Venous Thromboembolism Risk Score Research Articles

Simple, Effective and Validated. VTE CASE Risk Assessment Score for Venous Thromboembolism in Metastatic Germ Cell Tumour Patients Before First-Line Chemotherapy.

Venous thromboembolism (VTE) may jeopardise excellent treatment results of germ cell tumours (GCT). We previously constructed a VTE risk score for GCT patients qualified for first-line chemotherapy (CTH), including vein compression, clinical stage (CS) and haemoglobin concentration. Validating our score in a separate cohort and establishing the cut-off point for the score. Re-assessing the numerical score in the training cohort. We retrospectively analysed a new cohort of GCT patients staged IS-IIIC. Area under the curve of receiver-operating characteristic (AUC-ROC) was calculated for the developed score, Khorana Risk Score (KRS) and Padua Prediction Score (PPS). AUC-ROC of the integer score was calculated for the training cohort. Cut-off point was established by Youden's and Liu's indices. Among 336 eligible patients in the validation cohort, VTE occurred in 41 (12.2%). AUC-ROC for our score, KRS and PPS were 0.818 (95% confidence interval (CI): 0.746-0.891), 0.608 (0.529-0.688) and 0.634 (0.547-0.720), respectively, p < 0.001. The optimal cut-off point for a low/high risk was 6 (≤ 6 vs. ≥ 7). In the training cohort, 369 patients had complete data on vein compression. AUC-ROC for our score, KRS and PPS were 0.819 (95% CI: 0.758-0.879), 0.710 (0.637-0.782) and 0.725 (0.651-0.800), p ≤ 0.001 and 0.015, respectively. Positive and negative predictive values were 30.8% and 96.5%, respectively. Our VTE risk score is a handy tool for GCT patients before first-line CTH for metastatic disease. Outperforming KRS and PPS, it has a good discriminatory value, especially for identifying low-risk patients.

Validation of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) risk scores for venous thromboembolism and bleeding in an independent population

BackgroundMultiple guidelines recommend assessment of bleeding and venous thromboembolism (VTE) risk in adult medical inpatients to inform prevention strategies. There is no agreed-upon method for VTE and bleeding risk assessment. ObjectivesTo validate the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE and bleeding risk scores in an independent population. MethodsIn this retrospective study, we calculated the IMPROVE VTE and bleeding risk scores in medical inpatients admitted between 2010 and 2019 at the University of Vermont Medical Center (UVMMC). Patients were followed for in-hospital bleeding events while hospitalized and VTE events while hospitalized and for 3 months after discharge. We assessed calibration of the risk models by comparing the observed incidence of events in the UVMMC and IMPROVE populations across the published risk categories. We also assessed performance of the IMPROVE risk factors after refitting the models in the UVMMC population. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC). ResultsVTE occurred in 270 (1.1%) of 23,873 admissions, with 92 (34%) occurring during admission, and bleeding occurred in 712 (4.7%) of 15,240 admissions. When the IMPROVE-VTE risk factors were refitted to the UVMMC data, the AUC was 0.64. When the IMPROVE bleeding risk factors were refitted to the UVMMC data, the AUC was 0.67. The IMPROVE-VTE score tended to overestimate risk at higher scores, and the IMPROVE bleeding score underestimated risk at lower scores and overestimated risk at higher scores. ConclusionWhile the refitted IMPROVE VTE and bleeding risk scores had reasonable model fit, the scores were poorly calibrated and did not reliably identify or differentiate patients at risk for VTE and bleeding. Different methods are needed for risk assessment of medical inpatients for VTE and bleeding risk.

System-Wide Thromboprophylaxis Interventions for Hospitalized Patients at Risk of Venous Thromboembolism: Focus on Cross-Platform Clinical Decision Support.

Thromboprophylaxis of hospitalized patients at risk of venous thromboembolism (VTE) presents challenges owing to patient heterogeneity and lack of adoption of evidence-based methods. Intuitive practices for thromboprophylaxis have resulted in many patients being inappropriately prophylaxed. We conducted a narrative review summarizing system-wide thromboprophylaxis interventions in hospitalized patients. Multiple interventions for thromboprophylaxis have been tested, including multifaceted approaches such as national VTE prevention programs with audits, pre-printed order entry, passive alerts (either human or electronic), and more recently, the use of active clinical decision support (CDS) tools incorporated into electronic health records (EHRs). Multifaceted health-system and order entry interventions have shown mixed results in their ability to increase appropriate thromboprophylaxis and reduce VTE unless mandated through a national VTE prevention program, though the latter approach is potentially costly and effort- and time-dependent. Studies utilizing passive human or electronic alerts have also shown mixed results in increasing appropriate thromboprophylaxis and reducing VTE. Recently, a universal cloud-based and EHR-agnostic CDS VTE tool incorporating a validated VTE risk score revealed high adoption and effectiveness in increasing appropriate thromboprophylaxis and reducing major thromboembolism. Active CDS tools hold promise in improving appropriate thromboprophylaxis, especially with further refinement and widespread implementation within various EHRs and clinical workflows.

