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Shapiro M, Hamulyák EN, Leader A, Landau R, Middeldorp S, Gurevich-Shapiro A. Venous thromboembolism among physically active young adult females. Res Pract Thromb Haemost 2023; 7:102236. [PMID: 38193067 PMCID: PMC10772887 DOI: 10.1016/j.rpth.2023.102236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 01/10/2024] Open
Abstract
Background Young adult females are at risk of venous thromboembolism (VTE) due to various acquired and transient factors. In recent years, a growing number of females have engaged in strenuous physical activity, but its role as a risk factor for VTE is uncertain. Objectives To determine the incidence of VTE in young adult females engaged in strenuous physical activity. Methods A large national cohort of female individuals enlisted in the Israeli Defense Forces between 2012 and 2019 was analyzed. The study group consisted of participants undergoing strenuous physical training during their military service, while the control group maintained regular activity levels. We compared the incidence of VTE between the groups and adjusted for potential risk factors using a multivariate Cox analysis. Results The cohort included 160,718 female individuals aged 18 to 21years, of whom 11,745 engaged in strenuous physical activity and 148,973 served as controls. During a mean follow-up of 1.7 years, VTE occurred in 5 individuals (0.04%) in the strenuous activity group and 47 individuals (0.03%) in the control group. The incidence per 10,000 person-years was 2.41 (95% CI, 0.78-5.62) for the strenuous activity group and 1.82 (95% CI, 1.34-2.42) for the controls. Strenuous activity did not increase the risk for VTE in univariate or multivariate regression, with a hazard ratio (HR) of 1.27 (95% CI, 0.49-4.22). Use of oral contraceptives was the only significant risk factor, demonstrating dose effect; HR 1.95 (95% CI, 1.06-3.57) for low dose and HR 3.62 (95% CI, 1.40-9.37) for medium estrogen dose contraceptives. Conclusion Strenuous physical activity did not increase the risk for VTE among a large cohort of young adult female individuals.
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Affiliation(s)
- Michael Shapiro
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Eva N. Hamulyák
- Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Avi Leader
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Regev Landau
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Endocrine Department, Shamir Medical Center, Be'er Ya'akov, Israel
- Medical Corps, Israel Defense Forces, Tzrifin, Israel
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anna Gurevich-Shapiro
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Department of Systems Immunology, Weizmann Institute of Science, Rehovot, Israel
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Jarman AF, Mumma BE, White R, Dooley E, Yang NT, Taylor SL, Newgard C, Morris C, Cloutier J, Maughan BC. Sex differences in guideline-consistent diagnostic testing for acute pulmonary embolism among adult emergency department patients aged 18-49. Acad Emerg Med 2023; 30:896-905. [PMID: 36911917 PMCID: PMC10497718 DOI: 10.1111/acem.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a frequent diagnostic consideration in emergency department (ED) patients, yet diagnosis is challenging because symptoms of PE are nonspecific. Guidelines recommend the use of clinical decision tools to increase efficiency and avoid harms from overtesting, including D-dimer screening in patients not at high risk for PE. Women undergo testing for PE more often than men yet have a lower yield from testing. Our study objective was to determine whether patient sex influenced the odds of received guideline-consistent care. METHODS We performed a retrospective cohort study at two large U.S. academic EDs from January 1, 2016, to December 31, 2018. Nonpregnant patients aged 18-49 years were included if they presented with chest pain, shortness of breath, hemoptysis, or syncope and underwent testing for PE with D-dimer or imaging. Demographic and clinical data were exported from the electronic medical record (EMR). Pretest risk scores were calculated using manually abstracted EMR data. Diagnostic testing was then compared with recommended testing based on pretest risk. The primary outcome was receipt of guideline-consistent care, which required an elevated screening D-dimer prior to imaging in all non-high-risk patients. RESULTS We studied 1991 discrete patient encounters; 37% (735) of patients were male and 63% (1256) were female. Baseline characteristics, including revised Geneva scores, were similar between sexes. Female patients were more likely to receive guideline-consistent care (70% [874/1256] female vs. 63% [463/735] male, p < 0.01) and less likely to be diagnosed with PE (3.1% [39/1256] female vs. 5.3% [39/735] male, p < 0.05). The most common guideline deviation in both sexes was obtaining imaging without a screening D-dimer in a non-high-risk patient (75% [287/382] female vs. 75% [205/272] male). CONCLUSIONS In this cohort, females were more likely than males to receive care consistent with current guidelines and less likely to be diagnosed with PE.
