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Djulbegovic B, Boylan A, Kolo S, Scheurer DB, Anuskiewicz S, Khaledi F, Youkhana K, Madgwick S, Maharjan N, Hozo I. Converting IMPROVE bleeding and VTE risk assessment models into a fast-and-frugal decision tree for optimal hospital VTE prophylaxis. Blood Adv 2024; 8:3214-3224. [PMID: 38621198 DOI: 10.1182/bloodadvances.2024013166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024] Open
Abstract
ABSTRACT Current hospital venous thromboembolism (VTE) prophylaxis for medical patients is characterized by both underuse and overuse. The American Society of Hematology (ASH) has endorsed the use of risk assessment models (RAMs) as an approach to individualize VTE prophylaxis by balancing overuse (excessive risk of bleeding) and underuse (risk of avoidable VTE). ASH has endorsed IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) risk assessment models, the only RAMs to assess short-term bleeding and VTE risk in acutely ill medical inpatients. ASH, however, notes that no RAMs have been thoroughly analyzed for their effect on patient outcomes. We aimed to validate the IMPROVE models and adapt them into a simple, fast-and-frugal (FFT) decision tree to evaluate the impact of VTE prevention on health outcomes and costs. We used 3 methods: the "best evidence" from ASH guidelines, a "learning health system paradigm" combining guideline and real-world data from the Medical University of South Carolina (MUSC), and a "real-world data" approach based solely on MUSC data retrospectively extracted from electronic records. We found that the most effective VTE prevention strategy used the FFT decision tree based on an IMPROVE VTE score of ≥2 or ≥4 and a bleeding score of <7. This method could prevent 45% of unnecessary treatments, saving ∼$5 million annually for patients such as the MUSC cohort. We recommend integrating IMPROVE models into hospital electronic medical records as a point-of-care tool, thereby enhancing VTE prevention in hospitalized medical patients.
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Affiliation(s)
| | - Alice Boylan
- Medical University of South Carolina, Charleston, SC
| | - Shelby Kolo
- Medical University of South Carolina, Charleston, SC
| | | | | | - Flora Khaledi
- Medical University of South Carolina, Charleston, SC
| | | | | | | | - Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, IN
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Hu Z, Hu Y, Zhang S, Dong L, Chen X, Yang H, Su L, Hou X, Huang X, Shen X, Ye C, Tu W, Chen Y, Chen Y, Cai S, Zhong J, Dong L. Machine-learning-based models assist the prediction of pulmonary embolism in autoimmune diseases: A retrospective, multicenter study. Chin Med J (Engl) 2024:00029330-990000000-01099. [PMID: 38863118 DOI: 10.1097/cm9.0000000000003025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is a severe and acute cardiovascular syndrome with high mortality among patients with autoimmune inflammatory rheumatic diseases (AIIRDs). Accurate prediction and timely intervention play a pivotal role in enhancing survival rates. However, there is a notable scarcity of practical early prediction and risk assessment systems of PE in patients with AIIRD. METHODS In the training cohort, 60 AIIRD with PE cases and 180 age-, gender-, and disease-matched AIIRD non-PE cases were identified from 7254 AIIRD cases in Tongji Hospital from 2014 to 2022. Univariable logistic regression (LR) and least absolute shrinkage and selection operator (LASSO) were used to select the clinical features for further training with machine learning (ML) methods, including random forest (RF), support vector machines (SVM), neural network (NN), logistic regression (LR), gradient boosted decision tree (GBDT), classification and regression trees (CART), and C5.0 models. The performances of these models were subsequently validated using a multicenter validation cohort. RESULTS In the training cohort, 24 and 13 clinical features were selected by univariable LR and LASSO strategies, respectively. The five ML models (RF, SVM, NN, LR, and GBDT) showed promising performances, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.962-1.000 in the training cohort and 0.969-0.999 in the validation cohort. CART and C5.0 models achieved AUCs of 0.850 and 0.932, respectively, in the training cohort. Using D-dimer as a pre-screening index, the refined C5.0 model achieved an AUC exceeding 0.948 in the training cohort and an AUC above 0.925 in the validation cohort. These results markedly outperformed the use of D-dimer levels alone. CONCLUSION ML-based models are proven to be precise for predicting the onset of PE in patients with AIIRD exhibiting clinical suspicion of PE. TRIAL REGISTRATION Chictr.org.cn: ChiCTR2200059599.
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Affiliation(s)
- Ziwei Hu
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yangyang Hu
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Shuoqi Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Li Dong
- Department of Rheumatology and Immunology, Jingzhou Central Hospital, Yangtze University, Jinzhou, Hubei 434020, China
| | - Xiaoqi Chen
- Department of Rheumatology and Immunology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, China
| | - Huiqin Yang
- Department of Rheumatology, Wuhan No.1 Hospital, Wuhan, Hubei 430022, China
| | - Linchong Su
- Department of Rheumatology, Minda Hospital of Hubei Minzu University, Enshi, Hubei 445000, China
| | - Xiaoqiang Hou
- Department of Rheumatology and Immunology, The First College of Clinical Medical Science, China Three Gorges University, Yichang, Hubei 443003, China
| | - Xia Huang
- Department of Rheumatology, Minda Hospital of Hubei Minzu University, Enshi, Hubei 445000, China
| | - Xiaolan Shen
- Department of Rheumatology and Immunology, The First College of Clinical Medical Science, China Three Gorges University, Yichang, Hubei 443003, China
| | - Cong Ye
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Wei Tu
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yu Chen
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yuxue Chen
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Shaozhe Cai
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Jixin Zhong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Lingli Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
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Mongelli M, Lorusso D, Zanagnolo V, Pignata S, Colombo N, Cormio G. Venous Thromboembolism Prophylaxis in Gynecologic Oncology: A MITO-MaNGO Survey. Diagnostics (Basel) 2024; 14:1159. [PMID: 38893685 PMCID: PMC11172117 DOI: 10.3390/diagnostics14111159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
Cancer-associated thrombosis is the second leading cause of death in cancer patients, and its incidence has been increasing in recent years. This survey was aimed at gathering information regarding the management of thromboembolic prophylaxis within the MITO (Multicenter Italian Trials in Ovarian Cancer)-MaNGO (Mario Negri Gynecologic Oncology) groups. We designed a self-administered, multiple-choice online questionnaire available only for MITO-MaNGO members for one month, starting in May 2022 and ending in June 2022. We processed one response form per center, and 50 responses were analyzed, with most of the respondents (78%) over 40 years old. We found that 82% of them consider thromboembolic prophylaxis in gynecologic oncology to be relevant. In 82% of the centers, a standardized protocol on venous thromboembolism (VTE) prophylaxis is used, which is applied to both patients undergoing surgery and those undergoing chemotherapy. In the remaining 18% of centers, prophylaxis is used exclusively for patients undergoing chemotherapy treatment. Prophylaxis of patients undergoing surgery and chemotherapy treatment is managed in most cases by the surgeon (72%) and oncologist (76%), respectively. Only 26% of respondents use a thromboembolic risk assessment scale, and of these, those used are the Caprini Score (6%), Khorana Score (6%), and Wells Score (2%). The respondents have good knowledge of low-molecular-weight heparin (90%) and average knowledge of dicumarolics (40%), direct oral anticoagulants (DOACs) (68%), and antiplatelet agents (40%). The results of our survey indicate that there is a good awareness of thromboembolic prophylaxis in gynecologic oncology. Nevertheless, it is used less in outpatients than in patients undergoing surgery. Moreover, the thromboembolic risk assessment scores are barely used.
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Affiliation(s)
- Michele Mongelli
- Obstetrics and Gynecology Unit, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Domenica Lorusso
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico IRCCS, 00168 Rome, Italy
| | - Vanna Zanagnolo
- Department of Gynecologic Oncology, Istituto Europeo di Oncologia, 20141 Milan, Italy
| | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico IRCCS, Fondazione G. Pascale, 80131 Naples, Italy
| | - Nicoletta Colombo
- Gynecologic Oncology Program, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico IRCCS, 20139 Milan, Italy
- School of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy
| | - Gennaro Cormio
- S.S.D. Ginecologia Oncologica Clinicizzata, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
- Department of Interdisciplinary Medicine (DIM), University of Bari “Aldo Moro”, 70124 Bari, Italy
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Falanga A, Lorusso D, Colombo N, Cormio G, Cosmi B, Scandurra G, Zanagnolo V, Marietta M. Gynecological Cancer and Venous Thromboembolism: A Narrative Review to Increase Awareness and Improve Risk Assessment and Prevention. Cancers (Basel) 2024; 16:1769. [PMID: 38730721 PMCID: PMC11083004 DOI: 10.3390/cancers16091769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/24/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
The prevention and appropriate management of venous thromboembolism in cancer patients is of paramount importance. However, the literature data report an underestimation of this major problem in patients with gynecological cancers, with an inconsistent venous thromboembolism risk assessment and prophylaxis in this patient setting. This narrative review provides a comprehensive overview of the available evidence regarding the management of venous thromboembolism in cancer patients, focusing on the specific context of gynecological tumors, exploring the literature discussing risk factors, risk assessment, and pharmacological prophylaxis. We found that the current understanding and management of venous thromboembolism in gynecological malignancy is largely based on studies on solid cancers in general. Hence, further, larger, and well-designed research in this area is needed.
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Affiliation(s)
- Anna Falanga
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.F.); (N.C.)
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Domenica Lorusso
- Fondazione Policlinico Universitario A. Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Nicoletta Colombo
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.F.); (N.C.)
- Gynecologic Oncology Program, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Gennaro Cormio
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
- Department of Interdisciplinary Medicine (DIM), University “A. Moro”, 70124 Bari, Italy
| | - Benilde Cosmi
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy;
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giuseppa Scandurra
- Unità Operativa Oncologia Medica, Ospedale Cannizzaro di Catania, 95126 Catania, Italy;
| | | | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, 41125 Modena, Italy;
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Häfliger E, Kopp B, Darbellay Farhoumand P, Choffat D, Rossel JB, Reny JL, Aujesky D, Méan M, Baumgartner C. Risk Assessment Models for Venous Thromboembolism in Medical Inpatients. JAMA Netw Open 2024; 7:e249980. [PMID: 38728035 PMCID: PMC11087835 DOI: 10.1001/jamanetworkopen.2024.9980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/04/2024] [Indexed: 05/12/2024] Open
Abstract
Importance Thromboprophylaxis is recommended for medical inpatients at risk of venous thromboembolism (VTE). Risk assessment models (RAMs) have been developed to stratify VTE risk, but a prospective head-to-head comparison of validated RAMs is lacking. Objectives To prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs. Design, Setting, and Participants This prospective cohort study was conducted from June 18, 2020, to January 4, 2022, with a 90-day follow-up. A total of 4205 consecutive adults admitted to the general internal medicine departments of 3 Swiss university hospitals for hospitalization for more than 24 hours due to acute illness were screened for eligibility; 1352 without therapeutic anticoagulation were included. Exposures At admission, items of 4 RAMs (ie, the simplified and original Geneva score, the Padua score, and the IMPROVE [International Medical Prevention Registry on Venous Thromboembolism] score) were collected. Patients were stratified into high and low VTE risk groups according to each RAM. Main Outcomes and Measures Symptomatic VTE within 90 days. Results Of 1352 medical inpatients (median age, 67 years [IQR, 54-77 years]; 762 men [55.4%]), 28 (2.1%) experienced VTE. Based on the simplified Geneva score, 854 patients (63.2%) were classified as high risk, with a 90-day VTE risk of 2.6% (n = 22; 95% CI, 1.7%-3.9%), and 498 patients (36.8%) were classified as low risk, with a 90-day VTE risk of 1.2% (n = 6; 95% CI, 0.6%-2.6%). Sensitivity of the simplified Geneva score was 78.6% (95% CI, 60.5%-89.8%) and specificity was 37.2% (95% CI, 34.6%-39.8%); the positive likelihood ratio of the simplified Geneva score was 1.25 (95% CI, 1.03-1.52) and the negative likelihood ratio was 0.58 (95% CI, 0.28-1.18). In head-to-head comparisons, sensitivity was highest for the original Geneva score (82.1%; 95% CI, 64.4%-92.1%), while specificity was highest for the IMPROVE score (70.4%; 95% CI, 67.9%-72.8%). After adjusting the VTE risk for thromboprophylaxis use and site, there was no significant difference between the high-risk and low-risk groups based on the simplified Geneva score (subhazard ratio, 2.04 [95% CI, 0.83-5.05]; P = .12) and other RAMs. Discriminative performance was poor for all RAMs, with an area under the receiver operating characteristic curve ranging from 53.8% (95% CI, 51.1%-56.5%) for the original Geneva score to 58.1% (95% CI, 55.4%-60.7%) for the simplified Geneva score. Conclusions and Relevance This head-to-head comparison of validated RAMs found suboptimal accuracy and prognostic performance of the simplified Geneva score and other RAMs to predict hospital-acquired VTE in medical inpatients. Clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.
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Affiliation(s)
- Emmanuel Häfliger
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Basil Kopp
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Damien Choffat
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Jean-Luc Reny
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie Méan
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Horner DE, Davis S, Pandor A, Shulver H, Goodacre S, Hind D, Rex S, Gillett M, Bursnall M, Griffin X, Holland M, Hunt BJ, de Wit K, Bennett S, Pierce-Williams R. Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis. Health Technol Assess 2024; 28:1-166. [PMID: 38634415 PMCID: PMC11056814 DOI: 10.3310/awtw6200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Background Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs. Objectives We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research. Design We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines. Setting NHS hospitals, with primary data collection at four sites. Participants Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions. Interventions Prophylaxis for all patients, none and according to selected risk assessment models. Main outcome measures Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models. Results We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%. Limitations Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias. Conclusions Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research. Future work Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation. Study registration This study is registered as PROSPERO CRD42020165778 and Researchregistry5216. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in Health Technology Assessment; Vol. 28, No. 20. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Daniel Edward Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Oxford Road, Manchester, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Shulver
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Saleema Rex
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael Gillett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matthew Bursnall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Xavier Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Beverley Jane Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, King's Healthcare Partners, London, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queens University, Kingston, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shan Bennett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Iam-Arunthai K, Chamnanchanunt S, Thungthong P, Intalapaporn P, Nakhahes C, Suwanban T, Rojnuckarin P. Thrombosis and Bleeding Risk Scores Are Strongly Associated with Mortality in Hospitalized Patients with COVID-19: A Multicenter Cohort Study. J Clin Med 2024; 13:1437. [PMID: 38592277 PMCID: PMC10932358 DOI: 10.3390/jcm13051437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Internationally established guidelines mention pharmacological prophylaxis for all hospitalized COVID-19 patients. However, there are concerns regarding the efficacy and safety of anticoagulants. This study investigated the associations between thrombosis/bleeding risk scores and clinical outcomes. Methods: We conducted a retrospective review of adult patients admitted to two hospitals between 2021 and 2022. We analyzed clinical data, laboratory results, low molecular weight heparin (LMWH) use, thrombosis, bleeding, and 30-day survival. Results: Of the 160 patients, 69.4% were female, and the median age was 59 years. The rates of thrombotic complications and mortality were 12.5% and 36.3%, respectively. LMWH prophylaxis was administered to 73 of the patients (45.6%). The patients with high Padua prediction scores (PPS) and high IMPROVEVTE scores had a significantly higher risk of venous thromboembolism (VTE) compared to those with low scores (30.8% vs. 9.0%, p = 0.006 and 25.6% vs. 7.7%, p = 0.006). Similarly, elevated IMPROVEVTE and IMPROVEBRS scores were associated with increased mortality (hazard ratios of 7.49 and 6.27, respectively; p < 0.001). Interestingly, LMWH use was not associated with a decreased incidence of VTE when stratified by risk groups. Conclusions: this study suggests that COVID-19 patients with high thrombosis and bleeding risk scores have a higher mortality rate.
