Impact of sex, age, and risk factors for venous thromboembolism on the initial presentation of first isolated symptomatic acute deep vein thrombosis

Haemostatic gene variations in cervical cancer-associated venous thrombosis: considerations for clinical strategies

Venous thromboembolism (VTE) is a life-threatening haemostatic disease frequently diagnosed among the cancer population. The Khorana Score is currently the primal risk assessment model to stratify oncological patients according to their susceptibility to VTE, however, it displays a limited performance. Meanwhile, intensive research on VTE pathophysiology in the general population has uncovered a range of single-nucleotide polymorphisms (SNPs) associated with the condition. Nonetheless, their predictive ability concerning cancer-associated thrombosis (CAT) is controversial. Cervical cancer (CC) patients undergoing chemoradiotherapy often experience VTE, which negatively affects their survival. Thus, aiming for an improvement in thromboprophylaxis, new thrombotic biomarkers, including SNPs, are currently under investigation. In this study, the predictive capability of haemostatic gene SNPs on CC-related VTE and their prognostic value regardless of VTE were explored. Six SNPs in haemostatic genes were evaluated. A total of 401 CC patients undergoing chemoradiotherapy were enrolled in a retrospective cohort study. The implications for the time to VTE occurrence and overall survival (OS) were assessed. CAT considerably impacted the CC patients' OS (log-rank test, P < 0.001). SERPINE1 rs2070682 (T > C) showed a significant association with the risk of CC-related VTE (CC/CT vs. TT, log-rank test, P = 0.002; C allele, Cox model, hazard ratio (HR) = 6.99 and P = 0.009), while F2 rs1799963 (G > A) demonstrated an important prognostic value regardless of VTE (AA/AG vs. GG, log-rank test, P = 0.020; A allele, Cox model, HR = 2.76 and P = 0.026). For the remaining SNPs, no significant associations were detected. The polymorphisms SERPINE1 rs2070682 and F2 rs1799963 could be valuable tools in clinical decision-making, aiding in thromboprophylaxis and CC management, respectively.

Association between changed self-rated health and the risk of venous thromboembolism in Malmö Preventive Program: a cohort study

Poor self-rated health (SRH) is associated with incident arterial cardiovascular disease in both sexes. Studies on the association between SRH and incident venous thromboembolism (VTE) show divergent results in women and no association in men. This study focuses on the association between change in SRH and incident VTE in a cohort of 11,558 men and 6682 women who underwent a baseline examination and assessment of SRH between 1974 and 1992 and a re-examination in 2002-2006. To investigate if changes in SRH over time affect the risk of incident VTE in men and women. During a follow-up time from the re-examination of more than 16 years, there was a lower risk for incident VTE among women if SRH changed from poor at baseline to very good/excellent (HR 0.46, 95% CI 0.28; 0.74) at the re-examination. Stable good SRH (good to very good/excellent at the re-examination, HR 0.60, 95% CI 0.42; 0.89), or change from good SRH at baseline into poor/fair at the re-examination (HR 0.68, 95% CI 0.51; 0.90) were all significantly associated with a reduced risk for VTE. All comparisons were done with the group with stable poor SRH. This pattern was not found among men. Regardless of a decreased or increased SRH during life, having an SRH of very good/excellent at any time point seems to be associated with a decreased risk of VTE among women.

Age-Related Differences in the Presentation, Management, and Clinical Outcomes of 100,000 Patients With Venous Thromboembolism in the RIETE Registry

INTRODUCTION

Although older adults represent a significant proportion of patients with venous thromboembolism (VTE), the data on the impact of age-related differences in the clinical presentation, management, and outcomes of VTE are scarce.

METHODS

We analyzed data from the RIETE registry database, an ongoing global observational registry of patients with objectively confirmed VTE, to compare patient characteristics, clinical presentation, treatments, and outcomes between elderly (≥70 years) vs. non-elderly (<70 years) patients.

RESULTS

From January 2001 to March 2021, 100,000 adult patients were enrolled in RIETE. Elderly patients (47.9%) were more frequently women (58.2% vs. 43.5%), more likely had unprovoked VTE (50.5% vs. 45.1%) and most often presented with severe renal failure (10.2% vs. 1.2%) and acute pulmonary embolism (PE) (vs. deep vein thrombosis) (54.3% vs. 44.5%) compared to non-elderly patients (p<0.001 for all comparisons). For the PE subgroup, elderly patients more frequently had non-low risk PE (78.9% vs. 50.7%; p<0.001), respiratory failure (33.9% vs. 21.8%; p<0.001) and myocardial injury (40.0% vs. 26.2%; p<0.001) compared to non-elderly patients. Thrombolysis (0.9% vs. 1.7%; p<0.001) and direct oral anticoagulants (8.8% vs. 11.8%; p<0.001) were less frequently administered to elderly patients. Elderly patients showed a significantly higher 30-day all-cause mortality (adjusted odds ratio [OR] 1.36, 95%CI: 1.22-1.52) and major bleeding (OR, 2.08; 95%CI, 1.85-2.33), but a lower risk of 30-day VTE recurrences (OR, 0.62, 95%CI, 0.54-0.71).

CONCLUSIONS

Compared with non-elderly patients, elderly patients had a different VTE clinical profile. Advanced therapies were less frequently used in older patients. Age was an independent predictor of mortality.

Does Atrial Septal Anatomy Still Matter in the Etiological Evaluation of Ischemic Stroke Beyond the Age of 60?

BACKGROUND

Patent foramen ovale (PFO) is causally associated with stroke in some patients younger than 60 years, especially when it is large or associated with an atrial septal aneurysm (ASA). After 60 years of age, this association is less well understood. We assessed the relationships between detailed atrial septal anatomy and the cryptogenic nature of stroke in this population.