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Affiliation(s)
- Angela F Jarman
- Department of Emergency Medicine, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Richard White
- Department of Internal Medicine, Division of Rheumatology, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Emily Dooley
- University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Nuen Tsang Yang
- Department of Public Health Sciences, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Sandra L. Taylor
- Department of Public Health Sciences, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Craig Newgard
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Cynthia Morris
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA
| | - Jared Cloutier
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Brandon C Maughan
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
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Patel JP, Nzelu O, Roberts LN, Johns J, Ross J, Arya R. How do anticoagulants impact menstrual bleeding and quality of life? - The PERIOD study. Res Pract Thromb Haemost 2023; 7:100072. [PMID: 36861116 PMCID: PMC9969064 DOI: 10.1016/j.rpth.2023.100072] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 02/05/2023] Open
Abstract
Background There is increasing recognition that menstruating women prescribed anticoagulants experience heavy menstrual bleeding. Objectives The aim of this study is to report the extent of bleeding in menstruating women after commencing anticoagulants and the impact it has on their quality of life. Methods Women aged 18 to 50, initiated on anticoagulant therapy, were approached to take part in the study. In parallel, a control group of women was also recruited. Women were asked to complete the menstrual bleeding questionnaire and a pictorial blood assessment chart (PBAC) during their next 2 menstrual cycles. Differences between the control and anticoagulated group were compared. Significance was considered at < .05. Ethics committee approval: REC reference: 19/SW/0211. Results Fifty-seven women in the anticoagulation and 109 women in the control group returned their questionnaires. Women in the anticoagulated group reported an increase in the median length of their menstrual cycle from 5 to 6 days after commencing anticoagulation, compared to 5 days for women in the control group (P < .05). Anticoagulated women reported significantly higher PBAC scores as compared to the control group (P < .05), with two-thirds of women in the anticoagulation group reporting heavy menstrual bleeding. Women in the anticoagulation group reported worsening quality of life scores following the initiation of anticoagulation, compared with women in the control group (P < .05). Conclusion Heavy menstrual bleeding occurred in two-thirds of women commencing anticoagulants, who completed a PBAC, which had negative impact on their quality of life. Clinicians commencing anticoagulation therapy should be mindful of this, and recognized measures should be taken to help minimize this problem for menstruating individuals.
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Affiliation(s)
- Jignesh P. Patel
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, UK,Institute of Pharmaceutical Science, Faculty of Life Sciences and Medicine, King’s College London, UK,Correspondence Jignesh P. Patel, Institute of Pharmaceutical Science, School of Cancer and Pharmaceutical Sciences, King’s College London, Franklin-Wilkins Building, Stamford Street, London SE1 5RS, UK.
| | - Obianuju Nzelu
- Department of Women’s Health, King’s College Hospital Foundation NHS Trust, UK
| | - Lara N. Roberts
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, UK
| | - Jemma Johns
- Department of Women’s Health, King’s College Hospital Foundation NHS Trust, UK
| | - Jackie Ross
- Department of Women’s Health, King’s College Hospital Foundation NHS Trust, UK
| | - Roopen Arya
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, UK
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Linnemann B, Rott H, Zotz R, Hart C. Venous Thromboembolism Issues in Women. Hamostaseologie 2022; 42:290-299. [DOI: 10.1055/a-1919-9558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AbstractThe lifetime risk of venous thromboembolism (VTE) is slightly higher in women than in men. There are several issues related to VTE that are unique to women. Combined hormonal contraceptives and pregnancy increase the risk of VTE in women of childbearing age, whereas hormone replacement therapy increases the VTE risk of postmenopausal women. Hereditary thrombophilia and risk factors such as older age, obesity, or smoking contribute to the risk increase. In women diagnosed with acute hormone-related VTE who are treated with oral anticoagulants, adequate contraception is mandatory to avoid unwanted pregnancies. According to current knowledge, hormonal contraception may be continued during anticoagulant therapy but must be switched to an estrogen-free contraception method at least 6 weeks before the termination of anticoagulation. VTE is also a major cause of maternal morbidity and mortality during pregnancy and the postpartum period. Currently, assisted reproduction technologies such as in vitro fertilization are widely used to treat couples affected by infertility. Complications of fertility treatment comprise VTE cases, especially in women with ovarian hyperstimulation syndrome. With this review, we intended to focus on VTE issues in women and summarize current evidence and guideline recommendations.
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Affiliation(s)
- Birgit Linnemann
- Division of Angiology, University Center of Vascular Medicine, University Hospital Regensburg, Regensburg, Germany
| | | | - Rainer Zotz
- Centrum für Blutgerinnungsstörungen und Transfusionsmedizin, Düsseldorf, Germany
| | - Christina Hart
- Department of Haematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
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Owodunni OP, Lau BD, Wang J, Shaffer DL, Kraus PS, Holzmueller CG, Aboagye JK, Hobson DB, Varasteh Kia M, Armocida S, Streiff MB, Haut ER. Effectiveness of a Patient Education Bundle on Venous Thromboembolism Prophylaxis Administration by Sex. J Surg Res 2022; 280:151-162. [PMID: 35969933 DOI: 10.1016/j.jss.2022.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/14/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a frequent cause of preventable harm among hospitalized patients. Many prescribed prophylaxis doses are not administered despite supporting evidence. We previously demonstrated a patient-centered education bundle improved VTE prophylaxis administration broadly; however, patient-specific factors driving nonadministration are unclear. We examine the effects of the education bundle on missed doses of VTE prophylaxis by sex. METHODS We performed a post-hoc analysis of a nonrandomized controlled trial to evaluate the differences in missed doses by sex. Pre-intervention and intervention periods for patients admitted to 16 surgical and medical floors between 10/2014-03/2015 (pre-intervention) and 04/2015-12/2015 (intervention) were compared. We examined the conditional odds of (1) overall missed doses, (2) missed doses due to patient refusal, and (3) missed doses for other reasons. RESULTS Overall, 16,865 patients were included (pre-intervention 6853, intervention 10,012), with 2350 male and 2460 female patients (intervention), and 6373 male and 5682 female patients (control). Any missed dose significantly reduced on the intervention floors among male (odds ratio OR 0.55; 95% confidence interval CI, 0.44-0.70, P < 0.001) and female (OR 0.59; 95% CI, 0.47-0.73, P < 0.001) patients. Similar significant reductions ensued for missed doses due to patient refusal (P < 0.001). Overall, there were no sex-specific differences (P-interaction >0.05). CONCLUSIONS Our intervention increased VTE prophylaxis administration for both female and male patients, driven by decreased patient refusal. Patient education should be applicable to a wide range of patient demographics representative of the target group. To improve future interventions, quality improvement efforts should be evaluated based on patient demographics and drivers of differences in care.