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Affiliation(s)
- Kunapa Iam-Arunthai
- Division of Hematology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Supat Chamnanchanunt
- Division of Hematology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Pravinwan Thungthong
- Division of Hematology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Poj Intalapaporn
- Division of Infectious Diseases, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Chajchawan Nakhahes
- Division of Hematology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Tawatchai Suwanban
- Division of Hematology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Ponlapat Rojnuckarin
- Center of Excellence in Translational Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
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Dentali F, Campanini M, Bonaventura A, Fontanella L, Zuretti F, Tavecchia L, Mumoli N, Gnerre P, Ventrella F, Giustozzi M, Valerio A, Fontanella A. The Use of Risk Scores for Thromboprophylaxis in Medically Ill Patients-Rationale and Design of the RICO trial. TH OPEN 2024; 8:e55-e60. [PMID: 38222040 PMCID: PMC10786708 DOI: 10.1055/a-2209-4708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/22/2022] [Indexed: 01/16/2024] Open
Abstract
Background Venous thromboembolism (VTE) in hospitalized medically ill patients is a significant cause of morbidity and mortality. Guidelines suggest that VTE and bleeding risk assessment models (RAMs) should be integrated into the clinical decision-making process on thromboprophylaxis. However, poor evidence is available comparing the use of a RAM versus clinical judgement in evaluating VTE and bleeding occurrence. Methods Reducing Important Clinical Outcomes in hospitalized medical ill patients (RICO) is a multicenter, cluster-randomized, controlled clinical trial (ClinicalTrials.gov Identifier: NCT04267718). Acutely ill patients hospitalized in Internal Medicine wards are randomized to the use of RAMs-namely the Padua Prediction Score and the International Medical Prevention Registry on Venous Thromboembolism Bleeding Score-or to clinical judgement. The primary study outcome is a composite of symptomatic objectively confirmed VTE and major bleeding at 90-day follow-up. Secondary endpoints include the evaluation of clinical outcomes at hospital discharge and the assessment of VTE prophylaxis prescription during the study period. In order to demonstrate a 50% reduction in the primary outcome in the experimental group and assuming an incidence of the primary outcome of 3.5% in the control group at 90-day; 2,844 patients across 32 centers will be included in the study. Discussion The RICO trial is a randomized study of clinical management assessing the role of RAMs in hospitalized medical ill patients with the aim of reducing VTE and bleeding occurrence. The study has the potential to improve clinical practice since VTE still represents an important cause of morbidity and mortality in this setting.
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Affiliation(s)
- Francesco Dentali
- Division of Internal Medicine, Medical Center, Ospedale di Circolo & Fondazion Macchi, ASST Sette Laghi, Varese, Italy
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Mauro Campanini
- Department of Internal Medicine, Hospital “Maggiore della Carità,” Novara, Italy
| | - Aldo Bonaventura
- Division of Internal Medicine, Medical Center, Ospedale di Circolo & Fondazion Macchi, ASST Sette Laghi, Varese, Italy
| | - Luca Fontanella
- Department of Medicine, Ospedale Buonconsiglio Fatebenefratelli di Napoli, Naples, Italy
| | - Francesca Zuretti
- Division of Internal Medicine, Medical Center, Ospedale di Circolo & Fondazion Macchi, ASST Sette Laghi, Varese, Italy
| | - Luca Tavecchia
- Division of Internal Medicine, Medical Center, Ospedale di Circolo & Fondazion Macchi, ASST Sette Laghi, Varese, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Azienda Socio Sanitaria Territoriale (ASST) Ovest Milanese, Magenta, Italy
| | - Paola Gnerre
- Internal Medicine, “San Paolo” Hospital, Savona, Italy
| | - Francesco Ventrella
- Department of Internal Medicine, Hospital “G. Tatarella”—ASL-FG, Cerignola, Italy
| | - Michela Giustozzi
- Internal Vascular and Emergency Medicine—Stroke Unit, University of Perugia, Perugia, Italy
| | - Antonella Valerio
- Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti (FADOI) Research Center, Milan, Italy
| | - Andrea Fontanella
- Department of Medicine, Ospedale Buonconsiglio Fatebenefratelli di Napoli, Naples, Italy
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9
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Xiong W, Cheng Y, Zhao Y. Risk Scores in Venous Thromboembolism Guidelines of ESC, ACCP, and ASH: An Updated Review. Clin Appl Thromb Hemost 2024; 30:10760296241263856. [PMID: 38887044 PMCID: PMC11185021 DOI: 10.1177/10760296241263856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/24/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
Venous thromboembolism (VTE) is associated with high morbidity and mortality. Risk scores associated with VTE have been widely used in clinical practice. Among numerous scores published, those included in guidelines are usually typical risk scores which have been extensively validated and globally recognized. This review provides an updated overview of the risk scores associated with VTE endorsed by 3 guidelines which are highly recognized in the field of VTE including the European Society of Cardiology, American College of Chest Physicians, and American Society of Hematology, focusing on the development, modification, validation, and comparison of these scores, to provide a comprehensive and updated understanding of all the classic risk scores associated with VTE to medical readers including but not limited to cardiologists, pulmonologists, hematologists, intensivists, physicians, surgeons, and researchers. Although each score recommended by these guidelines was more or less validated, there may still be room for further improvement. It may still be necessary to seek simpler, more practical, and more universally applicable VTE-related risk scores in the future.
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Affiliation(s)
- Wei Xiong
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yi Cheng
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yunfeng Zhao
- Department of Pulmonary and Critical Care Medicine, Punan Hospital, Pudong New District, Shanghai, China
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10
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Bakhsh E. The Benefits and Imperative of Venous Thromboembolism Risk Screening for Hospitalized Patients: A Systematic Review. J Clin Med 2023; 12:7009. [PMID: 38002623 PMCID: PMC10672497 DOI: 10.3390/jcm12227009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/05/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Venous thromboembolism (VTE) is a major preventable condition in hospitalized patients globally. This systematic review evaluates the effectiveness and clinical significance of venous thromboembolism (VTE) risk-screening protocols in preventing VTE events among hospitalized patients. Databases, including PubMed, Embase and Cochrane, were searched without date limits for studies comparing outcomes between hospitalized patients who did and did not receive VTE risk screening using standard tools. Twelve studies, enrolling over 139,420 patients, were included. Study quality was assessed using the ROBVIS tool. The results were summarized narratively. The findings show significant benefits of using VTE risk screening versus usual care across various outcomes. Using recommended tools, like Caprini, Padua and IMPROVE, allowed for the accurate identification of high-risk patients who benefited most from prevention. Formal screening was linked to much lower VTE rates, shorter hospital stays, fewer deaths and better use of preventive strategies matched to estimated clot risk. This review calls for the widespread adoption of VTE risk screening as an important safety step for at-risk hospital patients. More high-quality comparative research is needed to validate screening tools in different settings and populations. In summary, VTE risk screening is essential for healthcare systems to reduce life-threatening VTE events and improve patient outcomes through properly targeted preventive methods.
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Affiliation(s)
- Ebtisam Bakhsh
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia
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11
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Solomon J, Dauber-Decker K, Richardson S, Levy S, Khan S, Coleman B, Persaud R, Chelico J, King D, Spyropoulos A, McGinn T. Integrating Clinical Decision Support Into Electronic Health Record Systems Using a Novel Platform (EvidencePoint): Developmental Study. JMIR Form Res 2023; 7:e44065. [PMID: 37856193 PMCID: PMC10623239 DOI: 10.2196/44065] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 06/21/2023] [Accepted: 07/31/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Through our work, we have demonstrated how clinical decision support (CDS) tools integrated into the electronic health record (EHR) assist providers in adopting evidence-based practices. This requires confronting technical challenges that result from relying on the EHR as the foundation for tool development; for example, the individual CDS tools need to be built independently for each different EHR. OBJECTIVE The objective of our research was to build and implement an EHR-agnostic platform for integrating CDS tools, which would remove the technical constraints inherent in relying on the EHR as the foundation and enable a single set of CDS tools that can work with any EHR. METHODS We developed EvidencePoint, a novel, cloud-based, EHR-agnostic CDS platform, and we will describe the development of EvidencePoint and the deployment of its initial CDS tools, which include EHR-integrated applications for clinical use cases such as prediction of hospitalization survival for patients with COVID-19, venous thromboembolism prophylaxis, and pulmonary embolism diagnosis. RESULTS The results below highlight the adoption of the CDS tools, the International Medical Prevention Registry on Venous Thromboembolism-D-Dimer, the Wells' criteria, and the Northwell COVID-19 Survival (NOCOS), following development, usability testing, and implementation. The International Medical Prevention Registry on Venous Thromboembolism-D-Dimer CDS was used in 5249 patients at the 2 clinical intervention sites. The intervention group tool adoption was 77.8% (4083/5249 possible uses). For the NOCOS tool, which was designed to assist with triaging patients with COVID-19 for hospital admission in the event of constrained hospital resources, the worst-case resourcing scenario never materialized and triaging was never required. As a result, the NOCOS tool was not frequently used, though the EvidencePoint platform's flexibility and customizability enabled the tool to be developed and deployed rapidly under the emergency conditions of the pandemic. Adoption rates for the Wells' criteria tool will be reported in a future publication. CONCLUSIONS The EvidencePoint system successfully demonstrated that a flexible, user-friendly platform for hosting CDS tools outside of a specific EHR is feasible. The forthcoming results of our outcomes analyses will demonstrate the adoption rate of EvidencePoint tools as well as the impact of behavioral economics "nudges" on the adoption rate. Due to the EHR-agnostic nature of EvidencePoint, the development process for additional forms of CDS will be simpler than traditional and cumbersome IT integration approaches and will benefit from the capabilities provided by the core system of EvidencePoint.
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Affiliation(s)
- Jeffrey Solomon
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Katherine Dauber-Decker
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Safiya Richardson
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Sera Levy
- Department of Psychiatry, Heersink School of Medicine, University of Alabama at Birmingham Medicine, Birmingham, AL, United States
| | - Sundas Khan
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Benjamin Coleman
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Rupert Persaud
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - John Chelico
- Physician Enterprise, CommonSpirit Health, Chicago, IL, United States
| | - D'Arcy King
- School of Psychology, Fielding Graduate University, Santa Barbara, CA, United States
| | - Alex Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Thomas McGinn
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Physician Enterprise, CommonSpirit Health, Chicago, IL, United States
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12
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Jani CT, Schooley RT, Mckay RR, Lippman SM. Cancer, more than a “COVID-19 co-morbidity”. Front Oncol 2023; 13:1107384. [PMID: 36994197 PMCID: PMC10040761 DOI: 10.3389/fonc.2023.1107384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/13/2023] [Indexed: 03/14/2023] Open
Abstract
Patients with cancer represent a particularly vulnerable population at risk of adverse outcomes related to COVID-19. Collectively, the initial studies, including patients with and without cancer, confirmed that patients with cancer had a higher risk of complications and death related to COVID-19. Subsequent studies on patients with COVID-19 and cancer investigated patient and disease-related factors associated with COVID-19 severity and morality. Multiple interconnected factors include demographics, comorbidities, cancer-associated variables, treatment side effects, and other parameters. However, there is a lack of clarity on the contributions of any one factor. In this commentary, we deconvolute the data of specific risk factors associated with worse outcomes due to COVID-19 in cancer patients and focus on understanding the recommended guidelines to mitigate COVID-19 risk in this vulnerable population. In the first section, we highlight the key parameters, including age and race, cancer status, type of malignancy, cancer therapy, smoking status and comorbidities that impact outcomes for cancer patients with COVID-19. Next, we discuss efforts made at the patient, health system, and population levels to mitigate the effects of the ongoing outbreak for patients with cancer, including (1) screening, barrier and isolation strategies (2), Masking/PPE (3), vaccination, and (4) systemic therapies (e.g., evusheld) to prevent disease onset in patients. In the last section, we discuss optimal treatment strategies for COVID-19, including additional therapies for patients with COVID-19 and cancer. Overall, this commentary focuses on articles with high yield and impact on understanding the evolving evidence of risk factors and management guidelines in detail. We also emphasize the ongoing collaboration between clinicians, researchers, health system administrators and policymakers and how its role will be important in optimizing care delivery strategies for patients with cancer. Creative patient-centered solutions will be critical in the coming years, post the pandemic.
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Affiliation(s)
- Chinmay T. Jani
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Robert T. Schooley
- Division of Hematology-Oncology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Rana R. Mckay
- Division of Hematology-Oncology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
- *Correspondence: Rana R. Mckay,
| | - Scott M. Lippman
- Division of Hematology-Oncology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
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Chi G, Violi F, Pignatelli P, Vestri A, Spagnoli A, Loffredo L, Hernandez AF, Hull RD, Cohen AT, Harrington RA, Goldhaber SZ, Gibson CM. External validation of the ADA score for predicting thrombosis among acutely ill hospitalized medical patients from the APEX Trial. J Thromb Thrombolysis 2023; 55:211-221. [PMID: 36566304 PMCID: PMC9789884 DOI: 10.1007/s11239-022-02757-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 12/25/2022]
Abstract
The ADA (Age-D-dimer-Albumin) score was developed to identify hospitalized patients at an increased risk for thrombosis in the coronavirus infectious disease-19 (COVID-19) setting. The study aimed to validate the ADA score for predicting thrombosis in a non-COVID-19 medically ill population from the APEX trial. The APEX trial was a multinational, randomized trial that evaluated the efficacy and safety of betrixaban vs. enoxaparin among acutely ill hospitalized patients at risk for venous thromboembolism. The study endpoints included the composite of arterial or venous thrombosis and its components. Metrics of model calibration and discrimination were computed for assessing the performance of the ADA score as compared to the IMPROVE score, a well-validated VTE risk assessment model. Among 7,119 medical inpatients, 209 (2.9%) had a thrombosis event up to 77 days of follow-up. The ADA score demonstrated good calibration for both arterial and venous thrombosis, whereas the IMPROVE score had adequate calibration for venous thrombosis (p > 0.05 from the Hosmer-Lemeshow test). For discriminating arterial and venous thrombosis, there was no significant difference between the ADA vs. IMPROVE score (c statistic = 0.620 [95% CI: 0.582 to 0.657] vs. 0.590 [95% CI: 0.556 to 0.624]; ∆ c statistic = 0.030 [95% CI: -0.022 to 0.081]; p = 0.255). Similarly, for discriminating arterial thrombosis, there was no significant difference between the ADA vs. IMPROVE score (c statistic = 0.582 [95% CI: 0.534 to 0.629] vs. 0.609 [95% CI: 0.564 to 0.653]; ∆ c statistic = -0.027 [95% CI: -0.091 to 0.036]; p = 0.397). For discriminating venous thrombosis, the ADA score was modestly superior to the IMPROVE score (c statistic = 0.664 [95% CI: 0.607 to 0.722] vs. 0.573 [95% CI: 0.521 to 0.624]; ∆ c statistic = 0.091 [95% CI: 0.011 to 0.172]; p = 0.026). The ADA score had a higher sensitivity (0.579 [95% CI: 0.512 to 0.646]; vs. 0.440 [95% CI: 0.373 to 0.507]) but lower specificity (0.625 [95% CI: 0.614 to 0.637] vs. 0.747 [95% CI: 0.737 to 0.758]) than the IMPROVE score for predicting thrombosis. Among acutely ill hospitalized medical patients enrolled in the APEX trial, the ADA score demonstrated good calibration but suboptimal discrimination for predicting thrombosis. The findings support the use of either the ADA or IMPROVE score for thrombosis risk assessment. The applicability of the ADA score to non-COVID-19 populations warrants further research.Clinical Trial Registration: http://www.clinicaltrials.gov . Unique identifier: NCT01583218.