A novel risk score for venous thromboembolism in lung cancer patients: a retrospective cohort study

Background: Venous thromboembolism (VTE) is a common and potentially fatal complication in patients with lung cancer. This study aimed to develop and validate a risk score for early prediction of VTE in these patients. Methods: Four hundred and one patients with lung cancer from three pulmonology departments hospitalized between January 2011 and December 2021 were retrospectively assessed. The population was divided into two groups: a Development Group (182 patients) and a validation group (199 patients). In the development group, the risk score system was developed, via univariate and multivariate analyses, based on demographic and clinicopathological variables; it was then validated in the validation group. Results: The incidence of VTE was 26.8% in the development group. It was 25.8%, and 27.6% in the internal and external validation groups, respectively. Hemoglobin level &lt;10g/l, metastasis, histological type poorly or undifferentiated non-small cell carcinoma, and active smoking were the items of the risk score system. This score allowed proper stratification of patients with either high or low risk of VTE in the development group (c statistic =0.703). The patients in the development group were classified into 3 risk groups: low risk (scores 0-1), moderate risk (scores 2-3), and high risk (scores 4-5). When validated in the validation group, there was a moderate loss of predictive power of the score (c statistic=0.641), but the categorization of the patients by the score remained clinically useful. Conclusions: This risk score requires prospective validation studies on a nationwide scale in order to use it as a valid tool for the prevention of VTE in lung cancer.

PB0101 Comparison of Padua Prediction Score and IMPROVE VTE Risk Score for Venous Thromboembolism at Admission to Assess Hypercoagulation in COVID-19 Patients

PB0101 Comparison of Padua Prediction Score and IMPROVE VTE Risk Score for Venous Thromboembolism at Admission to Assess Hypercoagulation in COVID-19 Patients

Polygenic risk scores for prediction of cancer-associated venous thromboembolism in the UK Biobank cohort study

BackgroundGuidelines recommend thromboprophylaxis for patients with cancer at high risk of venous thromboembolism (VTE). Polygenic risk scores may improve VTE prediction but have not yet been evaluated in patients with cancer. ObjectivesWe assessed the performance of the 5-, 37-, 297-, extended 297- (additionally including factor V Leiden and prothrombin G20210A), and 100-single-nucleotide polymorphism (SNP) scores in predicting cancer-associated VTE in the UK Biobank, a population-based, prospective cohort study. MethodsThe primary outcome was VTE during 12 months after cancer diagnosis. Cancer and VTE diagnosis were based on ICD-10 codes. Discrimination was evaluated by c-indices and subdistribution hazard ratios in the upper vs 3 lower quartiles of the scores in a competing risk model. As a comparison, the c-index was calculated for the Khorana cancer type risk classification. ResultsOf 36 150 patients with cancer (median age, 66 years; 48.7% females), 1018 (2.8%) developed VTE. C-indices at 12 months ranged from 0.56 (95% CI, 0.54-0.58) for the 5-SNP to 0.60 (95% CI, 0.58-0.62) for the extended 297-SNP scores. The subdistribution hazard ratios ranged from 1.36 (95% CI, 1.19-1.56) for the 5-SNP to 1.90 (95% CI, 1.68-2.16) for the extended 297-SNP scores and were consistent after adjusting for cancer type. For the Khorana cancer type classification, the c-index was 0.60 (95% CI, 0.58-0.61), which increased to 0.65 (95% CI, 0.63-0.67, +0.05; 95% CI, 0.04-0.07) when combined with the extended 297-SNP score. ConclusionThese findings demonstrate that polygenic VTE risk scores can identify patients with cancer with a 1.9-fold higher VTE risk independent of cancer type. Combined clinical-genetic scores to improve cancer-associated VTE prediction should be evaluated further.