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Affiliation(s)
- Oluwafemi P Owodunni
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Jiangxia Wang
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christine G Holzmueller
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland
| | - Jonathan K Aboagye
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah B Hobson
- The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Mujan Varasteh Kia
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephanie Armocida
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael B Streiff
- The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Johns Hopkins Surgery Center for Outcomes Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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6
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Special Considerations for Women of Reproductive Age on Anticoagulation. J Gen Intern Med 2022; 37:2803-2810. [PMID: 35641728 PMCID: PMC9411301 DOI: 10.1007/s11606-022-07528-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/29/2022] [Indexed: 01/07/2023]
Abstract
Anticoagulation poses unique challenges for women of reproductive age. Clinicians prescribing anticoagulants must counsel patients on issues ranging from menstruation and the possibility of developing a hemorrhagic ovarian cyst to teratogenic risks and safety with breastfeeding. Abnormal uterine bleeding affects up to 70% of young women who are treated with anticoagulation. As such, thoughtful clinical guidance is required to avoid having young women who are troubled by their menses, dose reduce, or prematurely discontinue their anticoagulation, leaving them at increased risk of recurrent thrombosis. Informed by a review of the medical literature, we present current recommendations for assisting patients requiring anticoagulation with menstrual management, prevention of hemorrhagic ovarian cysts, and avoiding unintended pregnancy. The subdermal implant may be considered a first-line option for those requiring anticoagulation, given its superior contraceptive effectiveness and ability to reliably reduce risk of hemorrhagic ovarian cysts. All progestin-only formulations-such as the subdermal implant, intrauterine device, injection, or pills-are generally preferred over combined hormonal pills, patch, or ring. Tranexamic acid, and in rare cases endometrial ablation, may also be useful in managing menorrhagia and dysmenorrhea. During pregnancy, enoxaparin remains the preferred anticoagulant and warfarin is contraindicated. Breastfeeding women may use warfarin, but direct oral anticoagulants are not recommended given their limited safety data. This practical guide for clinicians is designed to inform discussions of risks and benefits of anticoagulation therapy for women of reproductive age.
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Bikdeli B, Piazza G, Jimenez D, Muriel A, Wang Y, Khairani CD, Rosovsky RP, Mehdipoor G, O'Donoghue ML, Spagnolo P, Dreyer RP, Bertoletti L, López-Jiménez L, Núñez MJ, Blanco-Molina Á, Bates SM, Gerhard-Herman M, Goldhaber SZ, Monreal M, Krumholz HM. Sex Differences in PrEsentation, Risk Factors, Drug and Interventional Therapies, and OUtcomes of Elderly PatientS with Pulmonary Embolism: Rationale and design of the SERIOUS-PE study. Thromb Res 2022; 214:122-131. [DOI: 10.1016/j.thromres.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022]
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Scheres LJJ, Hylckama Vlieg A, Cannegieter SC. Sex‐specific aspects of venous thromboembolism: What is new and what is next? Res Pract Thromb Haemost 2022; 6:e12722. [PMID: 35619638 PMCID: PMC9127145 DOI: 10.1002/rth2.12722] [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: 11/24/2021] [Revised: 04/01/2022] [Accepted: 04/19/2022] [Indexed: 11/08/2022] Open
Abstract
Men seem to have a higher intrinsic risk of venous thromboembolism (VTE) than women, regardless of age. To date, this difference has not been explained. By integrating state‐of‐the‐art research presented at the International Society on Thrombosis and Haemostasis Congress of 2021 with the available literature, we address potential explanations for this intriguing risk difference between men and women. We discuss the role of exogenous and endogenous sex hormones as the most important known sex‐specific determinants of VTE risk. In addition, we highlight clues on the role of sex hormones and VTE risk from clinical scenarios such as pregnancy and the polycystic ovary syndrome. Furthermore, we address new potential sex‐specific risk factors and unanswered research questions, which could provide more insight in the intrinsic risk difference between men and women, such as body height and differences in body fat distribution, leading to dysregulation of metabolism and inflammation.