METHODS AND RESULTS

We reviewed all patients aged 60 to 80 years admitted to our stroke center for ischemic stroke who underwent contrast echocardiography between 2016 and 2021. The atherosclerosis, small-vessel disease, cardiac pathology, other causes, and dissection (ASCOD) classification was used to reevaluate the etiological workup. Associations between cryptogenic stroke and (1) PFO presence or (2) categories of PFO anatomy (nonlarge PFO without ASA, nonlarge PFO with ASA, large PFO without ASA, and large PFO with ASA) were assessed using logistic regression. Among 533 patients (median National Institutes of Health Stroke Scale score=1), PFO was present in 152 (prevalence, 28.5% [95% CI, 24.9-32.5]). Compared with noncryptogenic stroke, cryptogenic stroke (n=218) was associated with PFO presence (44.5% versus 17.5%; P<0.0001). Among patients with a PFO, septal anatomy categories were associated with cryptogenic stroke (P=0.02), with a strong association for patients with both large PFO and ASA (38.1% versus 14.5%, P=0.002).

CONCLUSIONS

PFO presence remains strongly associated with cryptogenic stroke between 60 and 80 years of age. Large PFO, ASA, and their association were strongly associated with cryptogenic stroke in this age group. Our results support performing contrast echocardiography even after 60 years of age, although the optimal secondary prevention therapy in this population remains to be determined in randomized trials.

Sex differences in long-term outcomes of patients with deep vein thrombosis

OBJECTIVE

Sex differences in short-term outcomes of patients with deep vein thrombosis (DVT) have been reported, but differences in long-term outcomes remain poorly characterized. This study aimed to evaluate sex differences in long-term mortality, venous thromboembolism (VTE)-related mortality, and bleeding-related mortality in patients with DVT at a tertiary care center.

METHODS

A retrospective chart review from 2012 to 2018 of all consecutive patients diagnosed with DVT was performed. Patients were grouped by sex, and baseline characteristics and treatment modalities were compared. Long-term outcomes of recurrent VTE, bleeding, and related mortalities were analyzed. Multivariable regression analysis was performed to determine factors associated with overall mortality.

RESULTS

A total of 1043 (female = 521 and male = 522) patients with DVT were captured in this study period. Female patients were older (64.7 vs 61.6 years old, p = 0.01) and less likely to be obese (68.2% vs. 71.1%, p = 0.04),but had a higher average Caprini score (6.73 vs 6.35, p = 0.04). There was no difference in anatomic extent of DVT, association with PE, and severity of PE between sexes. Most patients (80.5%) were treated with anticoagulation, with no differences in choice of anticoagulant or duration of anticoagulation between females and males. Male patients were more likely to undergo catheter-directed thrombolysis (CDT) for DVT (4.2% vs 1.7%, p = 0.02) and PE (2.7% vs 0.9%, p = 0.04). Female patients were more likely to receive systemic thrombolysis for PE (2.9% vs 1.1%, p = 0.05). After an average 2.3 years follow-up, there was significantly higher bleeding complications among females (22.2% vs 16.7%, p = 0.027). The overall mortality rate was 33.5% and not different between males and females. Females were more likely to experience VTE-related mortality compared to males (3.3% vs 0.6%, p = 0.002). On regression analysis, older age (OR = 1.04 [1.03-1.06]), cancer (OR = 7.64 [5.45-10.7]), and congestive heart failure (OR = 3.84 [2.15-6.86]) were independently associated with overall mortality.

CONCLUSIONS

In this study, there was no difference in overall long-term mortality between sexes for patients presenting with DVT. However, females had increased risk of long-term bleeding and VTE-related mortality compared to males.

Hand grip strength and risk of incident venous thromboembolism: The Tromsø study

Background

Hand grip strength (HGS), a common proxy of whole‐body muscular strength, is associated with a wide range of adverse health outcomes and mortality. However, there are limited data on the association between HGS and risk of venous thromboembolism (VTE).

Objectives

We aimed to investigate the association between HGS and risk of incident VTE in a population‐based cohort.

Methods

Participants (n = 13,704) from the fourth to seventh surveys of the Tromsø study (Tromsø4–Tromsø7, enrollment: 1994–2016) were followed throughout 2020, and all incident VTEs were recorded. HGS of the nondominant hand was measured using a Martin Vigorimeter (Tromsø4–Tromsø6) and a Jamar Digital Dynamometer (Tromsø7). Hazard ratios (HRs) for VTE with 95% confidence intervals (CIs) according to weak HGS (less than 25th percentile) versus normal HGS (25th percentile or greater) were estimated using Cox regression models and adjusted for age, sex, body height, body mass index, physical activity, cardiovascular disease, and cancer.

Results

During a median of 6.5 years of follow‐up, 545 incident VTEs occurred. Participants with weak HGS had a 27% higher risk of VTE (HR, 1.27; 95% CI, 1.03–1.57) compared to those with normal HGS. Subgroup analyses revealed that the point estimates were higher for unprovoked VTE (HR, 1.35; 95% CI, 0.96–1.91) and deep vein thrombosis (DVT; HR, 1.52; 95% CI, 1.14–2.01). Similar results were found in analyses restricted to men, women, and elderly (aged greater than 75 years).

Conclusion

A weak HGS was associated with increased risk of VTE, and particularly unprovoked VTE and isolated DVT. Our findings suggest that weak muscle strength may be a risk factor for VTE.