#3913 GENETIC SUSCEPTIBILITY AS AN EFFECT MODIFIER FOR THE ASSOCIATION BETWEEN CHRONIC KIDNEY DISEASE AND RISK OF VENOUS THROMBOEMBOLISM

Abstract Background and Aims The association between chronic kidney disease (CKD) and the risk of developing venous thromboembolism (VTE) is still controversial. Further, it is unknown if genetic predisposition modifies this relationship. This study was conducted to investigate plausible effect modification of genetic factors on the association between CKD and incident VTE. Method Population-based cohort study of the UK Biobank, including 397,658 participants of European ancestry that were free of VTE at recruitment. We used cystatin C combining creatinine estimated glomerular filtration rate (eGFR) and albuminuria to classify participants with CKD stages 1-5 according to the low, intermediate, and high/very high-risk groups suggested by KDIGO (Kidney Disease: Improving Global Outcomes). Cox proportional hazards model was applied to evaluate the associations of CKD with incident VTE. In addition, we used externally validated polygenic risk score (PRS) for VTE to evaluate whether the genetic predisposition modified the associations of interest. Results During median follow-up of 12.7 years, 11,372 participants developed VTE. As compared with low KDIGO risk category, covariate-adjusted hazard ratios (HR) and 95% confidence intervals (CI) for future VTE risk with intermediate and high/very high KDIGO risk categories at baseline were 1.278 (1.191-1.372) and 1.892 (1.658-2.159), respectively. Participants at high/very high risk of CKD prognosis and in the highest tertile of PRS had the highest risk of developing VTE (HR, 4.397; 95% CI, 3.639-5.313), and this group had shown the most conspicuous additive interactions between CKD and the genetic predisposition, which responsible for 1.389-fold relative excess risk and accounted for 31.6% of incident VTE. Also, when either eGFR or urine albumin-creatinine ratio (ACR) was treated as the exposure, similar associations and supra-additive interactions were yielded. Conclusion CKD is associated with future VTE, especially in those with high genetic risk.

The factors affecting the quality of life among women during the postpartum period

Objective: As healthcare has become increasingly patient-centered, outcomes such as disease-specific quality of life (QoL) have become increasingly important. This study aimed to determine the factors affecting the QoL of postpartum women and which factors make a difference and affect the QoL. Patients and Methods: A total of 175 postpartum mothers participated in this study. The Euro QoL 5 Dimension 5 Level (EQ 5D-5L) scale was used to measure the health-related QoL of postpartum women. Results: The QoL of women differed in age, delivery type, venous thromboembolism risk factors, parity, gravida, number of live births, and use of anticoagulant medication. According to multiple regression analyses, the “age” variable had a significant effect on the QoL. However, the variables of education, social security, employment status, and monthly income of the family were not significant determinants of QoL. Also, the “number of live births” variable did not significantly affect the QoL, other obstetric and clinical variables had a significant effect on the QoL. The gravida increased the QoL but the number of miscarriages and the venous thromboembolism risk score decreased the QoL. Conclusions: This study shows that, the QoL of women varies according to obstetric, socio-demographic, and clinical factors, and “age, gravida, the number of abortions and the venous thromboembolism risk score” variables have a significant effect on the QoL.

External validation of a novel electronic risk score for cancer-associated thrombosis in a comprehensive cancer center.

Venous thromboembolism (VTE) is a significant complication for cancer patients undergoing systemic therapy. We performed an independent external validation for a recently derived and validated a novel electronic health record (EHR) VTE risk score in a comprehensive cancer center. Adult patients with incident cancer diagnoses were identified from MD Anderson Cancer Center Tumor Registry 1/2017-1/2021. Baseline covariates extracted at the time of first-line systemic therapy included demographics, cancer site/histology, stage, treatment, complete blood count, body mass index, recent prolonged hospitalization, and history of VTE or paralysis. VTE was ascertained using an institution-specific natural language processing radiology algorithm (positive predictive value of 94.8%). The median follow-up for 21 142 cancer patients was 8.1 months. There were 1067 (5.7%) VTE within 6 months after systemic therapy. The distribution of the novel score for 0-, 1, 2, 3, 4, 5+ was 5661, 3558, 3462, 3489, 2918, and 2054; while the corresponding 6-month VTE incidence was 1.3%, 3.1%, 5.4%, 7.3%, 9.3%, and 13.8%, respectively (c statistic 0.71 [95% CI 0.69-0.72] with excellent calibration). In comparison, the Khorana score had a c statistic of 0.64 [95% CI 0.62-0.65]. The two risk scores had 80% concordance; the novel score reclassified 20% of Khorana score (3530 low-to-high with 9.0% VTE; 734 high-to-low with 3.4% VTE) and led to a 25% increment in VTEs captured in the high-risk group. In conclusion, the novel score demonstrated consistent discrimination and calibration across cohorts with heterogenous demographics. It could become a new standard to select high-risk populations for clinical trials and VTE monitoring.