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Affiliation(s)
- Luuk J. J. Scheres
- Department of Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS) Radboud University Medical Center Nijmegen The Netherlands
| | - Astrid Hylckama Vlieg
- Department of Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands
- Department of Internal Medicine Section of Thrombosis and Haemostasis Leiden University Medical Center Leiden The Netherlands
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9
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Abughanimeh OK, Marar RI, Tahboub M, Kaur A, Qasrawi A, Abu Ghanimeh M, Pluard T. Hereditary Thrombophilia Testing Among Hospitalized Patients: Is It Warranted? Cureus 2022; 14:e24855. [PMID: 35702453 PMCID: PMC9176828 DOI: 10.7759/cureus.24855] [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] [Accepted: 05/09/2022] [Indexed: 12/03/2022] Open
Abstract
Background Hereditary thrombophilias (HTs) are a group of inherited disorders that predispose the carrier to venous thromboembolism (VTE). It is estimated that 7% of the population has some form of HT. Although testing for HT has become routine for many hospitalized patients, knowing when to order the tests and how to interpret the results remains challenging. In the United States, there are no clear guidelines regarding testing for HT. We conducted a study to evaluate the utilization of HT testing among hospitalized patients to examine its impact on immediate management decisions and overall cost burden. In addition, we discuss the common reasons for healthcare providers to order these tests and review the data behind these reasons in the literature. Methodology A retrospective analysis of 2,402 patients who underwent HT testing between February 1, 2016, and January 31, 2018, was conducted. Eligible patients had at least one HT test ordered during hospitalization. The primary outcome was to determine the incidence of positive actionable tests. A positive actionable test was defined as a positive result that changed the anticoagulation intensity, type, or duration. Patients with a history of previous VTE, ongoing medical conditions requiring life-long anticoagulation, or unprovoked VTE were considered non-actionable. Results Among the 2,402 patients, 954 patients met the inclusion criteria with a mean age of 54 years. A total of 397 (41.6%) tests were ordered for acute VTE, while the rest were for non-VTE conditions, such as stroke, pregnancy complications, peripheral artery diseases, and others. Only 89 positive tests were actionable (14% of the positive tests, and 9.3% of the total ordered tests). There was a statistically significant association between increasing age and having both a positive test result (p = 0.006) and an actionable test (p = 0.046). The total cost of ordering these tests was estimated to be $566,585. Conclusions HT testing in the inpatient setting did not alter management in many cases and was associated with increased healthcare costs. The decision to order these tests should be individualized based on the clinical scenario.
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10
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Middeldorp S, Naue C, Köhler C. Thrombophilia, Thrombosis and Thromboprophylaxis in Pregnancy: For What and in Whom? Hamostaseologie 2022; 42:54-64. [PMID: 35196731 DOI: 10.1055/a-1717-7663] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Compared with nonpregnant women, pregnancy carries a four- to fivefold higher risk of venous thromboembolism (VTE). Despite increasing use of heparin prophylaxis in identified high-risk patients, pulmonary embolism still is the leading cause of maternal mortality in the western world. However, evidence on optimal use of thromboprophylaxis is scarce. Thrombophilia, the hereditary or acquired tendency to develop VTE, is also thought to be associated with complications in pregnancy, such as recurrent miscarriage and preeclampsia. In this review, the current evidence on optimal thromboprophylaxis in pregnancy is discussed, focusing primarily on VTE prevention strategies but also discussing the potential to prevent recurrent pregnancy complications with heparin in pregnant women with thrombophilia.
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Affiliation(s)
- Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christiane Naue
- Division of Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
| | - Christina Köhler
- Division of Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
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11
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Bikdeli B, Khairani CD, Barns BM, Rosovsky RP, Jimenez D, Monreal M, Sylvester KW, Middeldorp S, Bates SM, Krumholz HM, Goldhaber SZ, Hunt BJ, Piazza G. Women's representation in venous thromboembolism randomized trials and registries: The illustrative example of direct oral anticoagulants for acute treatment. Contemp Clin Trials 2022; 115:106714. [PMID: 35202841 DOI: 10.1016/j.cct.2022.106714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 12/22/2022]
Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, MA, USA; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, CT, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA.
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, MA, USA
| | - Briana M Barns
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachel P Rosovsky
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - Katelyn W Sylvester
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Saskia Middeldorp
- Department of Internal Medicine &, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Shannon M Bates
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, CT, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, MA, USA
| | - Beverley J Hunt
- Haemostasis and Thrombosis Centre, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, MA, USA
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12
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Vasiltseva OY, Vitt KN, Cherniavsky AM. [Features of pulmonary thromboembolism in women]. KARDIOLOGIIA 2021; 61:89-97. [PMID: 34882082 DOI: 10.18087/cardio.2021.11.n1147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/10/2020] [Accepted: 07/29/2020] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- O Ya Vasiltseva
- National Medical Research Center named after acad. E.N. Meshalkin, Novosibirsk
| | - K N Vitt
- Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk
| | - A M Cherniavsky
- National Medical Research Center named after acad. E.N. Meshalkin, Novosibirsk
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13
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Mazzolai L, Ageno W, Alatri A, Bauersachs R, Becattini C, Brodmann M, Emmerich J, Konstantinides S, Meyer G, Middeldorp S, Monreal M, Righini M, Aboyans V. Second consensus document on diagnosis and management of acute deep vein thrombosis: updated document elaborated by the ESC Working Group on aorta and peripheral vascular diseases and the ESC Working Group on pulmonary circulation and right ventricular function. Eur J Prev Cardiol 2021; 29:1248-1263. [PMID: 34254133 DOI: 10.1093/eurjpc/zwab088] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/25/2021] [Accepted: 05/07/2021] [Indexed: 12/14/2022]
Abstract
This consensus document is proposed to clinicians to provide the whole spectrum of deep vein thrombosis management as an update to the 2017 consensus document. New data guiding clinicians in indicating extended anticoagulation, management of patients with cancer, and prevention and management of post-thrombotic syndrome are presented. More data on benefit and safety of non-vitamin K antagonists oral anticoagulants are highlighted, along with the arrival of new antidotes for severe bleeding management.
