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Yamashita T, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Ikeda T, Mo M, Yamazaki T, Okumura Y, Hirayama A. Clinical Outcome After Discontinuation of Anticoagulation Therapy in Japanese Patients With Venous Thromboembolism ― Insights From the J’xactly Study ―. Circ Rep 2022; 4:371-377. [PMID: 36032386 PMCID: PMC9360983 DOI: 10.1253/circrep.cr-22-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Rivaroxaban, a direct oral anticoagulant, is used as first-line treatment to prevent venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). However, the frequency of rivaroxaban discontinuation and the subsequent clinical outcomes remain unclear. Methods and Results: The study was a subanalysis of the prospective, multicenter, observational J’xactly study, conducted in Japan, and included patients who underwent anticoagulant discontinuation without major bleeding and recurrent VTE. The modified intention-to-treat population (n=1,016) included 579 patients (57%) who underwent anticoagulant discontinuation during a mean follow-up period of 20.2 months (mean [±SD] anticoagulation period 6.9±6.2 months). Patients were divided into 3 groups: those with active cancer, those without active cancer and a transient risk factor for VTE, and those without active cancer or a transient risk factor and/or with previous VTE (unprovoked group). After discontinuation, VTE recurrence occurred in 4.1% of patients, with an annual incidence of 4.6%/year and an increased tendency in the unprovoked group; major bleeding occurred in 8 patients (1.4%; annual incidence 1.1%/year), of whom half were in the cancer group. Conclusions: This analysis of a real-world observational study provides data on VTE recurrence after rivaroxaban discontinuation, which will facilitate anticoagulant discontinuation according to individual risk-benefit considerations.
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Affiliation(s)
| | - Ikuo Fukuda
- Department of Cardiovascular Surgery, Suita Tokushukai Hospital
| | | | | | | | - Hideaki Maeda
- Division of Cardiovascular Surgery, Nihon University School of Medicine
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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Dorsey S, Ahmed F. Developments in distinguishing secondary vascular headache from primary headache disorders in clinical practice. Expert Rev Neurother 2021; 21:1357-1369. [PMID: 34553658 DOI: 10.1080/14737175.2021.1984882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Vascular headaches are secondary headache disorders with potentially devastating consequences if missed. Clinicians often struggle to distinguish these from primary headache disorders whereby there is no underlying structural pathology. Here, the authors describe the advancement in our understanding of vascular headache disorders, their clinical presentation and the developments in neuroimaging that facilitate diagnosis. AREAS COVERED Here the authors discuss the definition of primary and secondary headache disorders. They review the literature on the presentation, choice of neuroimaging and diagnostic tools that can be used to diagnose specific vascular headaches including Carotid or Vertebral artery dissection, Stroke, Temporal Arteritis, subarachnoid hemorrhage, cerebral venous thrombosis, Reversible Cerebral Vasoconstriction syndrome, Primary angiitis, AV malformation and Genetic vasculopathy. The authors discuss the influence of Covid-19 on the management of patients with headache. EXPERT OPINION Whilst developments in neuroimaging have been of paramount importance in the diagnosis of vascular headache disorders, there is no substitute for meticulous history taking and examination. Research has aided our understanding of clinical presentation, however further studies are needed as well as increased education of neurologists and acute physicians.
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Affiliation(s)
- Sophie Dorsey
- Department of Neurology, Hull University Teaching Hospitals, Hull, UK
| | - Fayyaz Ahmed
- Department of Neurology, Hull University Teaching Hospitals, Hull, UK.,Department of Neurosciences, Hull York Medical School, Hull, UK
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Diagnosis and Exclusion of Pulmonary Embolism. Thromb Res 2018; 163:207-220. [DOI: 10.1016/j.thromres.2017.06.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/30/2017] [Accepted: 06/05/2017] [Indexed: 12/21/2022]
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Franchini M, Dentali F. Recurrent venous thromboembolism: a role for ABO blood group? Thromb Haemost 2017; 110:1110-1. [DOI: 10.1160/th13-09-0780] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/02/2013] [Indexed: 11/05/2022]
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Riva N, Donadini MP, Ageno W. Epidemiology and pathophysiology of venous thromboembolism: similarities with atherothrombosis and the role of inflammation. Thromb Haemost 2017; 113:1176-83. [DOI: 10.1160/th14-06-0563] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 10/30/2014] [Indexed: 01/10/2023]
Abstract
SummaryVenous thromboembolism (VTE) is a multifactorial disease. Major provoking factors (e. g. surgery, cancer, major trauma, and immobilisation) are identified in 50–60 % of patients, while the remaining cases are classified as unprovoked. However, minor predisposing conditions may be detectable in these patients, possibly concurring to the pathophysiology of the disease, especially when co-existing. In recent years, the role of chronic inflammatory disorders, infectious diseases and traditional cardiovascular risk factors has been extensively investigated. Inflammation, with its underlying prothrombotic state, could be the potential link between these risk factors, as well as the explanation for the reported association between arterial and venous thromboembolic events.