Role of age, sex, and specific provoking factors on the distal versus proximal presentation of first symptomatic deep vein thrombosis: analysis of the SWIss Venous ThromboEmbolism Registry (SWIVTER)

We aimed to evaluate the impact of age, sex, and their interactions with provoking risk factors for deep vein thrombosis (DVT). In addition, we intended to provide additional insights on risk factors associated with the isolated distal versus proximal presentation of first symptomatic acute DVT, both being characterized by different prognosis. In the present analysis from the SWIss Venous ThromboEmbolism Registry (SWIVTER), we compared demographic and baseline characteristics in patients with isolated distal (n = 184; 35%) versus proximal (n = 346) DVT of the lower limbs without symptomatic pulmonary embolism, and identified factors related with the presenting thrombosis location. In the overall population, mean age was 59 ± 19 years, 266 (50%) were women, 106 (20%) patients had cancer, 86 (16%) recent surgery, and 52 (10%) acute infection/sepsis. In a multivariable analysis, recent surgery [odds ratio (OR) 2.92, 95% confidence interval (CI) 1.80-4.73] was independently associated with a diagnosis of isolated distal DVT, whereas cancer (OR 2.01, 95% CI 1.20-3.35), male sex aged 41 to 75 years (OR 2.21, 95% CI 1.33-3.67), and acute infection/sepsis (OR 2.71, 95% CI 1.29-5.66) with a diagnosis of proximal DVT. In SWIVTER, age, sex, and several provoking risk factors for VTE appeared to be related with the presenting location of first symptomatic DVT. Cancer, male sex, and acute infection/sepsis were associated with a proximal location of DVT, whereas recent surgery was associated with a distal presentation, likely acting as confounders for the association between thrombosis location and prognosis.

The Role of Vitamin D in the Relationship Between Gender and Deep Vein Thrombosis Among Stroke Patients

Introduction: Accumulating evidence had demonstrated that females had a higher risk of deep vein thrombosis (DVT) than males, but the mechanism was still unknown. Vitamin D was found to play an essential role in DVT, and gender may influence the serum vitamin D levels. This study aimed to explore whether vitamin D played a role in the gender difference in DVT.

Materials and Methods: A total of 444 patients with acute stroke were recruited, which were divided into the DVT group (n = 222) and the non-DVT group (n = 222). Serum vitamin D levels were measured after admission and were split into three categories, including deficiency (<50 nmol/L), insufficiency (52.5–72.5 nmol/L), and sufficiency (more than 75 nmol/L). Hierarchical regression analysis was adopted to analyze the relationship between gender and DVT, controlling the confounding factors.

Results: Females showed a higher proportion of DVT than males (60.7 vs. 42.5%, p < 0.001), and lower serum vitamin D levels than males (53.44 ± 16.45 vs. 69.43 ± 23.14, p < 0.001). Moreover, serum vitamin D levels were lower in the DVT group than in the non-DVT group (59.44 ± 19.61 vs. 66.24 ± 23.86, p < 0.001). Besides, the DVT group showed a lower proportion of vitamin D sufficiency than the non-DVT group (21.2 vs. 32.9%, p < 0.05). Hierarchical regression analysis showed that females had 2.083-fold (p < 0.001, unadjusted model) and 1.413-fold (p = 0.155, adjusted model) risk to develop DVT. In addition, the sufficiency status of vitamin D showed an independent protective effect on DVT (unadjusted model OR, 0.504, p = 0.004; adjusted model OR, 0.686, p = 0.011).

Conclusion: Females had a higher risk of DVT than males, and vitamin D may play an essential role in this relationship. Further studies are needed to explore whether vitamin D supplementation could reduce DVT risk in stroke patients, especially females.

[Features of pulmonary thromboembolism in women]

Pulmonary artery embolism (PAE) is usually a diagnosis of exclusion. Verification of a more common pathology takes time, which may become critical for treatment of pulmonary embolism and saving the patient's life. Since PAE is an acute disease, the time window for medical care largely determines the prognosis. Therefore, the differential diagnostic process should include thromboembolism already at the first visit. It is important to determine risk factors for PAE taking into account the patient's personality and gender. Obtained data may help the physician to determine quickly the expedience of visualizing studies, such as ventilation/perfusion scintigraphy, angiopulmonography, computed tomographic angiopulmonography. For women, it is important to collect specific information, such as the presence of large uterine fibroids, use of combined oral contraceptives or hormonal replacement therapy; to ask how long ago the patient had pregnancy and delivery, whether she has thrombophilia or oncological diseases.

Sex Differences in Chronic Thromboembolic Pulmonary Hypertension. Treatment Options over Time in a National Referral Center

(1) Background: Clinical presentation, disease distribution, or treatment received may provide insights into the reasons contributing to sex differences in chronic thromboembolic pulmonary hypertension (CTEPH). (2) Methods: We evaluated 453 patients (56% women) between 2007-2019. Data was collected from REHAP (Registro Español de Hipertensión Arterial Pulmonar) registry. Two time periods were selected to evaluate the influence of new treatments over time. (3) Results: Women were older. Baseline functional class was worse, and distance walked shorter in women compared with men. Women had higher pulmonary vascular resistances. Despite this, pulmonary endarterectomy (PEA) was carried out in more men, and women received more frequently pulmonary vasodilators exclusively. The 2014-2019 interval was associated with a better survival only among women. Interestingly, women had a more distal disease during this second period of time. (4) Conclusions: Even though women were older, and received invasive treatments less frequently, mortality was similar in both sexes. The introduction of balloon pulmonary angioplasty and the improvement of pulmonary endarterectomy, especially during the last years, could be associated with a survival benefit among women.

Incidence of Venous Thromboembolism and Effect of Anticoagulant Dosing in Hospitalized COVID-19 Patients

Background

Coronavirus disease 2019 (COVID-19) is characterized by coagulopathy and thrombotic events. We examined factors associated with development of venous thromboembolism (VTE) in COVID-19 and to discern if higher dose of anticoagulation was beneficial in these patients.

