Risk Of Recurrent VTE Research Articles

Pulmonary embolism: outpatient treatment and follow-up

Despite declining numbers - older people in particular - often die from pulmonary embolism. A rapid assessment of the risk in the event of a suspected embolism, the exclusion of comorbidities and the appropriate therapy are the focus of the current guidelines. Early and subsequent outpatient treatment of a patient with acute PE generally requires 3 criteria: low risk of early complications, the absence of serious comorbidities and the highest possible safety at home and, in the event of a complication, rapid access to acute care in the hospital. For patients with a high risk of VTE recurrence, the long-term dosage of secondary drug prophylaxis is not yet clear - studies are currently underway. In patients at moderate risk of VTE recurrence, low-dose secondary prophylaxis can be used to reduce the risk of bleeding. Outpatient pulmonary embolism follow-up care is becoming increasingly important, because studies have shown several times that serious long-term consequences can occur. In pulmonary embolism patients with persistent dyspnea, reduced performance or risk of CTEPH, an outpatient evaluation of the right ventricle using echocardiography, if necessary, in combination with the determination of natriuretic peptides or spiroergometry, is recommended.

Venous and Arterial Thromboembolism in Lung Cancer Patients: A Retrospective Analysis.

Background: Patients with lung cancer face an increased incidence of venous (VTE) and arterial (ATE) thromboembolism. Risk factors for thrombosis remain unclear, particularly the impact of the use of immune checkpoint inhibitors (ICIs). We sought to compare the incidence of VTE and ATE in lung cancer patients receiving platinum-based therapy versus those receiving ICIs alone or in combination with chemotherapy and to validate the Khorana risk score for predicting VTE in the era of ICIs. Methods: A retrospective single-institution data analysis of 173 patients diagnosed with locally advanced or metastatic lung cancer at the Jena University hospital between 2015 and 2021. Results: The study revealed a high incidence of VTE (17.9%) and ATE (5.8%). The VTE risk was higher in patients diagnosed with adenocarcinoma (OR 0.29, 95% CI 0.09-0.93) than in patients with other histological types. A prior venous event was associated with an increased risk of recurrent VTE (OR 4.46, 95% CI 1.20-16.63). The incidence of thrombosis under first-line platinum-based chemotherapy did not differ from the incidence under ICIs (p = 0.19). There were no differences in the subgroup of patients who received ICIs alone or combined immunochemotherapy (p = 0.43). The Khorana score failed to predict the risk of VTE correctly. Conclusions: We did not find evidence supporting the theory that ICI therapy (alone or combined) increases the risk of thrombotic events. Adenocarcinoma and a prior history of VTE were strongly associated with an increased risk of VTE. Other scores for thrombotic risk assessment in lung cancer patients should be tested in prospective studies.

Cancer complicated by thrombosis and thrombocytopenia: still a therapeutic dilemma

Individuals who have thrombocytopenia and cancer-associated thrombosis (CAT) are difficult to manage because they have a high risk of bleeding and recurrent thrombosis. The International Society on Thrombosis and Haemostasis guidelines for the management of thrombocytopenia in patients with CAT suggest two main approaches: either complete anticoagulation with transfusion support if necessary, or dose-modified anticoagulation while the platelet count is <50×109/L. Nevertheless, rather than being based on information from randomized controlled trials (RCTs), these recommendations were based on expert consensus. Recent research from two different countries has shown how this cohort’s management and results vary widely. While the United Kingdom study, Cancer-Associated Venous Thrombosis and Thrombocytopenia, found no significant differences in bleeding or recurrent thrombosis between full dose and modified dose groups, the North American Thrombocytopenia Related Outcomes with Venous thromboembolism study demonstrated a significantly lower risk of bleeding events in those receiving modified dose anticoagulation compared to full dose, without an increased risk of recurrent VTE. Therefore, an RCT is required to assess the best course of action for patients with CAT and thrombocytopenia. To define the standard of care for the management of patients with CAT and thrombocytopenia, a full-scale trial called the START randomized trial (STrategies for Anticoagulation in patients with thRombocytopenia and cancer-associated Thrombosis) is an international, multi-site pilot study that compares the use of platelet transfusions plus higher dose anticoagulation to modified dose anticoagulation in patients with thrombocytopenia and CAT receiving anticoagulation.