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Chang WT, Chang CL, Ho CH, Hong CS, Wang JJ, Chen ZC. Long-Term Effects of Unprovoked Venous Thromboembolism on Mortality and Major Cardiovascular Events. J Am Heart Assoc 2017; 6:JAHA.117.005466. [PMID: 28468786 PMCID: PMC5524092 DOI: 10.1161/jaha.117.005466] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background Patients with unprovoked venous thromboembolism (VTE) are at an increased risk of mortality, but whether their cardiovascular risks also increase remains to be determined. We aimed to investigate the factors associated with overall mortality and major adverse cardiovascular events in patients with unprovoked VTE. Methods and Results We identified 2154 patients newly diagnosed with unprovoked VTE from Taiwan's National Health Insurance Database between 2000 and 2013, excluding those with reversible etiologies, underlying cancer, or autoimmune diseases. These patients with VTE were compared with an age‐, sex‐, and cardiovascular risk‐matched cohort of 4308 controls. The risk of mortality and major adverse cardiovascular events in patients with VTE was 2.23 (CI, 1.93–2.57; P<0.0001) and 1.86 (CI, 1.65–2.09; P<0.0001) times, respectively, higher than that of the conditions in controls. These events mostly occurred during the first year after the diagnosis of unprovoked VTE. Among patients with VTE, advanced age, male sex, and comorbid diabetes mellitus indicated a higher incidence of mortality and major adverse cardiovascular events. Conversely, comorbid hyperlipidemia attenuated these risks. Conclusions This nation‐wide cohort study revealed that patients with unprovoked VTE, particularly older males with diabetes mellitus, had an elevated risk of both mortality and cardiovascular events. Risk of mortality and major adverse cardiovascular events were highest within the first year after diagnosis and persisted during the 10 years of follow‐up.
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Affiliation(s)
- Wei-Ting Chang
- Department of Cardiology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Chia-Li Chang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.,Department of Healthcare Administration and Medical Informatics, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.,Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Chon-Seng Hong
- Department of Cardiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Zhih-Cherng Chen
- Department of Cardiology, Chi Mei Medical Center, Tainan, Taiwan .,Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
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Recurrent Thrombotic Events after Discontinuation of Vitamin K Antagonist Treatment for Splanchnic Vein Thrombosis: A Multicenter Retrospective Cohort Study. Gastroenterol Res Pract 2015; 2015:620217. [PMID: 26508913 PMCID: PMC4609867 DOI: 10.1155/2015/620217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/01/2015] [Accepted: 02/02/2015] [Indexed: 01/24/2023] Open
Abstract
It is generally recommended that patients with splanchnic vein thrombosis (SVT) should receive a minimum of 3 months of anticoagulant treatment. However, little information is available on the long-term risk of recurrent thrombotic events. The aim of this study was to evaluate the risk of venous and arterial thrombosis after discontinuation of vitamin K antagonist (VKA) in SVT patients. Retrospective information from a cohort of SVT patients treated with VKA and followed by 37 Italian Anticoagulation Clinics, up to June 2013, was collected. Only patients who discontinued VKA and did not receive any other anticoagulant drug were enrolled in this study. Thrombotic events during follow-up were centrally adjudicated. Ninety patients were included: 33 unprovoked SVT, 27 SVT secondary to transient risk factors, and 30 with permanent risk factors. During a median follow-up of 1.6 years, 6 venous and 1 arterial thrombosis were documented, for an incidence of 3.3/100 patient-years (pt-y). The recurrence rate was highest in the first year after VKA discontinuation (8.2/100'pt-y) and in patients with permanent risk factors (10.2/100'pt-y). Liver cirrhosis significantly increased the risk of recurrence. In conclusion, the rate of recurrent vascular complications after SVT is not negligible, at least in some patient subgroups.
