Venous thromboembolic disease in systemic autoimmune diseases: An association to keep in mind

Long-Term Risk of VTE in Sarcoidosis: A Nationwide Cohort Study

BACKGROUND

Chronic inflammation is increasingly recognized as a risk factor for VTE, but unlike other inflammatory diseases including systemic lupus erythematosus and rheumatoid arthritis, data on the risk of VTE in patients with sarcoidosis are sparse.

RESEARCH QUESTION

Do patients with sarcoidosis have a higher long-term risk of VTE (pulmonary embolism or DVT, and each of these individually) compared with the background population?

STUDY DESIGN AND METHODS

Using Danish nationwide registries, patients aged ≥ 18 years with newly diagnosed sarcoidosis (two or more inpatient/outpatient visits, 1996-2020) without prior VTE were matched 1:4 by age, sex, and comorbidities with individuals from the background population. The primary outcome was VTE.

RESULTS

We included 14,742 patients with sarcoidosis and 58,968 matched individuals (median age, 44.7 years; 57.2% male). The median follow-up was 8.8 years. Absolute 10-year risks of outcomes for patients with sarcoidosis vs the background population were the following: VTE, 2.9% vs 1.6% (P < .0001), pulmonary embolism, 1.5% vs 0.7% (P < .0001), and DVT, 1.6% vs 1.0% (P < .0001), respectively. In multivariable Cox regression, sarcoidosis was associated with an increased rate of all outcomes in the first year after diagnosis (VTE: hazard ratio [HR], 4.94; 95% CI, 3.61-6.75) and after the first year (VTE: HR, 1.65; 95% CI, 1.45-1.87) compared with the background population. These associations persisted when excluding patients with a history of cancer and censoring patients with incident cancer during follow-up. Three-month mortality was not significantly different between patients with VTE with and without sarcoidosis (adjusted HR, 0.84; 95% CI, 0.61-1.15).

INTERPRETATION

In this nationwide cohort study, sarcoidosis was associated with a higher long-term risk of VTE compared with a matched background population.

Risk of venous thromboembolism in autoimmune diseases: A comprehensive review

Autoimmune diseases have specific pathophysiologic mechanisms leading to an increased risk of arterial and venous thrombosis. The risk of venous thromboembolism (VTE) varies according to the type and stage of the disease, and to concomitant treatments. In this review, we revise the most common autoimmune disease such as antiphospholipid syndrome, inflammatory myositis, polymyositis and dermatomyositis, rheumatoid arthritis, sarcoidosis, Sjogren syndrome, autoimmune haemolytic anaemia, systemic lupus erythematosus, systemic sclerosis, vasculitis and inflammatory bowel disease. We also provide an overview of pathophysiology responsible for the risk of VTE in each autoimmune disorder, and report current indications to anticoagulant treatment for primary and secondary prevention of VTE.

Effect of Corticosteroid Therapy in Patients With Cardiac Sarcoidosis on Frequency of Venous Thromboembolism

Sarcoidosis is a multisystem inflammatory condition with occasional cardiac involvement (CS), which may be associated with risk of venous thromboembolism (VTE). As data on VTE in CS are sparse and corticosteroid therapy has not been previously examined, we aim to determine the association between CS, corticosteroid treatment for CS, and VTE. Patients referred to our institution with concern for sarcoidosis and underwent a positron emission tomography (PET) scan were retrospectively assessed. Chi-squared and multivariate regression analyses were conducted to determine the association between a diagnosis of sarcoidosis, CS, corticosteroid use, and VTE events. Six hundred and forty nine patients were split into 3 categories: 235 with no sarcoidosis (NS), 91 with extra-cardiac sarcoidosis only (ECS), and 323 with CS (isolated CS and/or CS with extra cardiac sarcoid). Thirty nine CS, 7 ECS, and 9 NS patients developed PE while 44 CS, 3 ECS, and 18 NS patients developed DVT. On multivariate regression, neither CS nor ECS was an independent risk factor for VTE (p >0.05) but corticosteroid use was independently associated with VTE (HR 3.06, p = 0.007 for PE, HR 6.21, p <0.0001 for DVT). On logistic regression analysis, corticosteroid dose was found to be independently associated with both PE (p = 0.001) and DVT (p = 0.007). Optimal threshold for defining VTE risk with corticosteroid therapy was a prednisone-equivalent dose of 17.5 mg. In conclusion, contrary to previous studies, this current study found that neither sarcoidosis nor CS is an independent risk factor for VTE. Rather, corticosteroid therapy was associated with an increased risk of VTE.

