Personal History Of Venous Thromboembolism Research Articles

Surveying Patients' Experiences and Perspectives on Venous Thromboembolism Care: An International Study to Identify Gaps and Opportunities in Health Care Delivery

Background Patient experience is a well-recognized, independent dimension of health care delivery. Although considerable progress has been made in the diagnosis and management of venous thromboembolism (VTE), data on the patient experience are lacking. We aimed to capture patients' experiences with VTE and anticoagulation in order to prioritize efforts to improve VTE health care delivery. Methods An IRB-approved survey was developed with a multidisciplinary team of clinicians and patient advocates. The survey domains included patient demographics, health care experiences, perspectives, and potential gaps in healthcare received for VTE. The survey was pilot tested and subsequently distributed electronically from May-July 2023 through an international patient advocacy group targeting individuals with personal history of VTE. Data are described as counts and proportions. We used log binomial regression to calculate the risk ratios (RR) and 95% confidence intervals (CI) of outcomes associated with seeing a hematologist during or after hospital admission. Results Of a total of 1,050 participants, the majority were from the US (81%), including 49 states and the District of Columbia. A response rate could not be calculated given that the web-based survey was openly distributed. The majority of respondents were women (81%), 88% identified as white, and 71% were age 40-69 years. Most patients (68%) experienced their first VTE event >12 months prior to the study, 36% had >1 VTE events and the majority (62%) were diagnosed in the emergency department. Over one-third (35%) of respondents reported not receiving the correct diagnosis the first time they presented to medical care and 50% of these participants had at least 3 health care visits before reaching the correct diagnosis. The majority (93%) recall information regarding their VTE diagnosis was provided by physicians or advanced practitioners, 65% reported this conversation was <10 minutes, and only 55% felt the diagnosis was explained to their satisfaction. (Table) A minority (16%) of patients received printed or electronic information at the time of diagnosis. Almost all (97%) participants were treated with anticoagulation, but only 48% recalled being provided specific information about the medication including risks and benefits. Only 24% of 563 respondents who menstruate recall discussing the impact of anticoagulation on menstruation with providers, and all recalled discussing this only after they developed anemia or changes in their menstrual flow. Of the 105 participants who were offered the opportunity to speak with a health care advocate, most (73%) accepted it; of those not offered an advocate, 88% reported that they would have accepted the opportunity. Only 53% of respondents reported access to providers for questions regarding their VTE diagnosis. Of 702 patients who were admitted to the hospital for VTE, 32% reported returning to health care, as their symptoms did not improve or worsened, and 30% of these patients were readmitted. Most admitted patients (89%) reported receiving some information about VTE at discharge, but the information received did not match the topics patients wanted. For example, patients most frequently wanted information about support groups (65%), mental health (65%), recurrence risk (55%) and prevention strategies (49%), but few received this information (2%, 2%, 17%, and 33%, respectively (Figure). Most patients were seen by hematologists following discharge (59%) or during hospitalization (35%). Among admitted patients, those who saw a hematologist either during or after admission were significantly more likely to receive information about their VTE (RR: 1.15, 95% CI: 1.06-1.24) and about anticoagulation (RR: 1.23, 95% CI: 1.04-1.45) at discharge compared to patients who did not see a hematologist. Conclusion In this first large-scale international survey to capture patient experiences and gaps in VTE care delivery, we identified several potential areas for improvement. Efforts to enhance patient education could improve the patient experience. Further research could explore if better education translates to improved medication adherence, management of bleeding, avoiding polypharmacy, and ultimately clinical outcomes. Professional societies and patient advocacy groups can partner to build resources to improve the quality of care and patient satisfaction for people with VTE.

Longitudinal profile of estrogen-related thrombotic biomarkers after cessation of combined hormonal contraceptives

AbstractThe persistence of risk of venous thromboembolism (VTE) due to combined hormonal contraceptives (CHCs), after their cessation, is unknown but important to guide clinical practice. The objective of this prospective cohort study was to define the time until normalization of estrogen-related thrombotic biomarkers after CHC cessation. We enrolled women aged 18 to 50 years who had decided to stop their CHC, excluding those with a personal history of VTE, anticoagulation, or pregnancy. The study started before cessation of CHC, with 6 visits afterwards (at 1, 2, 4, 6, and 12 weeks after cessation). Primary outcomes were normalized sensitivity ratios to activated protein C (nAPCsr) and to thrombomodulin (nTMsr), with sex hormone–binding globulin (SHBG) as a secondary end point. We also included control women without CHC. Among 66 CHC users, from baseline until 12 weeks, average levels of nAPCsr, nTMsr, and SHBG decreased from 4.11 (standard deviation [SD], 2.06), 2.53 (SD, 1.03), and 167 nmol/L (SD, 103) to 1.27 (SD, 0.82), 1.11 (SD, 0.58), and 55.4 nmol/L (SD, 26.7), respectively. On a relative scale, 85.8%, 81.3%, and 76.2% of the decrease from baseline until 12 weeks was achieved at 2 weeks and 86.7%, 85.5%, and 87.8% at 4 weeks after CHC cessation, respectively. Levels were not meaningfully modified throughout the study period among 28 control women. In conclusion, CHC cessation is followed by a rapid decrease in estrogen-related thrombotic biomarkers. Two to 4 weeks of cessation before planned major surgery or withdrawal of anticoagulants in patients with VTE appears sufficient for the majority of women. The trial is registered at www.clinicaltrials.gov as #NCT03949985.