Methods

This study involves an observational study of prospectively collected data in the setting of a large community hospital in a rural setting in Northeast Georgia with COVID-19 between March 1, 2020 and February 5, 2021. Anticoagulation dose (none, standard, intermediate, and therapeutic dosages) was studied in adult patients (≥ 18 years). We constructed multivariable logistic regression model to examine the association of clinical characteristics with VTE. To examine the effect of dose of anticoagulation in preventing VTE, we used inverse probability weighted regression adjustment.

Results

Of the 4,645 patients with COVID-19, 251 (5.4%) patients were found to have VTE. Of these, 91 had pulmonary embolism, 148 had deep venous thrombosis (DVT) and 12 had both. A total of 129 of VTE cases were diagnosed at admission. Of all admissions, 12.9% did not receive any DVT prophylaxis, 70.4% received prophylactic dose, 1.3% received intermediate dose and 15.5% received therapeutic dose. Male gender (odds ratio (OR): 1.55, 95% confidence interval (CI): 1.0 - 2.4, P = 0.04) and Black race (OR: 2.0, 95% CI: 1.2 - 3.4, P = 0.01), along with higher levels of lactate dehydrogenase (LDH) and D-dimer were associated with higher odds of developing VTE. Patients receiving steroids had lower rates of VTE (3.9% vs. 8.3%, P < 0.001). Use of intermediate or therapeutic anticoagulation was not associated with lower odds of developing VTE. However, patients on therapeutic anticoagulation had lower odds of in hospital mortality when compared to standard dose (OR: 0.47, 95% CI: 0.27 - 0.80, P = 0.006).

Conclusions

In COVID-19, D-dimer and LDH can be useful in predicting VTE. Steroids appear to have some protective role in development of VTE. Therapeutic anticoagulation did not result in lower rates of VTE but was associated with in-hospital mortality.

Uric acid played a role in the association between gender and deep vein thrombosis in patients with stroke

BACKGROUND AND AIMS

Gender-specific differences were found in serum uric acid (SUA) levels and the risk of isolated distal deep vein thrombosis (IDDVT). This study aimed to explore the association among gender, SUA, and IDDVT in stroke patients.

METHODS AND RESULTS

Finally, 3404 patients were recruited and divided into two groups: IDDVT (n = 1233) and Non-IDDVT (n = 2171) groups. Propensity score matching (PSM) was conducted to match the patients. Binary logistic regression was adopted to explore the association between SUA and IDDVT, with the SUA divided into quartiles. After PSM, 975 patients were included in each group. Non-IDDVT group had a larger proportion of male than IDDVT group (64.9% vs. 52.7%, p < 0.001). Moreover, males showed higher SUA levels than females (316.7 ± 102.1 vs. 261.8 ± 94.0 μmol/L, t = 12.1, p < 0.001). The highest quartile of SUA (≥346 μmol/L) showed a lower risk of IDDVT (OR = 0.629, p = 0.001), while the lowest quartile (≤225 μmol/L) showed a higher risk of IDDVT (OR = 1.361, p = 0.022).

CONCLUSION

In patients with stroke, SUA played a protective role in IDDVT. Females had a higher risk of IDDVT, which may be owing to the lower SUA levels than males. In clinical practice, more attention should be paid to the risk of IDDVT in females, especially those with lower SUA levels.

Deep venous thrombosis in patients with neurological diseases: A multicenter, prospective study

OBJECTIVE

Patients with neurological diseases are liable to develop deep venous thrombosis (DVT) due to various factors. We investigated the prevalence, related factors, and prognosis of DVT in patients with neurological diseases.

METHODS

Patients admitted to four hospitals due to neurological diseases were prospectively recruited. Those with cerebrovascular diseases were excluded. To screen for DVT, ultrasonography was performed in patients with possible DVT risk, such as D-dimer > 1.0 µg/dL, recent surgery, active malignant diseases, recent bone fracture, decreased activity, or treatment with immunoglobulin or steroid therapy. Clinical characteristics were compared between patients with and without DVT.

RESULTS

A total of 106 patients (54 women, median 71 years old) were included. DVT was detected in 27 patients (26.0%) at the first assessment. All had DVT only in the calf; encephalopathy/meningitis (n = 4, 40.0%) had the highest prevalence of DVT among the underlying neurological diseases, followed by parkinsonian syndrome (n = 6, 37.5%). Independent predictors for DVT detection were malignant diseases (odds ratio, 11.7; 95% confidence interval, 1.0-301.4), modified Rankin Scale score ≥ 4 (5.4; 1.9-16.6), and D-dimer ≥ 2.0 µg/dL (5.7; 2.1-16.7). Ten patients were treated with anticoagulants, and no patients developed a symptomatic pulmonary embolism. No clinically evident pulmonary embolisms, systemic embolisms, or severe bleeding complications were observed in patients with DVT.

CONCLUSIONS

Asymptomatic DVT is not rare in patients with neurological diseases, especially in those with malignancy, decreased activity, or elevated D-dimer. The overall prognosis is favorable, but the potential risk of development of a pulmonary embolism should be recognized.