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Affiliation(s)
- Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Chemin de Mont-Paisible 18, CH-1011 Lausanne, Switzerland
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Via Ravasi 2, 21100 Varese, Italy
| | - Adriano Alatri
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Chemin de Mont-Paisible 18, CH-1011 Lausanne, Switzerland
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Grafenstraße 9, 64283 Darmstadt, Germany.,Departement of Vascular Medicine, Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Cecilia Becattini
- Departement of Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Marianne Brodmann
- Département of Internal Medicine, Division of Angiology, Medical University Graz, Graz, Austria
| | - Joseph Emmerich
- Department of Vascular Medicine, Groupe Hospitalier Paris Saint-Joseph and University of Paris, Paris, France
| | - Stavros Konstantinides
- Departement of Vascular Medicine, Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Barcelona, Spain
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital and Inserm 1094, Tropical Neuroepidemiology, School of Medicine, 2 avenue martin Luther-King 87042 Limoges, France
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14
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Which patients are at high risk of recurrent venous thromboembolism (deep vein thrombosis and pulmonary embolism)? Blood Adv 2021; 4:5595-5606. [PMID: 33170937 DOI: 10.1182/bloodadvances.2020002268] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/24/2020] [Indexed: 12/14/2022] Open
Abstract
Recurrent venous thromboembolism (VTE, or deep vein thrombosis and pulmonary embolism) is associated with mortality and long-term morbidity. The circumstances in which an index VTE event occurred are crucial when personalized VTE recurrence risk is assessed. Patients who experience a VTE event in the setting of a transient major risk factor (such as surgery associated with general anesthesia for >30 minutes) are predicted to have a low VTE recurrence risk following discontinuation of anticoagulation, and limited-duration anticoagulation is generally recommended. In contrast, those patients whose VTE event occurred in the absence of risk factors or who have persistent risk factors have a higher VTE recurrence risk. Here, we review the literature surrounding VTE recurrence risk in a range of clinical conditions. We describe gender-specific risks, including VTE recurrence risk following hormone- and pregnancy-associated VTE events. Finally, we discuss how the competing impacts of VTE recurrence and bleeding have shaped international guideline recommendations.
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15
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How I treat venous thromboembolism in pregnancy. Blood 2021; 136:2133-2142. [PMID: 32797192 DOI: 10.1182/blood.2019000963] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/11/2020] [Indexed: 12/11/2022] Open
Abstract
One to 2 pregnant women in 1000 will experience venous thromboembolism (VTE) during pregnancy or postpartum. Pulmonary embolism (PE) is a leading cause of maternal mortality, and deep vein thrombosis leads to maternal morbidity, with postthrombotic syndrome potentially diminishing quality of life for a woman's lifetime. However, the evidence base for pregnancy-related VTE management remains weak. Evidence-based guideline recommendations are often extrapolated from nonpregnant women and thus weak or conditional, resulting in wide variation of practice. In women with suspected PE, the pregnancy-adapted YEARS algorithm is safe and efficient, rendering computed tomographic pulmonary angiography to rule out PE unnecessary in 39%. Low molecular weight heparin (LMWH) in therapeutic doses is the treatment of choice during pregnancy, and anticoagulation (LMWH or vitamin K antagonists [VKAs]) should be continued until 6 weeks after delivery, with a 3-month minimum total duration. LMWH or VKA use does not preclude breastfeeding. Postpartum, direct oral anticoagulants are an option if a woman does not breastfeed and long-term use is intended. Management of delivery, including type of analgesia, requires a multidisciplinary approach and depends on local preferences and patient-specific conditions. Several options are possible, including waiting for spontaneous delivery with temporary LMWH interruption. Prophylaxis for recurrent VTE prevention in subsequent pregnancies is indicated in most women with a history of VTE.
