Predictors Of VTE Research Articles

Venous thromboembolism is associated with increased all-cause mortality in ALK-positive non-small cell lung cancer

BackgroundVenous thromboembolic events (VTE) are often diagnosed in ALK-positive lung cancer although it has not been demonstrated how their co-occurrence affects patients' survival.MethodsThe study included patients with ALK-positive lung cancer recognized in metastatic stage in the period 2017–2022. All received treatment with ALK inhibitors at The Maria Sklodowska-Curie National Research Institute of Oncology in Warsaw. The main aim of the study was to assess overall survival (OS) in relation to VTE occurrence. The additional purpose was to define predictors of VTE and OS.ResultsThe study included 54 patients in median age 60 years, men were a minority (25 / 46.3%). VTE was diagnosed in 12 (22.2%) patients: 9 (16.7%) cases with pulmonary embolism (PE), 2 cases with thrombosis in vena cava superior, one case with deep vein thrombosis and thrombosis in vena cava inferior. Among patients with PE: 2 patients died directly due to the first PE episode and one due to a recurrent PE. Patients with VTE had significantly shorter overall survival (median 11.7 vs. 37.4 months, log-rank test p = 0.003). The risk of all-cause mortality was increased significantly in both: VTE (HR = 3.47; 95%CI: 1.61—7.49; p = 0.0016) or alone PE (HR = 2.41; 95%CI: 1.06—5.50; p = 0.037). The risk of VTE diagnosis was significantly increased during active treatment with crizotinib (HR = 8.72; p = 0.0004) or alectinib (HR = 21.47; p = 0.000002). Metastases to liver and baseline leukocyte count > 11 × 10⁹/L were significant predictors of VTE and OS. Khorana score ≥ 3 points predicted OS (HR = 2,66; 95%CI: 1,05—6,75; p = 0,04), but remained insignificant for VTE.ConclusionThe diagnosis of any type of VTE or alone PE was associated with significantly worse overall survival in patients with ALK-positive non-small cell lung cancer.

A composite risk assessment model for venous thromboembolism

ObjectiveVenous thromboembolism (VTE) is a preventable cause of hospitalization-related morbidity and mortality. VTE prevention requires accurate risk stratification. Federal agencies mandated VTE risk assessment for all hospital admissions. We have shown that the widely used Caprini (30 risk factors) and Padua (11 risk factors) VTE risk-assessment models (RAMs) have limited predictive ability for VTE when used for all general hospital admissions. Here, we test whether combining the risk factors from all 23 available VTE RAMs improves VTE risk prediction. MethodsWe analyzed data from the first hospitalizations of 1,282,014 surgical and non-surgical patients admitted to 1298 Veterans Affairs facilities nationwide between January 2016 and December 2021. We used logistic regression to predict VTE within 90 days of admission using risk factors from all 23 available VTE RAMs. Area under the receiver operating characteristic curves (AUC), sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) were used to quantify the predictive power of our models. The metrics were computed at two diagnostic thresholds that maximized (1) the value of sensitivity + specificity-1; and (2) PPV and were compared using McNemar’s test. The Delong-Delong test was used to compare AUCs. ResultsAfter excluding those with missing data, 1,185,633 patients (mean age, 66 years; 93% male; and 72% White) were analyzed, of whom 33,253 (2.8%) had a VTE (deep venous thrombosis [DVT], n = 19,218, 1.6%; pulmonary embolism [PE], n = 10,190, 0.9%; PE + DVT, n = 3845, 0.3%). Our composite RAM included 102 risk factors and improved prediction of VTE compared with the Caprini RAM risk factors (AUC composite model: 0.74; AUC Caprini risk-factor model: 0.63; P < .0001). When the sum of sensitivity and specificity-1 was maximized, the composite model demonstrated small improvements in sensitivity, specificity and PPV; NPV was high in both models. When PPV was maximized, the PPV of the composite model was improved but remained low. The nature of the relationship between NPV and PPV precluded any further gain in PPV by sacrificing NPV and sensitivity. ConclusionsUsing a composite of 102 risk factors from all available VTE RAMs, we improved VTE prediction in a large, national cohort of >1 million general hospital admissions. However, neither model has a sensitivity or PPV that permits it to be a reliable predictor of VTE. We demonstrate the limits of currently available VTE risk prediction tools; no available RAM is ready for widespread use in the general hospital population.

Venous Thromboembolism Rates Have Not Decreased in Elective Lumbar Fusion Surgery from 2011 to 2020.