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Affiliation(s)
- Gerald Chi
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Francesco Violi
- I Clinica Medica, Sapienza University of Rome, and Medicina Cardiocentro, Naples, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Sapienza University of Rome, and Medicina Cardiocentro, Naples, Italy
| | - Annarita Vestri
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandra Spagnoli
- BioMedical Statistics Section, Department of Public health and Infectious Disease, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Loffredo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Russell D Hull
- Division of Cardiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' Hospitals, King's College, London, UK
| | - Robert A Harrington
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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14
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Enoxaparin Posology According to Prothrombotic Status and Bleeding Risk in Hospitalized Patients with SARS-CoV-2 Pneumonia. J Clin Med 2023; 12:jcm12030928. [PMID: 36769576 PMCID: PMC9918225 DOI: 10.3390/jcm12030928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/18/2023] [Accepted: 01/22/2023] [Indexed: 01/27/2023] Open
Abstract
Some patients with COVID-19 have complex hypercoagulable abnormalities that are related to mortality. The optimal dosage of low molecular weight heparin in hospitalized patients with SARS-CoV-2 pneumonia is still not clear. Our objective is to evaluate the effects of adapting the dosage of low molecular weight heparin to thrombotic and bleeding risk scales in this setting. We performed a cohort, retrospective, observational, and analytical study at the Hospital Universitario of Jerez de la Frontera, with patients admitted with SARS-CoV-2 pneumonia from 1 October 2020 to 31 January 2021. They were classified according to whether they received prophylactic, intermediate, or therapeutic doses of enoxaparin. The primary endpoint was intrahospital mortality. Secondary endpoints were the need for invasive ventilation, thromboembolic events, bleeding, and the usefulness of thrombotic and bleeding scales. After binary logistic regression analysis, considering confounding variables, it was found that the use of enoxaparin at therapeutic doses was associated with lower mortality during admission compared to prophylactic and intermediate doses (RR 0.173; 95% CI, 0.038-0.8; p = 0.025). IMPROVE bleeding risk score correlated with a higher risk of minor bleeding (RR 1.263; 95% CI, 1.105-1.573; p = 0.037). In adult hospitalized patients with SARS-CoV-2 pneumonia presenting elevated D-dimer and severe proinflammatory state, therapeutic doses of enoxaparin can be considered, especially if bleeding risk is low according to the IMPROVE bleeding risk score.
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15
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Khan S, King D, Osmani S, Harte O, Solomon J, Niranjan K, Rosenberg DJ. Provider Response to a Venous Thromboembolism Risk Assessment and Prophylaxis Ordering Tool: Observational Study. Appl Clin Inform 2022; 13:1214-1222. [PMID: 36577502 PMCID: PMC9797348 DOI: 10.1055/s-0042-1759770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/26/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Our health system launched an initiative to regulate venous thromboembolism (VTE) risk assessment and prophylaxis with electronically embedded risk assessment models based on validated clinical prediction rules. Prior to system-wide implementation, usability testing was conducted on the VTE clinical decision support system (CDSS) to assess provider perceptions, facilitate adoption, and usage of the tool. The objective of this study was to conduct usability testing with end users on the CDSS' risk assessment model and prophylaxis ordering components. METHODS This laboratory usability testing study was conducted with 24 health care providers. Participants were given two case scenarios that mirrored real-world scenarios to assess likelihood of use and adoption. During each case scenario, participants engaged in a think-aloud session, verbalizing their decision-making process while interacting with the tool. Following each case scenario, participants completed the System Usability Scale (SUS) and a posttask interview. Participants' comments and interactions with the VTE CDSS were placed into coding categories and analyzed for generalizable themes by three independent coders. RESULTS Of the 24 participants, 50% were female and the mean age of all participants was 32.76 years. The average SUS across the different services lines was 72.39 (C grade). Each participant's comments were grouped into three overarching themes: functionality, visibility/navigation, and content. Comments included personalizing workflow for each service line, minimizing the number of clicks, clearly defining risk models, including background on risk scores, and providing treatment guidelines for order sets. CONCLUSION An important step toward providing quality health care to patients at risk of developing a VTE event is providing user-friendly tools to providers. Following usability testing, our study revealed opportunities to positively impact provider behavior and acceptance. The rigor and breadth of this usability testing study and adoption of the optimizations should increase provider adoption and retention of the VTE CDSS.
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Affiliation(s)
- Sundas Khan
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
- Department of Medicine, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs (VA) Medical Center, Houston, Texas, United States
| | - D'Arcy King
- Department of Clinical Psychology, Fielding Graduate University, Santa Barbara, California, United States
| | - Soheb Osmani
- Department of Medicine, Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
| | - Owen Harte
- Department of Biological Sciences, College of Science, University of Notre Dame, Notre Dame, Indiana, United States
| | - Jeffrey Solomon
- Department of Medicine, Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
| | - Kunti Niranjan
- Department of Medicine, Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
| | - David J. Rosenberg
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
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Jagiasi BG, Chhallani AA, Dixit SB, Kumar R, Pandit RA, Govil D, Prayag S, Zirpe KG, Mishra RC, Chanchalani G, Kapadia FN. Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit. Indian J Crit Care Med 2022; 26:S51-S65. [PMID: 36896363 PMCID: PMC9989869 DOI: 10.5005/jp-journals-10071-24195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/03/2022] [Indexed: 11/05/2022] Open
Abstract
Deep vein thrombosis (DVT) is a preventable complication of critical illness, and this guideline aims to convey a pragmatic approach to the problem. Guidelines have multiplied over the last decade, and their utility has become increasingly conflicted as the reader interprets all suggestions or recommendations as something that must be followed. The nuances of grade of recommendation vs level of evidence are often ignored, and the difference between a "we suggest" vs a "we recommend" is overlooked. There is a general unease among clinicians that failure to follow the guidelines translates to poor medical practice and legal culpability. We attempt to overcome these limitations by highlighting ambiguity when it occurs and refraining from dogmatic recommendations in the absence of robust evidence. Readers and practitioners may find the lack of specific recommendations unsatisfactory, but we believe that true ambiguity is better than inaccurate certainty. We have attempted to comply with the guidelines on how to create guidelines.1 And to overcome the poor compliance with these guidelines.2 Some observers have expressed concern that DVT prophylaxis guidelines may cause more harm than good.3 We have placed greater emphasis on large randomized controlled trials (RCTs) with clinical end point and de-emphasized RCTs with surrogate end points and also de-emphasized hypothesis generating studies (observational studies, small RCTs, and meta-analysis of these studies). We have de-emphasized RCTs in non-intensive care unit populations like postoperative patients or those with cancer and stroke. We have also considered resource limitation settings and have avoided recommending costly and poorly proven therapeutic options. How to cite this article Jagiasi BG, Chhallani AA, Dixit SB, Kumar R, Pandit RA, Govil D, et al. Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit. Indian J Crit Care Med 2022;26(S2):S51-S65.
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Affiliation(s)
- Bharat G Jagiasi
- Critical Care Department, Reliance Hospital, Navi Mumbai, Maharashtra, India
| | | | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Rishi Kumar
- Department of Critical Care, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Rahul A Pandit
- Critical Care, Fortis Hospital, Mumbai, Maharashtra, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Shirish Prayag
- Critical Care, Prayag Hospital, Pune, Maharashtra, India
| | - Kapil G Zirpe
- Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Rajesh C Mishra
- Department of MICU, Shaibya Comprehensive Care Clinic, Ahmedabad, Gujarat, India
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Hillegass E, Lukaszewicz K, Puthoff M. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline 2022. Phys Ther 2022; 102:6585463. [PMID: 35567347 DOI: 10.1093/ptj/pzac057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
No matter the practice setting, physical therapists work with patients who are at risk for or who have a history of venous thromboembolism (VTE). In 2016, the first clinical practice guideline (CPG) addressing the physical therapist management of VTE was published with support by the American Physical Therapy Association's Academy of Cardiovascular and Pulmonary Physical Therapy and Academy of Acute Care, with a primary focus on lower extremity deep vein thrombosis (DVT). This CPG is an update of the 2016 CPG and contains the most current evidence available for the management of patients with lower extremity DVT and new key action statements (KAS), including guidance on upper extremity DVT, pulmonary embolism, and special populations. This document will guide physical therapist practice in the prevention of and screening for VTE and in the management of patients who are at risk for or who have been diagnosed with VTE. Through a systematic review of published studies and a structured appraisal process, KAS were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms based on the KAS were developed that can assist with clinical decision-making. Physical therapists, along with other members of the health care team, should implement these KAS to decrease the incidence of VTE, improve the diagnosis and acute management of VTE, and reduce the long-term complications of VTE.
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Affiliation(s)
- Ellen Hillegass
- Department of Physical Therapy, Mercer University, Atlanta, Georgia, USA
| | | | - Michael Puthoff
- Physical Therapy Department, St Ambrose University, Davenport, Iowa, USA
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18
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Galli E, Maggio E, Pomero F. Venous Thromboembolism in Sepsis: From Bench to Bedside. Biomedicines 2022; 10:biomedicines10071651. [PMID: 35884956 PMCID: PMC9313423 DOI: 10.3390/biomedicines10071651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 12/22/2022] Open
Abstract
Septic patients were commonly affected by coagulation disorders; thus, they are at high risk of thrombotic complications. In the last decades, novel knowledge has emerged about the interconnected and reciprocal influence of immune and coagulation systems. This phenomenon is called immunothrombosis, and it indicates an effective response whereby immune cells and the coagulation cascade cooperate to limit pathogen invasion and endothelial damage. When this network becomes dysregulated due to a systemic inflammatory activation, as occurs during sepsis, it can result in pathological thrombosis. Endothelium, platelets and neutrophils are the main characters involved in this process, together with the TF and coagulation cascade, playing a critical role in both the host defense and in thrombogenesis. A deeper understanding of this relationship may allow us to answer the growing need for clinical instruments to establish the thrombotic risk and treatments that consider more the connection between coagulation and inflammation. Heparin remains the principal therapeutical response to this phenomenon, although not sufficiently effective. To date, no other significant alternatives have been found yet. In this review, we discuss the role of sepsis-related inflammation in the development and resolution of venous thromboembolism and its clinical implications, from bench to bedside.
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Affiliation(s)
- Eleonora Galli
- Internal Medicine Residency Program, University of Turin, 10100 Turin, TO, Italy;
- Department of Internal Medicine, M. and P. Ferrero Hospital, 12060 Verduno, CN, Italy;
| | - Elena Maggio
- Department of Internal Medicine, M. and P. Ferrero Hospital, 12060 Verduno, CN, Italy;
| | - Fulvio Pomero
- Department of Internal Medicine, M. and P. Ferrero Hospital, 12060 Verduno, CN, Italy;
- Correspondence: ; Tel.: +39-01721408100
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19
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Abstract
Introduction COVID-19 associated VTE is a new disease entity with high morbidity and mortality. The aim of this paper is to review contemporary emerging literature on the incidence, pathophysiology, predictive prognostic indicators, and management consensus for Covid-19 related thrombotic complications, in particular DVT and PE. Methods A literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All searches were done via PubMed. References of review articles were further screened according to the exclusion criteria. Results In total, 154 records were identified and 20 duplicates were removed. A final 68 articles were included in the qualitative analysis. COVID-19 related thrombosis can affect multiple organs of the body, presenting in the form of arterial or venous thrombosis such as ischemic stroke, myocardial infarction, mesenteric ischemia, limb ischemia, DVT, or PE. DVT and PE has an overall incidence of 6–26%, and severely ill COVID-19 patients have even higher incidence of thromboembolism. On the other hand, incidence of arterial thromboembolism is much lower with incidence of 0.7%–3.7%. D-dimer is found to be an independent risk factor, and IMPROVE score, Caprini score, and Padua score have all been used as predictors. International guidelines suggest the use of low molecular weight heparin (LMWH) or fondaparinux for prophylaxis of VTE, and therapeutic dosage of weight adjusted LMWH for treatment if confirmed diagnosis. Conclusions Contemporary rapidly evolving evidence shows that COVID-19 associated thrombosis was a novel clinical entity, especially in severely ill COVID-19 patients. There are multiple society-driven guidelines only, but without any level 1 evidence for management regimen. The ideal dose for prophylaxis is not established and may vary depending on balance of bleeding and thrombosis risk. The risk of bleeding may be increased in patients in intensive care unit.