Evaluation of prothrombotic risk of two PROC hotspot mutations (Arg189Trp and Lys193del) in Chinese population: a retrospective study

BackgroundR189W and K193del of protein C (PC) were hotspot mutations in Chinese population with venous thromboembolism (VTE), but almost two-thirds of patients with above mutations coexisting with other genetically or aquiredly prothrombotic risk factors. The aim of this study is to clarify the independent contributions of R189W or K193del to VTE risk.Methods490 unrelated patients with a personal history of VTE and 410 healthy participants were enrolled in this study. Data of their demographics, family history, genetic and acquired thrombosis risk factors were collected and statistically analyzed.ResultsPC R189W and K193del were identified in 3/410 (0.7%) and 7/410 (1.7%) healthy controls, and in 27/490 (5.5%) and 43/490 (8.8%) patients with VTE, respectively. Notably, about 70% of these mutant carriers combined with other genetic or acquired thrombophilic factors. After adjustment for age, gender, other inherited and acquired risk factors, we demonstrated that R189W and K193del were associated with 5.781-fold and 4.365-fold increased risk of VTE, respectively, which were significantly lower than the prothrombotic risk of anticoagulant deficiencies induced from rare mutations. Independent R189W or K193del mutation was not associated with earlier first-onset age as well as higher recurrent rate of VTE. However, combination of other genetic or acquired thrombophilic factors had supra-additive effects on those consequences. The more additional risk factors the patients had, the younger first-onset ages and higher risk of recurrence would be.ConclusionsAs the most frequent mutations for PC deficiency in Chinese population, both R189W and K193del mutations had limited independent contributions to VTE development compared with other rare mutations in PROC gene, but may act in concert with other genetic defects or acquired thrombotic risk factors to produce the final severe phenotype.

Risk Factors for Venous Thromboembolism in Women of Childbearing Age.

Women have the potential to develop venous thromboembolism (VTE) during their lifetimes. The risk of VTE in women of childbearing age is modulated by the presence of individual risk factors (such as personal history of VTE, increasing age, smoking, inherited thrombophilia, immobility), exposure to hormonal risk factors (such as pregnancy and oral contraceptives), and family history. In pregnant women, multifetal pregnancy, preeclampsia or eclampsia, caesarean section and use of artificial reproductive assistance can increase the risk of VTE. In women taking combined oral contraceptives (COC), a higher dose of estrogen, and the type of progesterone can increase the risk of VTE. VTE has a higher likelihood of occurring when the combination of risk factors crosses the threshold for thrombosis. Data from Grandone and colleagues enhance our understanding of the relative importance of family history as a risk predictor and suggest that family history is an even more powerful predictor for pregnancy- or COC-associated VTE than for VTE occurring outside of pregnancy or COC.

P454 No increased postoperative risk of venous thromboembolism nor infectious complications after JAK inhibitor exposure in patients with ulcerative colitis undergoing colectomy