Retrospective cohort study. This study aimed to (1) evaluate for any temporal trends in the rates of VTE, deep venous thrombosis (DVT), pulmonary embolism (PE), and mortality from 2011 to 2020 and (2) identify the predictors of VTE following lumbar fusion surgery. Annual incidences of 30-day VTE, DVT, PE, and mortality were calculated for each of the operation year groups from 2011 to 2020. Multivariable Poisson regression was utilized to test the association between operation year and primary outcomes, as well as to identify significant predictors of VTE. A total of 121,205 patients were included. There were no statistically significant differences in VTE, DVT, PE, or mortality rates among the operation year groups. Multivariable regression analysis revealed that compared to 2011, operation year 2019 was associated with significantly lower rates of DVT. Age, BMI, prolonged operation time, prolonged length of stay, non-home discharge, anterior fusion, smoking status, functional dependence, and chronic steroid use were identified as independent predictors of VTE following lumbar fusion. Female sex, Hispanic ethnicity, and outpatient surgery setting were identified as protective factors from VTE in this cohort. Rates of VTE after lumbar fusion have remained mostly unchanged between 2011 and 2020. Older age, higher BMI, longer operation time, prolonged length of stay, non-home discharge, anterior fusion, smoking, functional dependence, and steroid use were independent predictors of VTE after lumbar fusion, while female sex, Hispanic ethnicity, and outpatient surgery were the protective factors.

Risk and factors associated with venous thromboembolism following abdominal transplantation

BackgroundVenous thromboembolism (VTE) remains under-studied among patients undergoing kidney, liver and pancreas (abdominal) transplantation. We characterized the risk and predictors of VTE using a nationally-representative cohort. MethodsThe 2014–2019 Nationwide Readmissions Database was queried to identify all adults undergoing abdominal transplantation. Patients who developed pulmonary embolism or deep venous thrombosis were considered the VTE cohort (others: nonVTE). Multivariable models were developed to identify factors linked with VTE and assess the independent associations between VTE and key outcomes. ResultsOf ~141,977 transplant recipients, 1.9 % (2722) developed VTE. The VTE cohort was similarly female (39.2 vs 38.0, p = 0.51), but more often demonstrated a higher Elixhauser comorbidity index (4.19 ± 1.40 vs 3.93 ± 1.39, p < 0.001).After adjustment, congestive heart failure (AOR 1.54, 95%CI 1.25–1.91), cardiac arrhythmias (AOR 1.54, 95%CI 1.34–1.78), peripheral vascular disease (AOR 1.29, 95%CI 1.02–1.63), coagulopathies (AOR 1.63, 95%CI 1.38–1.92), previous history of VTE (AOR 1.14, 95%CI 1.06–1.22), and heparin-induced thrombocytopenia (AOR 2.61, 95%CI 2.07–3.28) were associated with VTE. The development of VTE was linked with significantly greater in-hospital mortality (AOR 4.56, 95%CI 2.07–10.10), as well as infectious (AOR 2.59, 95%CI 1.55–4.21), cardiac (AOR 2.59, 95%CI 1.39–4.82), and respiratory (AOR 1.78, 95%CI 1.21–2.63) complications. VTE was further associated with increased length of stay (+8.18 days, 95%CI +1.32–15.41), expenditures (+$42,000, 95%CI $24,800-59,210), and odds of VTE upon readmission (AOR 4.51, 95%CI 1.32–15.41). ConclusionsVTE after abdominal transplantation is linked with significantly greater in-hospital mortality, complications, resource utilization, and risk of VTE at readmission. Novel risk assessments and prophylaxis protocols are needed to reduce VTE incidence and sequelae.

Postoperative venous thromboembolism risk-prediction in foot and ankle fracture surgery

BackgroundVenous thromboembolism (VTE) are rare but serious complications after foot and ankle fracture surgery. A consensus definition of a high-risk patient has not been reached, leading to significant variability in the use of pharmacologic agents for VTE prophylaxis. The aim of this study was to develop a model for predicting VTE risk in patients undergoing surgery for foot and ankle fractures that is usable and scalable in clinical practice. MethodsA retrospective review of 15,342 patients, within the ACS-NSQIP database, who had undergone surgical repair of foot and ankle fractures from 2015 to 2019 was performed. Univariate analysis evaluated differences in demographics and comorbidities. Stepwise multivariate logistic regression was generated based on a 60 % development cohort to evaluate risk factors for VTE. A receiver operator curve based on the 40 % test cohort calculated area under the curve (AUC) to measure the accuracy of the model in predicting VTE within the 30-day postoperative period. ResultsOf the 15,342 patients, 1.2 % patients experienced VTE, and 98.8 % patients did not. Patients who experienced VTE were significantly older and had an overall higher comorbidity burden. Those who had VTE spent on average 10.5 more minutes in the operating room. In the final model, age over 65, diabetes, dyspnea, CHF, dialysis, wound infection and bleeding disorders were all found to be significant predictors of VTE after controlling for all other factors. The model generated an AUC of 0.731, indicating good predictive accuracy. The predictive model is publicly available at https://shinyapps.io/VTE_Prediction/. ConclusionsIn alignment with previous studies, we identified increased age and bleeding disorders as independent risk factors for VTE after foot and ankle fracture surgery. This is one of the first studies to generate and test a model for identifying patients at risk for VTE in this population. This evidence-based model may help surgeons prospectively identify high-risk patients who may benefit from pharmacologic VTE prophylaxis.

Predictors of pregnancy-associated venous thromboembolism: A case-control study.