Antipsychotic-related risk of recurrent VTE

Antipsychotic-related risk of recurrent VTE

Comparative effectiveness and safety of apixaban and low-molecular weight heparin among patients with venous thromboembolism and active cancer in an extended treatment setting

Abstract Background The 2020 European Society of Cardiology guidelines recommend extended anticoagulant (AC) treatment among patients with VTE and with progressive or persistent risk factors (such as cancer) as they are at a high risk of a recurrent VTE episode. Purpose The study evaluated the risk of recurrent VTE and major bleeding (MB) among patients with VTE and active cancer prescribed apixaban or LMWH (reference) for ≥3 months. Methods This retrospective study included patients ≥18 years with VTE who initiated apixaban or LMWH within 30 days following the first VTE event using a large administrative claims database, representing ≥140 million patients enrolled in US health plans. Data from July 1, 2016, through April 30, 2022, was used. Patients were required to have ≥3 months of continuous enrollment (CE) and ≥3 months of continuous primary AC treatment following the date of apixaban/LMWH initiation. The end of 3 months of primary treatment was designated as index date. The follow-up period was from the day after the index date until the earliest of disenrollment, discontinuation of index anticoagulant, switch to another anticoagulant, or the end of the study period. The MB and recurrent VTE outcomes were evaluated and compared in the follow-up period. Inverse-probability treatment weighting (IPTW) was used to balance the treatment cohorts on relevant demographic and clinical characteristics including VTE and cancer-related variables. Incidence rate for the outcomes were calculated per 100 person-years. Cox proportional hazard models were used to evaluate the adjusted risk of recurrent VTE and MB reported as hazard ratios (HR) along with 95% confidence interval (CI). Results After the eligibility criteria was met, the study included 13,527 apixaban and 2,914 LMWH treated patients with VTE and active cancer. Post IPTW, the treatment cohorts were balanced on baseline patient characteristics (Figure 1). In the follow-up period, the incidence rates (IR) per 100 person-years for recurrent VTE and MB were lower for apixaban than LMWH among patients with VTE and active cancer (Figure 2). Apixaban patients had a lower risk of recurrent VTE (HR: 0.42; 95% CI: 0.34–0.53) and MB (HR: 0.50; 95% CI: 0.41–0.61) when compared to LMWH (Figure 2). Conclusion In this observational cohort analysis of patients with VTE and active cancer, extended anticoagulation treatment of ≥3 months with apixaban was associated with a lower risk of recurrent VTE and MB compared with LMWH. Additional research is required to confirm these findings.Figure 1Figure 2

Abstract 18463: Direct Oral Anticoagulants versus Vitamin K Antagonists in Morbidly Obese Patients (BMI ≥ 40): An Updated Systematic Review and Meta-Analysis

Introduction: The safety and efficacy of direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) remain unknown in patients with BMI ≥ 40 kg/m 2 . We aim to evaluate the risk of recurrent VTE and major bleeding in patients with a BMI ≥ 40 when started on DOACs versus VKAs. Methods: We conducted a systematic literature search according to PRISMA guidelines to identify studies using the terms: “venous thromboembolism”, “Vitamin K antagonists” and “direct oral anticoagulants”. After the screening, We extracted the data till May 2023 in a data extraction sheet. Our inclusion criteria were: adult patients, morbidly obese (BMI ≥ 40 kg/m 2 ), who were on DOACs or VKAs for VTE or atrial fibrillation. We used a variance-weighted random-effects model to analyze data on DOACs vs. VKAs, estimating event rates and odds ratios while assessing heterogeneity. Data were analyzed using the ‘meta’ package in R. Results: Our analysis included a total of 16 studies (n= 62704 patients). Obese patients on DOACs had a significant reduction in the risk of recurrent VTEs compared to VKAs OR 0.72 (95% CI: 0.59 - 0.88, I2 :19%). Also, DOACs were associated with a lower risk of major bleeding compared to VKAs in morbidly obese patients (OR = 0.65, 95% CI: 0.58 - 0.74, I2 :0%). For non-major bleeding, although the statistical significance was not reached, a consistent trend favoring DOACs was observed (OR = 0.76, 95% CI: 0.47-1.21). (Figure1) Conclusions: Among morbidly obese patients (BMI ≥ 40), DOACs are associated with a significantly lower risk of recurrent VTEs, and major bleeding compared to VKA. For non-major bleeding, there was a trend favoring DOACs over VKA. Increased recruitment of obese patients in clinical trials is needed to provide us with robust data for informed clinical decision-making.