Metabolic Syndrome Increases Risk of Venous Thromboembolism Recurrence after Acute Pulmonary Embolism

Rationale: Metabolic syndrome (MetS), the clinical clustering of hypertension, dyslipidemia, insulin resistance, and abdominal obesity, has been associated with a prothrombotic and hypofibrinolytic state, although data linking MetS with venous thromboembolism (VTE) remain limited.Objectives: The aim of this study was to measure the prevalence of MetS in patients with pulmonary embolism (PE) across a large population and to examine its impact on VTE recurrence.Methods: This was a retrospective, population-based analysis using deidentified information from a large statewide database, the Indiana Network for Patient Care. All patients with an International Classification of Diseases-defined diagnosis of PE from 2004 to 2017 were included. We measured the frequency with which patients with PE carried a comorbid diagnosis of each MetS component. Multiple logistic regression analysis was performed with VTE recurrence as the dependent variable to test the independent effect of MetS diagnosis, with a statistical model using a directed acyclic graph to account for potential confounders and mediators. Kaplan-Meier curves were constructed to compare rates of VTE recurrence over time based on the presence or absence of MetS and its individual components.Results: A total of 72,936 patients were included in this analysis. The most common MetS component was hypertension with a prevalence of 59%, followed by hyperlipidemia (41%), diabetes mellitus (24%), and obesity (22%). Of these patients, 69% had at least one comorbid component of MetS. The overall incidence of VTE recurrence was 17%, increasing stepwise with each additional MetS component and ranging from 6% in patients with zero components to 37% in those with all four. Logistic regression analysis yielded an adjusted odds ratio of 3.03 (95% CI, 2.90-3.16) for the effect of composite diagnosis requiring at least three of the four components of MetS diagnosis on VTE recurrence.Conclusions: The presence of comorbid MetS in patients with PE is associated with significantly higher rates of VTE recurrence, supporting the importance of recognizing these risk factors and initiating appropriate therapies to reduce recurrence risk.

Sex-specific differences in the presentation, clinical course, and quality of life of patients with acute venous thromboembolism according to baseline risk factors. Insights from the PREFER in VTE

INTRODUCTION

Sex and the presence of specific provoking risk factors, along with age, influence the presentation and prognosis of venous thromboembolism (VTE). We investigated the presentation, course and quality of life in women and men with acute VTE classified according to their VTE provoking factors.

METHODS

PREFER in VTE is an international, non-interventional registry of patients with a first episode of acute symptomatic VTE. Baseline provoking factors were classified as follows: major transient, minor transient, active cancer, and none identifiable. The primary outcome was recurrent VTE. Quality of life and treatment satisfaction were secondary outcomes.

RESULTS

Of 3,455 patients with acute VTE, 1,623 (47%) were women. The mean age at the time of VTE was 61 (SD 18) in women, 60 (SD 15) in men. The distribution of provoking risk factors was similar between sexes, despite a tendency for higher frequency of minor and major transient risk factors in women, and cancer or unprovoked VTE in men. At 12-month follow-up, VTE recurrence was reported in 74 (6.5%) women and 80 (6.4%) men (absolute risk difference -0.1%, 95% CI -1.9%; +2.1%). In patients with unprovoked VTE, the VTE recurrence rate was 38/612 (6.2%) in women and 53/798 (6.6%) in men (absolute risk difference -0.4, 95% CI -3.0; +2.1%). Multivariable Cox regressions confirmed the absence of sex differences. Quality of life and treatment satisfaction scores one year after VTE were lower in women than in men irrespective of the provoking risk factors (p<0.001 for both scores).

CONCLUSIONS

Despite differences in the provoking risk factors for VTE, women and men had a similar rate VTE recurrence at one year. After acute VTE, women had lower quality of life and treatment satisfaction scores.

Profile of Patients with Isolated Distal Deep Vein Thrombosis versus Proximal Deep Vein Thrombosis or Pulmonary Embolism: RE-COVERY DVT/PE Study

Isolated distal deep vein thrombosis (IDDVT) is presumed to be more benign than proximal DVT (PDVT) or pulmonary embolism (PE), suggesting a need for different management approaches. This subgroup analysis of the RE-COVERY DVT/PE global, observational study investigated patient characteristics, hospitalization details, and anticoagulant therapy in patients with IDDVT in real-world settings in 34 countries enrolled from January 2016 to May 2017. Data were analyzed descriptively according to the type and location of the index venous thromboembolism (VTE): IDDVT, PDVT ± distal DVT (DDVT), and PE ± DVT. Of the 6,095 eligible patients, 323 with DVT located outside the lower limb and no PE were excluded. Of the remaining 5,772 patients, 17.6% had IDDVT, 39.9% had PDVT ± DDVT, and 42.5% had PE ± DVT. IDDVT patients were younger and had fewer risk factors for VTE than the other groups. Other comorbidities were less frequent in the IDDVT group, except for varicose veins, superficial thrombophlebitis, and venous insufficiency. IDDVT patients were less likely to be diagnosed in an emergency department (22.3 vs. 29.7% for PDVT ± DDVT and 45.4% for PE ± DVT) or hospitalized for VTE (29.2 vs. 48.5% for PDVT ± DDVT and 75.0% for PE ± DVT). At hospital discharge or 14 days after diagnosis (whichever was later), non-vitamin K antagonist oral anticoagulants were the most commonly used anticoagulants (55.6% for IDDVT, 54.7% for PDVT ± DDVT, and 52.8% for PE ± DVT). Although differences in patient characteristics, risk factors, and clinical management were identified, anticoagulant treatment of IDDVT was almost equal to that of PDVT or PE. Prospective studies should investigate whether, in a global perspective, this is an appropriate use of anticoagulants. TRIAL REGISTRATION NUMBER:  ClinicalTrials.gov NCT02596230.

A risk score for iliofemoral patients with deep vein thrombosis

OBJECTIVE

Deep vein thrombosis (DVT) is a common condition with a high risk of post-thrombotic morbidity, especially in patients with a proximal thrombus. Successful iliofemoral clot removal has been shown to decrease the severity of post-thrombotic syndrome. It is assumed that earlier thrombus lysis is associated with a better outcome. Generally, the earlier IFDVT is confirmed, the earlier thrombus lysis could be performed. d-Dimer levels and Wells score are currently used to assess the preduplex probability for DVT; however, some studies indicate that the d-dimer value varies depending on the thrombus extent and localization. Using d-dimer and other risk factors might facilitate development of a model selecting those with an increased risk of IFDVT that might benefit from early referral for additional analysis and adjunctive iliofemoral thrombectomy.