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Affiliation(s)
- Nicole M Cheng
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Hong Kong, China
| | - Yiu Che Chan
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Hong Kong, China
| | - Stephen W Cheng
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Hong Kong, China
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20
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Choffat D, Farhoumand PD, Jaccard E, de la Harpe R, Kraege V, Benmachiche M, Gerber C, Leuzinger S, Podmore C, Truong MK, Dumans-Louis C, Marti C, Reny JL, Aujesky D, Rakovic D, Limacher A, Rossel JB, Baumgartner C, Méan M. Risk stratification for hospital-acquired venous thromboembolism in medical patients (RISE): Protocol for a prospective cohort study. PLoS One 2022; 17:e0268833. [PMID: 35609087 PMCID: PMC9128957 DOI: 10.1371/journal.pone.0268833] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 05/09/2022] [Indexed: 12/04/2022] Open
Abstract
Background Hospital-acquired venous thromboembolism (VTE) is one of the leading preventable causes of in-hospital mortality. However, its risk assessment in medically ill inpatients is complicated due to the patients’ heterogeneity and complexity of currently available risk assessment models (RAMs). The simplified Geneva score provides simplicity but has not yet been prospectively validated. Immobility is an important predictor for VTE in RAMs, but its definition is inconsistent and based on subjective assessment by nurses or physicians. In this study, we aim to prospectively validate the simplified Geneva score and to examine the predictive performance of a novel and objective definition of in-hospital immobilization using accelerometry. Methods and analysis RISE is a multicenter prospective cohort study. The goal is to recruit 1350 adult inpatients admitted for medical illness in three Swiss tertiary care hospitals. We collect data on demographics, comorbidities, VTE risk and thromboprophylaxis. Mobility from admission to discharge is objectively measured using a wrist-worn accelerometer. Participants are followed for 90 days for the occurrence of symptomatic VTE (primary outcome). Secondary outcomes are the occurrence of clinically relevant bleeding, and mortality. The evolution of autonomy in the activities of daily living, the length of stay, and the occurrence of readmission are also recorded. Time-dependent area under the curve, sensitivity, specificity, and positive and negative predictive values are calculated for each RAM (i.e. the simplified and original Geneva score, Padua, and IMPROVE score) with and without the objective mobility measures to assess their accuracy in predicting hospital-acquired VTE at 90 days. Ethics and expected impact The ethics committee approved the protocol and the study was registered on ClinicalTrials.gov as NCT04439383. RISE has the potential to optimize VTE risk stratification, and thus to improve the quality of care of medically hospitalized patients.
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Affiliation(s)
- Damien Choffat
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- * E-mail:
| | - Pauline Darbellay Farhoumand
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Evrim Jaccard
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Roxane de la Harpe
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Vanessa Kraege
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Malik Benmachiche
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Christel Gerber
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Salomé Leuzinger
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Clara Podmore
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Minh Khoa Truong
- Division of Pneumology, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Céline Dumans-Louis
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Christophe Marti
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Jean-Luc Reny
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Damiana Rakovic
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Jean-Benoît Rossel
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- CTU Bern, University of Bern, Bern, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie Méan
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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21
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Nascimento DDC, Rolnick N, Neto IVDS, Severin R, Beal FLR. A Useful Blood Flow Restriction Training Risk Stratification for Exercise and Rehabilitation. Front Physiol 2022; 13:808622. [PMID: 35360229 PMCID: PMC8963452 DOI: 10.3389/fphys.2022.808622] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/04/2022] [Indexed: 11/18/2022] Open
Abstract
Blood flow restriction training (BFRT) is a modality with growing interest in the last decade and has been recognized as a critical tool in rehabilitation medicine, athletic and clinical populations. Besides its potential for positive benefits, BFRT has the capability to induce adverse responses. BFRT may evoke increased blood pressure, abnormal cardiovascular responses and impact vascular health. Furthermore, some important concerns with the use of BFRT exists for individuals with established cardiovascular disease (e.g., hypertension, diabetes mellitus, and chronic kidney disease patients). In addition, considering the potential risks of thrombosis promoted by BFRT in medically compromised populations, BFRT use warrants caution for patients that already display impaired blood coagulability, loss of antithrombotic mechanisms in the vessel wall, and stasis caused by immobility (e.g., COVID-19 patients, diabetes mellitus, hypertension, chronic kidney disease, cardiovascular disease, orthopedic post-surgery, anabolic steroid and ergogenic substance users, rheumatoid arthritis, and pregnant/postpartum women). To avoid untoward outcomes and ensure that BFRT is properly used, efficacy endpoints such as a questionnaire for risk stratification involving a review of the patient’s medical history, signs, and symptoms indicative of underlying pathology is strongly advised. Here we present a model for BFRT pre-participation screening to theoretically reduce risk by excluding people with comorbidities or medically complex histories that could unnecessarily heighten intra- and/or post-exercise occurrence of adverse events. We propose this risk stratification tool as a framework to allow clinicians to use their knowledge, skills and expertise to assess and manage any risks related to the delivery of an appropriate BFRT exercise program. The questionnaires for risk stratification are adapted to guide clinicians for the referral, assessment, and suggestion of other modalities/approaches if/when necessary. Finally, the risk stratification might serve as a guideline for clinical protocols and future randomized controlled trial studies.
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Affiliation(s)
- Dahan da Cunha Nascimento
- Department of Physical Education, Catholic University of Brasília (UCB), Brasília, Brazil
- Department of Gerontology, Catholic University of Brasília (UCB), Brasília, Brazil
- *Correspondence: Dahan da Cunha Nascimento,
| | - Nicholas Rolnick
- The Human Performance Mechanic, Lehman College, New York, NY, United States
| | - Ivo Vieira de Sousa Neto
- Laboratory of Molecular Analysis, Graduate Program of Sciences and Technology of Health, University of Brasília, Brasília, Brazil
| | - Richard Severin
- Department of Physical Therapy, College of Applied Health Sciences, The University of Illinois at Chicago, Chicago, IL, United States
- Department of Physical Therapy, Robbins College of Health and Human Sciences, Baylor University, Waco, TX, United States
| | - Fabiani Lage Rodrigues Beal
- Department of Gerontology, Catholic University of Brasília (UCB), Brasília, Brazil
- Department of Nutrition, Health and Medicine School, Catholic University of Brasília (UCB), Brasília, Brazil
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22
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Violi F, Pignatelli P, Vestri A, Spagnoli A, Cipollone F, Ceccarelli G, Oliva A, amitrano M, Pirro M, Taliani G, Cangemi R, Lichtner M, Pugliese F, Falcone M, Venditti M, Mastroianni CM, Loffredo L. THE ADA (AGE-D-DIMER-ALBUMIN) SCORE TO PREDICT THROMBOSIS IN SARS-CoV-2. Thromb Haemost 2022; 122:1567-1572. [DOI: 10.1055/a-1788-7592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV2)-related
pneumonia is associated with venous and arterial thrombosis . Aim of the study was to find-out a
new score for predicting thrombosis in patients with SARS-CoV-2.
Methods: We included a
cohort of 674 patients affected by SARS-CoV-2, not requiring intensive care units, and
followed-up during the hospitalization until discharge. Routinary analyses performed at
in-hospital admission included also serum albumin and D-dimer while arterial and venous
thromboses were the end-points of the study.
Results: During the follow-up thrombotic events
110 were registered; patients with thrombotic events were older and had lower albumin and higher
D-dimer, compared to thrombotic event-free ones. On multivariable logistic regression with step
by stepwise procedure age, serum albumin, D-dimer, were independently associated with thrombotic
events. The linear combination of age, D-dimer, albumin allowed to build-up the ADA score, whose
AUC was 0.752 (95% CI, 0.708-0.795). ADA score was internally validated by bootstrap sampling
procedure giving an AUC of 0.752 (95% CI: 0.708 - 0.794).
Conclusions: Combination of age,
D-dimer, albumin in the ADA score allows identifying SARS-CoV-2 patients at higher risk of
thrombotic events.
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Affiliation(s)
- Francesco Violi
- Policlinico Umberto I, I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Roma, Italy
| | | | - Annarita Vestri
- BioMedical Statistics and Clinical Epidemiology Centre, Department of Experimental Medicine, Sapienza University of Rome, Roma, Italy
| | - Alessandra Spagnoli
- Department of Public Health and Infectious Diseases., University of Rome La Sapienza, Rome, Italy
| | | | | | | | - maria amitrano
- Medicine, Azienda Ospedaliera S. G. Moscatti Hospital, avellino, Italy
| | | | | | | | | | | | | | | | | | - Lorenzo Loffredo
- Medicina Interna e Specialità Mediche, Università La Sapienza, Rome, Italy
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23
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Forgo G, Micieli E, Ageno W, Castellucci LA, Cesarman‐Maus G, Ddungu H, De Paula EV, Dumantepe M, Guillermo Esposito MC, Konstantinides SV, Kucher N, McLintock C, Ní Áinle F, Spyropoulos AC, Urano T, Hunt BJ, Barco S. An update on the global use of risk assessment models and thromboprophylaxis in hospitalized patients with medical illnesses from the World Thrombosis Day steering committee: Systematic review and meta-analysis. J Thromb Haemost 2022; 20:409-421. [PMID: 34822215 PMCID: PMC9299991 DOI: 10.1111/jth.15607] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/18/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a leading cause of cardiovascular morbidity and mortality. The majority of VTE events are hospital-associated. In 2008, the Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) multinational cross-sectional study reported that only approximately 40% of medical patients at risk of VTE received adequate thromboprophylaxis. METHODS In our systematic review and meta-analysis, we aimed at providing updated figures concerning the use of thromboprophylaxis globally. We focused on: (a) the frequency of patients with an indication to thromboprophylaxis according with individual models; (b) the use of adequate thromboprophylaxis; and (c) reported contraindications to thromboprophylaxis. Observational nonrandomized studies or surveys focusing on medically ill patients were considered eligible. RESULTS After screening, we included 27 studies from 20 countries for a total of 137 288 patients. Overall, 50.5% (95% confidence interval [CI]: 41.9-59.1, I2 99%) of patients had an indication to thromboprophylaxis: of these, 54.5% (95% CI: 46.2-62.6, I2 99%) received adequate thromboprophylaxis. The use of adequate thromboprophylaxis was 66.8% in Europe (95% CI: 50.7-81.1, I2 98%), 44.9% in Africa (95% CI: 31.8-58.4, I2 96%), 37.6% in Asia (95% CI: 25.7-50.3, I2 97%), 58.3% in South America (95% CI: 31.1-83.1, I2 99%), and 68.6% in North America (95% CI: 64.9-72.6, I2 96%). No major differences in adequate thromboprophylaxis use were found across risk assessment models. Bleeding, thrombocytopenia, and renal/hepatic failure were the most frequently reported contraindications to thromboprophylaxis. CONCLUSIONS The use of anticoagulants for VTE prevention has been proven effective and safe, but thromboprophylaxis prescriptions are still unsatisfactory among hospitalized medically ill patients around the globe with marked geographical differences.
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Affiliation(s)
- Gabor Forgo
- Department of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Evy Micieli
- Department of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Walter Ageno
- Department of Clinical MedicineUniversity of InsubriaVareseItaly
| | - Lana A. Castellucci
- Department of MedicineOttawa Hospital Research InstituteUniversity of OttawaOttawaONCanada
| | | | | | | | - Mert Dumantepe
- Department of Cardiovascular SurgeryUskudar University School of MedicineIstanbulTurkey
| | | | | | - Nils Kucher
- Department of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Claire McLintock
- National Women's Health Auckland City Hospital Auckland New ZealandAucklandNew Zealand
| | - Fionnuala Ní Áinle
- Department of HaematologyMater Misericordiae University Hospital and Rotunda HospitalDublinIreland
- School of MedicineUniversity College DublinDublinIreland
| | - Alex C. Spyropoulos
- Institute for Health Innovations and Outcomes ResearchFeinstein Institutes for Medical Research and the Zucker School of Medicine at Hofstra/NorthwellNew YorkNew YorkUSA
- Department of Medicine, Anticoagulation and Clinical Thrombosis ServicesNorthwell Health at Lenox Hill HospitalNew YorkNew YorkUSA
| | - Tetsumei Urano
- Shizuoka Graduate University of Public HealthShizuokaJapan
| | - Beverley J. Hunt
- Thrombosis & Haemophilia CentreGuys & St Thomas’ NHS Foundation TrustLondonUK
| | - Stefano Barco
- Department of AngiologyUniversity Hospital ZurichZurichSwitzerland
- Center for Thrombosis and HemostasisUniversity Medical Center MainzMainzGermany
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24
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Sato T, Ogihara Y, Fujimoto N, Usami A, Hamaguchi T, Tanabe M, Okamoto R, Nakase S, Dohi K. Prevalence and Clinical Characteristics of Proximal Deep Venous Thrombosis After a High-Density Coronavirus Disease 2019 Cluster in a Japanese Psychiatric Hospital. Circ J 2022; 86:458-463. [DOI: 10.1253/circj.cj-21-0987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Toru Sato
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Naoki Fujimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | | | | | - Masaki Tanabe
- Department of Clinical Laboratory, Mie University Hospital
| | - Ryuji Okamoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | | | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
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25
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Rothberg MB, Hamilton A, Greene MT, Fox J, Lisheba O, Milinovich A, Gautier TN, Kim P, Kaatz S, Hu B. Derivation and Validation of a Risk Factor Model to Identify Medical Inpatients at Risk for Venous Thromboembolism. Thromb Haemost 2021; 122:1231-1238. [PMID: 34784645 DOI: 10.1055/a-1698-6506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) prophylaxis is recommended for hospitalized medical patients at high risk for VTE. Multiple risk assessment models exist, but few have been compared in large data sets. METHODS We constructed a derivation cohort using 6 years of data from 13 hospitals to identify risk factors associated with developing VTE within 14 days of admission. VTE was identified using a complex algorithm combining administrative codes and clinical data. We developed a multivariable prediction model and applied it to 2 validation cohorts: a temporal cohort, including two additional years and a cross-validation, in which we refit the model excluding one hospital at a time, and applied the refitted model to the holdout hospital. Performance was evaluated using the C-statistic. RESULTS The derivation cohort included 160,928 patients with a 14-day VTE rate of 0.79%. The final multivariable model contained 13 patient risk factors. The model had an optimism corrected C-statistic of 0.80 and good calibration. The temporal validation cohort included 55,301 patients, with a VTE rate of 0.74%. Based on the c-statistic, the Cleveland Clinic Model (CCM) outperformed the Padua model (0.76 vs. 0.72, p<0.01). The CCM was more sensitive (65.8% vs. 60.4%, p=0.05) and more specific (74.9% vs. 71.4%, p<.001), with higher positive (1.9% vs. 1.5%, p<.001) and negative predictive values (99.7% vs. 99.6%, p=0.01). C-statistics for the CCM at individual hospitals ranged from 0.64 to 0.76. CONCLUSION A new VTE risk assessment model outperformed the Padua model. After further validation it could be recommended for widespread use.
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Affiliation(s)
- Michael B Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, United States.,Department of Internal Medicine, Cleveland Clinic, Cleveland, United States
| | - Aaron Hamilton
- Department of Internal Medicine, Cleveland Clinic, Cleveland, United States
| | - M Todd Greene
- University of Michigan Medical School, Ann Arbor, United States
| | - Jacqueline Fox
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, United States
| | - Oleg Lisheba
- Enterprise Analytics eResearch Department, Cleveland Clinic, Cleveland, United States
| | - Alex Milinovich
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, United States
| | - Thomas N Gautier
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, United States
| | - Priscilla Kim
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, United States
| | | | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, United States
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26
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Gupta A, Chegondi M, Billa RD, Bloxham J, Badheka A, Faustino IV, Faustino EVS. Validation of risk assessment models for venous thromboembolism and bleeding in critically ill adolescents. Thromb Res 2021; 208:106-111. [PMID: 34743033 DOI: 10.1016/j.thromres.2021.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine the performance of risk assessment models that were developed for adults, in predicting venous thromboembolism (VTE) and bleeding in critically ill adolescents. STUDY DESIGN We conducted a retrospective cohort study of adolescents 12 to 17 years old admitted to the pediatric intensive care unit who received cardiopulmonary support but did not have VTE on admission nor received anticoagulation. Discrimination, using areas under the receiver operating characteristic (AUROC) and precision-recall (AUPRC) curves, and calibration, using Hosmer-Lemeshow test, of the Geneva, Padua, IMPROVE VTE and IMPROVE Bleed models were calculated. RESULTS Of 536 adolescents analyzed, 7 (1.3%) developed VTE and 13 (2.4%) bled. AUROCs of the Geneva, Padua and IMPROVE VTE models ranged from 0.46 to 0.59, with 95% confidence intervals (CI) including 0.5. AUPRCs ranged from 0.011 to 0.017, with 95% CIs including 0.013. Only IMPROVE VTE model had non-statistically significant Hosmer-Lemeshow test. IMPROVE Bleed model had AUROC and AUPRC of 0.75 and 0.062, with 95% CIs excluding 0.5 and 0.024, respectively. Hosmer-Lemeshow test was not statistically significant. CONCLUSION Despite similarities in coagulation between adolescents and adults, risk assessment models for VTE in adults should not be used for critically ill adolescents. The model for bleeding may be useful.