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16
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Giersch GEW, Charkoudian N, Pereira T, Edgell H, Freeberg KA, Craighead DH, Neill M, Allison EY, Zapcic AK, Smith KJ, Bock JM, Casey DP, Shenouda N, Ranadive SM, Tremblay JC, Williams AM, Simpson LL, Meah VL, Ruediger SL, Bailey TG, Pereira HM, Lei TH, Perry B, Mündel T, Freemas JA, Worley ML, Baranauskas MN, Carter SJ, Johnson BD, Schlader ZJ, Bates LC, Stoner L, Zieff G, Poles J, Adams N, Meyer ML, Hanson ED, Greenlund IM, Bigalke JA, Carter JR, Kerr ZY, Stanford K, Pomeroy A, Boggess K, de Souza HLR, Meireles A, Arriel RA, Leite LHR, Marocolo M, Chapman CL, Atencio JK, Kaiser BW, Comrada LN, Halliwill JR, Minson CT, Williams JS, Dunford EC, MacDonald MJ, Santisteban KJ, Larson EA, Reed E, Needham KW, Gibson BM, Gillen J, Barbosa TC, Cardoso LLY, Gliemann L, Tamariz-Ellemann A, Hellsten Y, DuBos LE, Babcock MC, Moreau KL, Wickham KA, Vagula M, Moir ME, Klassen SA, Rodrigues A. Commentaries on Point:Counterpoint: Investigators should/should not control for menstrual cycle phase when performing studies of vascular control. J Appl Physiol (1985) 2021; 129:1122-1135. [PMID: 33197376 DOI: 10.1152/japplphysiol.00809.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Gabrielle E W Giersch
- Thermal and Mountain Medicine Division, United States Army Research Institute for Environmental Medicine, Natick, Massachusetts,Oak Ridge Institute for Science and Education, Oak Ridge, Tennnessee
| | - Nisha Charkoudian
- Thermal and Mountain Medicine Division, United States Army Research Institute for Environmental Medicine, Natick, Massachusetts
| | - T Pereira
- School of Kinesiology and Health Sciences, York University, Toronto, Ontario, Canada
| | - H Edgell
- School of Kinesiology and Health Sciences, York University, Toronto, Ontario, Canada
| | - Kaitlin A Freeberg
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado
| | - Daniel H Craighead
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado
| | - Matthew Neill
- Department of Kinesiology, Lakehead University, Thunder Bay, Ontario, Canada
| | - Elric Y Allison
- Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Andrea K Zapcic
- Department of Kinesiology, Lakehead University, Thunder Bay, Ontario, Canada
| | - Kurt J Smith
- Integrative Physiology Lab, Department of Kinesiology and Nutrition, University of Chicago, Chicago, Illinois
| | - Joshua M Bock
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darren P Casey
- Department of Physical Therapy and Rehabilitation Science, Carver College of Medicine, University of Iowa, Iowa City, Iowa,Abboud Cardiovascular Research Center, Carver College of Medicine, University of Iowa, Iowa City, Iowa,Fraternal Order of Eagles Diabetes Research Center, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Ninette Shenouda
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware
| | - Sushant M Ranadive
- Department of Kinesiology, University of Maryland, College Park, Maryland
| | - Joshua C Tremblay
- Centre for Heart, Lung and Vascular Health, University of British Columbia–Okanagan, Kelowna, British Columbia, Canada
| | - Alexandra M Williams
- Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, Canada,International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, Canada
| | - Lydia L Simpson
- Extremes Research Group, School of Sport, Health and Exercise Sciences, Bangor University, Bangor, United Kingdom
| | - Victoria L Meah
- Program for Pregnancy and Postpartum Health, Faculty of Kinesiology, Sport, and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Stefanie L Ruediger
- Physiology and Ultrasound Laboratory in Science and Exercise, Centre of Research on Exercise, Physical Activity and Health, The University of Queensland, Australia
| | - Tom G Bailey
- Physiology and Ultrasound Laboratory in Science and Exercise, Centre of Research on Exercise, Physical Activity and Health, The University of Queensland, Australia,School of Nursing, Midwifery and Social Work, The University of Queensland, Australia
| | - Hugo M Pereira
- Department of Health and Exercise Science, University of Oklahoma, Norman, Oklahoma
| | - Tze-Huan Lei
- College of Physical Education, Hubei Normal University, Huangshi, China,Laboratory for Applied Human Physiology, Graduate School of Human Development and Environment, Kobe University, Kobe, Japan
| | - Blake Perry
- School of Health Sciences, Massey University, Wellington, New Zealand
| | - Toby Mündel
- School of Sport Exercise and Nutrition, Massey University, Palmerston North, New Zealand
| | - Jessica A Freemas
- H.H. Morris Human Performance Laboratories, Dept. of Kinesiology, School of Public Health, Indiana University, Bloomington, Indiana
| | - Morgan L Worley
- H.H. Morris Human Performance Laboratories, Dept. of Kinesiology, School of Public Health, Indiana University, Bloomington, Indiana
| | - Marissa N Baranauskas
- H.H. Morris Human Performance Laboratories, Dept. of Kinesiology, School of Public Health, Indiana University, Bloomington, Indiana
| | - Stephen J Carter
- H.H. Morris Human Performance Laboratories, Dept. of Kinesiology, School of Public Health, Indiana University, Bloomington, Indiana
| | - Blair D Johnson
- H.H. Morris Human Performance Laboratories, Dept. of Kinesiology, School of Public Health, Indiana University, Bloomington, Indiana
| | - Zachary J Schlader
- H.H. Morris Human Performance Laboratories, Dept. of Kinesiology, School of Public Health, Indiana University, Bloomington, Indiana
| | - Lauren C Bates
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lee Stoner
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gabriel Zieff
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jillian Poles
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nathan Adams
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michelle L Meyer
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Erik D Hanson
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ian M Greenlund
- Department of Health and Human Development, Montana State University, Bozeman, Montana,Department of Psychology, Montana State University, Bozeman, Montana
| | - Jeremy A Bigalke
- Department of Health and Human Development, Montana State University, Bozeman, Montana,Department of Psychology, Montana State University, Bozeman, Montana
| | - Jason R Carter
- Department of Health and Human Development, Montana State University, Bozeman, Montana,Department of Psychology, Montana State University, Bozeman, Montana