MP72-20 FREQUENCY OF HIGH GENETIC RISK SCORE FOR VENOUS THROMBOEMBOLISM IN PATIENTS UNDERGOING SURGERY FOR UROLOGIC MALIGNANCIES

You have accessJournal of UrologyCME1 Apr 2023MP72-20 FREQUENCY OF HIGH GENETIC RISK SCORE FOR VENOUS THROMBOEMBOLISM IN PATIENTS UNDERGOING SURGERY FOR UROLOGIC MALIGNANCIES Clark Judge, Zhuqing Shi, Jun Wei, Andrew Rifkin, S. Lilly Zheng, John Hollingsworth, Brian Helfand, Jianfeng Xu, and James Kearns Clark JudgeClark Judge More articles by this author , Zhuqing ShiZhuqing Shi More articles by this author , Jun WeiJun Wei More articles by this author , Andrew RifkinAndrew Rifkin More articles by this author , S. Lilly ZhengS. Lilly Zheng More articles by this author , John HollingsworthJohn Hollingsworth More articles by this author , Brian HelfandBrian Helfand More articles by this author , Jianfeng XuJianfeng Xu More articles by this author , and James KearnsJames Kearns More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003340.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients with urologic malignancies. Risk factors for urologic patient with cancer include undergoing surgery (particularly pelvic surgery) and inherited genetic mutations. Recent GWAS have revealed multiple single nucleotide polymorphisms associated with VTE risk. A genetic risk score for VTE (GRSVTE) has previously been validated, and may provide superior risk stratification for VTE compared with established risk calculators. The GRSVTE represents the relative risk of VTE for patients compared with the general population. The objective of this study was to evaluate the association between incidence of VTE in patients with urologic malignancies and inherited genetic risk factors. METHODS: We analyzed patients with urologic malignancies from the United Kingdom Biobank (UKB), a population-based study of 500,000 volunteers age 40-69 years recruited in 2006 from the United Kingdom. Patients were included if they had a diagnosis of cancer in one of the following organs: penis, prostate, testis, kidney, renal pelvis and ureter, bladder, or unspecified urinary or male genital organs. We defined GRSVTE high risk as a value>1.5. Incident VTE rates were evaluated based on primary cancer site, mutation status, and GRSVTE. Multivariable analysis adjusting for age at recruitment, gender and genetic background was performed to determine hazard ratios of VTE. RESULTS: The study cohort included 17,424 patients with urologic malignancy. Of these patients, 530 developed incident VTE. Compared to 6.3% of patients with carriers of FVL/F2, 15.13% had a higher GRSVTE (>1.5) (Table). The increased risk for VTE was similar between patients with GRSVTE>1.5 and FVL/F2. When evaluating each specific urologic malignancy, these same trends held true. CONCLUSIONS: The GRSVTE is significantly associated with incidence of VTE in patients diagnosed with urologic malignancy. The GRSVTE can explain a significantly greater proportion of patients who develop VTE compared to other genetic causes. Patients with elevated genetic risk for VTE may benefit from more aggressive monitoring or anticoagulation in the perioperative setting. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1032 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Clark Judge More articles by this author Zhuqing Shi More articles by this author Jun Wei More articles by this author Andrew Rifkin More articles by this author S. Lilly Zheng More articles by this author John Hollingsworth More articles by this author Brian Helfand More articles by this author Jianfeng Xu More articles by this author James Kearns More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparison of 90-Day Adverse Events Associated With Aspirin and Potent Anticoagulation Use for Venous Thromboembolism Prophylaxis: A Cohort Study of 72,288 Total Knee and 35,142 Total Hip Arthroplasty Patients

BackgroundWhile aspirin is acceptable for venous thromboembolism (VTE) prophylaxis following total joint arthroplasty in most patients, more potent agents are used in patients considered higher risk for VTE. We evaluated the efficacy and safety of aspirin versus potent anticoagulation agents following total knee arthroplasty (TKA) and total hip arthroplasty (THA). MethodsA cohort study of 72,288 TKA and 35,142 THA from the Kaiser Permanente Total Joint Replacement Registry was performed (2009 to 2019). Identified medications were aspirin, factor Xa inhibitors, low-molecular-weight heparin (LMWH), and warfarin. A validated VTE risk score was assigned to each patient. Propensity score-weighted logistic regressions were used to evaluate 90-day VTEs. Noninferiority testing was performed with a margin of 1.25 using the upper bound (UB) of the 1-sided 95% CI. ResultsFor TKA, aspirin was not inferior to LMWH (odds ratio [OR] = 0.77, UB = 1.09) and warfarin (OR = 0.64, UB = 0.90); there was no evidence to support noninferiority of aspirin compared to factor Xa inhibitors. Findings were consistent for THA (LMWH: OR = 0.59, UB = 0.75; warfarin: OR = 0.69, UB = 0.89). TKA was considered higher risk for VTE, whereas aspirin use demonstrated noninferiority compared to warfarin (OR = 0.54, UB = 0.81), we lacked evidence of noninferiority when compared to LMWH and factor Xa inhibitors. We lacked evidence of noninferiority of aspirin versus any potent anticoagulation in higher-risk THA. ConclusionAspirin was found to be effective and safe for VTE prevention in primary total joint arthroplasty, including in patients considered higher risk for VTE. Level of EvidenceIII

Trends in Venous Thromboembolism Readmission Rates after Ischemic Stroke and Intracerebral Hemorrhage.