BackgroundVenous thromboembolism (VTE), manifesting as pulmonary embolism (PE) or deep vein thrombosis (DVT), is the most common cause of morbidity and death during pregnancy and the postpartum period. We conducted this study to describe the predictors of pregnancy-associated VTE (DVT and PE).MethodsA case-control study was conducted at a tertiary care center in Riyadh. A total of 380 patients were included in this study, 180 of whom were diagnosed with pregnancy-associated thrombosis and 200 of them showed no VTE. Demographic data and data on risk factors of VTE were collected by reviewing the medical charts and the risk assessment tool of the Royal College of Obstetricians and Gynecologists, respectively. The main outcome measures were VTE, manifesting as PE or DVT.ResultsThe following factors were identified as the predictors of VTE through multivariate analysis: family history [Odds ratio (OR) = 50.47, 95% Confidence Interval (CI): 6.78–375.64, P < 0.0001)], thrombophilia (OR = 21.99, 95% CI: 2.83–170.63, P = 0.003), and presence of gross varicose veins (OR = 17.15, 95% CI: 3.93–74.87, P < 0.0001).ConclusionsThe findings of this study showed that family history, thrombophilia, and the presence of gross varicose veins were risk factors for VTE, exceeding other transient risk factors. Hence, prophylaxis is highly recommended for those women who present with any of these factors.

The rate of venous thromboembolism in patients with non-small cell lung cancer treated with chemotherapy or check point inhibitors.

e21053 Background: Treatment with immune checkpoint inhibitors (CPI) targeting PD-1 or PD-L1 significantly improves progression free survival and overall survival in patients with non-small cell lung cancer (NSCLC). Emerging literature suggests that the proinflammatory state of CPIs may increase the risk of thromboembolism, both venous (VTE) and arterial (ATE), which is of great concern as thromboembolism remains a major cause of mortality in patients with NSCLC. We performed a retrospective cohort study to evaluate thromboembolic outcomes in patients on immunotherapy for NSCLC. Methods: We reviewed the records of all patients diagnosed with stage IV NSCLC between December 2016 and December 2019 and treated with chemotherapy, CPIs, or both in one of the largest integrated academic health systems in Western Pennsylvania. Khorana scores (to predict the risk of future VTE) were calculated for each patient based on available data at the time of diagnosis. Logistic regression analyses were done to evaluate clinical predictors of VTE. Survival outcomes were analyzed using Kaplan-Meier estimates and a log rank test was used to compare survival estimates. Data was analyzed using SPSS v26 (IBM Corp). Results: A total of 110 patients with stage IV NSCLC were identified, 87.1% had ECOG ≤2, 67.0% had adenocarcinoma and 25.7% had squamous cell carcinoma, and 39.1% had PD-L1 staining ≥50%. Immunotherapy related adverse events (IrAE) of any grade were found in 28.2%. Overall, 25.5% received chemotherapy only, 27.7% received CPIs alone, and 45.5% received chemo + CPIs. A Khorana score of ≥2 was found in 43.6% of patients. Prophylactic anticoagulation was used in 0.9% of patients. VTE was detected in 18.3% and ATE in 10.0% of the cohort; therapeutic anticoagulation was given in 14.7% of patients. Median overall survival was 25.5 months (95% CI 18.7-32.3) in patients without VTE versus 13.7 months (95% CI 3.1-24.3) in patients with a VTE diagnosis (HR 1.96, 95% CI 1.11-3.45; p = 0.02). Khorana score of ≥2 was not a significant predictor of VTE in this cohort (univariate OR 1.34, p = 0.53, multivariate OR 1.13, p = 0.81), but was associated with worse survival (HR 2.38, 95% CI 1.48-3.83, p &lt; 0.001). Conclusions: In this retrospective cohort, VTE was associated with decreased overall survival. While no significant association between elevated Khorana score and VTE was identified, elevated Khorana score at the time of diagnosis was an independent predictor of survival in patients with NSCLC. Of note, there was a low rate of prophylactic anticoagulation in this cohort.

ABO blood group type and risk of venous thromboembolism in patients with cancer

AbstractVenous thromboembolism (VTE) is common in patients with cancer. Although in the general population blood type non-O is associated with increased VTE risk, the impact of ABO blood type on risk of cancer-associated VTE has not been clarified. To determine the influence of ABO blood type on cancer-associated VTE risk, we conducted an analysis within the Vienna Cancer and Thrombosis Study, a prospective cohort study including patients with newly diagnosed or recurrent cancer observed for the primary outcome VTE. Restricted cubic spline analysis was performed and specific time-restricted subdistribution hazard ratios (SHR) were calculated to investigate the association between non-O blood type and VTE over time. One thousand, seven hundred and eight patients were included in the analysis (median follow-up time: 24 months; interquartile range: 10-24), and 151 patients developed VTE (8.8%). During the first 3 months of follow-up, there was no association between non-O blood type and VTE risk (SHR: 1.00; 95% confidence interval [CI]: 0.60-1.67). Thereafter, non-O blood type was associated with a higher VTE risk (SHR: 1.79; 95% CI: 1.12-2.85). Furthermore, non-O blood type was associated with increased VTE risk in patients with intermediate and low thrombotic risk tumor types (SHR: 1.73; 95% CI: 1.09-2.73) but not in very high-risk types (pancreatic, gastroesophageal, and brain cancer; SHR: 0.94; 95% CI: 0.55-1.61). This association was weakened after adjustment for factor VIII. Non-O blood type is a time-dependent predictor of VTE in patients with cancer. It is associated with increased VTE risk beyond 3 months of follow-up and in patients with intermediate- and low-risk tumor types.