METHODS

All consecutive adult patients from a retrospective cohort of STAR diagnostic center (primary care) in Rotterdam suspected of having DVT between September 2004 and August 2016 were assessed for this retrospective study. The diagnostic workup for DVT including Wells score and d-dimer were performed as well as complete duplex ultrasound examination. Patients with objective evidence of DVT were categorized according to thrombus localization using the Lower Extremity Thrombolysis classification. Logistic regression analysis was done for a model predicting IFDVT. The cut-off value of the model was determined using a receiver operating characteristic curve.

RESULTS

A total of 3381 patients were eligible for study recruitment, of whom 489 (14.5%) had confirmed DVT. We developed a multivariate model (sensitivity of 77% and specificity of 82%; area under the curve, 0.90; 0.86-0.93) based on d-dimer, Wells score, age, and anticoagulation use, which is able to distinguish IFDVT patients from all patients suspected of DVT.

CONCLUSIONS

This multivariate model adequately distinguishes IFDVT among all suspected DVT patients. Practically, this model could give each patient a preduplex risk score, which could be used to prioritize suspected IFDVT patients for an immediate imaging test to confirm or exclude IFDVT. Further validation studies are needed to confirm potential of this prediction model for IFDVT.

Epidemiology and 3-year outcomes of combined oral contraceptive-associated distal deep vein thrombosis

BACKGROUND

Distal deep vein thrombosis (infrapopliteal DVT without proximal DVT or pulmonary embolism [PE]) generally shares the same triggering risks factors as proximal DVT. In women of childbearing age, a frequent triggering risk factor is the use of combined oral contraceptive (COC) pills. However, data on the epidemiology and long-term outcomes of COC-associated distal DVT are lacking.

OBJECTIVES

To assess the epidemiology and long-term outcomes of COC-associated distal DVT.

METHODS

Using data from the OPTIMEV (Optimisation de l'Interrogatoire dans l'évaluation du risque thrombo-Embolique Veineux [Optimization of Interrogation in the Assessment of Thromboembolic Venous Risk]) multicenter cohort study of patients with objectively confirmed venous thromboembolism (VTE) enrolled between 2004 and 2006, we assessed in nonpregnant or postpartum women aged ≤ 50 years without cancer or history of VTE (i) proportion of COC-associated distal DVTs among women with distal DVTs and among women with COC-associated VTEs (distal DVT, proximal DVT, or PE) and (ii) 3-year incidence of death, bleeding, and VTE recurrence.

RESULTS

COC-associated distal DVTs (n = 54) represented 43.9% of all distal DVTs and 51.9% of COC-associated VTEs. All but one woman with a COC-associated distal DVT received therapeutic anticoagulation for a median of 3 months. At 3-year follow-up, all women with COC-associated distal DVTs were alive, and none had bled during anticoagulant treatment or had experienced a DVT or PE recurrence after stopping anticoagulants. Similar results were found in patients with COC-associated proximal DVT and PE: The VTE recurrence rate was 1.7% per patient-year (PY) and 0% PY, respectively, and there were no deaths or major bleeds in either group.

CONCLUSIONS

Distal DVT was the most frequent clinical presentation of COC-associated VTE and had similarly favorable long-term outcomes as other COC-associated VTE.

Development and validation of an informative manual on venous thromboembolism for the lay population

Objective

To develop an informative manual on venous thromboembolism prevention for the lay population and to estimate evidences of content and face validity.

Methods

A methodological study conducted in three stages. The first stage was the preparation of the manual, followed by content validation with cardiovascular specialists who judged clarity, theoretical relevance and practical pertinence on a 4-point Likert scale. Items with a content validity index ≤0.75 were revised and re-evaluated. The last stage was the face validation by lay people, who were interviewed regarding item understanding and visual appearance. Items with more than 80.0% positive opinions were considered adequate.

Results

The manual was developed containing nine illustrations, definition of the disease, risk factors, signs and symptoms, and preventive measures. In the first assessment round, the validity index was 1.0 for the text of all sections, with suggestions for language adjustments. As to the illustrations, the validity indexes ranged from 0.67 to 1.0. In the second round, the validity index reached 1.0 for all items. A total of 40 lay people participated in the face validation, and all considered the paper type and font size appropriate, as well as the font used as readable; 97.5% were able to understand the information contained in the manual; 98.0% considered it esthetically beautiful; and 90.0% considered the reading not tiresome.

Conclusion

The informative manual on venous thromboembolism prevention was prepared, its content validated by experts, and considered appropriate by the lay population. These results suggest that the manual may be used as a preventive educational strategy for venous thromboembolism.

Prevalence and associations of incidental nonvenous duplex findings discovered during lower extremity venous imaging

OBJECTIVE

Venous duplex imaging defines venous pathology (VP). Unexpected clinically relevant findings are also found but rarely mentioned in the literature. This study aims to define the prevalence of ancillary findings (nonvenous duplex) by study type and venous outcome and subgroup associations with primary study indication and risk factors.

METHODS

Our vascular laboratory database was queried for lower extremity venous duplex studies with comments regarding ancillary findings and associated patient demographics, primary study indication, associated conditions, and venous study outcome.