Anticoagulant prophylaxis in pregnant women with a history of venous thromboembolism: A systematic review and meta-analysis

BackgroundVenous thromboembolism (VTE) remains one of the leading causes of morbidity and mortality during pregnancy and the postpartum period. Despite that, the prevention and management of VTEs in pregnant patients is an area of great debate. ObjectivesThe aim of this systematic review was to evaluate the risk of VTE recurrence during pregnancy for pregnant patients with prior personal history of VTE and the effect of LMWH on such risk. MethodsMEDLINE and EMBASE were searched between January 2000 to December 2022. We included studies that evaluated pregnant patients with previous personal history of VTE and assessed VTE recurrence with or without thromboprophylaxis. A meta-analysis of proportions was done through a Freeman–Tukey transformation using random effect models. Results30 studies were included in this systematic review. The studies included 5075 pregnant patients with a previous history of DVT or PE. We found a wide variability in thromboprophylaxis strategies. The estimated pooled proportions of VTE recurrence were 2.5% (95% CI 1.8–3.3) in patients who were consistently on anticoagulation during pregnancy (pre- and post-partum), 4.7% (95% CI 1.8–8.8) in patients who received anticoagulation in the postpartum period only, and 13.6% (95% CI 6.5 to 22.8) in patients who were not on anticoagulation. ConclusionsIn patients with a previous VTE history receiving prophylactic anticoagulation (either both pre- and post-partum or post-partum only), the estimates of VTE recurrence were lower than for patients who did not receive prophylaxis, however, a direct comparison was not possible. The optimal thromboprophylaxis strategy remains unknown.

Assessment of bleeding risk in cancer patients treated with anticoagulants for venous thromboembolic events.

Anticoagulant is the cornerstone of the management of VTE at the cost of a non-negligible risk of bleeding. Reliable and validated clinical tools to predict thromboembolic and hemorrhagic events are crucial for individualized decision-making for the type and duration of anticoagulant treatment. We evaluate the available risk models in real life cancer patients with VTE. The objectives of the study were to describe the bleeding of cancer patients with VTE and to evaluate the performance of the different bleeding models to predict the risk of bleeding during a 6-month follow-up. VTE-diagnosed patient's demographic and clinical characteristics, treatment regimens and outcomes for up to 6 months were collected. The primary endpoint was the occurrence of a major bleeding (MB) or a clinically relevant non major bleeding (CRNMB) event, categorized according to the ISTH criteria. During the 6-months follow-up period, 26 out of 110 included patients (26.7%) experienced a bleeding event, with 3 recurrences of bleeding. Out of the 29 bleeding events, 19 events were CRNMB and 10 MB. One patient died because of a MB. Bleeding occurred in 27 % of the patients treated with DOACs and 22% of the patients treated with LMWH. Most of the bleedings were gastrointestinal (9 events, 31%); 26.9% of the bleedings occurred in patient with colorectal cancer and 19.6% in patients with lung cancer. In our cohort, none of the 10 RAMs used in our study were able to distinguish cancer patients with a low risk of bleeding, from all bleeding or non-bleeding patients. The Nieto et al. RAM had the best overall performance (C-statistic = 0.730, 95% CI (0.619-0.840)). However, it classified 1 out of 5 patients with major bleeding in the low risk of bleeding group. The rest of the RAMs showed a suboptimal result, with a range of C-statistic between 0.489, 95%CI (0.360-0.617)) and 0.532, 95%CI (0.406-0.658)). The management of CAT patients is challenging due to a higher risk of both recurrent VTE and bleeding events, as compared with non-cancer patients with VTE. None of the existing RAMs was able to consistently identify patients with risk of anticoagulant associated bleeding events.