Venous thromboembolism (VTE) is a life-threatening complication of stroke. We evaluated nationwide rates and risk factors for hospital readmissions with VTE after an intracerebral hemorrhage (ICH) or acute ischemic stroke (AIS) hospitalization. Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmission Database, we included patients with a principal discharge diagnosis of ICH or AIS from 2016 to 2019. Patients who had VTE diagnosis or history of VTE during the index admission were excluded. We performed Cox regression models to determine factors associated with VTE readmission, compared rates between AIS and ICH and developed post-stroke VTE risk score. We estimated VTE readmission rates per day over a 90-day time window post-discharge using linear splines. Of the total 1,459,865 patients with stroke, readmission with VTE as the principal diagnosis within 90 days occurred in 0.26% (3,407/1,330,584) AIS and 0.65% (843/129,281) ICH patients. The rate of VTE readmission decreased within first 4-6 weeks (P<0.001). In AIS, cancer, obesity, higher National Institutes of Health Stroke Scale (NIHSS) score, longer hospital stay, home or rehabilitation disposition, and absence of atrial fibrillation were associated with VTE readmission. In ICH, longer hospital stay and rehabilitation disposition were associated with VTE readmission. The VTE rate was higher in ICH compared to AIS (adjusted hazard ratio 2.86, 95% confidence interval 1.93-4.25, P<0.001). After stroke, VTE readmission risk is highest within the first 4-6 weeks and nearly three-fold higher after ICH vs. AIS. VTE risk is linked to decreased mobility and hypercoagulability. Studies are needed to test short-term VTE prophylaxis beyond hospitalization in high-risk patients.

Venous thromboembolism risk score during hospitalization in pregnancy: results of 10694 prospective evaluations in a clinical trial

ObjectivesHospitalization during pregnancy and childbirth increases the risk of Venous Thromboembolism Risk (VTE). This study applied a VTE risk score to all hospitalized pregnant women to ascertain its effectiveness in preventing maternal death from VTE until 3 months after discharge. MethodsIn this interventional study, patients were classified as low- or high-risk according to the VTE risk score (Clinics Hospital risk score). High-risk patients (score ≥ 3) were scheduled for pharmacological Thromboprophylaxis (TPX). Interaction analysis of the main risk factors was performed using Odds Ratio (OR) and Poisson regression with robust variance. ResultsThe data of 10694 cases (7212 patients) were analyzed; 1626 (15.2%, 1000 patients) and 9068 (84.8%, 6212 patients) cases were classified as high-risk (score ≥ 3) and low-risk (score < 3), respectively. The main risk factors (Odds Ratio, 95% Confidence Interval) for VTE were age ≥ 35 and < 40 years (1.6, 1.4–1.8), parity ≥ 3 (3.5, 3.0–4.0), age ≥ 40 years (4.8, 4.1–5.6), multiple pregnancies (2.1, 1.7–2.5), BMI ≥ 40 kg/m2 (5.1, 4.3–6.0), severe infection (4.1, 3.3–5.1), and cancer (12.3, 8.8–17.2). There were 10 cases of VTE: 7/1636 (0.4%) and 3/9068 (0.03%) in the high- and low-risk groups, respectively. No patient died of VTE. The intervention reduced the VTE risk by 87%; the number needed to treat was 3. ConclusionsThis VTE risk score was effective in preventing maternal deaths from VTE, with a low indication for TPX. Maternal age, multiparity, obesity, severe infections, multiple pregnancies, and cancer were the main risk factors for VTE.

Risk factors for venous thromboembolism (VTE) after adrenalectomy for adrenal cortical neoplasms.

Incidence of venous thromboembolism (VTE) after adrenalectomy for adrenal cortical carcinoma (ACC) is unknown. Herein, we aim to identify the relative incidence and risk factors of VTE after adrenalectomy for ACC. The American College of Surgeons National Surgical Quality Improvement Programdatabase was queried to identify patients who underwent adrenalectomy for ACC, Cushing syndrome (CS), and benign adrenal cortical syndromes (BACS). Univariable and multivariable analyses were used to determine clinical characteristics, 30-day postoperative VTE occurrences, and associated risk factors. Khorana oncologic risk score (KRS) for VTE was calculated and compared between groups. A total of 5896 patients were analyzed: 576 ACC, 371 CS, and 4949 BACS. Postoperative VTE occurred 0.9%, with the highest rate occurring in ACC (2.6% ACC vs. 1.6% CS vs. 0.7% BACS, p < 0.001). Forty percent of VTEs in theACC cohort were diagnosed postdischarge. ACC patients with KRS ≥ 2 had a 9.6% incidence of VTE (p = 0.007). Multivariable analysis identified increased age (p = 0.03), presence of adrenal cancer (p = 0.01), and KRS ≥ 2 (p = 0.005) as risk factors for VTE after adrenalectomy. Postoperative VTE after adrenalectomy occurs most frequently for ACC. ACC patients with increased age and/or Khorana score ≥2 should be considered for extended VTE prophylaxis.