| | - Zachary Y Kerr
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kathleen Stanford
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alex Pomeroy
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kim Boggess
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hiago L R de Souza
- Physiology and Human Performance Research Group, Department of Physiology, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Anderson Meireles
- Physiology and Human Performance Research Group, Department of Physiology, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Rhai A Arriel
- Physiology and Human Performance Research Group, Department of Physiology, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Laura H R Leite
- Physiology and Human Performance Research Group, Department of Physiology, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Moacir Marocolo
- Physiology and Human Performance Research Group, Department of Physiology, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | | | - Jessica K Atencio
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Brendan W Kaiser
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Lindan N Comrada
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - John R Halliwill
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | | | - Jennifer S Williams
- Vascular Dynamics Lab, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Emily C Dunford
- Vascular Dynamics Lab, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Maureen J MacDonald
- Vascular Dynamics Lab, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | | | - Emily A Larson
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Emma Reed
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Karen W Needham
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Brandon M Gibson
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Jenna Gillen
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada
| | - Thales C Barbosa
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Licy L Yanes Cardoso
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Lasse Gliemann
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
| | | | - Ylva Hellsten
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
| | - Lyndsey E DuBos
- Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Matthew C Babcock
- Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kerrie L Moreau
- Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado,Veterans Affairs Eastern Colorado Geriatric Research, Educational and Clinical Center, Denver, Colorado
| | - Kate A Wickham
- Environmental Ergonomics Laboratory, Department of Kinesiology, Brock University, St. Catharines, Ontario, Canada
| | | | - M Erin Moir
- School of Kinesiology, University of Western Ontario, London, Ontario, Canada
| | | | - Alex Rodrigues
- Physiology and Human Performance Research Group, Department of Physiology, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
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17
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Weaver J, Shoaibi A, Truong HQ, Larbi L, Wu S, Wildgoose P, Rao G, Freedman A, Wang L, Yuan Z, Barnathan E. Comparative Risk Assessment of Severe Uterine Bleeding Following Exposure to Direct Oral Anticoagulants: A Network Study Across Four Observational Databases in the USA. Drug Saf 2021; 44:479-497. [PMID: 33651368 PMCID: PMC7994226 DOI: 10.1007/s40264-021-01060-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND Antithrombotic therapies are associated with an increased bleeding risk. Abnormal uterine bleeding data have been reported in clinical trials of patients with venous thromboembolism (VTE), but data are limited for patients with atrial fibrillation (AF). OBJECTIVE Using real-world data from four US healthcare databases (October 2010 to December 2018), we compared the occurrence of severe uterine bleeding among women newly exposed to rivaroxaban, apixaban, dabigatran, and warfarin stratified by indication. METHODS To reduce potential confounding, patients in comparative cohorts were matched on propensity scores. Treatment effect estimates were generated using Cox proportional hazard models for each indication, in each database, and only for pairwise comparisons that met a priori study diagnostics. If estimates were homogeneous (I2 < 40%), a meta-analysis across databases was performed and pooled hazard ratios reported. RESULTS Data from 363,919 women newly exposed to a direct oral anticoagulant or warfarin with a prior diagnosis of AF (60.8%) or VTE (39.2%) were analyzed. Overall incidence of severe uterine bleeding was low in the populations exposed to direct oral anticoagulants, although relatively higher in the younger VTE population vs the AF population (unadjusted incidence rates: 2.8-33.7 vs 1.9-10.0 events/1000 person-years). In the propensity score-matched AF population, a suggestive, moderately increased risk of severe uterine bleeding was observed for rivaroxaban relative to warfarin [hazard ratios and 95% confidence intervals from 0.83 (0.27-2.48) to 2.84 (1.32-6.23) across databases with significant heterogeneity], apixaban [pooled hazard ratio 1.45 (0.91-2.28)], and dabigatran [2.12 (1.01-4.43)], which were sensitive to the time-at-risk period. In the propensity score-matched VTE population, a consistent increased risk of severe uterine bleeding was observed for rivaroxaban relative to warfarin [2.03 (1.19-3.27)] and apixaban [2.25 (1.45-3.41)], which were insensitive to the time-at-risk period. CONCLUSIONS For women who need antithrombotic therapy, personalized management strategies with careful evaluation of benefits and risks are required. CLINICALTRIALS. GOV REGISTRATION NCT04394234; registered in May 2020.
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Affiliation(s)
- James Weaver
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Azza Shoaibi
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Huy Q Truong
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Leila Larbi
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Shujian Wu
- Janssen Research & Development, LLC, Horsham, PA, USA
| | - Peter Wildgoose
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Gowtham Rao
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Amy Freedman
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Lu Wang
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Zhong Yuan
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA.