Abstract Background Total colectomy for ulcerative colitis (UC) is associated with postoperative morbidity, including venous thromboembolism (VTE), in patients who already have a 2 to 4-fold risk for thromboembolic events. In light of recent concerns on increased major adverse events associated with JAK inhibitor exposure, we aimed to evaluate the postoperative VTE risk as well as other (non)infectious complications in UC patients undergoing colectomy after JAK inhibitor use. Methods This retrospective cohort study included all UC patients who underwent colectomy between 2013 and 2021 in our tertiary IBD center, and documented the 180-day postoperative non-infectious and infectious risks (table 1). Clinically relevant information included patient demographics, comorbidities, family history of IBD, personal history of VTE, intake of oral anticonception, smoking behaviour, disease characteristics including indication for colectomy, preoperative serum laboratory values, perioperative drug exposure (table 2) and surgical characteristics including low-molecular weight heparin (LMWH) prophylaxis (table 3). Results One-hundred seventy-nine UC patients (43.6% women, median [IQR] age 42.0 [28.5 – 56.2] years) underwent colectomy due to refractory disease (n=154) or suspected dysplasia or carcinoma (n=25). Forty-nine patients (27.4%) were operated urgently. In the twelve weeks prior to surgery, 55 (30.7%) patients had received anti-TNF agents, 40 (22.3%) anti-adhesion therapy, 16 (8.9%) anti-IL12/23, 2 (1.1%) investigational agents and 36 (20.1%) JAK inhibitors. Preoperatively, 27 patients (15.1%) were administered a moderate to high dose of systemic corticosteroids. All patients received antithrombotic prophylactic LMWH postoperatively, except for two patients who developed a gastrointestinal bleeding. During the 180-day postoperative period, a total of 3 patients (1.7%; mean age 51 years, 1 female) developed an intra-abdominal thrombosis, found by coincidence on CT scan. In all patients risk factors were identified, e.g. inflammatory state, cancer, high dose of corticosteroids. No VTE was seen in the patients who underwent colectomy while on JAK inhibitor. Only two out of 36 JAK inhibitor treated patients (5.6%) developed an infectious complication, while the overall risk of developing an infectious complication was 19.5%. Conclusion The overall risk for UC patients to develop VTE after colectomy is low with adequate antithrombotic prophylactic therapy. We did not observe any VTE in patients who were exposed to JAK inhibitors prior to surgery, nor did we see an increased risk on short-term infectious complications in this patient group. All patients who developed VTE despite LMWH had additional risk factors.

Prevalence of venous thromboembolism in patients undergoing diagnostic venous ultrasound during the first SARS-CoV-2 pandemic.

Background: Venous thromboembolism appears to be associated with severe COVID-19 infection than in those without it. However, this varies considerably depending on the cohort studied. The aims of this single-centre, multi-site retrospective cross-sectional study were to assess the number of all venous scans performed in the first month of pandemic in a large university teaching hospital, to evaluate the incidence of deep venous thrombosis (DVT), and assess the predictive ability of the clinical information available on the electronic patient record in planning work-up for DVT and prioritising ultrasound scans. Patients and methods: All consecutive patients undergoing venous ultrasound for suspected acute DVT between 1st of March and 30th of April 2020 were considered. Primary outcome was the proportion of scans positive for DVT; the secondary outcomes included association of a positive SARS-CoV-2 PCR test, demographic, clinical factors, and Wells scores. Results: 819 ultrasound scans were performed on 762 patients across the Trust in March and April 2020. This number was comparable to the corresponding pre-pandemic cohort from 2019. The overall prevalence of DVT in the studied cohort was 16.1% and was higher than before the pandemic (11.5%, p=.047). Clinical symptoms consistent with COVID-19, irrespective of the SARS-CoV-2 PCR test result (positive_COVID_PCR OR 4.97, 95%CI 2.31-10.62, p<.001; negative_COVID_PCR OR 1.97, 95%CI 1.12-3.39, p=.016), a history of AF (OR 0.20, 95%CI 0.03-0.73, p=.037), and personal history of venous thromboembolism (VTE) (OR 1.95, 95%CI 1.13-3.31, p=.014), were independently associated with the diagnosis of DVT on ultrasound scan. Wells score was not associated with the incidence of DVT. Conclusions: Amongst those referred for the DVT scan, SARS-CoV-2 PCR test was associated with an increased risk of VTE and should be taken into consideration when planning DVT work-up and prioritising diagnostic imaging. We postulate that the threshold for imaging should possibly be lower.

A retrospective study on the use of low-molecular-weight heparin for prevention of pregnancy-related recurrent venous thromboembolism and obstetrical complications.

The risk of venous thromboembolism (VTE) is increased during pregnancy and it is further increased together with pregnancy complications in women with personal history of VTE and thrombophilia abnormalities. It is unclear how the use of low-molecular-weight heparin (LMWH) may prevent such complications. To evaluate the potential benefits and risks of the use of LMWH for prevention of pregnancy-related VTE and obstetrical complications in the first pregnancy after a previous VTE. This retrospective cohort study includes fertile women referred to the Thrombosis Center from January 2000 to September 2018 for a thrombophilia work-up, after having had at least one previous VTE and one pregnancy thereafter. Data on pregnancy-related recurrent VTE, pregnancy outcomes and the use of LMWH were collected. Among 208 women, no thrombosis or major bleeding was recorded in 138 pregnancies conducted with LMWH, whereas 10 VTE (14%) were recorded in 70 pregnancies conducted without. Nine women (90%) with recurrent VTE had had a previous hormone-related event. The incidence of miscarriage was lower in pregnancies with LMWH than in those without (11% vs. 26%, relative risk 0.4, 95% confidence interval: 0.2-0.8), whereas late obstetrical complications and terminations were similar in the two groups. The prevalence of terminations was doubled in women with thrombophilia (12%) than in those without (6%). LMWH prophylaxis during pregnancy appears to be effective and safe for the prevention of recurrent VTE and may reduce the incidence of miscarriage.