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Affiliation(s)
- Anjali Gupta
- Pediatric Intensive Care Unit, Yale-New Haven Children's Hospital, New Haven, CT, USA
| | - Madhuradhar Chegondi
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Ramya Deepthi Billa
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Jodi Bloxham
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Aditya Badheka
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Isaac V Faustino
- Department of Statistics, University of Connecticut, Storrs, CT, USA
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27
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Lin CC, Chen CC, Li CI, Liu CS, Lin WY, Lin CH, Yang SY, Li TC. Derivation and validation of a clinical prediction model for risks of venous thromboembolism in diabetic and general populations. Medicine (Baltimore) 2021; 100:e27367. [PMID: 34596150 PMCID: PMC8483831 DOI: 10.1097/md.0000000000027367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 09/09/2021] [Indexed: 01/05/2023] Open
Abstract
Most studies on the prediction of venous thromboembolism (VTE) focused on hospitalized, surgery, and cancer patients or women receiving hormonal contraceptives or menopausal hormone therapy. No study considered diabetic and general populations to establish a VTE prediction model, especially in Asia. We developed a predictive model for VTE among type 2 diabetic patients and the general population.This study considered 2 nationwide retrospective cohort studies consisting of 52,427 diabetic participants and 508,664 participants from the general population aged 30 to 85 years during 2001 to 2004 in Taiwan. All participants were followed up until VTE event, death, or December 2011. The outcome event was VTE, including deep venous thrombosis and pulmonary embolism. Candidate predictors consisted of socio-demographic factors, diabetes-related factors and biomarkers, comorbidities, and medicine use. Our study followed the procedures proposed by the Framingham Heart Study to develop prediction models by using a Cox regression model. The predictive accuracy and performance characteristics were assessed using the area under curve of receiver operating characteristics curve and calibration of a risk score were performed by Hosmer-Lemeshow goodness-of-fit test.The common factors for persons with type 2 diabetes and general population included age, hospitalization status 1 year before the baseline, hypertension, chronic kidney disease, chronic obstructive pulmonary disease, and anti-diabetes medications; the specific factors for persons with type 2 diabetes consisted of body mass index, glycosylated hemoglobin A1C, and creatinine; and the factors for general population included gender, peripheral vascular disease, cancer, hypertension medication, cardiovascular medication, and non-steroidal anti-inflammatory drug. The area under curve of 3-, 5-, and 8-year VTE prediction models were 0.74, 0.71, and 0.69 in the diabetic population and 0.77, 0.76, and 0.75 in the general population, respectively.The new clinical prediction models can help identify a high risk of VTE and provide medical intervention in diabetic and general populations.
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Affiliation(s)
- Cheng-Chieh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Ching-Chu Chen
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Endocrinology and Metabolism, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Ing Li
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chiu-Shong Liu
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Wen-Yuan Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsueh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Shing-Yu Yang
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Tsai-Chung Li
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
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28
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A Review of Current and Future Antithrombotic Strategies in Surgical Patients-Leaving the Graduated Compression Stockings Behind? J Clin Med 2021; 10:jcm10194294. [PMID: 34640311 PMCID: PMC8509226 DOI: 10.3390/jcm10194294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/15/2021] [Accepted: 09/18/2021] [Indexed: 11/16/2022] Open
Abstract
Venous thromboembolism (VTE) remains an important consideration within surgery, with recent evidence looking to refine clinical guidance. This review provides a contemporary update of existing clinical evidence for antithrombotic regimens for surgical patients, providing future directions for prophylaxis regimens and research. For moderate to high VTE risk patients, existing evidence supports the use of heparins for prophylaxis. Direct oral anticoagulants (DOACs) have been validated within orthopaedic surgery, although there remain few completed randomised controlled trials in other surgical specialties. Recent trials have also cast doubt on the efficacy of mechanical prophylaxis, especially when adjuvant to pharmacological prophylaxis. Despite the ongoing uncertainty in higher VTE risk patients, there remains a lack of evidence for mechanical prophylaxis in low VTE risk patients, with a recent systematic search failing to identify high-quality evidence. Future research on rigorously developed and validated risk assessment models will allow the better stratification of patients for clinical and academic use. Mechanical prophylaxis' role in modern practice remains uncertain, requiring high-quality trials to investigate select populations in which it may hold benefit and to explore whether intermittent pneumatic compression is more effective. The validation of DOACs and aspirin in wider specialties may permit pharmacological thromboprophylactic regimens that are easier to administer.
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Makatsariya AD, Slukhanchuk EV, Bitsadze VO, Khizroeva JK, Tretyakova MV, Shkoda AS, Elalamy I, Di Renzo GC, Rizzo G, Pyatigorskaya NV, Solopova AG, Grigoreva KN, Nakaidze IA, Mitryuk DV. The Effect of Various Types of Anticoagulant Therapy on the Reduction of Mortality in COVID-19. ANNALS OF THE RUSSIAN ACADEMY OF MEDICAL SCIENCES 2021. [DOI: 10.15690/vramn1551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is a viral infection that, in severe course, leads to the development of a cytokine storm, systemic inflammatory response and coagulopathy. Unlike other sepsis-associated disseminated intravascular coagulopathy, COVID-19 induced coagulopathy is realized mainly in thrombosis. Researchers around the world are currently developing adequate diagnostic, monitoring and anticoagulant therapy approaches to safely and effectively manage patients with severe COVID-19. The need to develop laboratory monitoring is due to the fact that 20% of patients have changes in hemostasis indicators, while in patients with a severe form of the disease, they are present in 100% of cases. In case of deaths from COVID-19, there is an increase in the concentration of D-dimer and fibrinogen degradation products. Thus, the severity of hemostasis disorders has an important prognostic value. Anticoagulant therapy is included in the list of all recommendations as an effective means of reducing mortality from COVID-19. The questions of the recommended groups and doses of anticoagulant drugs are still open. The approach to the choice of an anticoagulant should be based not only on risk factors, characteristics of the course of the disease, anamnesis, but also on the wishes of the patient during long-term therapy at the post-hospital stage.
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Djulbegovic M, Chen K, Sureshanand S, Chaudhry S. Overuse of Primary Thromboprophylaxis in Medical Inpatients at Low Risk of Venous Thromboembolism. J Gen Intern Med 2021; 36:2883-2885. [PMID: 33464465 PMCID: PMC8390711 DOI: 10.1007/s11606-020-05993-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/12/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Mia Djulbegovic
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA. .,Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA. .,Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Kevin Chen
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Soundari Sureshanand
- Joint Data Analyst Team, Yale University, New Haven, CT, USA.,Yale Center for Clinician Investigation, New Haven, CT, USA
| | - Sarwat Chaudhry
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA.,Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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31
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Rodriguez JJ, Munoz OC, Porres-Aguilar M, Mukherjee D. Thromboembolic Complications in Severe COVID-19: Current Antithrombotic Strategies and Future Perspectives. Cardiovasc Hematol Disord Drug Targets 2021; 21:23-29. [PMID: 33719953 DOI: 10.2174/1871529x21666210315123347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/18/2021] [Accepted: 02/15/2021] [Indexed: 01/08/2023]
Abstract
The coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus (SARS- CoV-2) is our latest pandemic and has turned out to be a global public health crisis. One of the special characteristics of this disease is that it may predispose patients to thrombotic disease both in the venous and arterial circulation. We review arterial and venous thromboembolic complications in patients with COVID-19, epidemiology, pathogenesis, hematologic biomarkers, and current antithrombotic strategies. Future perspectives and clinical trials are ongoing to determine the best thromboprophylaxis strategies in the hospitalized patients with severe COVID-19.
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Affiliation(s)
- Juan J Rodriguez
- Facultad de Medicina, Universidad Autonoma Bucaramanga, Bucaramanga, Colombia
| | - Oscar C Munoz
- Department of Interventional Cardiology, Del Sol Medical Center, El Paso, TX 79925, United States
| | - Mateo Porres-Aguilar
- Division of Adult Thrombosis Medicine, Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC) at Jewish General Hospital, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Department of Medicine, Texas Tech University Health Sciences Center at El Paso, El Paso, TX 79905, United States
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Pandor A, Tonkins M, Goodacre S, Sworn K, Clowes M, Griffin XL, Holland M, Hunt BJ, de Wit K, Horner D. Risk assessment models for venous thromboembolism in hospitalised adult patients: a systematic review. BMJ Open 2021; 11:e045672. [PMID: 34326045 PMCID: PMC8323381 DOI: 10.1136/bmjopen-2020-045672] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 06/23/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Hospital-acquired thrombosis accounts for a large proportion of all venous thromboembolism (VTE), with significant morbidity and mortality. This subset of VTE can be reduced through accurate risk assessment and tailored pharmacological thromboprophylaxis. This systematic review aimed to determine the comparative accuracy of risk assessment models (RAMs) for predicting VTE in patients admitted to hospital. METHODS A systematic search was performed across five electronic databases (including MEDLINE, EMBASE and the Cochrane Library) from inception to February 2021. All primary validation studies were eligible if they examined the accuracy of a multivariable RAM (or scoring system) for predicting the risk of developing VTE in hospitalised inpatients. Two or more reviewers independently undertook study selection, data extraction and risk of bias assessments using the PROBAST (Prediction model Risk Of Bias ASsessment Tool) tool. We used narrative synthesis to summarise the findings. RESULTS Among 6355 records, we included 51 studies, comprising 24 unique validated RAMs. The majority of studies included hospital inpatients who required medical care (21 studies), were undergoing surgery (15 studies) or receiving care for trauma (4 studies). The most widely evaluated RAMs were the Caprini RAM (22 studies), Padua prediction score (16 studies), IMPROVE models (8 studies), the Geneva risk score (4 studies) and the Kucher score (4 studies). C-statistics varied markedly between studies and between models, with no one RAM performing obviously better than other models. Across all models, C-statistics were often weak (<0.7), sometimes good (0.7-0.8) and a few were excellent (>0.8). Similarly, estimates for sensitivity and specificity were highly variable. Sensitivity estimates ranged from 12.0% to 100% and specificity estimates ranged from 7.2% to 100%. CONCLUSION Available data suggest that RAMs have generally weak predictive accuracy for VTE. There is insufficient evidence and too much heterogeneity to recommend the use of any particular RAM. PROSPERO REGISTRATION NUMBER Steve Goodacre, Abdullah Pandor, Katie Sworn, Daniel Horner, Mark Clowes. A systematic review of venous thromboembolism RAMs for hospital inpatients. PROSPERO 2020 CRD42020165778. Available from https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=165778https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=165778.
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Affiliation(s)
| | | | | | - Katie Sworn
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Mark Clowes
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Xavier L Griffin
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Holland
- Department of Clinical and Biomedical Sciences, University of Bolton, Bolton, UK
| | - Beverley J Hunt
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kerstin de Wit
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
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Ferreira CR, de Bastos M, Diniz ML, Mancini RA, Raposo YS, Alves SM, Rezende SM. Inter-observer reliability of a risk assessment model for venous thromboembolism in acutely-ill medical hospitalized patients: Results from a prospective cohort study. Phlebology 2021; 36:827-834. [PMID: 34192948 DOI: 10.1177/02683555211021226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To analyze the inter-observer reliability of risk for venous thromboembolism (VTE) in a population of adult acutely-ill medical patients. METHODS In this prospective cohort study, we collected risk factors and risk classification for VTE using RAM IMPROVE7. Kappa statistics was used to evaluate inter-observer reliability between lead clinicians and trained researchers. We evaluated occurrence of VTE in patients with mismatched classification. RESULTS We included 2,380 patients, median age 70 years (interquartile range [IQR], 58-79), 56.2% female. Adjusted Kappa for VTE risk factors ranged from substantial (0.64, 95% confidence interval [CI], 0.61-0.67) for "immobilization", to almost perfect (0.98; 95% CI 0.97-0.99) for "thrombophilia"; risk classification was 0.64 (95% CI 0.60-0.67). Divergent risk classification occurred in 434 patients (18.2%) of whom seven (1.6%) developed VTE. CONCLUSION Despite substantial to almost perfect reliability between observers for risk factors and risk classification, lead clinicians tended to underestimate the risk for VTE.
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Affiliation(s)
- Cassia Rl Ferreira
- University Hospital, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.,Hospital Governador Israel Pinheiro, Belo Horizonte, Minas Gerais, Brazil
| | - Marcos de Bastos
- Hospital Governador Israel Pinheiro, Belo Horizonte, Minas Gerais, Brazil.,Faculdade da Saúde e Ecologia Humana (FASEH), Vespasiano, Minas Gerais, Brazil
| | - Mirella L Diniz
- University Hospital, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Renan A Mancini
- University Hospital, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Yan S Raposo
- Faculdade da Saúde e Ecologia Humana (FASEH), Vespasiano, Minas Gerais, Brazil
| | - Samara Mpg Alves
- Hospital Governador Israel Pinheiro, Belo Horizonte, Minas Gerais, Brazil
| | - Suely M Rezende
- University Hospital, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.,Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Woller SC, Stevens SM, Fazili M, Lloyd JF, Wilson EL, Snow GL, Bledsoe JR, Horne BD. Post-discharge thrombosis and bleeding in medical patients: A novel risk score derived from ubiquitous biomarkers. Res Pract Thromb Haemost 2021; 5:e12560. [PMID: 34263106 PMCID: PMC8265782 DOI: 10.1002/rth2.12560] [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] [Received: 03/25/2021] [Revised: 05/20/2021] [Accepted: 05/31/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Some hospitalized medical patients experience venous thromboembolism (VTE) following discharge. Prophylaxis extended beyond hospital discharge (extended duration thromboprophylaxis [EDT]) may reduce this risk. However, EDT is costly and can cause bleeding, so selecting appropriate patients is essential. We formerly reported the performance of a mortality risk prediction score (Intermountain Risk Score [IMRS]) that was minimally predictive of 90-day hospital-associated venous thromboembolism (HA-VTE) and major bleeding (HA-MB). We used the components of the IMRS to calculate de novo risk scores to predict 90-day HA-VTE (HA-VTE IMRS) and major bleeding (HA-MB IMRS). METHODS From 45 669 medical patients we randomly assigned 30 445 to derive the HA-VTE IMRS and the HA-MB IMRS. Backward stepwise regression and bootstrapping identified predictor covariates from the blood count and basic chemistry. These candidate variables were split into quintiles, and the referent quintile was that with the lowest event rate for HA-VTE and HA-MB; respectively. A clinically relevant rate of HA-VTE and HA-MB was used to inform outcome rates. Performance was assessed in the derivation set of 15 224 patients. RESULTS The HA-VTE IMRS and HA-MB IMRS area under the receiver operating curve (AUC) in the derivation set were 0.646, and 0.691, respectively. In the validation set, the HA-VTE IMRS and HA-MB IMRS AUCs were 0.60 and 0.643. CONCLUSIONS Risk scores derived from components of routine labs ubiquitous in clinical care identify patients that are at risk for 90-day postdischarge HA-VTE and major bleeding. This may identify a subset of patients with high HA-VTE risk and low HA-MB risk who may benefit from EDT.