Incidence of bleeding and recurrence in isolated distal deep vein thrombosis: findings from the Venous Thrombosis Registry in Østfold Hospital

BackgroundIsolated distal deep vein thrombosis (IDDVT) is a common presentation of deep vein thrombosis. There are limited data on the long-term risk of recurrence after IDDVT. ObjectivesWe aimed to determine the short- and long-term incidence of venous thrombosis (VTE) recurrence after cessation of anticoagulation and the 3-month incidence of bleeding during anticoagulant treatment in patients with IDDVT. MethodsBetween January 2005 and May 2020, 475 patients with IDDVT and without active cancer were identified from the Venous Thrombosis Registry in Østfold Hospital, which is an ongoing registry of consecutive patients with VTE at Østfold Hospital, Norway. Major and clinically relevant, nonmajor bleeding as well as recurrent VTE were registered, and the cumulative incidences of these events were assessed. ResultsThe median age of the patients was 59 years (IQR, 48-72 years), 243 (51%) patients were women, and 175 events (36.8%) were classified as unprovoked. The 1-, 5-, and 10-year cumulative incidences of recurrent VTE were 5.6% (95% CI, 3.7-8.4), 14.7% (95% CI, 11.1-19.4), and 27.2% (95% CI, 21.1-34.5), respectively. The recurrence rates were higher for unprovoked IDDVT than for provoked IDDVT. Among the recurrent events, 18 (29%) were pulmonary embolisms and 21 (33%) were proximal deep vein thromboses. The 3-month cumulative incidence of major bleeding was 1.5% (95% CI, 0.7-3.1) overall and 0.8% (95% CI, 0.2-3.1) when restricted to patients treated with direct oral anticoagulants. ConclusionDespite initial treatment, the long-term risk of VTE recurrence after first-time IDDVT is high. The bleeding rates during anticoagulation, particularly with direct oral anticoagulants, were acceptably low.

Clinical profile and outcome of isolated pulmonary embolism: a systematic review and meta-analysis.

Isolated pulmonary embolism (PE) appears to be associated with a specific clinical profile and sequelae compared to deep vein thrombosis (DVT)-associated PE. The objective of this study was to identify clinical characteristics that discriminate both phenotypes, and to characterize their differences in clinical outcome. We performed a systematic review and meta-analysis of studies comparing PE phenotypes. A systematic search of the electronic databases PubMed and CENTRAL was conducted, from inception until January 27, 2023. Exclusion criteria were irrelevant content, inability to retrieve the article, language other than English or German, the article comprising a review or case study/series, and inappropriate study design. Data on risk factors, clinical characteristics and clinical endpoints were pooled using random-effects meta-analyses. Fifty studies with 435,768PE patients were included. In low risk of bias studies, 30% [95% CI 19-42%, I 2=97%] of PE were isolated. The Factor V Leiden [OR: 0.47, 95% CI 0.37-0.58, I 2=0%] and prothrombin G20210A mutations [OR: 0.55, 95% CI 0.41-0.75, I 2=0%] were significantly less prevalent among patients with isolated PE. Female sex [OR: 1.30, 95% CI 1.17-1.45, I 2=79%], recent invasive surgery [OR: 1.31, 95% CI 1.23-1.41, I 2=65%], a history of myocardial infarction [OR: 2.07, 95% CI 1.85-2.32, I 2=0%], left-sided heart failure [OR: 1.70, 95% CI 1.37-2.10, I 2=76%], peripheral artery disease [OR: 1.36, 95% CI 1.31-1.42, I 2=0%] and diabetes mellitus [OR: 1.23, 95% CI 1.21-1.25, I 2=0%] were significantly more frequently represented among isolated PE patients. In a synthesis of clinical outcome data, the risk of recurrent VTE in isolated PE was half that of DVT-associated PE [RR: 0.55, 95% CI 0.44-0.69, I 2=0%], while the risk of arterial thrombosis was nearly 3-fold higher [RR: 2.93, 95% CI 1.43-6.02, I 2=0%]. Our findings suggest that isolated PE appears to be a specific entity that may signal a long-term risk of arterial thrombosis. Randomised controlled trials are necessary to establish whether alternative treatment regimens are beneficial for this patient subgroup. None.