Do Patients with a Family or Personal History of Venous Thromboembolism have an Increased Risk of Recurrence?

A family (FH) and personal history (PH) of venous thromboembolism (VTE) are commonly evaluated risk factors for recurrence. We examined the association between FH/PH of VTE and the risk of recurrence and whether a stronger history status (i.e., both FH/PH vs. no FH/PH) carries an increased recurrence risk. We prospectively followed 813 patients aged ≥ 65 years with acute VTE from 9 Swiss hospitals. We classified patients into four groups: no FH/PH, FH only, PH only, and both FH/PH. The primary outcome was recurrent VTE during the full observation period. We examined the association between FH/PH status and the time to VTE recurrence using competing risk regression, adjusting for confounders and periods of anticoagulation. Of 813 patients with VTE, 59% had no FH/PH, 11% a FH only, 24% a PH only, and 7% had both a FH and PH of VTE. Overall, 105 patients had recurrent VTE during the full observation period. After adjustment, patients with a FH only (subhazard ratio [SHR] 0.8, 95% confidence interval [CI] 0.4-1.7), PH only (SHR 1.5, 95% CI 0.9-2.5), and both FH/PH (SHR 1.4, 95% CI 0.6-3.1) did not have an increased risk of recurrent VTE compared with those without FH/PH. When we considered the period after the completion of initial anticoagulation only, the results were similar. Our findings indicate that in patients with acute VTE, a FH and/or PH of VTE does not convey an increased risk of recurrent VTE. In particular, we did not find a "dose-effect" relationship between FH/PH status and VTE recurrence.

Prior History of Venous Thromboembolism Is a Significant Risk Factor for Recurrence of Thrombosis after Cancer Diagnosis

Introduction: The risk of venous thromboembolism (VTE) is increased in patients with cancer and contributes to significant morbidity, treatment delays and mortality. The Khorana score is the most well-validated VTE risk prediction tool that guides use of prophylactic anticoagulation in patients with cancer. The Khorana score includes cancer type, body mass index (BMI), hemoglobin, platelet count and leukocyte count but not a prior history of VTE which may increase the risk of recurrent VTE. Scant published data have suggested that a personal history of VTE increases the risk of VTE recurrence by 2 to 7-fold after cancer diagnosis. In this study, we examine the impact of history of VTE on VTE recurrence in a large cohort of patients with cancer. Methods: We performed a retrospective cohort study of patients diagnosed with cancer using aggregated de-identified data from electronic medical record of &amp;gt;300 major hospitals in US (IBM Watson Explorys). Patients with a personal history of VTE (deep vein thrombosis and/ or pulmonary embolism) more than one year prior to the diagnosis of cancer were included. Within this cohort, patients who developed recurrent VTE within 180 days of diagnosis of cancer were identified. The primary end-point was the incidence of cancer associated VTE (CVTE) in patients with prior history of VTE as compared to patients without history of VTE. Baseline characteristics including age, race, gender, BMI, prothrombotic mutations (Factor V Leiden, prothrombin gene 20210A mutation), antineoplastic agent use, cancer type and laboratory values (as included in Khorana risk score) were compared in all patients. Results: A total of 4,159,400 patients with a diagnosis of cancer were included. Of these, 138,820 patients (3.3%) had a history of VTE &amp;gt;1 year prior to being diagnosed with cancer. The incidence of CVTE at 180 days was 10-fold higher in those with prior history of VTE compared to those without (36.9% vs 3.66%; OR 15.4, 95% CI 15.22-15.6, P value &amp;lt;0.0001). While the inherent risk of CVTE varied based on cancer type (highest risk of 10.5% in pancreatic cancer), the risk of recurrent VTE in patients with prior VTE history is magnified to a similar degree across all cancer types as shown in Figure 1. Baseline characteristics including age, race, gender and cancer type distribution were similar in all groups, as shown in Table 1. Factor V Leiden mutation or activated protein C resistance (FVL/APC) was more prevalent in patients with prior history of VTE and subsequent CVTE (3%) as compared to all patients with CVTE regardless of history (1%), as shown in Table 1. A higher BMI was noted in patients with prior history of VTE (49% and 71% respectively in patients with and without CVTE) as compared to 41% in all patients with CVTE. Greater use of antineoplastic agents (41%) was noted in the group of patients with prior history of VTE and subsequent CVTE as compared to patients with prior VTE but no CVTE (36%). Conclusion: Our study highlights that a prior personal history of VTE &amp;gt;1 year before cancer diagnosis significantly increases the risk of cancer associated VTE independently, regardless of other established risk factors for VTE suggesting that this group of patients, especially those undergoing anti-cancer treatment may benefit from prophylactic anticoagulation. Increased incidence of FVL/ APC in patients with prior history of VTE and recurrent CVTE may reflect increased testing for prothrombotic mutations in this cohort. Our ongoing efforts include examining the effect of addition of history of VTE to the Khorana score. Finally, large prospective observational studies would be key to assess the impact of history of VTE on cancer thrombosis. Disclosures No relevant conflicts of interest to declare.