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Affiliation(s)
- Scott C. Woller
- Department of MedicineIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | - Scott M. Stevens
- Department of MedicineIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | - Masarret Fazili
- Department of MedicineIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
| | - James F. Lloyd
- Department of InformaticsIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
| | - Emily L. Wilson
- Intermountain Statistical Data CenterIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
| | - Gregory L. Snow
- Intermountain Statistical Data CenterIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
| | - Joseph R. Bledsoe
- Department of Emergency MedicineIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
- Department of Emergency MedicineStanford UniversityStanfordCAUSA
| | - Benjamin D. Horne
- Intermountain Medical Center Heart InstituteMurrayUTUSA
- Division of Cardiovascular MedicineStanford UniversityStanfordCAUSA
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Goldin M, Lin SK, Kohn N, Qiu M, Cohen SL, Barish MA, Gianos E, Diaz A, Richardson S, Giannis D, Chatterjee S, Coppa K, Hirsch JS, Ngu S, Firoozan S, McGinn T, Spyropoulos AC. External validation of the IMPROVE-DD risk assessment model for venous thromboembolism among inpatients with COVID-19. J Thromb Thrombolysis 2021; 52:1032-1035. [PMID: 34146235 PMCID: PMC8214061 DOI: 10.1007/s11239-021-02504-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 01/20/2023]
Abstract
There is a need to discriminate which COVID-19 inpatients are at higher risk for venous thromboembolism (VTE) to inform prophylaxis strategies. The IMPROVE-DD VTE risk assessment model (RAM) has previously demonstrated good discrimination in non-COVID populations. We aimed to externally validate the IMPROVE-DD VTE RAM in medical patients hospitalized with COVID-19. This retrospective cohort study evaluated the IMPROVE-DD VTE RAM in adult patients with COVID-19 admitted to one of thirteen Northwell Health hospitals in the New York metropolitan area between March 1, 2020 and April 27, 2020. VTE was defined as new-onset symptomatic deep venous thrombosis or pulmonary embolism. To assess the predictive value of the RAM, the receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Of 9407 patients who met study criteria, 274 patients developed VTE with a prevalence of 2.91%. The VTE rate was 0.41% for IMPROVE-DD score 0–1 (low risk), 1.21% for score 2–3 (moderate risk), and 5.30% for score ≥ 4 (high risk). Approximately 45.7% of patients were classified as high VTE risk, 33.3% moderate risk, and 21.0% low risk. Discrimination of low versus moderate-high VTE risk demonstrated sensitivity 0.971, specificity 0.215, PPV 0.036, and NPV 0.996. ROC AUC was 0.703. In this external validation study, the IMPROVE-DD VTE RAM demonstrated very good discrimination to identify hospitalized COVID-19 patients at low, moderate, and high VTE risk.
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Affiliation(s)
- Mark Goldin
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
- North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Stephanie K Lin
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
| | - Nina Kohn
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
| | - Michael Qiu
- Department of Information Services, Northwell Health, New Hyde Park, USA
| | - Stuart L Cohen
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
| | - Matthew A Barish
- North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Eugenia Gianos
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Division of Cardiology, Lenox Hill Hospital, Northwell Health, New York, USA
| | - Anise Diaz
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
| | - Safiya Richardson
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
| | - Dimitrios Giannis
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
| | - Saurav Chatterjee
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Kevin Coppa
- Department of Information Services, Northwell Health, New Hyde Park, USA
| | - Jamie S Hirsch
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
- Department of Information Services, Northwell Health, New Hyde Park, USA
| | - Sam Ngu
- Department of Medicine, Northwell Health, Manhasset, USA
| | | | - Thomas McGinn
- CommonSpirit Health, Baylor College of Medicine, Houston, TX, USA
| | - Alex C Spyropoulos
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA.
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA.
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Snoga JL, Benitez RM, Kim S, Creager O, Lusk KA. A clinical focus on the use of extended-duration thromboprophylaxis in medically ill patients. Am J Health Syst Pharm 2021; 78:1057-1065. [PMID: 33580664 DOI: 10.1093/ajhp/zxab039] [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: 11/13/2022] Open
Abstract
PURPOSE This review describes and analyzes literature to provide recommendations for use of extended-duration thromboprophylaxis (EDT) in medically ill patients. SUMMARY Guidelines recommend pharmacologic thromboprophylaxis for patients at increased thrombosis risk during hospitalization and recommend against extending thromboprophylaxis beyond hospitalization. Despite these recommendations, observational data demonstrate that venous thromboembolism (VTE) risk persists following hospital discharge. A MEDLINE literature search was performed to identify original research evaluating the safety and efficacy of EDT. Eight meta-analyses and 5 randomized controlled trials-each varying in the agents studied (enoxaparin, rivaroxaban, apixaban, and betrixaban)-were selected for inclusion. Collectively, the evaluated data demonstrates that EDT reduces the incidence of VTE at the expense of increasing the risk of major bleeding and without providing mortality reduction. Variations in enrollment criteria, differences in EDT strategies, and uncertainty regarding proper patient selection limit the applicability of EDT in practice. Rivaroxaban and betrixaban gained Food and Drug Administration (FDA) approval on the basis of results of the APEX and MARINER trials and a post hoc analysis of the MAGELLEN trial results. Although a number of agents are FDA approved for use in EDT, clinicians must carefully weigh the risks vs benefits of EDT with these agents until studies demonstrate a more favorable risk-benefit profile. CONCLUSION Evidence to support EDT in medically ill patients is inconclusive and has highlighted the need for an individualized approach. The reviewed evidence supports guideline recommendations from both the American College of Chest Physicians and the American Society of Hematology that recommend against routine use of EDT in the majority of medically ill patients. Future studies are needed to optimize the risk-benefit profile of EDT and to ensure proper patient selection.
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Affiliation(s)
- Jenna L Snoga
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA
| | - Rebekah M Benitez
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA
| | - Subin Kim
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA
| | - Olivia Creager
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA
| | - Kathleen A Lusk
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA
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Buckheit D, Lefemine A, Sobieraj DM, Hobbs L. Venous Thromboembolism Prophylaxis in Underweight Hospitalized Patients. Clin Appl Thromb Hemost 2021; 27:10760296211018752. [PMID: 34080451 PMCID: PMC8182211 DOI: 10.1177/10760296211018752] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There is limited evidence about optimal anticoagulant dosing for venous thromboembolism (VTE) prophylaxis in underweight patients. The purpose of this study was to characterize dosing strategies used in underweight patients and compare the incidence of bleeding and VTE to patients receiving a standard dose. This multi-center retrospective study evaluated medicine patients who weighed 45 kilograms or less and received VTE prophylaxis with unfractionated heparin or enoxaparin. We categorized subjects into groups as either standard or reduced dose and compared the incidence of bleeding and VTE between groups. Of the 300 patients included in the outcome analysis, 40.7% received a reduced dose regimen, most often enoxaparin 30 mg daily. Standard dose was associated with major bleeding compared with reduced dose, when adjusted for age, gender and admission hemoglobin (odds ratio 4.73, 95% confidence interval 1.05 to 21.34). Incidence of clinically relevant non-major bleeding (2.4% vs. 1.1%) and VTE (0.6% vs. 0%) were similar between groups. Anticoagulant dose reduction for VTE prophylaxis in underweight hospitalized medicine patients is common practice and associated with less major bleeding.
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Affiliation(s)
- Douglas Buckheit
- Department of Pharmacy Services, Hartford Hospital, Hartford, CT, USA
| | - Amanda Lefemine
- University of Rhode Island College of Pharmacy, Kingston, RI, USA
| | - Diana M Sobieraj
- Department of Pharmacy Services, Hartford Hospital, Hartford, CT, USA.,Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Laura Hobbs
- Department of Pharmacy Services, Hartford Hospital, Hartford, CT, USA
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Prediction of Symptomatic Venous Thromboembolism in Critically Ill Patients: The ICU-Venous Thromboembolism Score. Crit Care Med 2021; 48:e470-e479. [PMID: 32187076 DOI: 10.1097/ccm.0000000000004306] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To identify risk factors and develop a prediction score for in-hospital symptomatic venous thromboembolism in critically ill patients. DESIGN Retrospective cohort study. SETTING Henry Ford Health System, a five-hospital system including 18 ICUs. PATIENTS We obtained data from the electronic medical record of all adult patients admitted to any ICU (total 264 beds) between January 2015 and March 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Symptomatic venous thromboembolism was defined as deep vein thrombosis, pulmonary embolism, or both, diagnosed greater than 24 hours after ICU admission and confirmed by ultrasound, CT, or nuclear medicine imaging. A prediction score (the ICU-Venous Thromboembolism score) was derived from independent risk factors identified using multivariable logistic regression. Of 37,050 patients who met the eligibility criteria, 529 patients (1.4%) developed symptomatic venous thromboembolism. The ICU-Venous Thromboembolism score consists of six independent predictors: central venous catheterization (5 points), immobilization greater than or equal to 4 days (4 points), prior history of venous thromboembolism (4 points), mechanical ventilation (2 points), lowest hemoglobin during hospitalization greater than or equal to 9 g/dL (2 points), and platelet count at admission greater than 250,000/μL (1 point). Patients with a score of 0-8 (76% of the sample) had a low (0.3%) risk of venous thromboembolism; those with a score of 9-14 (22%) had an intermediate (3.6%) risk of venous thromboembolism (hazard ratio, 6.7; 95% CI, 5.3-8.4); and those with a score of 15-18 (2%) had a high (17.7%) risk of venous thromboembolism (hazard ratio, 28.1; 95% CI, 21.7-36.5). The overall C-statistic of the model was 0.87 (95% CI, 0.85-0.88). CONCLUSIONS Clinically diagnosed symptomatic venous thromboembolism occurred in 1.4% of this large population of ICU patients with high adherence to chemoprophylaxis. Central venous catheterization and immobilization are potentially modifiable risk factors for venous thromboembolism. The ICU-Venous Thromboembolism score can identify patients at increased risk for venous thromboembolism.
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39
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Risk-assessment models for VTE and bleeding in hospitalized medical patients: an overview of systematic reviews. Blood Adv 2021; 4:4929-4944. [PMID: 33049056 DOI: 10.1182/bloodadvances.2020002482] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/27/2020] [Indexed: 12/11/2022] Open
Abstract
Multiple risk-assessment models (RAMs) for venous thromboembolism (VTE) in hospitalized medical patients have been developed. To inform the 2018 American Society of Hematology (ASH) guidelines on VTE, we conducted an overview of systematic reviews to identify and summarize evidence related to RAMs for VTE and bleeding in medical inpatients. We searched Epistemonikos, the Cochrane Database, Medline, and Embase from 2005 through June 2017 and then updated the search in January 2020 to identify systematic reviews that included RAMs for VTE and bleeding in medical inpatients. We conducted study selection, data abstraction and quality assessment (using the Risk of Bias in Systematic Reviews [ROBIS] tool) independently and in duplicate. We described the characteristics of the reviews and their included studies, and compared the identified RAMs using narrative synthesis. Of 15 348 citations, we included 2 systematic reviews, of which 1 had low risk of bias. The reviews included 19 unique studies reporting on 15 RAMs. Seven of the RAMs were derived using individual patient data in which risk factors were included based on their predictive ability in a regression analysis. The other 8 RAMs were empirically developed using consensus approaches, risk factors identified from a literature review, and clinical expertise. The RAMs that have been externally validated include the Caprini, Geneva, IMPROVE, Kucher, and Padua RAMs. The Padua, Geneva, and Kucher RAMs have been evaluated in impact studies that reported an increase in appropriate VTE prophylaxis rates. Our findings informed the ASH guidelines. They also aim to guide health care practitioners in their decision-making processes regarding appropriate individual prophylactic management.
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Risk models for VTE and bleeding in medical inpatients: systematic identification and expert assessment. Blood Adv 2021; 4:2557-2566. [PMID: 32542391 DOI: 10.1182/bloodadvances.2020001937] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/29/2020] [Indexed: 01/04/2023] Open
Abstract
Risk assessment models (RAMs) for venous thromboembolism (VTE) and bleeding in hospitalized medical patients inform appropriate use of thromboprophylaxis. Our aim was to use a novel approach for selecting risk factors for VTE and bleeding to be included in RAMs. First, we used the results of a systematic review of all candidate factors. Second, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of the evidence for the identified factors. Third, we using a structured approach to select factors to develop the RAMs, by building on clinical and methodological expertise. The expert panel made judgments on whether to include, potentially include, or exclude risk factors, according to domains of the GRADE approach and the Delphi method. The VTE RAM included age >60 years, previous VTE, acute infections, immobility, acute paresis, active malignancy, critical illness, and known thrombophilia. The bleeding RAM included age ≥65 years, renal failure, thrombocytopenia, active gastroduodenal ulcers, hepatic disease, recent bleeding, and critical illness. We identified acute infection as a factor that was not considered in widely used RAMs. Also, we identified factors that require further research to confirm or refute their importance in a VTE RAM (eg, D-dimer). We excluded autoimmune disease which is included in the IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) bleeding RAM. Our results also suggest that sex, malignancy, and use of central venous catheters (factors in the IMPROVE bleeding RAM) require further research. In conclusion, our study presents a novel approach to systematically identifying and assessing risk factors to be included or further explored during RAM development.
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Ozsu S, Gunay E, Konstantinides SV. A review of venous thromboembolism in COVID-19: A clinical perspective. THE CLINICAL RESPIRATORY JOURNAL 2021; 15:506-512. [PMID: 33484090 PMCID: PMC8013308 DOI: 10.1111/crj.13330] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/19/2021] [Indexed: 01/08/2023]
Abstract
Coronavirus disease-19 (COVID-19) started in Wuhan, China in December 2019 and spread to all around the world in a short period of time. Hospitalized patients with COVID-19 mostly could suffer from an abnormal coagulation activation risk with increased venous thrombosis events and a poor clinical course. The reported incidence rates of thrombotic complications in hospitalized COVID-19 patients vary between 2.6 and 85% (both in non-critically ill and critically ill patients). The risk of venous thromboembolism is not known in non-hospitalized patients with COVID-19. There are numerous studies and guidelines for administration of thromboprophylaxis for COVID-19 cases. All hospitalized COVID-19 patients should take pharmacological thromboprophylaxis if there is no contraindication. However, there is no consensus on this issue. In this review, we discussed all these approaches in a critical perspective.