Intermediate-Dose Versus Low-Dose Low-Molecular-Weight Heparin in Pregnant and Post-Partum Women with a History of Venous Thromboembolism (Highlow Study): An Open-Label, Multicentre, Randomised, Controlled Trial

ABSTRACT Venous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and mortality, but its prevention, medical thromboprophylaxis, can cause bleeding complications. Without thromboprophylaxis, up to 10% of women with a history of VTE are at risk of pregnancy-related recurrence. For those women with a history of VTE who are not on long-term anticoagulation medication, guidelines recommend subcutaneous low-molecular-weight heparin (LMWH) in all women in the postpartum stage. For those with moderate or high risk of recurrent VTE, antepartum thromboprophylaxis is recommended. In both cases, the optimal dose of heparin is unknown, and professional societies do not provide clear specific guidance often recommending multiple different dosing approaches without clear evidence to guide recommendations. The aim of this study was to assess the efficacy and safety of low- versus intermediate-dose LMWH in pregnant women with a history of VTE. This was an open-label, randomized controlled study conducted at 70 hospitals in the Netherlands, France, Belgium, Norway, Demark, Canada, the United States, and Russia. Included were adult pregnant women with a history of objectively confirmed VTE, either unprovoked or provoked by hormonal or minor risk factors, and a gestational age ≤14 weeks. Excluded were women with previous VTE related to a major risk factor, indication for therapeutic-dose anticoagulants, or contraindication to LMWH. Eligible women were randomly assigned to receive either weight-adjusted intermediate-dose heparin or fixed, low-dose heparin. Participants self-administered their allocated dose of heparin once daily and participated in in-person or telephone contacts 2 weeks after randomization; at 20 and 30 weeks of gestation; and 1 week, 6 weeks, and 3 months postpartum. The primary efficacy outcome was symptomatic VTE, and the primary safety outcome was major bleeding. A total of 1110 women were included in the analysis—555 were randomized to the intermediate-dose group and 555 to the low-dose group. Approximately 81% of women had a history of VTE related to hormone use, pregnancy, or the postpartum period. From randomization to 6 weeks postpartum, VTE occurred in 2% of women in the intermediate-dose group and 3% in the low-dose group (relative risk, 0.69; 95% confidence interval, 0.32–1.47; P = 0.33). Antepartum VTE occurred in 1% of women in each treatment group; postpartum VTE occurred in 1% in the intermediate-dose group and 2% in the low-dose group. These findings remained consistent up to 3 months postpartum. From randomization to 6 weeks postpartum, major bleeding occurred in 4% of women in the intermediate-dose group and 4% in the low-dose group (relative risk, 1.16; 95% confidence interval, 0.65–2.09; p = 0.63). Antepartum major bleeding occurred in <1% of women in each treatment group. Early postpartum bleeding occurred in 4% in the intermediate-dose group and 3% in the low-dose group. Last postpartum bleeding occurred in <1% in the intermediate-dose group and none in the low-dose group. In comparing weight-adjusted, intermediate-dose LMWH with fixed, low-dose LMWH, the risk of VTE was similar in pregnant women with a history of VTE in the antepartum and postpartum periods. Moreover, no differences were observed in the occurrence of major bleeding between the 2 treatment groups. These findings provide evidence-based guidance that low-dose heparin is appropriate for preventing pregnancy-related recurrent VTE.