Effectiveness and Safety of Twice Daily Versus Thrice Daily Subcutaneous Unfractionated Heparin for Venous Thromboembolism Prophylaxis at a Tertiary Medical Center

Background: The direct comparison of twice daily (BID) and thrice daily (TID) dosing of subcutaneous low dose unfractionated heparin (LDUH) for venous thromboembolism (VTE) prophylaxis in a mixed inpatient population is not well-studied. Objective: This study evaluated the effectiveness and safety of BID compared to TID dosing of LDUH for prevention of VTE. Methods: Retrospective, single-center analysis of patients who received LDUH for VTE prophylaxis between July and September 2015. Outcomes were identified by ICD-9 codes. A matched cohort was created using propensity scores and multivariate analysis was conducted to identify independent risk factors for VTE. The primary outcome was incidence of symptomatic VTE. Results: In the full cohort, VTE occurred in 0.71% of patients who received LDUH BID compared to 0.77% of patients who received LDUH TID (p = 0.85). There was no difference in major (p = 0.85) and minor (p = 0.52) bleeding between the BID and TID groups. For the matched cohort, VTE occurred in 1.4% of BID patients and 2.1% of TID patients (p = 0.32). Major bleed occurred in 0.36% of BID patients and 0.52% of TID patients (p = 0.7), while a minor bleed was seen in 3.4% of BID patients and 2.1% of TID patients (p = 0.13). Personal history of VTE (p = 0.002) and weight (p = 0.035) were independently associated with increased risk of VTE. Conclusion: This study did not demonstrate a difference in effectiveness or safety between BID and TID dosing of LDUH for VTE prevention.

Characteristics and Outcomes Among Patients With Early Venous Thromboembolic Events After Lung Transplant

BackgroundDespite several previous studies reporting a high frequency of venous thromboembolism (VTE) after lung transplant (LT), few actionable risk factors have been identified. There are limited data regarding the practice patterns of anticoagulation use among patients with LT. MethodsAll adult patients with single or bilateral LT between 2012 and 2016 were included (n = 324; mean age, 56.3 ± 13.3 years; male, 61.1%). Demographic, clinical, and laboratory variables before and after LT were recorded. Follow-up data included survival up to 3 years post-transplant. Development of VTE during the first 30 days after LT was the primary outcome variable. ResultsThe overall incidence of VTE during the first 30 days after LT was 29.9% (n = 97), among which the majority were upper extremity thromboses. Female sex, personal history of VTE, hospitalization at the time of transplant, and use of 3 or more central venous catheters during index hospitalization were independently associated with VTE. The use of anticoagulants was independently associated with a reduced risk of VTE. Despite increased morbidity, the development of VTE was not associated with worse post-transplant survival. ConclusionsA significant proportion of patients develop early VTE after LT. Limiting the number of central catheters to < 3 during the post-transplant period, along with the early institution of thromboprophylaxis, may lower the risk of VTE.

Heat-induced thrombosis extension after endovenous laser ablation: a clinical case

Endothermal heat-induced thrombosis (EHIT) is a complication of endovenous thermal ablation in treatment of varicose veins. Existing classifications do not account for the length of thrombus extension floating in the deep venous system. While the risk of extension is minor, the consequences can be baleful.Aim. To report a rare clinical case of endothermal heat-induced thrombosis extension formed in spite of ongoing anticoagulant treatment in a patient with endovenous laser ablation.Results. A 39 years-old man with endovenous laser ablation of the right great saphenous vein had class 2 EHIT with 1.92 cm length on the next day after surgery. Rivaroxaban was prescribed at a dose of 15 mg 2 times a day. EHIT extension above the inguinal ligament occurred on the 15th day after surgery, despite oral anticoagulant treatment. Open thrombectomy with high ligation was ordered. Postoperative period without complications. Preoperative Caprini score was 6 (varicose veins, BMI&gt; 25 kg/m2 , minor surgery, personal history of venous thromboembolism (VTE)).Conclusion. The reported clinical case illustrates that both the choice of treatment strategy and follow-up of patients with EHIT need to account for the combined risk of embolism with existing EHIT and potential thrombus extension with subsequent massive embolism.