Correlation between Potential Risk Factors and Pulmonary Embolism in Sarcoidosis Patients Timely Treated

Background. Some studies with inconclusive results have reported a link between sarcoidosis and an increased risk of pulmonary embolism (PE). This study aimed at assessing a possible correlation between potential risk factors and PE in sarcoidosis patients. Methods. A total of 256 sarcoidosis patients (84 males and 172 females; mean age at diagnosis 49 ± 13) were enrolled after giving written informed consent. Clinical evaluations, laboratory and radiology tests were performed to evaluate the presence of pulmonary embolism. Results. Fifteen sarcoidosis patients with PE (4 males and 11 females; mean age at diagnosis 50 ± 11), diagnosed by lung scintigraphy and 241 sarcoidosis patients without PE (80 males and 161 females; mean age at diagnosis 47 ± 13), were observed. There was a statistically significant increase of the presence of antiphospholipid antibodies in the sarcoidosis group with pulmonary embolism. There was no statistically significant difference between the two groups as to smoking habit, obesity or hereditary thrombophilia frequency (p > 0.05, respectively). Conclusions. This study demonstrates a significant correlation between the presence of antiphospholipid antibody positivity and the pulmonary embolism events in our sarcoidosis patients. Furthermore, we propose screening for these antibodies and monitoring, aimed at timely treatment.

Sarcoidosis: Pitfalls and Challenging Mimickers

Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.

Association of Sarcoidosis With Increased Risk of VTE: A Population-Based Study, 1976 to 2013

OBJECTIVE

The goal of this study was to investigate the risk of VTE among patients with sarcoidosis.

METHODS

A cohort of 345 incident cases of sarcoidosis and 345 sex- and age-matched comparator subjects in Olmsted County, Minnesota, from 1976 to 2013 were identified from the comprehensive medical record linkage system. Medical records were reviewed for DVT and pulmonary embolism (PE). The cumulative incidence was estimated, adjusted for the competing risk of death. Cox proportional hazards models were used to compare the rate of development of these events between patients with sarcoidosis and the nonsarcoidosis comparison cohort.

RESULTS

The prevalence of VTE, DVT, and PE prior to the index date was not significantly different between case and comparator subjects. The risk of incident VTE adjusted for age, sex, and calendar year was significantly higher among patients with sarcoidosis (hazard ratio [HR], 3.04 [95% CI, 1.47-6.29]). Significantly elevated risk was observed in both subtypes of VTE, with an HR of 3.14 (95% CI, 1.32-7.48) for DVT and an HR of 4.29 (95% CI, 1.21-15.23) for PE. A sensitivity analysis including only VTE events that occurred at least 6 months after the index date adjusted for age, sex, and calendar year revealed somewhat lower HRs: VTE, 2.73 (95% CI, 1.30-5.72); DVT, 3.00 (95% CI, 1.25-7.20); and PE, 3.58 (95% CI, 0.98-13.03).

CONCLUSIONS

An increased risk of VTE among patients with sarcoidosis was observed in this population-based cohort.

Ankylosing spondylitis and risk of venous thromboembolism: A systematic review and meta-analysis

Background:

Several immune-mediated inflammatory disorders, such as rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematosus have been linked to an increased risk of venous thromboembolism (VTE). However, the data on ankylosing spondylitis (AS) are limited.

Methods:

We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing the risk of VTE and possible pulmonary embolism (PE) in patients with AS versus non-AS participants. Pooled risk ratio and 95% confidence intervals were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird.

Results:

Of 423 potentially relevant articles, three studies met our inclusion criteria and thus, were included in the data analysis. The pooled risk ratio of VTE in patients with AS was 1.60 (95% confidence interval: 1.05–2.44). The statistical heterogeneity of this study was high with an I² of 93%.

Conclusion:

Our study demonstrated a statistically significant increased VTE risk among patients with AS.