Predictive risk factors for venous thromboembolism in neurosurgical patients: A retrospective analysis single center cohort study

BackgroundVenous thromboembolism (VTE) has a major effect on morbidity and mortality in neurosurgical patients. However, identifying risk factors that may be useful in practice is a challenge. The purpose of this study was to investigate the incidence and determine the predictors of VTE in patients undergoing neurosurgery. Materials and methodsThis retrospective, single-center cohort study was conducted on adult patients admitted to a private hospital for a primary elective neurosurgical procedure between January 2015 and December 2020. Univariate analysis was used to examine clinical factors, and multivariable regression analysis was used to identify predictors of VTE. The area under the receiver-operating characteristic (AUROC) curve demonstrated the fitting model and discrimination power. ResultsA total of 350 patients who underwent neurological surgery were identified. There were 26 patients (7.4%) with VTE. The final predictors were found to be statistically significant in the multivariate binary logistic regression analysis, including non-Asian populations (p value < 0.001, odds ratio [OR]: 6.11, 95% confidence interval [CI] = 2.20–16.89), lack of postoperative ambulation (p value = 0.009, OR: 9.25, 95% CI = 1.17–48.83), and septic shock complication (p value = 0.001, OR: 5.36, 95% CI = 1.46–19.62). The AUROC was 0.708 (95% CI 0.61–0.80). ConclusionAlthough the incidence of VTE in patients receiving neurosurgery is minimal, it is also higher in non-Asian patients, those who lack of postoperative ambulation, and patients with septic shock complications. This approach may be useful to predict thromboembolism in neurosurgical patients. External validation of the prognostic model requires more investigation.

Cytomegalovirus infection is a risk factor for venous thromboembolism in ANCA-associated vasculitis

BackgroundVenous thromboembolism (VTE) is a common complication in patients with anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) and confers significant morbidity and mortality. Both acute and past cytomegalovirus (CMV) infection have been identified as risk factors for VTE in immunocompetent and immunosuppressed individuals. Here, we examine whether past exposure to CMV is a risk factor for VTE amongst patients with AAV.MethodsWe retrospectively analysed outcomes of patients with a new diagnosis of AAV from a UK cohort. All confirmed cases of VTE where CMV IgG serology was available were recorded. Retrospective collection of the same data for patients at a North American centre was used as a validation cohort.ResultsVTE was common with 12% of patients from the study cohort (total 259 patients) developing an event during the median follow-up period of 8.5 years of which 60% occurred within the first 12 months following diagnosis. Sixteen percent of CMV seropositive patients developed a VTE compared with 5% of patients who were seronegative (p = 0.007) and CMV seropositivity remained an independent predictor of VTE in multivariable analysis (HR 2.96 [1.094–8.011] p = 0.033). CMV seropositivity at diagnosis was confirmed as a significant risk factor for VTE in the American validation cohort (p = 0.032).ConclusionsVTE is common in patients with AAV, especially within the first year of diagnosis. Past infection with CMV is an independent risk factor associated with VTE in AAV.

COVID-19 and Risk of VTE in Ethnically Diverse Populations

BackgroundLimited existing data suggest that the novel COVID-19 may increase risk of VTE, but information from large, ethnically diverse populations with appropriate control participants is lacking.Research QuestionDoes the rate of VTE among adults hospitalized with COVID-19 differ from matched hospitalized control participants without COVID-19?Study Design and MethodsWe conducted a retrospective study among hospitalized adults with laboratory-confirmed COVID-19 and hospitalized adults without evidence of COVID-19 matched for age, sex, race or ethnicity, acute illness severity, and month of hospitalization between January 2020 and August 2020 from two integrated health care delivery systems with 36 hospitals. Outcomes included VTE (DVT or pulmonary embolism ascertained using diagnosis codes combined with validated natural language processing algorithms applied to electronic health records) and death resulting from any cause at 30 days. Fine and Gray hazards regression was performed to evaluate the association of COVID-19 with VTE after accounting for competing risk of death and residual differences between groups, as well as to identify predictors of VTE in patients with COVID-19.ResultsWe identified 6,319 adults with COVID-19 and 6,319 matched adults without COVID-19, with mean ± SD age of 60.0 ± 17.2 years, 46% women, 53.1% Hispanic, 14.6% Asian/Pacific Islander, and 10.3% Black. During 30-day follow-up, 313 validated cases of VTE (160 COVID-19, 153 control participants) and 1,172 deaths (817 in patients with COVID-19, 355 in control participants) occurred. Adults with COVID-19 showed a more than threefold adjusted risk of VTE (adjusted hazard ratio, 3.48; 95% CI, 2.03-5.98) compared with matched control participants. Predictors of VTE in patients with COVID-19 included age ≥ 55 years, Black race, prior VTE, diagnosed sepsis, prior moderate or severe liver disease, BMI ≥ 40 kg/m2, and platelet count > 217 k/μL.InterpretationAmong ethnically diverse hospitalized adults, COVID-19 infection increased the risk of VTE, and selected patient characteristics were associated with higher thromboembolic risk in the setting of COVID-19.