Interleukin-10 levels and the risk of thromboembolism according to COMPASS-Cancer associated thrombosis score in breast cancer patients prior to undergoing doxorubicin-based chemotherapy.

Venous thromboembolism (VTE) is an important cause of morbidity/mortality in cancer patients, and COMPASS-CAT score must be used to VTE-risk prediction. There is a relationship between cytokines and thrombus formation and/or resolution. This study aimed to investigate the VTE risk and cytokines level in breast cancer patients prior to chemotherapy with doxorubicin (DOXO). Eighty women with breast cancer and indication for DOXO treatment were selected. TNF, IL-1β, IL-6, and IL-10 were measured after the diagnosis and immediately before DOXO treatment. All 80 patients presented a high risk for VTE when evaluated by COMPASS-CAT model (score ≥7). A positive correlation was observed between IL-10 plasma levels and VTE risk score. Our data showed that higher IL-10 levels before chemotherapy are associated to increased risk of VTE in breast cancer patients. This finding suggests that IL-10 levels and the combination with COMPASS-CAT score could be good markers to predict increased risk of VTE in these patients.

Venous Thromboembolism Risk Score and Pregnancy.

Venous thromboembolism (VTE) is a major contributor to maternal morbidity and mortality worldwide. Pregnancy is associated with the development of a baseline hypercoagulable state. The two strongest risk factors for pregnancy-associated VTE are previous VTE and/or high risk thrombophilia. The others risk factors for VTE during pregnancy are well known such as maternal, pregnancy and delivery characteristics. Considering the variation in recommendation in guidelines and low-quality evidence on the prevention, diagnosis and treatment, practice differs between countries and clinical institutions. Some authors developed risk scores, enabling individualized estimation of thrombotic risk during pregnancy, and permitting implementation of a risk-adapted strategy for thromboprophylaxis during pregnancy and postpartum. This review describes the existing VTE risk scores during the antenatal and postnatal period. The important message beyond the score used is that all women should undergo VTE risk factor assessment. The use of a Computerized Clinical Decision Support System for VTE risk assessment should be explored in obstetrics.

We Have Come Full Circle for Venous Thromboembolism Prevention: Commentary on an article by Emanuele Chisari, MD, et al.: "Aspirin Is an Effective Prophylaxis for Venous Thromboembolism in Ambulatory Patients with Femoral Neck Fracture Undergoing Hip Arthroplasty".