Low D-dimer levels at diagnosis of venous thromboembolism are associated with reduced risk of recurrence: data from the TROLL registry

BackgroundVenous thromboembolism (VTE) is a frequent disease with a high risk of recurrence. It has been suggested that the D-dimer level at the time of VTE diagnosis can be used to identify patients at a low risk of recurrence. ObjectivesWe aimed to investigate the impact of D-dimer levels measured at the time of VTE diagnosis on the risk of recurrence in a large cohort of patients with a first-time VTE. MethodsThe study included 2585 patients with first symptomatic non-cancer–associated VTE from the Venous Thrombosis Registry in Østfold Hospital (TROLL) (2005-2020). All recurrent events during the follow-up were recorded, and cumulative incidences of recurrence were estimated according to D-dimer levels of ≤1900 ng/mL (≤25th percentile) and >1900 ng/mL. ResultsDuring a median follow-up of 3.3 years, 395 patients experienced a recurrent VTE. The 1- and 5-year cumulative incidences of recurrence were 2.9% (95% CI: 1.8-4.6) and 11.4% (95% CI: 8.7-14.8), respectively, in those with a D-dimer concentration of ≤1900 ng/mL and 5.0% (95% CI, 4.0-6.1) and 18.3% (95% CI: 16.2-20.6), respectively, in those with a D-dimer concentration of >1900 ng/mL, respectively. In patients with unprovoked VTE, the 5-year cumulative incidence was 14.3% (95% CI: 10.3-19.7) in the ≤1900-ng/mL category, and 20.2% (95% CI: 17.3-23.5) in the >1900-ng/mL category. ConclusionsD-dimer levels within the lowest quartile, measured at the time of VTE diagnosis, were associated with lower recurrence risk. Our findings imply that D-dimer levels measured at the time of diagnosis may be used to identify patients with VTE at a low risk of recurrent VTE.

Outcome of antithrombotic therapy in cancer patients with catheter-related thrombosis: a systematic review.

The guidelines' recommendations for anticoagulation in cancer patients with catheter-related thrombosis are unclear. The aim of this systematic review was to assess anticoagulation management in cancer patients with catheter-related thrombosis (CRT) based on previously published studies. As of June 10, 2023,we searched databases including PubMed, Embase, and Cochrane and included 11 observational studies that met the criteria. We evaluated 770 adults with active cancer and objectively confirmed patients with CRT who were using drugs including warfarin, LMWH, and new oral anticoagulants as antithrombotic therapy. We extracted outcome data, including thrombosis recurrence, catheter dysfunction, major bleeding, and death, and performed a meta-analysis. In this study we found that the risk of VTE recurrence was higher with rivaroxaban, the risk of bleeding and death appeared to be greater with warfarin, and although the risk of catheter dysfunction due to LMWH is a concern, it is still a more reasonable option for cancer patients with catheter-related thrombosis. http://www.clinicaltrials.gov, identifier (CRD42022367979).