Predictors of venous thromboembolism in hospitalized patients with inflammatory bowel disease and colon cancer: A retrospective cohort study

IntroductionVenous thromboembolism (VTE) in patients with inflammatory bowel disease (IBD) and colon cancer (CC) increases morbidity and mortality. Risk of thrombosis in IBD and CC is well established. Still, it remains unclear how interaction of thrombotic properties in patients with both diseases predict development of VTE. Materials and methodsThe Nationwide Inpatient Sample was sourced (2005–2014) for data on patients admitted with IBD-CC who developed VTE. The main outcome was predictors of VTE. Secondary outcomes were length of stay and total charge of admission. Results7625 adults were admitted from 2005 to 2014 with a co-diagnosis of IBD and CC. 197 (2.6%) were coded to have VTE as a top three diagnosis. Multivariate logistic regression showed that black patients (11.9% vs 6.0%; aOR 2.04, 95% CI = 1.26–3.31, P < 0.004) and patients with metastatic disease (27.9% vs 16.7%; aOR 1.77, 95% CI = 1.27–2.47, P = 0.001) had higher odds of having VTE. Patients with uncomplicated diabetes (8.1% vs 15.5%; aOR 0.48, 95% CI = 0.28–0.84, P = 0.010) had lower odds. Obesity and anemia were significantly associated with VTE in univariate logistic regression, but lost significance after multivariate regression. Additionally, VTE was associated with increased length of stay (8.41 vs 6.87 days, P = 0.006) and admission cost ($64,388 vs $50,874, P = 0.010). ConclusionsPatients with IBD and CC likely have unique procoagulant properties that differ from patients with IBD or CC alone. Knowledge of these predictors can assist efforts to risk stratify IBC-CC patients, and can aid development of an individualized approach to DVT prophylaxis in this population.

Venous thromboembolism in patients hospitalized for knee and hip joint replacement surgery

Abstract Background Venous thromboembolism (VTE) is a frequent acute cardiovascular disease, leading to significant morbidity and mortality worldwide. Major trauma, surgery, immobilisation and joint replacements are major provoking factors for VTE. In particular, patients undergoing knee and hip joint replacement surgery are at high risk of developing VTE perioperatively, even in the era of established pharmacological thromboprophylaxis. Without thromboprophylaxis, as many as 20–60% of patients may develop perioperative VTE. Purpose As recent studies indicate an increasing number of total knee and hip replacement surgeries in European countries and the United States, aims of our study were to investigate a) total burden and temporal trends of VTE complications following knee (KJR) and hip joint replacement (HJR) in Germany 2005–2016 and to identify b) predictors of VTE during hospitalization. Methods In an analysis of the nationwide German inpatient sample, we included all hospitalized patients with elective primary KJR and HJR in Germany between 2005 and 2016 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2016, own calculations). We analyzed temporal trends of surgical procedure, mortality, and VTE, and identified predictors of VTE. Results A total of 1,804,496 hospitalized patients underwent KJR (65.1% women, 53.4% aged ≥70 years) and 1,885,839 received HJR (59.1% women, 51.4% ≥70 years). VTE was documented in 23,297 (1.3% of total) KJR patients and in 11,554 HJR patients (0.6%). The number of primary KJR (129,832 in 2005 to 167,881 in 2016 [β-(slope)-estimate 1978 per year; 95% CI 1951 to 2004, P&amp;lt;0.001]) and primary HJR (145,223 in 2005 to 171,421 in 2016 [β-estimate 1818 per year; 95% CI 1083 to 2553, P&amp;lt;0.001]) increased during this twelve-year period. In-hospital VTE decreased from 1.9% to 0.9% (β-estimate −0.77 [95% CI: −0.81 to −0.72], P&amp;lt;0.001) after KJR and from 0.9% to 0.5% (β-estimate −0.71 (95% CI: −0.77 to −0.65), P&amp;lt;0.001) after HJR. In parallel, in-hospital death rate dropped from 0.14% (184 deaths) to 0.09% (146 deaths) (β-estimate −0.44 [95% CI: −0.59 to −0.30], P&amp;lt;0.001) after KJR and from 0.33% to 0.29% (β-estimate −0.11 (95% CI: −0.20 to −0.02), P=0.018) after HJR. Infections during hospitalization were associated with a higher VTE risk. VTE events were associated with in-hospital death in KJR (OR 20.86 [95% CI: 18.78–23.15], P&amp;lt;0.001) and HJR (OR 15.19 [95% CI: 14.19–16.86], P&amp;lt;0.001) independently from age, sex and comorbidities. Conclusions While total numbers of KJR and HJR interventions increased in Germany between 2005 and 2016, the rate of VTE decreased substantially. VTE complications were associated with 15-to 21-fold increase of in-hospital case-fatality rate. Perioperative infections increased the risk for VTE substantially. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503), institutional grant for the Center for Thrombosis and Hemostasis. The authors are responsible for the contents of this publication.