Commentary In their study, Chisari et al. add to the recent literature that has shown that aspirin is as effective as other anticoagulants at preventing symptomatic venous thromboembolism (VTE) for surgical lower-extremity conditions. This evidence may be practice-changing for surgeons treating patients with hip fractures and once again elevates aspirin to a preferred prophylactic option. After decades of opinion and evidence that aspirin was not the best prophylaxis for preventing VTE, the pendulum is now strongly swinging back toward aspirin. Studies on elective hip and knee arthroplasty provide the highest-quality evidence to answer important questions about preventing VTE. In patients undergoing elective procedures, tight study control is more feasible than in other conditions in which VTE is a high risk, such as trauma. Previous guidelines for these elective surgical procedures indicated that aspirin was less effective than more powerful anticoagulants. However, more recent studies have suggested otherwise. For instance, a systematic review and meta-analysis of randomized clinical trials found that aspirin for VTE prevention was as safe and effective as other anticoagulants1. Aspirin is now routine for standard-risk patients undergoing hip or knee arthroplasty, but patients with other risk factors for VTE are still considered for more powerful anticoagulation. One such risk factor is trauma. Patients with hip fractures are at extremely high risk for VTE, for reasons including that trauma is a procoagulant, there could be endothelial damage, there could be relative immobility, and hip fractures tend to occur in elderly patients with other comorbid risk factors. Because of these increased risks, patients with hip fracture have not commonly been treated with aspirin and other anticoagulants have been recommended. For instance, in a 2019 update on current practice, the authors noted that, for patients with hip fracture, other chemoprophylaxis has been found to be more effective than aspirin2. In the current study, Chisari et al. show that aspirin prophylaxis for patients with femoral neck fracture treated with arthroplasty is equivalent to prophylaxis with other anticoagulants. The patients in the aspirin group actually had lower rates of VTE, but, when statistical balancing through propensity matching was employed, there was no difference in the VTE rates between the 2 groups. This suggests that aspirin could be used routinely for VTE prophylaxis in these patients. Surgeons should consider a few other factors before broadly accepting the results of this study. First, this was a retrospective study, and it is clear that aspirin was chosen for patients with a lower risk of VTE. However, the propensity matching employed, utilizing an accepted VTE risk score, increases confidence that similar groups of patients were compared. Second, all patients were mobilized on the same day as or the day after the surgical procedure, and all had mechanical compression devices as part of the treatment protocol. The absence of these best practices could have changed the results. Finally, even among the trauma group, there were patients who were higher-risk than others. Exactly which categories of these high-risk patients benefit from more powerful anticoagulation remains unknown. In 1 study of hip and knee arthroplasty, aspirin was equivalent to other anticoagulants even in high-risk patients3. It is interesting to speculate why there is new evidence about a drug that has been studied for decades. After all, aspirin is not new for VTE prophylaxis, so why is it making this data-driven resurgence? Here are a few speculative answers. Perhaps we now have better research or perhaps the disease process has changed in some way. These seem unlikely. Maybe there was bias against the simpler option of aspirin in earlier studies. There clearly has been a shift in studies toward relying on only clinically important outcome measures. For instance, in the current study, only clinically apparent deep vein thrombosis or pulmonary embolism was included as outcomes, compared with surrogates based on imaging studies or ultrasound frequently used in the past. This might be an important difference. Finally, as in this study, aspirin is now combined with early mobilization and mechanical compression devices, things that were not routine in earlier studies. Although it is hard to know what has driven the strong trend toward literature that demonstrates aspirin equivalence to other anticoagulants, this change does give me the feeling of having gone full circle and now we are back to where we started with aspirin.

Evaluation of the Khorana score for prediction of venous thromboembolism in patients with multiple myeloma

BackgroundGuidelines recommend thromboprophylaxis for patients with multiple myeloma (MM) at high risk for venous thromboembolism (VTE). However, the optimal risk prediction model for VTE in MM remains unclear. Khorana et al developed a VTE risk score (Khorana score) in ambulatory cancer patients receiving chemotherapy. We aimed to evaluate the predictive ability of the Khorana score in patients with MM. MethodsWe identified patients with MM within the Veterans Affairs health care system between 2006 and 2013. The Khorana score was calculated before treatment initiation. Using logistic regression, the relationship between risk group and VTE was assessed at 3 and 6 months. We tested model discrimination using the concordance statistic. ResultsIn the cohort of 2870 patients with MM, there were 1328 at low risk (0 points), 1521 at intermediate risk (1‐2 points), and 21 at high risk (≥3 points) for VTE by the Khorana score. The 6‐month cumulative incidence of VTE was 5.1% (95% confidence interval [CI], 4.0%‐6.4%) in low risk, 3.9% (95% CI, 3.0%‐5.0%) in intermediate risk, 4.8% (95% CI, 0.3%‐20.2%) in high risk. The Khorana score did not strongly discriminate between patients who did and did not develop VTEs at 3 or 6 months (concordance statistic, 0.58; 95% CI, 0.54‐0.63; and 0.53, 95% CI, 0.50‐0.57, respectively. ConclusionsIn conclusion, in this cohort of 2870 patients with MM, the Khorana score did not predict VTE. Our study supports the need to use myeloma‐specific risk models to predict VTE risk in patients with MM.

Real World Validation of VTE Risk Models in Newly Diagnosed Multiple Myeloma in a Community Setting