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Affiliation(s)
- Savas Ozsu
- Department of Chest DiseasesErdem Healthy GroupİstanbulTurkey
| | - Ersin Gunay
- Department of Chest DiseasesYuksek Ihtisas University School of Medicine, Medical Park Ankara HospitalAnkaraTurkey
| | - Stavros V. Konstantinides
- Department of Cardiology, Center for Thrombosis and HemostasisJohannes Gutenberg University of MainzLangenbeckstrGermany
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Palazzuoli A, Giustozzi M, Ruocco G, Tramonte F, Gronda E, Agnelli G. Thromboembolic Complications in Covid-19: From Clinical Scenario to Laboratory Evidence. Life (Basel) 2021; 11:life11050395. [PMID: 33925334 PMCID: PMC8145351 DOI: 10.3390/life11050395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/20/2022] Open
Abstract
SARS-Cov-2 infection, a pandemic disease since March 2020, is associated with a high percentage of cardiovascular complications mainly of a thromboembolic (TE) nature. Although clinical patterns have been described for the assessment of patients with increased risk, many TE complications occur in patients with apparently moderate risk. Notably, a recent statement from the European Society of Cardiology (ESC) atherosclerosis and vascular biology working group pointed out the key role of vascular endothelium for the recruitment of inflammatory and thrombotic pathways responsible for both disseminated intravascular coagulation and cardiovascular complications. Therefore, a better understanding of the pathophysiological process linking infection to increased TE risk is needed in order to understand the pathways of this dangerous liaison and possibly interrupt it with appropriate treatment. In this review, we describe the histological lesions and the related blood coagulation mechanisms involved in COVID-19, we define the laboratory parameters and clinical risk factors associated with TE events, and propose a prophylactic anticoagulation treatment in relation to the risk category. Finally, we highlight the concept that a solid risk assessment based on prospective multi-center data would be the challenge for a more precise risk stratification and more appropriate treatment.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, University of Siena, Viale Bracci, 53100 Siena, Italy; (G.R.); (F.T.)
- Correspondence: ; Tel.: +39-577-585-363 or +39-577-585-461; Fax: +39-577-233-480
| | - Michela Giustozzi
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, 06121 Perugia, Italy; (M.G.); (G.A.)
| | - Gaetano Ruocco
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, University of Siena, Viale Bracci, 53100 Siena, Italy; (G.R.); (F.T.)
| | - Francesco Tramonte
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, University of Siena, Viale Bracci, 53100 Siena, Italy; (G.R.); (F.T.)
| | - Edoardo Gronda
- Department of Medicine and Medical Specialties, IRCCS Foundation Ca’ Granda Hospital, 20126 Milan, Italy;
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, 06121 Perugia, Italy; (M.G.); (G.A.)
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Sartori M, Favaretto E, Cosmi B. Relevance of immobility as a risk factor for symptomatic proximal and isolated distal deep vein thrombosis in acutely ill medical inpatients. Vasc Med 2021; 26:542-548. [PMID: 33813966 DOI: 10.1177/1358863x21996825] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Immobility is a well-recognized risk factor for deep vein thrombosis (DVT) in surgical patients, whereas the level of DVT risk conferred by immobility is less defined in patients on medical wards. The aim of this study was to establish whether immobility and its duration are associated with the risk of DVT in acutely ill medical inpatients. We conducted a cohort study in acutely ill medical inpatients. Patients underwent whole leg ultrasound for suspected lower extremity DVT and were divided into two groups according to presence or absence of immobility, defined as total bed rest or sedentary without bathroom privileges. The endpoint was the detection of proximal DVT or isolated distal DVT (IDDVT). Among the 252 acutely ill medical inpatients with immobility (age 82.6 ± 10.3 years, female 63.9%), ultrasound showed 36 (14.3%) proximal DVTs and 39 (15.5%) IDDVTs, while there were 11 (4.4%) proximal DVTs and 26 (10.5%) IDDVTs among the 248 inpatients without immobility (age 73.6 ± 14.2 years, female 54.8%). The risk of proximal DVT was higher in immobile than in mobile patients (OR 3.59, 95% CI: 1.78-7.23, p = 0.0001), whereas the risk of IDDVT was similar between the two groups (OR 1.56, 95% CI: 0.92-2.66, p = 0.111). During the first 3 days of hospitalization, the frequency of all DVTs was similar in patients with and without immobility, but it was 0.26 ± 0.03 vs 0.18 ± 0.03, respectively, after 4 days. In conclusion, immobility for more than 3 days is a risk factor for proximal DVT in acutely ill medical inpatients.
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Affiliation(s)
- Michelangelo Sartori
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elisabetta Favaretto
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Benilde Cosmi
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Paz Rios LH, Minga I, Kwak E, Najib A, Aller A, Lees E, Macrinici V, Rezaei Bookani K, Pursnani A, Caprini J, Spyropoulos AC, Tafur A. Prognostic Value of Venous Thromboembolism Risk Assessment Models in Patients with Severe COVID-19. TH OPEN 2021; 5:e211-e219. [PMID: 34179684 PMCID: PMC8219405 DOI: 10.1055/s-0041-1730293] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/09/2021] [Indexed: 12/16/2022] Open
Abstract
Introduction Severe novel corona virus disease 2019 (COVID-19) causes dysregulation of the coagulation system with arterial and venous thromboembolism (VTE). We hypothesize that validated VTE risk scores would have prognostic ability in this population. Methods Retrospective observational cohort with severe COVID-19 performed in NorthShore University Health System. Patients were >18 years of age and met criteria for inpatient or intensive care unit (ICU) care. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) and Caprini scores were calculated and patients were stratified. Results This study includes 184 patients, mostly men (63.6%), Caucasian (54.3%), 63 years old (interquartile range [IQR]: 24-101), and 57.1% of them required ICU care. Twenty-seven (14.7%) thrombotic events occurred: 12 (6.5%) cases of disseminated intravascular coagulation (DIC), 9 (4.9%) of pulmonary embolism, 5 (2.7%) of deep vein thrombosis, and 1 (0.5%) stroke. Among them, 86 patients (46.7%) died, 95 (51.6%) were discharged, and 3 (1.6%) were still hospitalized. "Moderate risk for VTE" and "High risk for VTE" by IMPROVE score had significant mortality association: (hazard ratio [HR]: 5.68; 95% confidence interval [CI]: 2.93-11.03; p < 0.001) and (HR = 6.22; 95% CI: 3.04-12.71; p < 0.001), respectively, with 87% sensitivity and 63% specificity (area under the curve [AUC] = 0.752, p < 0.001). "High Risk for VTE" by Caprini score had significant mortality association (HR = 17.6; 95% CI: 5.56-55.96; p < 0.001) with 96% sensitivity and 55% specificity (AUC = 0.843, p < 0.001). Both scores were associated with thrombotic events when classified as "High risk for VTE" by IMPROVE (HR = 6.50; 95% CI: 2.72-15.53; p < 0.001) and Caprini scores (HR = 11.507; 95% CI: 2.697-49.104; p = 0.001). Conclusion The IMPROVE and Caprini risk scores were independent predictors of mortality and thrombotic events in severe COVID-19. With larger validation, this can be useful prognostic information.
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Affiliation(s)
- Luis H. Paz Rios
- Cardiovascular Division, Department of Medicine, NorthShore University Health System, Evanston, Illinois, United States
| | - Iva Minga
- Cardiovascular Division, Department of Medicine, NorthShore University Health System, Evanston, Illinois, United States
| | - Esther Kwak
- Department of Medicine, NorthShore University Health System, Evanston, Illinois, United States
| | - Ayman Najib
- Department of Medicine, NorthShore University Health System, Evanston, Illinois, United States
| | - Ashley Aller
- Department of Medicine, NorthShore University Health System, Evanston, Illinois, United States
| | - Elizabeth Lees
- Department of Medicine, NorthShore University Health System, Evanston, Illinois, United States
| | - Victor Macrinici
- Department of Medicine, NorthShore University Health System, Evanston, Illinois, United States
| | - Kaveh Rezaei Bookani
- Cardiovascular Division, Department of Medicine, NorthShore University Health System, Evanston, Illinois, United States
| | - Amit Pursnani
- Cardiovascular Division, Department of Medicine, NorthShore University Health System, Evanston, Illinois, United States
| | - Joseph Caprini
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States
| | - Alex C. Spyropoulos
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, NY, NY, United States
| | - Alfonso Tafur
- Cardiovascular Division, Department of Medicine, NorthShore University Health System, Evanston, Illinois, United States
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Cheng HR, Huang GQ, Wu ZQ, Wu YM, Lin GQ, Song JY, Liu YT, Luan XQ, Yuan ZZ, Zhu WZ, He JC, Wang Z. Individualized predictions of early isolated distal deep vein thrombosis in patients with acute ischemic stroke: a retrospective study. BMC Geriatr 2021; 21:140. [PMID: 33632136 PMCID: PMC7908755 DOI: 10.1186/s12877-021-02088-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/09/2021] [Indexed: 02/06/2023] Open
Abstract
Background Although isolated distal deep vein thrombosis (IDDVT) is a clinical complication for acute ischemic stroke (AIS) patients, very few clinicians value it and few methods can predict early IDDVT. This study aimed to establish and validate an individualized predictive nomogram for the risk of early IDDVT in AIS patients. Methods This study enrolled 647 consecutive AIS patients who were randomly divided into a training cohort (n = 431) and a validation cohort (n = 216). Based on logistic analyses in training cohort, a nomogram was constructed to predict early IDDVT. The nomogram was then validated using area under the receiver operating characteristic curve (AUROC) and calibration plots. Results The multivariate logistic regression analysis revealed that age, gender, lower limb paralysis, current pneumonia, atrial fibrillation and malignant tumor were independent risk factors of early IDDVT; these variables were integrated to construct the nomogram. Calibration plots revealed acceptable agreement between the predicted and actual IDDVT probabilities in both the training and validation cohorts. The nomogram had AUROC values of 0.767 (95% CI: 0.742–0.806) and 0.820 (95% CI: 0.762–0.869) in the training and validation cohorts, respectively. Additionally, in the validation cohort, the AUROC of the nomogram was higher than those of the other scores for predicting IDDVT. Conclusions The present nomogram provides clinicians with a novel and easy-to-use tool for the prediction of the individualized risk of IDDVT in the early stages of AIS, which would be helpful to initiate imaging examination and interventions timely.
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Affiliation(s)
- Hao-Ran Cheng
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Gui-Qian Huang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Zi-Qian Wu
- Department of Neurology, Wenzhou Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, Wenzhou, 325000, Zhejiang, China
| | - Yue-Min Wu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Gang-Qiang Lin
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Jia-Ying Song
- School of Mental Health, Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Yun-Tao Liu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Xiao-Qian Luan
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Zheng-Zhong Yuan
- Department of Traditional Chinese Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Wen-Zong Zhu
- Department of Neurology, Wenzhou Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, Wenzhou, 325000, Zhejiang, China.
| | - Jin-Cai He
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China.
| | - Zhen Wang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China.
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Martins TD, Filho RM, Romano AVC, Annichino-Bizzacchi JM. Comment and Update on "Using Artificial Intelligence to Manage Thrombosis Research, Diagnosis, and Clinical Management". Semin Thromb Hemost 2021; 47:112-114. [PMID: 33525044 DOI: 10.1055/s-0040-1721754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Tiago Dias Martins
- School of Chemical Engineering, Laboratory of Optimization, Design, and Advanced Control, University of Campinas, Campinas, São Paulo, Brazil.,Departamento de Engenharia Química, Instituto de Ciências Ambientais, Químicas e Farmacêuticas, Universidade Federal de São Paulo, Diadema, São Paulo, Brazil
| | - Rubens Maciel Filho
- School of Chemical Engineering, Laboratory of Optimization, Design, and Advanced Control, University of Campinas, Campinas, São Paulo, Brazil
| | - Anna Virginia Calazans Romano
- Departamento de Engenharia Química, Instituto de Ciências Ambientais, Químicas e Farmacêuticas, Universidade Federal de São Paulo, Diadema, São Paulo, Brazil
| | - Joyce Maria Annichino-Bizzacchi
- Hematology and Hemotherapy Center, University of Campinas/Hemocentro-Unicamp, Instituto Nacional de Ciência e Tecnologia do Sangue, Campinas, São Paulo, Brazil
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Nemani A, von zur Mühlen C, Steffen F, Schulte J, Bode C, Krohn-Grimberghe M. Do Inpatients Receive Risk-Based Prophylactic Treatment for Thrombotic Events? Clin Appl Thromb Hemost 2021; 27:1076029621995563. [PMID: 33872084 PMCID: PMC8058795 DOI: 10.1177/1076029621995563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Current guidelines recommend risk-based use of prophylaxis for preventing medical inpatients from venous thromboembolism (VTE). Little is known about the current prescription practice, and even less whether differences between subspecialists like cardiologists, usually treating patients with thrombotic or thromboembolic diseases, and gastroenterologists, treating more patients with gastrointestinal bleeding complications, exist. METHODS We performed a retrospective chart review of patients on cardiology and gastroenterology wards of our university hospital. Patients with a clear indication for anticoagulation and contraindication against antithrombotic treatment were excluded. A total of 450 patients per specialty were included. Quantitative risk assessment models were used to determine the risk of a VTE (Padua Prediction Score (PPS), IMPROVE Score) and bleeding (IMPROVE-Bleeding and HAS-BLED Score). RESULTS The overall rate of VTE prophylaxis was high in both patient populations. Significant more low-risk cardiology compared to gastroenterology patients received drug-based prophylaxis. Furthermore, crucial discrepancies were found in the way individual patients would be classified based on PPS and IMPROVE Score. Finally, not the risk category but the length of hospital stay was best at predicting which patient received prophylaxis.