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18
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Samuelson Bannow BT, Chi V, Sochacki P, McCarty OJT, Baldwin MK, Edelman AB. Heavy menstrual bleeding in women on oral anticoagulants. Thromb Res 2021; 197:114-119. [PMID: 33212377 PMCID: PMC7775335 DOI: 10.1016/j.thromres.2020.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/19/2020] [Accepted: 11/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although heavy menstrual bleeding (HMB) is a known complication of anticoagulant therapy, rates of HMB in users of the direct oral anticoagulants (OACs) apixaban and rivaroxaban are largely unknown. METHODS We performed a retrospective cohort study of menstruating women prescribed rivaroxaban, apixaban and warfarin over a six-year period (2012-2018). The primary outcome was HMB requiring medical or surgical intervention. We used descriptive statistics and logistic regression to evaluate associations between OAC type, age, history of HMB, and the primary outcome. RESULTS We identified 195 women of reproductive-age with a new therapeutic OAC prescription (62 on rivaroxaban, 54 on apixaban, 79 on warfarin). A minority (26/195, 13.3%) had a documented history of HMB, including 9 rivaroxaban users, 7 apixaban users and 10 warfarin users but most women (117/195, 60%) had no menstrual history documented. One third of subjects (64/195) required treatment for HMB within 6 months of starting OAC therapy. After controlling for a history of HMB, rivaroxaban users were 1.4 times more likely to require treatment as compared to users of other OACs. DISCUSSION We found an association between rates of HMB necessitating medical or surgical intervention and rivaroxaban use. We also found that the majority of women did not have a documented menstrual history, suggesting that many providers do not inquire about menstrual bleeding when starting OAC therapy. Menstruating women, particularly those with a history of HMB, may be at increased risk for HMB necessitating medical treatment depending on the type of OAC used.
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Affiliation(s)
- Bethany T Samuelson Bannow
- The Hemophilia Center at OHSU, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA; Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Vivia Chi
- OHSU School of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | | | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Maureen K Baldwin
- Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Alison B Edelman
- Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
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19
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Áinle FN, Kevane B. Which patients are at high risk of recurrent venous thromboembolism (deep vein thrombosis and pulmonary embolism)? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:201-212. [PMID: 33275736 PMCID: PMC7727525 DOI: 10.1182/hematology.2020002268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Recurrent venous thromboembolism (VTE, or deep vein thrombosis and pulmonary embolism) is associated with mortality and long-term morbidity. The circumstances in which an index VTE event occurred are crucial when personalized VTE recurrence risk is assessed. Patients who experience a VTE event in the setting of a transient major risk factor (such as surgery associated with general anesthesia for >30 minutes) are predicted to have a low VTE recurrence risk following discontinuation of anticoagulation, and limited-duration anticoagulation is generally recommended. In contrast, those patients whose VTE event occurred in the absence of risk factors or who have persistent risk factors have a higher VTE recurrence risk. Here, we review the literature surrounding VTE recurrence risk in a range of clinical conditions. We describe gender-specific risks, including VTE recurrence risk following hormone- and pregnancy-associated VTE events. Finally, we discuss how the competing impacts of VTE recurrence and bleeding have shaped international guideline recommendations.
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Affiliation(s)
- Fionnuala Ní Áinle
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- Department of Hematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland; and
- Irish Network for VTE Research
| | - Barry Kevane
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland; and
- Irish Network for VTE Research
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20
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O’Rourke E, Toolan S, Bedos A, Tierney A, Jennings C, O’Neill A, Áinle FN, Kevane B. “What will happen in the future?” A personal VTE journey. THROMBOSIS UPDATE 2020. [DOI: 10.1016/j.tru.2020.100013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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21
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Bistervels IM, Scheres LJJ, Hamulyák EN, Middeldorp S. Sex matters: Practice 5P's when treating young women with venous thromboembolism. J Thromb Haemost 2019; 17:1417-1429. [PMID: 31220399 PMCID: PMC6852403 DOI: 10.1111/jth.14549] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 05/21/2019] [Accepted: 06/13/2019] [Indexed: 12/15/2022]
Abstract
Sex matters when it comes to venous thromboembolism (VTE). We defined 5P's - period, pill, prognosis, pregnancy, and postthrombotic syndrome - that should be discussed with young women with VTE. Menstrual blood loss (Period) can be aggravated by anticoagulant therapy. This seems particularly true for direct oral anticoagulants. Abnormal uterine bleeding can be managed by hormonal therapy, tranexamic acid, or modification of treatment. The use of combined oral contraceptives (Pill) is a risk factor for VTE. The magnitude of the risk depends on progestagen types and estrogen doses used. In women using therapeutic anticoagulation, concomitant hormonal therapy does not increase the risk of recurrent VTE. Levonorgestrel-releasing intrauterine devices and low-dose progestin-only pills do not increase the risk of VTE. In young women VTE is often provoked by transient hormonal risk factors that affects prognosis. Sex is incorporated as predictor in recurrent VTE risk assessment models. However, current guidelines do not propose using these to guide treatment duration. Pregnancy increases the risk of VTE by 4-fold to 5-fold. Thrombophilia and obstetric risk factors further increase the risk of pregnancy-related VTE. In women with a history of VTE, the risk of recurrence during pregnancy or post partum appears to be influenced by risk factors present during the first VTE. In most women with a history of VTE, antepartum and postpartum thromboprophylaxis with low-molecular-weight heparin is indicated. Women generally are affected by VTE at a younger age then men, and they have to deal with long-term complications (Post-thrombotic syndrome) of deep vein thrombosis early in life.
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Affiliation(s)
- Ingrid M. Bistervels
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Luuk J. J. Scheres
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Eva N. Hamulyák
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
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