status, and larger hospitals. Predictors for the development of PE were pulmonary circulation disorders, fluid/electrolyte disorders, anemia, black ethnicity and teaching hospital status. Patients undergoing LD or LF are at inherent risk of thromboembolic events. DVT and PE are more common after LF procedures. Preoperative pulmonary circulation disorders, fluid/electrolyte disorders, deficiency anemia, and teaching hospital status were significant risk factors for developing both DVT and PE. Preventive measures in patients at risk may decrease the incidence of thromboembolic events. 4.

Trends in pulmonary embolism morbidity and mortality in Australia

IntroductionPulmonary embolism (PE) is a common cause of morbidity and mortality. In this study, we investigated patterns of morbidity and mortality from PE in Australia. Materials & MethodsAustralian government databases were used to extract data on age and sex specific rates of mortality between 1997 and 2007, and hospital separations between 1998/9 and 2009/10 to examine changes over time and between age and sex groups. ResultsIn 2007, 320 deaths were ascribed to PE in Australia, corresponding to a mortality rate of 1.73 per 100 000 population per year. Between 1997 and 2007, the Australian mortality rate decreased in both sexes, but this was significant only in females. By comparison, in 2009/10 there were 9,847 hospital separations for PE, corresponding to a rate of 53.1 per 100 000 population per year. In contrast to the fall in mortality rates, hospital separation rates significantly increased over the study period. Females had higher rates of morbidity and mortality from PE than males. While the mortality rates among the elderly population decreased significantly (from 48.4 to 34.3 per 100 000 population per year in those aged over 85 years), there were significant increases in PE mortality in the younger female age groups. ConclusionsAlthough mortality rates are decreasing, PE remains a significant cause of morbidity and mortality in Australia, especially in females and the elderly. The burden of morbidity and mortality from PE in Australia is comparable to that found in America and a number of European countries.

Safety and Efficacy of Multimodal Thromboprophylaxis Following Total Knee Arthroplasty: A Comparative Study of Preferential Aspirin vs. Routine Coumadin Chemoprophylaxis

Multimodal thromboprophylaxis encompasses preoperative VTE risk stratification, regional anesthesia, mechanical prophylaxis, and early mobilization. We determined if aspirin can be safely used for adjuvant chemoprophylaxis in patients who have a low thromboembolic risk. 1016 consecutive patients undergoing TKA received multimodal thromboprophylaxis. Aspirin was used in 67% of patients and Coumadin 33% (high risk patients, or who were on Coumadin before surgery). This study group was compared to 1001 consecutive patients who received multimodal thromboprophylaxis and routine Coumadin chemoprophylaxis. There was no significant difference in rates of VTE, PE, bleeding, complications, readmission and 90-day mortality between the two groups. There was a significantly higher rate of wound related complications in the control group (p=0.03). Multimodal thromboprophylaxis with aspirin given to the majority of patients at a low VTE risk is safe and effective in patients undergoing primary TKA.

Sonographic and Clinical Features of Upper Extremity Deep Venous Thrombosis in Critical Care Patients

Background-Aim. Upper extremity deep vein thrombosis (UEDVT) is an increasingly recognized problem in the critically ill. We sought to identify the prevalence of and risk factors for UEDVT, and to characterize sonographically detected thrombi in the critical care setting. Patients and Methods. Three hundred and twenty patients receiving a subclavian or internal jugular central venous catheter (CVC) were included. When an UEDVT was detected, therapeutic anticoagulation was started. Additionally, a standardized ultrasound scan was performed to detect the extent of the thrombus. Images were interpreted offline by two independent readers. Results. Thirty-six (11.25%) patients had UEDVT and a complete scan was performed. One (2.7%) of these patients died, and 2 had pulmonary embolism (5.5%). Risk factors associated with UEDVT were presence of CVC [(odds ratio (OR) 2.716, P = 0.007)], malignancy (OR 1.483, P = 0.036), total parenteral nutrition (OR 1.399, P = 0.035), hypercoagulable state (OR 1.284, P = 0.045), and obesity (OR 1.191, P = 0.049). Eight thrombi were chronic, and 28 were acute. We describe a new sonographic sign which characterized acute thrombosis: a double hyperechoic line at the interface between the thrombus and the venous wall; but its clinical significance remains to be defined. Conclusion. Presence of CVC was a strong predictor for the development of UEDVT in a cohort of critical care patients; however, the rate of subsequent PE and related mortality was low.

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Reply to Letter to Editor

Rivaroxaban for Prevention of Venous Thromboembolism after Total Knee Arthroplasty: Impact on Healthcare Costs Based on the RECORD3 Study.

Introduction: Rivaroxaban is a novel, oral, direct Factor Xa inhibitor in advanced clinical development for the prevention and treatment of thromboembolic disorders, including the prophylaxis for venous thromboembolism (VTE) after major orthopaedic surgery. In RECORD3, the first pivotal phase III study, rivaroxaban 10 mg once daily had superior efficacy to enoxaparin 40 mg once daily for the reduction of VTE following total knee arthroplasty (TKA). Mean duration of prophylaxis was 12.1 days. The primary endpoint (deep vein thrombosis [DVT], pulmonary embolism [PE], and all-cause mortality) occurred in 9.6% of the rivaroxaban group and in 18.9% of the enoxaparin group (RRR 49%; p<0.001; modified intention-to-treat), and symptomatic VTE occurred in 1.0% and 2.6%, respectively. There was no difference in major bleeding between rivaroxaban and enoxaparin. This analysis was designed to show the impact of this efficacy improvement on healthcare costs from a payer's perspective. Preventing DVT, PE, and all-cause mortality (primary endpoint) and symptomatic VTE events have economic benefits, because fewer healthcare resources are required.Methods: The impact of rivaroxaban on healthcare resources in the US and UK were assessed using the resource utilization in the RECORD3 trial, and the reduced administration cost associated with an oral therapy. Only non-drug costs borne by the healthcare sector were included in the analysis. The cost of symptomatic VTE was taken from published sources in the US, and from the 2007 NICE Guidelines in the UK. It was assumed that asymptomatic events had no impact on healthcare costs. It was also conservatively assumed that nurses spend three minutes per day administering a subcutaneous enoxaparin dose and training patients to self-inject for out-patient use. For costing purposes, the duration of hospitalization was 5 days. In the UK, full blood counts should be taken every 3 days while receiving enoxaparin.Results: The total cost associated with healthcare resource use in the US was $290 per patient with enoxaparin and $98 with rivaroxaban (excluding rivaroxaban and enoxaparin drug costs). This implies a resource use saving of $192 per patient due to the improved health outcomes with rivaroxaban. This improvement was driven primarily by the reduced costs of hospitalization for symptomatic events. In the UK, the total cost of resource use per patient was £48 ($78) with enoxaparin and £5 ($8) with rivaroxaban. The reduced healthcare cost of £43 ($70) per patient was driven equally by reduced hospitalization and reduced monitoring. The substantial difference in cost impact is due to higher US hospitalization costs. These results exclude the impact of post-thrombotic syndrome (PTS), the estimated 5-year rate of which is 21% in asymptomatic patients and 30% in symptomatic patients. Estimated costs for PTS treatment is more than $11,000 in the USA, and £4,000 ($6472) in the UK. Given the reduced incidence of both asymptomatic and symptomatic events with rivaroxaban, there would be even further savings in healthcare costs associated with rivaroxaban, due to a reduction in PTS.Conclusions: The clinical results shown by rivaroxaban for the prevention of VTE after TKA also result in savings to healthcare costs. With more than 600,000 US patients having hip or knee arthroplasty annually, these potential cost savings are significant.