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Beam DM, Kahler ZP, Kline JA. Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis. Acad Emerg Med 2015; 22:788-95. [PMID: 26113241 PMCID: PMC5034796 DOI: 10.1111/acem.12711] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/12/2015] [Accepted: 01/23/2015] [Indexed: 12/14/2022]
Abstract
Objectives The study hypothesis was that a target‐specific anticoagulant would allow successful home treatment of selected patients with deep vein thrombosis (DVT) and pulmonary embolism (PE) diagnosed in two urban emergency departments (EDs). Methods A protocol was established for treating low‐risk DVT or PE patients with rivaroxaban and clinic, follow‐up at both 2 to 5 weeks, and 3 to 6 months. Patients were determined to be low‐risk by using a modified version of the Hestia criteria, supplemented by additional criteria for patients with active cancer. Acceptable outcome rates were defined as venous thromboembolism (VTE) recurrence ≤ 2.1% or bleeding ≤ 9.4% during treatment. VTE recurrence required positive imaging of any VTE. The International Society of Thrombosis and Hemostasis definition of major or clinically relevant nonmajor bleeding was used. Results From March 2013 through April 2014, a total of 106 patients were treated. Seventy‐one (68%) had DVT, 30 (28%) had PE, and five (3%) had both, representing 51% of all DVTs and 27% of all PEs diagnosed in both EDs during the period of study. The 106 patients have been followed for a mean (±SD) of 389 (±111) days (range = 213 to 594 days). No patient had VTE recurrence, and no patient had a major or clinically relevant bleeding event while on therapy (none of the 106, 0%, 95% confidence interval [CI] = 0% to 3.4%). However, three patients 2.8% (95% CI = 1% to 8%) had recurrent DVT after cessation of therapy. Conclusions Patients diagnosed with VTE and immediately discharged from the ED while treated with rivaroxaban had a low rate of VTE recurrence and bleeding.
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Affiliation(s)
- Daren M. Beam
- The Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
- The Department of Cellular and Integrative Physiology Indiana University School of Medicine Indianapolis IN
| | - Zachary P. Kahler
- The Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
| | - Jeffrey A. Kline
- The Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
- The Department of Cellular and Integrative Physiology Indiana University School of Medicine Indianapolis IN
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Kline JA, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 1: Clinical Factors that Increase Risk. J Emerg Med 2015; 48:771-80. [DOI: 10.1016/j.jemermed.2014.12.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/17/2014] [Accepted: 12/21/2014] [Indexed: 12/14/2022]
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Dunic I, Vlajinac H, Marinkovic J, Maksimovic M, Radak D. Management of chronic venous disease by general practitioners in Serbia: a cross-sectional study. Postgrad Med 2014; 126:134-40. [PMID: 24685977 DOI: 10.3810/pgm.2014.03.2749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic venous disease (CVD) is one of the most prevalent medical conditions in the general population worldwide. OBJECTIVE To evaluate the management of CVD provided by general practitioners (GPs). METHODS AND MATERIALS The 2-center cross-sectional study comprised 2284 patients with CVD diagnosed and treated by GPs. Demographic and clinical data were obtained by physical examinations and standardized interviews. RESULTS Patients were counseled about different types of therapy; lifestyle advice was recommended to 88.8%, venoactive drugs to 90.8%, compression therapy to 44.0% of patients, anticoagulants to 16.7%, surgical treatment to 8.3%, and other types of therapy were recommended to 7.8% of patients. The most common types of treatment were dual and triple therapies recommended to 39.5% and 33.1%, respectively. The number of therapies recommended to patients increased with CVD progression. Treatment was not recommended to < 1% of patients. Only 8.4% of patients were referred to a vein specialist. CONCLUSIONS Although GPs had undergone special medical training about CVD before they were included in the study, some patients did not receive complete management of their condition. Continuous training of GPs and clinical guidelines for the management of CVD may help GPs to make adequate decisions.
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Affiliation(s)
- Ivana Dunic
- City Service of Dermatology and Venereology, Department for Prevention and Treatment Peripheral Vascular Diseases, Belgrade, Serbia.
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