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Affiliation(s)
- Armin Nemani
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Constantin von zur Mühlen
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Friederike Steffen
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Johannes Schulte
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Christoph Bode
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Marvin Krohn-Grimberghe
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
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Prognostic factors for VTE and bleeding in hospitalized medical patients: a systematic review and meta-analysis. Blood 2020; 135:1788-1810. [PMID: 32092132 DOI: 10.1182/blood.2019003603] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/12/2020] [Indexed: 12/29/2022] Open
Abstract
There may be many predictors of venous thromboembolism (VTE) and bleeding in hospitalized medical patients, but until now, systematic reviews and assessments of the certainty of the evidence have not been published. We conducted a systematic review to identify prognostic factors for VTE and bleeding in hospitalized medical patients and searched Medline and EMBASE from inception through May 2018. We considered studies that identified potential prognostic factors for VTE and bleeding in hospitalized adult medical patients. Reviewers extracted data in duplicate and independently and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. Of 69 410 citations, we included 17 studies in our analysis: 14 that reported on VTE, and 3 that reported on bleeding. For VTE, moderate-certainty evidence showed a probable association with older age; elevated C-reactive protein (CRP), D-dimer, and fibrinogen levels; tachycardia; thrombocytosis; leukocytosis; fever; leg edema; lower Barthel Index (BI) score; immobility; paresis; previous history of VTE; thrombophilia; malignancy; critical illness; and infections. For bleeding, moderate-certainty evidence showed a probable association with older age, sex, anemia, obesity, low hemoglobin, gastroduodenal ulcers, rehospitalization, critical illness, thrombocytopenia, blood dyscrasias, hepatic disease, renal failure, antithrombotic medication, and presence of a central venous catheter. Elevated CRP, a lower BI, a history of malignancy, and elevated heart rate are not included in most VTE risk assessment models. This study informs risk prediction in the management of hospitalized medical patients for VTE and bleeding; it also informs guidelines for VTE prevention and future research.
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Gerotziafas GT, Catalano M, Colgan MP, Pecsvarady Z, Wautrecht JC, Fazeli B, Olinic DM, Farkas K, Elalamy I, Falanga A, Fareed J, Papageorgiou C, Arellano RS, Agathagelou P, Antic D, Auad L, Banfic L, Bartolomew JR, Benczur B, Bernardo MB, Boccardo F, Cifkova R, Cosmi B, De Marchi S, Dimakakos E, Dimopoulos MA, Dimitrov G, Durand-Zaleski I, Edmonds M, El Nazar EA, Erer D, Esponda OL, Gresele P, Gschwandtner M, Gu Y, Heinzmann M, Hamburg NM, Hamadé A, Jatoi NA, Karahan O, Karetova D, Karplus T, Klein-Weigel P, Kolossvary E, Kozak M, Lefkou E, Lessiani G, Liew A, Marcoccia A, Marshang P, Marakomichelakis G, Matuska J, Moraglia L, Pillon S, Poredos P, Prior M, Salvador DRK, Schlager O, Schernthaner G, Sieron A, Spaak J, Spyropoulos A, Sprynger M, Suput D, Stanek A, Stvrtinova V, Szuba A, Tafur A, Vandreden P, Vardas PE, Vasic D, Vikkula M, Wennberg P, Zhai Z. Guidance for the Management of Patients with Vascular Disease or Cardiovascular Risk Factors and COVID-19: Position Paper from VAS-European Independent Foundation in Angiology/Vascular Medicine. Thromb Haemost 2020; 120:1597-1628. [PMID: 32920811 PMCID: PMC7869052 DOI: 10.1055/s-0040-1715798] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023]
Abstract
COVID-19 is also manifested with hypercoagulability, pulmonary intravascular coagulation, microangiopathy, and venous thromboembolism (VTE) or arterial thrombosis. Predisposing risk factors to severe COVID-19 are male sex, underlying cardiovascular disease, or cardiovascular risk factors including noncontrolled diabetes mellitus or arterial hypertension, obesity, and advanced age. The VAS-European Independent Foundation in Angiology/Vascular Medicine draws attention to patients with vascular disease (VD) and presents an integral strategy for the management of patients with VD or cardiovascular risk factors (VD-CVR) and COVID-19. VAS recommends (1) a COVID-19-oriented primary health care network for patients with VD-CVR for identification of patients with VD-CVR in the community and patients' education for disease symptoms, use of eHealth technology, adherence to the antithrombotic and vascular regulating treatments, and (2) close medical follow-up for efficacious control of VD progression and prompt application of physical and social distancing measures in case of new epidemic waves. For patients with VD-CVR who receive home treatment for COVID-19, VAS recommends assessment for (1) disease worsening risk and prioritized hospitalization of those at high risk and (2) VTE risk assessment and thromboprophylaxis with rivaroxaban, betrixaban, or low-molecular-weight heparin (LMWH) for those at high risk. For hospitalized patients with VD-CVR and COVID-19, VAS recommends (1) routine thromboprophylaxis with weight-adjusted intermediate doses of LMWH (unless contraindication); (2) LMWH as the drug of choice over unfractionated heparin or direct oral anticoagulants for the treatment of VTE or hypercoagulability; (3) careful evaluation of the risk for disease worsening and prompt application of targeted antiviral or convalescence treatments; (4) monitoring of D-dimer for optimization of the antithrombotic treatment; and (5) evaluation of the risk of VTE before hospital discharge using the IMPROVE-D-dimer score and prolonged post-discharge thromboprophylaxis with rivaroxaban, betrixaban, or LMWH.
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Affiliation(s)
- Grigoris T. Gerotziafas
- Hematology and Thrombosis Center, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Sorbonne Université, Paris, France
- Research Group Cancer, Haemostasis and Angiogenesis,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
| | - Mariella Catalano
- Research Center on Vascular Disease & Angiology Unit, Department of Biomedical Science, L Sacco Hospital, University of Milan, Milan, Italy
| | - Mary-Paula Colgan
- Department of Vascular Surgery, St. James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - Zsolt Pecsvarady
- Department of Vascular Medicine, Flor Ferenc Teaching Hospital, Kistarcsa, Hungary
| | - Jean Claude Wautrecht
- Service de Pathologie Vasculaire, Hôpital ERASME, Université Libre de Bruxelle, Brussels, Belgium
| | - Bahare Fazeli
- Immunology Department, Avicenna (Bu-Ali) Research Institute, Mashhad University of Medical Sciences, Iran
| | - Dan-Mircea Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Katalin Farkas
- Department of Angiology, St. Imre University Teaching Hospital, Budapest, Hungary
| | - Ismail Elalamy
- Hematology and Thrombosis Center, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Sorbonne Université, Paris, France
- Research Group Cancer, Haemostasis and Angiogenesis,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
- Department of Obstetrics and Gynecology, I.M.Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, & the Thrombosis and Hemostasis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Jawed Fareed
- Department of Pathology, Loyola University Medical Center, Maywood, Illinois, United States
| | - Chryssa Papageorgiou
- Service Anesthésie, Réanimation et Médecine Périopératoire, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de médecine, Sorbonne Université, Paris, France
| | | | - Petros Agathagelou
- Department of Inrterventional Cardiology, American Heart Institute of Cyprus, Nicosia, Cyprus
| | - Darco Antic
- Clinic for Hematology, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Luciana Auad
- Medicina Vascular, Sanatorio Allende Córdoba, Ciencias Médicas, Universidad Católica de Córdoba, Argentina
| | - Ljiljana Banfic
- University Hospital Center, School of Medicine University of Zagreb, Croatia
| | | | - Bela Benczur
- Balassa Janos County Hospital, University Medical School, Szeged, Hungary
| | | | - Francesco Boccardo
- Department of Cardio-Thoracic-Vascular and Endovascular Surgery, Unit of Lymphatic Surgery, IRCCS S. Martino Hospital, University of Genoa, Italy
| | - Renate Cifkova
- Department of Preventive Cardiology, Thomayer Teaching Hospital, Prague, Czech Republic
| | - Benilde Cosmi
- Angiology and Blood Coagulation, Department of Specialty, Diagnostic and Experimental Medicine, S. Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Sergio De Marchi
- Angiology Unit, Cardiovascular and Thoracic and Medicine Department, Verona University Hospital, Verona, Italy
| | - Evangelos Dimakakos
- Vascular Unit of 3rd Department of Internal Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A. Dimopoulos
- Hellenic Society of Hematology, Athens, Greece
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Gabriel Dimitrov
- Research Center on Vascular Disease & Angiology Unit, Department of Biomedical Science, L Sacco Hospital, University of Milan, Milan, Italy
| | - Isabelle Durand-Zaleski
- Université de Paris, CRESS, INSERM, INRA, URCEco, AP-HP, Hôpital de l'Hôtel Dieu, Paris, France
| | - Michael Edmonds
- Diabetic Foot Clinic, King's College Hospital, London, United Kingdom
| | | | - Dilek Erer
- Department of Cardiovascular Surgery, Faculty of Medicine, Gazi University, Besevler/Ankara, Turkey
| | - Omar L. Esponda
- Internal Medicine Department, Hospital Perea, Mayaguez, Puerto Rico, United States
| | - Paolo Gresele
- Section of Internal and Cardiovascular Medicine, Department of Medicine, -University of Perugia, Perugia, Italy
| | - Michael Gschwandtner
- MedizinischeUniverstiät Wien, Universitätsklinik für Innere Medizin II, Klinische Abteilung für Angiologie, Vienna, Austria
| | - Yongquan Gu
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing China
| | - Mónica Heinzmann
- Medicina Vascular, Sanatorio Allende Córdoba, Ciencias Médicas, Universidad Católica de Córdoba, Argentina
| | - Naomi M. Hamburg
- The Whitaker Cardiovascular Institute Department of Medicine Boston University School of Medicine, Boston, Massachusetts, United States
| | - Amer Hamadé
- Vascular Medicine Unit, Internal Medicine Department, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Noor-Ahmed Jatoi
- Department Vascular Medicine, Mulhouse Hospital Center, Mulhouse, France
| | - Oguz Karahan
- Department of Cardiovascular Surgery, Medical School of Alaaddin Keykubat University, Alanya/Antalya, Turkey
| | - Debora Karetova
- Second Department of Medicine, Department of Cardiovascular Medicine, Charles University in Prague, Prague, Czech Republic
| | - Thomas Karplus
- Department of Vascular Medicine, Concord Repatriation General Hospital, Sydney, Australia
| | - Peter Klein-Weigel
- Klinik für Angiologie, Zentrum für Innere Medizin II, Ernst von Bergmann Klinikum, Potsdam, Germany
| | - Endre Kolossvary
- Department of Angiology, St. Imre University Teaching Hospital, Budapest, Hungary
| | - Matija Kozak
- Department for Vascular Diseases, Medical Faculty of Ljubljana, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Eleftheria Lefkou
- Board member of the Institute for the Study and Education on Thrombosis and Antithrombotic Therapy, Athens, Greece
| | - Gianfranco Lessiani
- Angiology Unit, Internal Medicine Department., Città Sant' Angelo Hospital, AUSL 03, Pescara, Italy
| | - Aaron Liew
- Portiuncula University Hospital, Soalta University Health Care Group, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Antonella Marcoccia
- Unità di Medicina Vascolare e Autoimmunità, CRIIS-Centro di riferimento interdisciplinare per la Sclerosi Sistemica, Rome, Italy
| | - Peter Marshang
- Department of Internal Medicine, Central Hospital of Bolzano, Bolzano, Italy
| | | | - Jiri Matuska
- MATMED s.r.o., Private Angiology Facility, Hodonin, Czech Republic
| | - Luc Moraglia
- Angiologie Centre Cours du Médoc, Médecine Vasculaire Travail, Bordeaux, France
| | - Sergio Pillon
- UOSD Angiology, San Camillo-Forlanini Hospital, National Health Institute ISS, Rome, Italy
| | - Pavel Poredos
- Medical Association of Slovenia and SMA, Slovenia Academic Research Centre, Slovenian Medical Academy, Ljubljana, Slovenia
| | - Manlio Prior
- Angiology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | | | - Oliver Schlager
- Division of Angiology, Department of Internal Medicine 2, Medical University of Vienna, Vienna, Austria
| | - Gerit Schernthaner
- Division of Angiology, Department of Internal Medicine 2, Medical University of Vienna, Vienna, Austria
| | - Alexander Sieron
- Department of Internal Medicine, Angiology and Physical Medicine, Medical University of Silesia, Katowice, Poland
- Specialist Hospital, Bytom, Jan Długosz University in Częstochowa, Częstochowa, Poland
| | - Jonas Spaak
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Stockholm County, Sweden
| | - Alex Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research, New York, New York, United States
| | - Muriel Sprynger
- Cardiology Department, University Hospital Sart Tilman, Liege, Belgium
| | - Dusan Suput
- Center for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Agata Stanek
- Department of Internal Medicine, Angiology and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Bytom, Poland
| | - Viera Stvrtinova
- Faculty of Medicine, Comenius University, Bratislava, Slovak Republic
| | - Andrzej Szuba
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Poland
| | - Alfonso Tafur
- Vascular Medicine University of Chicago, Northshore Cardiovascular Institute, Skokie, Illinois, US Army
| | - Patrick Vandreden
- Research Group Cancer, Haemostasis and Angiogenesis,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
| | - Panagiotis E. Vardas
- Medical School of Crete, University of Crete and Heart Sector, Hellenic Healthcare Group, Athens, Greece
| | - Dragan Vasic
- Department of Noninvasive vascular laboratory, Clinic of Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Paul Wennberg
- Department of Cardiovascular Medicine, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, United States
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Peking University Health Science Center, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
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Gafter-Gvili A, Drozdinsky G, Zusman O, Kushnir S, Leibovici L. Venous Thromboembolism Prophylaxis in Acute Medically Ill Patients: A Retrospective Cohort Study. Am J Med 2020; 133:1444-1452.e3. [PMID: 32445719 DOI: 10.1016/j.amjmed.2020.04.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Current guidelines recommend pharmacologic prophylaxis for medical patients at high risk for venous thromboembolism. We aimed to assess the benefit and safety of venous thromboembolism prophylaxis in acutely ill medical patients hospitalized. METHODS We prepared a retrospective cohort study in a tertiary hospital in Israel with patients hospitalized in medical departments with an admission lasting more than 48 hours during 2014-2017. PRIMARY OUTCOME 30-day mortality. SECONDARY OUTCOMES 90-day incidence of pulmonary embolism, symptomatic deep vein thrombosis, and major bleeding. Propensity-weighted logistic multivariate analysis was performed. RESULTS A total of 18,890 patient-unique episodes were included in the analysis. Of them, 3206 (17.0%) received prophylaxis. A total of 1309 (6.9%) died, 540/3206 (16.8%) of those who received venous thromboembolism prophylaxis and 769/15,864 (4.9%) of those who did not. Prophylaxis was not associated with a reduction in mortality, multivariable-adjusted odds ratio propensity-weighted (OR) 0.99 (95% confidence interval [CI], 0.84-1.14). One hundred forty-two patients (0.7%) developed venous thromboembolism, 44/3206 (1.4%) of those who received prophylaxis and 98/15,864 (0.6%) of those who did not. Prophylaxis was not associated with reduction in venous thromboembolism in the whole cohort, multivariable-adjusted propensity-weighted OR 1.09 (95% CI, 0.52-2.29). Prophylaxis was associated with an increase in major bleeding (multivariable-adjusted propensity-weighted OR 1.24; 95% CI, 1.04-1.48). CONCLUSION The current practice of routinely administering venous thromboembolism prophylaxis to medically ill patients considered at high risk for thrombosis resulted in a high risk for bleeding without a clear clinical benefit, and should be reassessed.
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Affiliation(s)
- Anat Gafter-Gvili
- Department of Medicine A and Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Genady Drozdinsky
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Oren Zusman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
| | - Shiri Kushnir
- Research and Development Unit, Rabin Medical Centre, Beilinson Hospital, Petah-Tikva, Israel
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
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