Background:Multiple Myeloma (MM) is associated with increased risk for venous thromboembolism (VTE). Treatment, such as dexamethasone, immunomodulatory drugs (IMID), alkylating agents, and doxorubicin, alter hemostatic pathways and thus promote thrombogenesis 1. MM patients with VTE have a 3-fold increase in mortality compared to those without VTE, so identifying those at risk and aiming to prevent VTE events is important 2. Several clinical VTE risk prediction scores have been developed, including the SAVED score, IMPEDE VTE score, and more recently the PRISM score 2,4,5. The National Comprehensive Cancer Network suggests that patient with MM on IMID therapy should be on aspirin, or therapeutic anticoagulation for those at “high risk”3. However, it remains unclear which risk model, if any, should be used.Our objective was to validate the three published risk assessment tools in a community setting and assess the predictive ability of each.Methods:We conducted a retrospective chart review of all patients with newly diagnosed multiple myeloma who started chemotherapy at Gundersen Health System (La Crosse, WI) between 2010 and 2020 who had at least 6 months of follow up documented. Patients with prior indication for ongoing therapeutic anticoagulation or a diagnosis of VTE within 6 months prior to starting therapy were excluded. Total scores for IMPEDE VTE, SAVED and PRISM scores were calculated from the chemotherapy start date. Statistical analysis included Chi-square, Fisher's exact and Wilcoxon rank sum tests, and Kaplan Meier survival analysis. A p-value ≤ 0.05 was considered significant and all analysis was completed in SAS version 9.4.Results:Our cohort contained 123 patients diagnosed with MM. Average age was 68 years (SD 12.1, range 37-92). Our study included 68 (55%) males and 55 (45%) females with 121 (98%) being White/Caucasian. The mean BMI of patients was 29.4 kg/m2 (SD 7.0, range 18.6-54.4). Kaplan Meier survival analysis showed a 5-year survival rate of 53.1% (95% CI [42.7%, 63.4%]). In the entire cohort, 10 (8.1%) patients were diagnosed with VTE (as compared to 5.8% in IMPEDE study, 8.7% in SAVED study and 8.2% in PRISM study) with 80.0% occurring within 6 months of treatment start date. Aspirin was the most frequently used agent for thromboprophylaxis with 88 (86.3%) patients receiving either 81, 162, or 325 mg of aspirin. IMID therapy was given to 76 (61.8%) patients, 114 (92.7%) received dexamethasone and 114 (92.7%) received proteasome inhibitors. Amongst those on IMIDs, 72 (94.7%) patients received prophylaxis, most commonly aspirin. Abnormal metaphase cytogenetics were noted in 104 (85.4%) patients.Neither the IMPEDE VTE (p=0.6), SAVED (p=0.9) nor PRISM risk scores (p=0.3) were able to statistically predict VTE outcome in our patient population. Using the IMPEDE score, 7 patients in the intermediate risk group and 3 patients in the low-risk group had a VTE. In the SAVED model, 5 patients in the low-risk group and 5 patients in the high-risk group had a VTE. Using the PRISM risk score, all 10 of the patients with VTE were in the intermediate risk group. Most patients who were on IMID therapy fell into the intermediate risk group on the IMPEDE VTE and PRISM scoring systems, and the SAVED score had an approximately equal patient distribution between the high risk and low risk group.Conclusions:Our patients with multiple myeloma had similar rates of VTE as compared to the published models, with the majority occurring in the first 6 months of chemotherapy. In total, our patients on IMID therapy received appropriate prophylaxis with aspirin. Overall, 8.1% of our patients had a VTE event. However, none of the three risk models were able to predict the development of VTE. In fact, many of the VTE events occurred in patients who were felt to be low or intermediate risk. While the sample size is small and from a single health system, we had excellent follow up and ability to closely examine each chart for treatment and outcomes. Further efforts should focus on collaboration across institutions to increase the sample size, to validate and compare existing models. The majority of myeloma treatment occurs in the community; thus, it is important to ensure the findings are reproducible in that patient population. DisclosuresNo relevant conflicts of interest to declare.

Validation of the Khorana Venous Thromboembolism Risk Score in Japanese Cancer Patients.

Although the Khorana venous thromboembolism (VTE) risk score (KRS) is well recognized as a simple VTE risk assessment method in patients with cancer, whether it is suitable for Asian populations is unclear. This study validated KRS for the prediction of VTE and investigated the value of the KRS in predicting mortality in Japanese patients with cancer. A body mass index value of 25kg/m2 or more was defined as obesity according to World Health Organization consensus. A total of 27,687 patients with cancer were subdivided into low- (0), intermediate- (1-2), and high-score (3) groups by the KRS. The primary and secondary endpoints were VTE and all-cause mortality, respectively. The prevalence of VTE was 1.7%, 7.3%, and 11.0% for low-, intermediate-, and high-score patients, respectively. Receiver operating characteristic (ROC) analysis showed that the KRS significantly predicted VTE (area under the curve, 0.679; 95% confidence interval [CI] 0.666-0.692; P< 0.001). The cutoff value for the KRS was 1.0. Logistic regression analysis demonstrated that the KRS was an independent predictor of VTE (odds ratio 1.766; 95%CI 1.673-1.865; P< 0.01). The cutoff value of the KRS for all-cause mortality determined by ROC analysis was 2.0. Kaplan-Meier analysis demonstrated a significantly higher incidence of mortality in the KRS≥2 group than in the KRS 0-1 group (log-rank: P< 0.01). The KRS was useful in Japanese patients with cancer and might be a potentially useful marker for theprediction of mortality. Establishing optimal scores for Japanese subjects is mandatory because of its low diagnosticability. (KUMAMON Cancer registry; UMIN000047554).