Pediatric Splanchnic Vein Thrombosis: Systematic Review and Meta-Analysis

Background: The clinical characteristics of splanchnic vein thrombosis (SVT) in pediatric patients and its optimal treatment strategies are unknown. Aim: We aimed to study the risk factors for pediatric SVT and the efficacy and safety of anticoagulant therapy. Methods: MEDLINE and EMBASE were searched up to December 2021. We only included studies which reported SVT treatment and outcomes, including rates of SVT re-canalization, progression or recurrence, as well as rates of bleeding and mortality. SVT anticoagulation responsewas pooled using inverse variance and generalized linear mixed and random-effects models. Results: A total of 508 patients were included across 17 studies. Of pediatric SVT cases, 308 presented with portal vein thrombosis, 175 with Budd-Chiari syndrome, 3 with splenic vein thrombosis, 2 with mesenteric vein thrombosis, and 20 with thromboses involving multiple sites. Anticoagulant therapy was prescribed in 187 patients; However, outcome was reported only in 153 of these patients. Of 321 patients who did not receive anticoagulation, outcome was reported in 139. The pooled proportion of response to anticoagulant therapy (assessed by any recanalization) was 55.9% (95% confidence interval (CI): 39%-71%, I2 = 56%) (Figure 1). In patients who did not receive anticoagulation, recanalization rate was 43.7% (95% confidence interval (CI): 13%-80%, I2 = 81%) (Figure 2). Major bleeding was reported in 3.7% (7/187) of patients who received anticoagulant therapy and 0.6 % (2/321) in patients who did not receive anticoagulant therapy, and non-major bleeding was reported in 4.8% (9/187) and 14.3% (46/321) respectively. Mortality was reported in 10.4% (53/508) of pediatric SVT patients (42 were treated with anticoagulation and 11 did not). VTE recurrence was rare, and reported in 0.8% of SVT patients (4/508) all of whom received anticoagulant therapy. Conclusions: In pediatric patients with SVT, anticoagulant therapy appears to be associated with high recanalization rates and low risk of thrombus progression and bleeding. The incidence of VTE recurrence remains low and comparable to the risk of VTE recurrence in pediatric patients with other types of VTE. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Antiplatelet agents for the treatment of deep venous thrombosis.

Antiplatelet agents for the treatment of deep venous thrombosis.

Racial differences in venous thromboembolism: A surveillance program in Durham County, North Carolina

BackgroundVenous thromboembolism (VTE) affects approximately 1–2 individuals per 1000 annually and is associated with an increased risk for pulmonary hypertension, postthrombotic syndrome, and recurrent VTE. ObjectiveTo determine risk factors, incidence, treatments, and outcomes of VTE through a 2‐year surveillance program initiated in Durham County, North Carolina (population approximately 280,000 at time of study). Patients/MethodsWe performed a retrospective analysis of data actively collected from three hospitals in Durham County during the surveillance period. ResultsA total of 987 patients were diagnosed with VTE, for an annual rate of 1.76 per 1000 individuals. Hospital‐associated VTE occurred in 167 hospitalized patients (16.9%) and 271 outpatients who were hospitalized within 90 days of diagnosis (27.5%). Annual incidence was 1.98 per 1000 Black individuals compared to 1.25 per 1000 White individuals (p < 0.0001), and Black individuals with VTE were younger than White individuals (p < 0.0001). Common risk factors included active cancer, prolonged immobility, and obesity, and approximately half were still taking anticoagulant therapy 1 year later. A total of 224 patients died by 1 year (28.5% of patients for whom outcomes could be confirmed), and Black patients were more likely to have recurrent VTE than White patients during the first 6 months following initial presentation (9.4% vs. 4.1%, p = 0.01). ConclusionsOngoing surveillance provides an effective strategy to identify patients with VTE and monitor treatment and outcomes. We demonstrated that hospital‐associated VTE continues to be a major contributor to the burden of VTE and confirmed the higher incidence of VTE in Black compared to White individuals.

No VTE Recurrence After 1-Year Follow-Up of Hospitalized Patients With COVID-19 and a VTE Event: A Prospective Study

No VTE Recurrence After 1-Year Follow-Up of Hospitalized Patients With COVID-19 and a VTE Event: A Prospective Study

Rosuvastatin treatment decreases plasma procoagulant phospholipid activity after a VTE: A randomized controlled trial