A Stitch in Time Saves Clots: Venous Thromboembolism Chemoprophylaxis in Traumatic Brain Injury

BackgroundVenous thromboembolism chemoprophylaxis (VTE-CHEMO) is often delayed in patients with traumatic brain injury because of the concern for intracranial hemorrhage (ICH) progression. We hypothesize that (1) late time to VTE-CHEMO (≥48 h) is associated with higher incidence of VTE, and (2) VTE-CHEMO use does not correlate with ICH progression. Materials and methodsThis is a multiinstitutional retrospective study of patients with traumatic brain injury admitted between 2014 and 2016. Inclusion criteria were head Abbreviated Injury Code ≥2, ICH present on initial head computed tomography, and two or more head computed tomography scans after admission. The primary outcome was VTE, and the secondary outcome was ICH progression. Patients were classified as receiving VTE-CHEMO early (<48 h) or late (≥48 h). Multivariable analysis with Cox proportional hazards regression was performed. ResultsOverall, 1803 patients were included. Patients with VTE (n = 137) were more likely to have spinal cord injury, blunt cerebrovascular injury, pelvic or femur fractures, and missed VTE-CHEMO doses. After multivariable regression, body mass index >30 (hazard ratio [HR], 1.05; P = 0.002), Injury Severity Score (HR, 1.004; P < 0.001), pelvic or femur fractures (HR, 1.05; P < 0.0001), spinal cord injury (HR, 1.28; P = 0.02), and missed VTE-CHEMO doses (HR, 1.08; P = 0.01) were significant predictors of VTE. In those who required neurosurgery, late VTE-CHEMO predicted VTE (HR, 1.21; P = 0.0001). Overall, 32% patients experienced ICH progression, which did not correlate with VTE-CHEMO use or timing. ConclusionsThis multicenter study highlights benefits from early VTE-CHEMO and identifies high-risk groups who may benefit from more aggressive prophylaxis. These data also emphasize risk to patients by withholding VTE-CHEMO.

Developing a model for predicting venous thromboembolism in obese pregnant women in a national study

IntroductionVenous thromboembolism (VTE) in pregnancy and postpartum is a leading cause of maternal morbidity and mortality in developed countries, where obesity is a known risk for this complication. Current guidelines vary in which patients qualify for VTE prophylaxis, precluding a uniform approach for management. We sought to derive a risk prediction model for VTE in obese pregnant women. Materials and methodsWe performed a retrospective cohort analysis using the Consortium on Safe Labor (CSL) database. Women ages 16–45 who were pregnant with singletons and had an obese body mass index (>30 kg/m2) were included in our study population. Multivariable logistic regression was used in order to identify predictors of venous thromboembolism. ResultsOf the 83,500 women who met inclusion criteria, on average women were 27.8 years old, 38.6 weeks gestation, with body mass index of 35.8, and cesarean delivery incidence of 35.2%. 109 women (0.13%) experienced a VTE event. Independent predictors of VTE in our final multivariable predictive model included: mode of delivery, body mass index, pregestational diabetes, chronic heart disease, preeclampsia, blood transfusion (intrapartum or postpartum), prenatal history of thromboembolic disorder, and postpartum maternal length of stay. A receiver operating characteristic curve was developed to assess the model; area under the curve was 0.826. ConclusionsWe developed a strong predictive model using a large, retrospective database to distinguish risk of VTE in obese pregnant women, which may provide the foundation for future protocol development of obstetrical thromboprophylaxis in obese women.

Venous thromboembolism in patients hospitalized for hip joint replacement surgery

BackgroundVenous thromboembolism (VTE) is a potentially life-threatening disease. Major transient risk factors include trauma, surgery, and immobilization. Patients undergoing hip joint replacement (HJR) are characterized by a high risk of postoperative VTE, but data on the time trends of VTE rates in this population are sparse. MethodsIn an analysis of the German nationwide inpatient sample, we included all hospitalizations for elective primary HJR in Germany from 2005 to 2016. Time trends of the surgical procedure, overall death rates, and VTE rates were analysed, and predictors of VTE identified. ResultsOverall, 1,885,839 inpatients with elective primary HJR (59.1% women, 51.4% ≥70 years) were included in the analysis. During hospitalization, VTE was documented in 11,554 (0.6%) patients. While total numbers of primary HJR increased from 145,223 in 2005 to 171,421 in 2016 (β-(slope)-estimate 1818 [95%CI 1083 to 2553], P < 0.001), in-hospital VTE decreased from 1288 (0.9%) to 843 (0.5%) cases (β-estimate −0.71 [95%CI -0.77 to −0.65], P < 0.001), and in-hospital death rate from 0.33% (476 deaths) to 0.29% (498 deaths) (β-estimate −0.11 [95%CI -0.20 to −0.02], P = 0.018). Infections during hospitalization were associated with higher VTE risk than cancer and cardiovascular events. VTE events were independently associated with an increased death risk (OR 15.19 [95%CI 14.19–16.86], P < 0.001). ConclusionsWhile total numbers of HJR increased significantly in Germany between 2005 and 2016, in-hospital rates of VTE decreased from 0.9% to 0.5%. Patients with perioperative VTE had a 15-fold increase of in-hospital death. Cancer, cardiovascular disease and perioperative infections were associated with higher risk for VTE.