RESULTS

There were 52,215 venous studies performed, 48,425 to evaluate for venous occlusion (acute/chronic) and 3790 for venous reflux. Of these studies, 15,810 found VP and 36,405 found no venous disease. There were 875 studies with venous disease that had ancillary duplex findings (5.5%) noted as 559 (3.5%) with prominent lymph node(s) (LN), 179 (1.1%) Baker's cyst (BC), 44 (0.3%) hematoma/mass (HM), 31 (0.2%) arterial aneurysm, and 16 (0.1%) arterial occlusion. There were 3130 studies free of VP with ancillary findings (8.6%) noted as 2258 (6.2%) prominent LN(s), 626 (1.7%) BC, 156 (0.4%) HM, 37 (0.1%) arterial aneurysm, and 22 (0.06%) arterial occlusion. The overall prevalence of ancillary findings was 8.62%. Analysis demonstrated statistically more ancillary findings in venous occlusion (odds ratio [OR], 1.25) studies, which was the largest group at 13 to 1. Studies free of venous disease had more ancillary findings (P < .001) with an OR of 1.88 and similar results were noted for LN(s), BC, and hematoma. Studies with VP favored a finding of aneurysm (OR, 0.52). Subgroup analyses demonstrated that those with prominent LN(s) were statistically older and male and BC statistically older in those with coexistent venous disease. BC subgroup analysis showed that studies free of venous disease were 2.5 times more likely to report pain as the primary study indication (P < .0001). In general, within ancillary subgroups, leg symptoms were statistically more prominent on the side with ancillary pathology and free of venous disease.

CONCLUSIONS

Ancillary findings are not uncommon and are more common in studies found free of VP. The most common are LNs, BC and HM and, within subgroups, significant leg symptoms favors the presence of ancillary findings without coexisting venous disease. Ancillary findings should be an integral part of a quality report.

Association between obesity and venous thromboembolism

Background and aims

Obesity is associated with numerous pathological conditions, including venous thromboembolism (VTE). VTE is a multifactorial disease; more than half of the hospitalized patients are at risk for VTE.

We aimed to assess the risk of VTE associated with obesity, taking into account the class of obesity (according to the body mass index), gender, age and the intervention of other acquired risk factors.

Methods

A case-control study including 732 patients was designed. Collected data included: age, gender, body mass index, pregnancy/postpartum state, use of hormonal therapy, personal and family history of VTE, smoking, prolonged immobilization and the presence of comorbidities - acquired risk factors for VTE. The risk of VTE was expressed as odds ratio (OR) with 95% confidence interval. Multiple logistic regression analysis was used to detect the independent risk factors. P value <0.05 was considered significant statistic.

Results

Obesity was associated with a 6.2-fold increased risk for VTE. The risk of VTE associated with obesity was highest in patients aged >50 years and in cases included in classes II and III of obesity. The interaction between obesity and another acquired risk factor has almost doubled the risk of VTE. Multivariate logistic regression analysis showed obesity as an independent risk factor for VTE for both female and male patients.

Conclusions

Obesity is an independent and moderate risk factor for VTE. The risk increases with body mass index, age and the presence of other acquired risk factors.

Experience of a 40-day (6 week) LMWH treatment for isolated distal deep vein thrombosis

Clinical significance of distal deep vein thrombosis (DVT) is important as it can potentially result in pulmonary embolism (PE), DVT extension, DVT recurrence and post-thrombotic syndrome (PTS). Controversy remains about the necessity and modalities of anticoagulation in all distal DVT. Evaluation of the efficiency of a 40-day weight-based low molecular weight heparin (LMWH) treatment in a cohort of 119 consecutive patients with distal DVT. Compression ultrasonography of the lower limb was performed initially for diagnosis as well as at the end of the treatment to identify persistence or resolution of the blood clot. A 3-month follow-up estimated the rates of PE, DVT recurrence, DVT extension, PTS and bleeding. Risk factors for DVT were considered to evaluate a possible correlation between them and the outcomes. In 71.4% of the patients the blood clot was totally dissolved and thrombus persistence was statistically associated with the number of initially involved veins. DVT recurrence occurred in 5% of patients and was also associated with the number of initial clotted veins. DVT extension and PTS rates were present in 1.7% and 3.4% respectively and no patient was diagnosed with PE or bleeding. This retrospective study including a limited number of patients and no control group supports that a 40-day weight-based LMWH treatment after distal DVT seems to be efficient when one single vein is initially affected whereas for multiple vein distal DVT and to avoid potential DVT recurrence, longer than 6 weeks of anticoagulant treatment is required. Our results support safety of the treatment, its potential to prevent DVT extension and the occurrence of PE.

Optimal management of hormonal contraceptives after an episode of venous thromboembolism

Optimal management of hormonal contraception in patients with venous thromboembolism (VTE) requires an individualized approach considering its potential benefits and complications during and after anticoagulant treatment. Potential benefits include prevention of pregnancy and mitigation of menstrual bleeding that is often worsened after start of anticoagulation therapy. Current evidence suggests that patients may opt for a continuation of (all forms of) hormonal contraception during anticoagulant treatment, provided that they are adequately informed by the treating physicians. Combined oral contraceptives should be stopped before anticoagulant therapy may be discontinued, preferably after the second last menstrual cycle of the intended anticoagulant treatment period. If hormonal contraceptive treatment needs to be initiated in patients with a history of VTE, oral prostagen-only therapy or intra-uterine devices are to be preferred: this may be independent of the anticoagulation status and in light of a negligible risk of (recurrent) VTE associated with their use.

Sex-specific differences in chronic thromboembolic pulmonary hypertension. Results from the European CTEPH registry

BACKGROUND

Women are more susceptible than men to several forms of pulmonary hypertension, but have better survival. Sparse data are available on chronic thromboembolic pulmonary hypertension (CTEPH).