BackgroundVenous thromboembolism (VTE) is a frequent cardiovascular disease with severe complications, including recurrence and death. There is a great need for alternative prophylactic treatment options as anticoagulation is accompanied by increased bleeding risk. Statins are reported to reduce the risk of incident and recurrent VTE, but the mechanisms are elusive. Procoagulant phospholipids (PPL), and phosphatidylserine in particular, are crucial for efficient coagulation activation, but no studies have investigated the effect of statin treatment on plasma PPL activity. ObjectivesTo investigate the impact of rosuvastatin treatment on plasma PPL activity and levels of extracellular vesicles (EVs). Patients/MethodsPatients with a history of VTE (≥18 years) allowed to stop anticoagulant treatment were randomized to either 20 mg/day of rosuvastatin treatment or no treatment for 28 days in the Statins Reduce Thrombophilia (NCT01613794) trial. Plasma samples were collected at baseline and study end. PPL activity was measured in samples from 245 participants using a factor Xa‐dependent clotting assay and EV levels by flow cytometry. ResultsRosuvastatin treatment yielded an overall 22% (95% confidence interval [CI] −38.2 to −5.8) reduction in PPL activity, and 37% (95% CI −62.9 to −11.2) reduction in PPL activity in participants with a history of pulmonary embolism. The effect of rosuvastatin on plasma PPL activity was not explained by changes in total cholesterol nor change in levels of total‐ or platelet‐derived EVs. ConclusionsRosuvastatin treatment caused a substantial decrease in plasma PPL activity, suggesting that a PPL‐dependent attenuation of coagulation activation may contribute to a reduced VTE risk following statin treatment.

Validation of a predictive model for identifying an increased risk for recurrence in adolescents and young adults with a first provoked thromboembolism

BackgroundTo develop and validate a predictive model to determinate patients at increased risk to suffer from recurrence following a first provoked deep vein thrombosis (VTE).Methods: Predictive variables, i.e. male sex [1 point], inherited thrombophilia (IT) status (none [0 points], single [1 point], combined variants [2 points]), blood group non-0, and age at first VTE onset were included into a risk assessment model, which was derived in 511 patients and then validated in 509 independent subjects. ResultsVTE recurrence risk score (maximum 4 points, range 0–3) was below two for patients scored as low-risk (LRS) and ≥2 for patients at high-risk (HRS). Within a median time of 3 years after withdrawal of anticoagulation (AC) recurrence rate in LRG (derivation) was 11.8% versus 26.0% in HRS (p < 0.001). In the validation cohort within 2.2 years the recurrence rate was 9.8% in LRS versus 30.1% in HRS (p < 0.001). In multivariable analysis adjusted for age at first VTE and blood group the recurrent risk in HRS was significantly increased compared with the LRS (derivation: hazard/95% confidence interval: 3.7/1.75–7.91; validation: 4.7/2.24–9.81; combined 5.2/1.92–13.9). Model specificity (sensitivity) was 79.0% (52.0%) in the derivation cohort compared with 78.0% (43.0%) in the validation group.In conclusion, in the prediction model presented here the risk of VTE recurrence was associated with male gender and combined ITs. Based on the negative predictive value calculated the model may identify patients with a first provoked VTE not being at risk for recurrence.

Factor Xa inhibitors versus low molecular weight heparin for the treatment of cancer associated venous thromboembolism; A meta-analysis of randomized controlled trials and non-randomized studies.

We compared the safety and efficacy of Xa-inhibitors to LMWH for treatment of venous thromboembolism in mixed and gastrointestinal cancer cohorts (CA-VTE). A systematic search identified RCTs and non-randomized studies (NRS) comparing Xa-inhibitors to LMWH for treating CA-VTE. Relative risks were computed. Certainty was assessed using the GRADE approach. Xa-inhibitors reduced the risk of recurrent VTE (RR0.64;0.49-0.84) and NRS (RR0.74;0.60-0.92;Moderate-Low Certainty). There was no significant difference in recurrent PE in RCTs (RR0.72;0.50-1.02) and NRS (1.43;0.65-3.12;Low-Very Low Certainty). Xa-inhibitors increased the risk of overall bleeding events in RCTs (RR1.45;1.05-2.01) and NRS (RR1.72;1.42-2.08;Moderate-Low Certainty), and the risk of major bleeding events in NRS (RR1.56;1.17-2.07), but not in RCTs (RR1.33;0.94-1.89; Low-Very Low Certainty). Similar results were detected in gastrointestinal cancer patients. Xa-inhibitors may reduce the risk of recurrent VTE, but not recurrent PE compared to LMWH. A higher overall bleeding risk, and a questionably higher major bleeding risk was found with Xa-inhibitor use.