Molecular Subtyping to Predict Risk of Venous Thromboembolism in Patients with Advanced Lung Adenocarcinoma: A Cohort Study

Background Venous thromboembolism (VTE) is a common complication in cancer care and can be predicted based on validated risk assessment tools. Innovative new therapeutics in non-small cell lung cancer (NSCLC) have changed practice patterns and mortality, and new predictors of VTE are therefore needed to better identify high risk patients in this setting. The incidence of VTE according to specific molecular subtypes of NSCLC has not been fully evaluated. The aim of this study was to evaluate rates of VTE in lung adenocarcinoma in relation to their molecular subtype and the association of VTE with survival. Methods We conducted a retrospective cohort study at Cleveland Clinic Taussig Cancer Institute, approved by the institutional review board. We identified advanced lung adenocarcinoma patients from 7/2002 through 07/2017 for whom molecular classification was available and treatment/follow-up was at the Cleveland Clinic. VTE diagnoses including deep-vein thrombosis (DVT) and pulmonary embolism (PE) were identified by electronic medical record review. Patients were classified according to their molecular subtype: wild-type, ALK-mutant or EFGR-mutant. VTE-free survival and overall survival (OS) rates for these categories were estimated by the Kaplan-Meier method and evaluated for association with VTE using Cox proportional hazard regression in each cohort. VTE was analyzed as a conditional, time-dependent covariate with respect to OS. Results The study population included 461 patients, 43.0% male, with a median age at diagnosis of 67 (range, 27-90) years. Of these, 157 (34.1%) were never-smokers. According to molecular subtypes, 165 patients were EGFR-mutant (35.8%), 46 (10.0%) ALK-mutant and 250 (54.2%) were wild-type. All patients had adenocarcinoma and 158 of 211 (74.9%) received a specific tyrosine kinase inhibitor according to their driver mutation. VTE occurred in 98/461 (21.3%) during a follow up of 33.1 months. Highest rates of VTE were observed in patients with ALK-mutant cancers (43.5%, N=20/46) followed by patients with EGFR-mutant cancers (21.2% N=35/165) and wild-type cancers (17.2%, N=43/250) (P &amp;lt; 0.05) (Figure 1). Cumulative rates of VTE at one year of follow-up were 20.7 % for ALK-mutant cancers, 11.1% for EGFR-mutant cancers, and 10.7% for wild-type cancers. The most common VTE event was DVT (49.0%, N=48/98) followed by PE (45.9%, N=45)). Overall survival was significantly worse in patients who experienced VTE in each molecular subgroup: ALK-mutant [HR 2.44 95% CI 1.03 - 5.79, p = 0.043], EGFR-mutant [HR 2.27 95% CI 1.43 - 3.59 p = 0.0005] and wild-type [HR 3.84 95% CI 2.67 - 5.52 p &amp;lt; 0.0001]) Conclusions VTE complicates more than one fifth of advanced lung adenocarcinoma patients. Nearly half of VTE events are PE. VTE is associated with worse survival across molecular subtypes. Patients with ALK-mutant advanced lung adenocarcinomas have the highest rates of VTE, exceeding those observed in patients with pancreas cancers and myeloma. These findings should be taken into consideration in decision-making regarding thromboprophylaxis. Figure 1 Disclosures Velcheti: Foundation Medicine: Consultancy; AstraZeneca: Consultancy; Novartis: Consultancy; Genentech: Consultancy; BMS: Consultancy; Reddy Labs: Consultancy; Alkermes: Consultancy; Boston Scientific: Consultancy; Merck: Consultancy. McCrae:Dova Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Pfizer Pharmaceutical: Membership on an entity's Board of Directors or advisory committees; Rigel Pharmaceutical: Membership on an entity's Board of Directors or advisory committees; Sanofi Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Khorana:Janssen: Consultancy; Bayer: Consultancy; Pfizer: Consultancy; Sanofi: Consultancy.

Prevalence of venous thromboembolism in admissions and readmissions with and without syncope: a nationwide cohort study.

The Pulmonary Embolism in Syncope Italian Trial reported 17.3% prevalence of pulmonary embolism (PE) in patients admitted with syncope. We investigated the prevalence of venous thromboembolism [VTE, including PE and deep vein thrombosis (DVT)] in syncope vs. non-syncope admissions and readmissions, and if syncope is an independent predictor of VTE. We conducted an observational study of index admissions of the 2013-14 Nationwide Readmission Database. We excluded patients <18 years, December discharges, died during hospitalization, hospital transfers, and missing length of stay. Encounters were stratified by the presence or absence of DVT/PE and syncope diagnoses. Multivariable logistic regression analysis was used to evaluate the association between syncope and VTE. There were 38 655 570 admissions, of whom 285 511 had syncope. In the overall cohort, syncope occurred in 1.6% of VTE and 1.8% in non-VTE admissions. In a multivariable model, syncope was associated with a lower prevalence of VTE [odds ratio (OR) 0.76, 95% confidence interval (CI) 0.75-0.78; P < 0.001]. In index syncope vs. non-syncope admissions, the prevalence of DVT, PE, and VTE were 0.4 ± 0.06% vs. 1.3 ± 0.12%, 0.2 ± 0.04% vs. 1.2 ± 0.11%, and 0.5 ± 0.07% vs. 2.1 ± 0.14% (all P < 0.001), respectively. At 30 days, the prevalence of DVT, PE, and VTE in syncope vs. non-syncope were 2.2 ± 0.14% vs. 2.1 ± 0.14% (P = 0.38), 1.4 ± 0.12% vs. 1.2 ± 0.11% (P = 0.01), and 2.6 ± 0.17% vs. 3.0 ± 0.17% (P = 0.99), respectively. Syncope admissions were associated with a lower prevalence of VTE as compared to non-syncope admissions. Syncope should not trigger an automatic PE workup, rather, should be put into context of patient presentation.