Awareness and Perception of Thromboembolism and Thromboprophylaxis among Hospitalized Patients in Jordan.

Background and Objective: Despite the established importance of thromboprophylaxis in patients with Venous Thromboembolism (VTE), a limited number of studies have assessed the awareness of VTE and thromboprophylaxis therapy among the affected patients. The aim of the current study was to assess awareness and to explore variables associated with awareness about VTE and its thromboprophylaxis.Methods: A cross-sectional study was conducted on hospitalized patients who received thromboprophylaxis (5000 units of heparin subcutaneously (SC) q8-12h, or 30-40 mg of enoxaparin SC once daily). In addition to the sociodemographic variables, awareness and perception of VTE and its thromboprophylaxis were assessed using a validated questionnaire. Multiple logistic regressions were conducted to build a model of variables significantly associated with VTE awareness.Results: A total of 225 patients participated in the study, with only 38.2% and 22.2% of the participants being aware of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) respectively. Logistic regression showed that the participants with low educational level had 3.046 value, with the odds being not aware of DVT or PE compared with participants with high educational level. Participants without a personal history of VTE had 7.374 value, with the odds being not aware of DVT or PE compared with those who had a personal history of VTE. Participants who had a negative perception of VTE had 2.582 value, with the odds being not aware of DVT or PE compared with participants who had a positive perception and those who did not have any information about DVT or PE had 13.727 value, with the odds being not aware of DVT or PE.Conclusion: The findings reveal that there is a lack of awareness about VTE and its thromboprophylaxis among the study participants. Patients with lower educational level and those with no history of previous VTE need awareness improvement about VTE and its thromboprophylaxis. Clinical Pharmacists need to focus on providing information about VTE and improving patients’ perception about VTE and its thromboprophylaxis with the aim of improving the awareness about VTE, and hence the better health outcome.

A Review of Inappropriate D-Dimer Ordering at a Canadian Tertiary Care Centre

Introduction The D-dimer has been validated for use in the diagnosis of venous thromboembolism (VTE). The high sensitivity of the assay allows for safe exclusion of VTE in patients with low pre-test probability. Pre-test probability scores such as the Wells score for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) have been established to help guide physicians on when to order a D-dimer in patients with suspected VTE. We sought to explore the landscape of D-dimer ordering at our institution and what clinical circumstances trigger D-dimer ordering. Methods We conducted a retrospective chart review of 237 patients in whom a D-dimer has been ordered over a 3-month period from January to March 2018 at the University of Alberta Hospital, Edmonton, Canada. Charts were reviewed for the following parameters: Specialty of ordering physician, apparent indication for ordering, patient risk factors for VTE and evidence of pre-test probability calculation. If no pre-test probability was recorded, we retrospectively calculated Wells DVT or PE scores depending on the apparent indication. We then reviewed subsequent investigations thought to be influenced by interpretation of the D-dimer. These included ventilation/perfusion scans (V/Q scan), ultrasound Doppler studies and Computerized Tomography pulmonary angiography (CTPA). Results Of the 237 charts reviewed, 84.4% of D-dimers were ordered in the Emergency Department while only 14.3% were drawn on admitted patients. Sixty-nine percent of the patients were identified as having at least one risk factor for the development of VTE with prolonged hospitalization (5.5%) and personal history of VTE (4.2%) being the most common. Indication for ordering was suspected VTE in 76.3% of patients while the indications was unclear in 12.7% of patients. An initial pre-test probability score was recorded for only 3 patients. Of the D-dimers ordered, 47.7% were above the upper limit of normal (≥ 0.50 mg/L) and considered a positive test. Forty five CTPAs and 27 V/Q scans were performed with only 4 (1.69%) and 6 (2.53%) confirming the presence of pulmonary emboli, respectively. Doppler ultrasounds were performed on 18 patients (7.6%) with only one confirming a DVT. Conclusions Our data shows that the majority of physicians at our institution fail to utilize pre-test probability tools prior to ordering a D-dimer. This leads to unnecessary costs, overuse of imaging studies and results in low rates of positive scans. Disclosures Wu: Bayer: Other: Local PI for trial ; BMS-Pfizer: Other: Local PI for trial ; Daiichi-Sankyo: Other: Local PI for trial .