METHODS

We investigated sex-specific differences in the clinical presentation of CTEPH, performance of pulmonary endarterectomy (PEA), and survival.

RESULTS

Women constituted one-half of the study population of the European CTEPH registry (N = 679) and were characterized by a lower prevalence of some cardiovascular risk factors, including prior acute coronary syndrome, smoking habit, and chronic obstructive pulmonary disease, but more prevalent obesity, cancer, and thyroid diseases. The median age was 62 (interquartile ratio, 50-73) years in women and 63 (interquartile ratio, 53-70) in men. Women underwent PEA less often than men (54% vs 65%), especially at low-volume centers (48% vs 61%), and were exposed to fewer additional cardiac procedures, notably coronary artery bypass graft surgery (0.5% vs 9.5%). The prevalence of specific reasons for not being operated, including patient's refusal and the proportion of proximal vs distal lesions, did not differ between sexes. A total of 57 (17.0%) deaths in women and 70 (20.7%) in men were recorded over long-term follow-up. Female sex was positively associated with long-term survival (adjusted hazard ratio, 0.66; 95% confidence interval, 0.46-0.94). Short-term mortality was identical in the two groups.

CONCLUSIONS

Women with CTEPH underwent PEA less frequently than men, especially at low-volume centers. Furthermore, they had a lower prevalence of cardiovascular risk factors and were less often exposed to additional cardiac surgery procedures. Women had better long-term survival.

Systemic and Local Factors’ Influence on the Topological Differences in Deep Vein Thrombosis

Background and Objectives: Deep vein thrombosis (DVT) is a common cause of intra-hospital morbidity and mortality, and its most severe complication is pulmonary thromboembolism. The risk factors that influence the apparition of DVT are generally derived from Virchow’s triad. Since the most severe complications of DVT occur in proximal rather than distal deep vein thrombosis, the aim of this study was to identify the factors influencing the apparition of proximal DVT. Materials and Methods: This was a transversal, cohort study. The study included 167 consecutive patients with lower limb DVT over a two-year period. The following data were recorded or determined: general data, conditions that are known to influence DVT, medical history and coagulation or thrombophilia-related genetic variations. Results: In the univariate analysis, male gender, neoplasia, previous DVT and mutated factor V Leiden were all associated with proximal DVT, while bed rest was associated with distal DVT. In the multivariate analysis, male gender, previous DVT and factor V Leiden mutation were independently correlated with proximal DVT, while bed rest was independently associated with distal deep vein thrombosis. Conclusion: Our observations point out that the factors indicating a systemic involvement of coagulation were correlated with proximal DVT, while local factors were associated with distal DVT.

Venous thromboembolism in young adults: Findings from the RIETE registry

BACKGROUND

Little is known on the clinical characteristics, risk factors and outcomes during anticoagulation in young patients with acute venous thromboembolism (VTE).

METHODS

We used data from the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry to assess the clinical characteristics, risk factors and outcomes during anticoagulation in VTE patients aged 10-24 years. Data were separately analyzed according to initial presentation and gender.

RESULTS

Of 76,719 patients with VTE, 1571 (2.0%) were aged 10-24 years. Of these, 989 (63%) were women and 669 (43%) presented with pulmonary embolism (PE). Most women were using estrogens (680, 69%) or were pregnant (101, 10%), while 59% of men had unprovoked VTE. Women were more likely to present with PE (48% vs. 34%). The majority (87%) of PE patients had Sat O₂ levels ≥90% at baseline. The vast majority (97%) of PE patients were at low risk according to the PESI score, many (90%) at very low risk. During the course of anticoagulation (median, 192 days), 40 patients had VTE recurrences, 17 had major bleeding and 10 died (3 died of PE). Women had as many VTE recurrences as major bleeds (15 vs. 14 events), while men had many more VTE recurrences than major bleeding (25 vs. 3 events).

CONCLUSIONS

VTE is associated with low risk of short-term mortality in young adults. Noticeable gender differences exist in the risk factor profile and the risk of VTE recurrences and major bleeding in the course of anticoagulation.

Recurrence Risk after First Symptomatic Distal versus Proximal Deep Vein Thrombosis According to Baseline Risk Factors

Background  It remains unclear whether the distal location of deep vein thrombosis (DVT) is independently associated with a lower risk of recurrence in all patients, or represents a marker of the presence and severity of provoking factors for venous thromboembolism (VTE).

Methods  We investigated the impact of distal (vs. proximal) DVT location on the risk of developing symptomatic, objectively confirmed recurrent VTE in 831 patients with a first acute symptomatic DVT not associated with pulmonary embolism (PE), who were stratified by the presence of transient or persistent risk factors at baseline. The primary outcome was symptomatic, objectively diagnosed recurrent VTE, including proximal DVT and PE.

Results  A total of 205 (24.7%) patients presented with a transient risk factor, 189 (22.7%) with a minor persistent risk factor, 202 (24.3%) with unprovoked DVT, and 235 (28.3%) with cancer-associated DVT. One-hundred twenty-five patients (15.0%) experienced recurrent DVT or PE. The largest relative difference between patients with distal (vs. proximal) DVT was observed in the absence of identifiable risk factors (adjusted hazard ratio [aHR]: 0.11; 95% CI [confidence interval]: 0.03–0.45). In patients with cancer, distal and proximal DVT had a comparable risk of recurrence (aHR: 0.70; 95% CI: 0.28–1.78]).

Conclusions  The distal (vs. proximal) location of first acute symptomatic DVT represented, in the absence of any identifiable transient or persistent risk factors, a favorable prognostic factor for recurrence. In contrast, the prognostic impact of DVT location was weaker if persistent provoking risk factors for VTE were present, notably cancer.