Role of extracellular vesicles in autoimmune diseases

Extracellular vesicles (EVs) consist of exosomes released upon fusion of multivesicular bodies with the cell plasma membrane and microparticles shed directly from the cell membrane of many cell types. EVs can mediate cell-cell communication and are involved in many processes including inflammation, immune signaling, angiogenesis, stress response, senescence, proliferation, and cell differentiation. Accumulating evidence reveals that EVs act in the establishment, maintenance and modulation of autoimmune processes among several others involved in cancer and cardiovascular complications. EVs could also present biomedical applications, as disease biomarkers and therapeutic targets or agents for drug delivery.

Venous thromboembolism related to warm autoimmune hemolytic anemia: a case-control study

BACKGROUND

The risk of venous thromboembolism (VTE) during warm autoimmune hemolytic anemia (wAIHA) is apparent in several published series. Unlike proximate disorders (autoimmune thrombocytopenia, non-immune hemolytic diseases) little is known about the presentation and risk factors for VTE in this setting.

OBJECTIVE

To determine the frequency, presentation and risk factors for VTE associated with wAIHA.

METHODS

We performed a single center retrospective study of adult patients (>18years) followed for wAIHA between 2009 and 2013. VTE risk factors were systematically assessed. The characteristics of patients with or without VTE were compared. VTE presentation and precipitating factors were analyzed. The Padua VTE risk score was calculated in each case.

RESULTS

Forty patients were included. wAIHA was idiopathic in 24 patients (60%). Twelve patients (30%) had Evans syndrome. Mean lowest hemoglobin level was 6.6g/dl [3.7-11.5]. Eight patients (20%) presented VTE after the appearance of wAIHA, at a mean age of 52.5years. All patients had pulmonary embolus, associated with a deep venous thrombosis in 4 cases. At the time of VTE 7/8 patients had frank hemolysis (median hemoglobin level: 7g/dL) and 6/8 were outpatients with a low Padua VTE risk score. The frequency of usual VTE risk factor was similar in cases and controls. By contrast, lowest hemoglobin level was significantly lower in patients that experienced VTE (5.3 vs 7.2g/dL, p=0.016). During the first episode of wAIHA, patients with concurrent VTE had a more pronounced anemia (5.3 vs 7.4g/dL, p=0.026). At the time of VTE, anemia was more severe when no other precipitating factor was present (6 vs 8.9g.dL, p=0.04).

CONCLUSION

In our cohort, 20% of patients with wAIHA presented VTE. The vast majority of VTE occurred during severe hemolytic flares and were not attributable to usual VTE risk factors. VTE prophylaxis is advisable in any patient admitted for wAIHA, irrespective of Padua VTE risk score. Prophylaxis also seems reasonable for outpatients with marked hemolysis.

Systemic sclerosis and risk of venous thromboembolism: A systematic review and meta-analysis

BACKGROUND

Several chronic inflammatory disorders, such as rheumatoid arthritis, inflammatory myositis, and systemic vasculitides, have been linked to an increased risk of venous thromboembolism (VTE). However, the data on systemic sclerosis (SSc) remains unclear.

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing risk of VTE in patients with SSc versus non-SSc participants. Pooled risk ratio and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

Out of 776 potentially relevant articles, five eligible studies were identified and included in the data analysis. The pooled risk ratio of VTE in patients with SSc was 2.51 (95% CI, 1.79-3.54). The statistical heterogeneity of this study was high with an I² of 90%.

CONCLUSIONS

Our study demonstrated a statistically significant increased VTE risk among patients with SSc.

Psoriasis and risk of venous thromboembolism: a systematic review and meta-analysis

BACKGROUND

Several chronic inflammatory disorders, such as rheumatoid arthritis and systemic lupus erythematosus, have been shown to increase venous thromboembolism (VTE) risk but the data on psoriasis is unclear.

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio or standardized incidence ratio comparing VTE risk in patients with psoriasis vs. non-psoriasis participants. Pooled risk ratio and 95% confidence intervals were calculated using a random effect, generic inverse variance method.

RESULT

Four studies were identified and included in our data analysis. The pooled risk ratio of VTE in patients with psoriasis was 1.46 (95% CI, 1.29-1.66). The statistical heterogeneity of this meta-analysis was high with an I(2) of 86%.

CONCLUSION

Our study demonstrated a statistically significant increased VTE risk among patients with psoriasis.