Postpartum Venous Thromboembolism Prophylaxis May Cause More Harm than Benefit: A Critical Analysis of International Guidelines Through an Evidence-based Lens

(BJOG. 2018;125:1109–1116) Prothrombotic hemostatic changes make pregnant and postpartum women logical targets for venous thromboembolism (VTE) prophylaxis. Most obstetric VTE guidelines recommend low–molecular-weight heparin (LMWH) for many postpartum women, including most delivering by cesarean. Although evidence is limited, a small subset of pregnant and postpartum women is at very high risk of VTE. Women with a personal history of VTE, potent thrombophilia, or prolonged immobilization usually receive and likely benefit from antenatal and postpartum LMWH prophylaxis. This perception of benefit has spread to women with more common risk factors, in whom the risk of VTE is lower.

Therapeutic Implications of Inherited Thrombophilia in Pregnancy.

Inherited (hereditary) thrombophilia is a genetic disorder that affects coagulation, being responsible for more than 60% of idiopathic (spontaneous or unprovoked) thromboembolic events. Association of inherited thrombophilia with pregnancy increases the risk of thromboembolic disease, and it may be related to many complications, such as preeclampsia, recurrent miscarriage intrauterine growth restriction, early detachment of placenta, and prematurity. Interpretation of a positive test for thrombophilia in pregnant women is difficult because they have many natural changes in the coagulation system. Genetic diagnosis of thrombophilia, after a thrombotic event or during a pregnancy complication, has a major importance, not only to define its etiology but also to determine the duration of anticoagulant treatment and risk stratification for prophylaxis treatment. Literature search was performed using electronic database (PubMed) between April 1981 and November 2018. We used different keywords and MeSH terms to generate the most relevant results related to the inherited thrombophilia and its impact on pregnancy. Screening for inherited thrombophilia in young women is recommended in case of personal history of venous thromboembolism, first-degree relatives with a history of high-risk thrombophilia, or personal history of second-trimester miscarriage. Decision to recommend thromboprophylaxis with anticoagulant treatment in pregnant women with inherited thrombophilia is determined by history of venous thromboembolism, type and associated risk of inherited thrombophilia, and presence of additional risk factors. Low-molecular-weight heparins are the preferred agents for prophylaxis in pregnancy, while the doses vary depending on thrombophilia type, personal history, and associated risk factors. Association between 2 procoagulant conditions, inherited thrombophilia and pregnancy, has an important impact for the mother and fetus. This review will summarize the impact of each inherited prothrombotic factor on cardiovascular and pregnancy outcomes and will discuss the role of anticoagulation treatment for women diagnosed with inherited thrombophilia.

Perioperative venous thromboembolism prophylaxis in prostate cancer surgery.

To describe a patient and procedure specific approach to selecting Venous thromboembolism (VTE) prophylaxis for men who undergo radical prostatectomy. We performed a literature search and narrative review of VTE after radical prostatectomy. We describe the current paradigm of perioperative thromboprophylaxis and underlying rationale. Relevant findings from the European Association of Urology thromboprophylaxis guidelines are interpreted and summarized. The use of extended post-operative thromboprophylaxis for patients who undergo radical prostatectomy is appropriate when the risk of symptomatic VTE outweighs the risk of major bleeding. Patient and procedure factors impact VTE risk. Patient risk can be stratified as low, moderate or high based on 4 factors; age > 75, BMI > 35, VTE in a first degree relative, and personal history of VTE. Procedure risk of VTE and bleeding can be stratified by modality of surgery (open, laparoscopic, robotic) and extent of pelvic lymphadenectomy. Using these factors, patients at the lowest risk for VTE will have an expected incidence of VTE of 0.4-0.8% and those at highest risk from 1.5 to 15.7%. Incidence of major bleeding ranges from 0.4 to 1.4%. These ranges emphasize the need to consider the net benefit for each specific patient. Use of mechanical prophylaxis is supported by weaker evidence but has fewer harms and is likely reasonable for most patients. Many patients who undergo radical prostatectomy will benefit from extended post-operative thromboprophylaxis. Risk of thrombosis is likely higher with open approach and extended lymph node dissection. The net benefit of treatment should be considered using patient- and procedure-specific criteria. When the net benefit is negligible or possibly harmful no pharmacological thromboprophylaxis should be used.