P14.25 Venous thromboembolic events in patients with brain metastases: the PICOS score

Abstract BACKGROUND Venous thromboembolic events are significant complications in patients and possibly associated with an unfavorable outcome. Thrombosis risk is poorly defined for patients with brain metastasis, and available risk calculation scores are not validated for these patients. MATERIAL AND METHODS We identified 811 patients with brain metastasis followed at our institution and screened electronic charts retrospectively for the occurrence of venous thromboembolic events, along with candidate risk factors. Risk factors were tested in uni- and multivariate analyses and finally integrated in a score model for risk prediction. RESULTS Venous thromboembolic events were documented in 97 of 811 patients (12.0%). Primary tumors with high thrombogenicity (p=0.02, odds ratio 1.7, 95% CI 1.1–2.8), dexamethasone (p=0.011, odds ratio 2.27, 95% CI 1.5–4.5), chemotherapy (p=0.005, odds ratio 3.4, 95% CI 1.6–7.5), BMI &gt; 35 kg/m2 (p=0.002, odds ratio 3.4, 95% CI 1.6–7.5) and immobilization (p=0.003, odds ratio 2.4, 95% CI 1.3–4.3) were confirmed as independent predictors of VTE. We derived a score model for venous thromboembolic event prediction, the PICOS (thrombogenic Primary, Immobilization, Chemotherapy, Obesity, Steroids) score (0–7 points). Receiver Operating Characteristic Curve Analysis demonstrated its prognostic accuracy (AUC=0.71, 95% CI 0.64–0.77), and its predictive capability was superior to that of other scores proposed for the evaluation of venous thromboembolic event risk such as the Khorana (AUC=0.51) or CONKO (AUC=0.52) scores. CONCLUSION We report a rate of venous thrombotic events of 12.0% in our cohort of 811 patients with brain metastasis. We define a risk model for prediction in of venous thrombotic events in patients with BM, the PICOS score. It may become a valuable tool for the identification of brain metastasis patients at high risk for venous thromboembolic events and be helpful for guidance of clinicians towards decision whether to start thrombosis prophylaxis. Further, the PICOS score might be used for stratification in controlled studies.

MLTI-19. VENOUS THROMBOEMBOLIC EVENTS IN PATIENTS WITH BRAIN METASTASES: THE PICOS SCORE

BACKGROUND: Venous thromboembolic events are significant complications in patients and possibly associated with an unfavorable outcome. Thrombosis risk is poorly defined for patients with brain metastasis, and available risk calculation scores are not validated for these patients. METHODS: We identified 811 patients with brain metastasis followed at our institution and screened electronic charts retrospectively for the occurrence of venous thromboembolic events, along with candidate risk factors. Risk factors were tested in uni- and multivariate analyses and finally integrated in a score model for risk prediction. RESULTS: Venous thromboembolic events were documented in 97 of 811 patients (12.0%). Primary tumors with high thrombogenicity (p=0.02, odds ratio 1.7, 95% CI 1.1–2.8), dexamethasone (p=0.011, odds ratio 2.27, 95% CI 1.5–4.5), chemotherapy (p=0.005, odds ratio 3.4, 95% CI 1.6–7.5), BMI > 35 kg/m2 (p=0.002, odds ratio 3.4, 95% CI 1.6–7.5) and immobilization (p=0.003, odds ratio 2.4, 95% CI 1.3–4.3) were confirmed as independent predictors of VTE. We derived a score model for venous thromboembolic event prediction, the PICOS (thrombogenic Primary, Immobilization, Chemotherapy, Obesity, Steroids) score (0–7 points). Receiver Operating Characteristic Curve Analysis demonstrated its prognostic accuracy (AUC=0.71, 95% CI 0.64–0.77), and its predictive capability was superior to that of other scores proposed for the evaluation of venous thromboembolic event risk such as the Khorana (AUC=0.51) or CONKO (AUC=0.52) scores. CONCLUSIONS: We report a rate of venous thrombotic events of 12.0% in our cohort of 811 patients with brain metastasis. We define a risk model for prediction in of venous thrombotic events in patients with BM, the PICOS score. It may become a valuable tool for the identification of brain metastasis patients at high risk for venous thromboembolic events and be helpful for guidance of clinicians towards decision whether to start thrombosis prophylaxis. Further, the PICOS score might be used for stratification in controlled studies.