The effect of recanalization on long‐term neurological outcome after cerebral venous thrombosis

Background Studies with limited sample size and with discordant results described the recanalization time-course of cerebral venous thrombosis (CVT). The neurological outcome after a first episode of CVT is good, but the role of recanalization on neurological dependence is still debated. Objectives The aim of the study is to assess the recanalization rate after cerebral venous thrombosis (CVT) and its prognostic role in long-term neurological outcome. Patients/Methods In a retrospective observational multicenter cohort study, patients with an acute first episode of CVT with at least one available imaging test during follow-up were enrolled. Patency status of the vessels was categorized as complete, partial or not recanalized. Neurological outcome was defined using the modified Rankin scale (mRS) as good (mRS = 0-1) or poor (mRS = 2-6). Results Five-hundred and eight patients (median [IQR] age, 39 [28.5-49] years; 26% male) were included. Complete or partial recanalization was not differently represented in patients undergoing scans at different periods of time (from 28-day to 3 month-period up to a 1-3 year-period). mRS at the time of follow-up imaging was available in 483 patients; 92.8% of them had a mRS of 0-1. CVT recanalization (odds ratio [OR], 2.56; 95% confidence interval [CI], 1.59-4.13) was positively associated, whereas cancer (OR, 0.29; 95% CI, 0.09-0.88), and personal history of venous thromboembolism (VTE) (OR, 0.36; 95% CI, 0.14-0.92) were negatively associated as independent predictors of favorable (mRS = 0-1) outcome at follow-up. Conclusions Most patients with a first CVT had complete or partial recanalization at follow-up. Recanalization was independently associated with a favorable neurological outcome.

Incidence and predictors of venous thromboembolism in inherited myopathies: A higher risk in myotonic dystrophy

The risk for venous thromboembolism (VTE) in inherited myopathies, which can lead to chronic immobilization, is unknown. To evaluate incidence of VTE in inherited myopathies, including for patients who lost ambulation, to compare it to incidence of VTE in general population and to identify predictors of VTE events in inherited myopathies. We retrospectively enrolled 2810 adult patients with genetically proven myopathy, admitted to our institutions between January 2000 and November 2014. We collected any information relative to their demographic and genetic characteristics, their muscular functional status including ambulation and the occurrence of VTE. We determined the incidence of venous thromboembolism in this population by using Kaplan–Meier product-limit method, compared it to general population with log-rank test and assessed its predictors with multivariable Cox modeling. Over a median follow-up of 8.5 years, 102 patients developed venous thromboembolism, representing a cumulative incidence of 6.2%, higher than in general population matched on age and sex. We identified four independent predictors of VTE: age (hazard-ratio ( HR ) = 1.02, 95%CI = 1.01–1.04, P = 0.002), a personal history of VTE ( HR = 5.54, 95%CI = 2.91–10.5, P < 0.0001), a diagnosis of myotonic dystrophy (DM) ( HR = 4.63, 95%CI = 2.63–8.18, P < 0.0001) and permanent loss of ambulation inpatients with DM ( HR = 4.07, 95%CI = 1.14–14.5, P = 0.030). Loss of ambulation alone was not a significant independent predictor of VTE. VTE in inherited myopathies is not a rare condition and is more frequent than in general population. We identified four independent predictors of VTE in these patients. Patients with DM represented the population with the highest risk of VTE.

Ovarian Vein Thrombosis: Incidence of Recurrent Venous Thromboembolism and Survival.

To identify the risk of venous thromboembolism recurrence, major bleeding, and mortality in patients with ovarian vein thrombosis so as to better define optimal treatment strategies. Patients with ovarian vein thrombosis (1990-2015) and age- and gender-matched patients with contemporary leg deep vein thrombosis (DVT) were assessed for differences in etiology, venous thromboembolism recurrence, and survival in a case-control study. Over the timeframe of this study, only 219 ovarian vein thrombosis cases were identified compared with 13,417 leg DVTs. Median duration of follow-up was 1.23 years (interquartile range 0.25-4.14). Pulmonary embolism was identified at presentation in 6% of patients with ovarian vein thrombosis and 16% of those with DVT (P=.001). Frequent causes of ovarian vein thrombosis included cancer, hormonal stimulation, surgery, and hospitalization. Cancer was twofold more frequent in patients with ovarian vein thrombosis (44% compared with 21%; P<.01). Despite being less frequently treated with anticoagulation (ovarian vein thrombosis 54% compared with DVT 98%, P<.001), venous thromboembolism recurrence rates were similar between groups (ovarian vein thrombosis 2.3 compared with DVT 1.8 per 100 patient-years, P=.49). A personal history of venous thromboembolism and preceding surgery was found to be an independent risk factor for venous thromboembolism recurrence among those treated with anticoagulation (hazard ratio 6.7, P=.04 and hazard ratio 13.6, P=.03, respectively). There was no significant difference in overall survival. Ovarian vein thrombosis is a rare thrombotic condition with an incidence 60-fold lower compared with leg DVT in our institution. The striking association with cancer adversely affects overall survival rates in patients with ovarian vein thrombosis. Venous thromboembolism recurrence rates argue for anticoagulation with a direct oral anticoagulant or vitamin K antagonist, particularly in those with a history of venous thromboembolism.