The prevention of venous thromboembolism recurrence in the elderly: a still open issue

INTRODUCTION

Venous thromboembolism (VTE) is frequent in the elderly, with an unclear recurrence risk. After the initial and early maintenance anticoagulant treatment, the decision about its extension versus recurrences is difficult because of the high risk of bleeding in this population. Areas covered: This paper analyzes recent literature on VTE recurrence and risk of bleeding associated with extended anticoagulation in elderly patients with VTE, focusing on available data regarding efficacy and safety of old anticoagulant or recent direct oral anticoagulant (DOACs). Expert commentary: The following are clinically important and still unmet needs in elderly patients with VTE: the current real risks for recurrence or for bleeding are still uncertain; the available clinical predictive rules for recurrence are of less use; in general, the phase III trials on DOACs proved less satisfactory in the elderly than in the general population; low dose DOACs use for extended treatment seems promising and data on long periods of therapy are needed; low dose aspirin does not seem an appropriate therapeutic alternative to anticoagulants due to the high rate of bleeding in the elderly; antithrombotic drugs, with low risk of bleeding should be assessed as alternative therapeutic options for extended treatment in the elderly.

Cardiovascular profile in critically ill elderly medical patients: prevalence, mortality and length of stay

PURPOSE

Data are demonstrating the increase in utilization of critical care by the elderly. Around 11% of ICU patients are ≥80years-old.

METHODS

An observational retrospective study was conducted between 2003 and 2011, including elderly patients (≥80years old) admitted from medical services to the intensive care unit (ICU) in a tertiary university hospital. The final sample size was N=202.

RESULTS

Mortality rates were: ICU 34.1%, in-hospital 44% and 1-year cumulative mortality 55.4% (20.4% for hospital survivors). Multivariate analysis showed that APACHE II score: OR 1.10, 95% CI (1.03-1.18), SAPS II score: OR 1.03, 95% CI (1.01-1.06), a score <3 on the Cruz Roja Hospital mental scale: 0.51 OR, 95% CI (0.01-0.57) and ICU admission for cardiovascular disease: OR 5.05, 95% CI (1.98-12.84) were independently associated with mortality ICU. Factors independently associated with 1-year mortality were: dyslipidemia OR 7.25 (1.47-35.60), chronic kidney failure OR 13.23, 95% CI (2.28-76.6), stroke OR 10.44, 95% CI (2.26-48.25) and antihypertensive treatment OR 0.08, 95% CI (0.01-0.48). In multiple linear regression, ICU length of stay was associated with mechanical ventilation B coefficient 6.41, 95% CI (1.18-11.64) and in-hospital length of stay was related to age: B coefficient -2.17, 95% CI (-4.02 to -0.33).

CONCLUSIONS

Prevalence of cardiovascular risk factors and cardiovascular disease was high, and basal cardiovascular treatment was underused. Primary diagnosis for cardiovascular disease at ICU admission should be assessed as predictor of ICU mortality. Intensifying cardiovascular basal treatment could decrease 1-year mortality. Cardiovascular profile did not show an effect on in-hospital mortality and length of stay.

Concomitant use of proton pump inhibitors and clopidogrel in patients with coronary, cerebrovascular, or peripheral artery disease in the factores de Riesgo y ENfermedad Arterial (FRENA) registry

BACKGROUND

Among patients receiving clopidogrel for coronary artery disease, concomitant therapy with proton pump inhibitors (PPIs) has been associated with an increased risk for recurrent coronary events.

PATIENTS AND METHODS

Factores de Riesgo y ENfermedad Arterial (FRENA) is an ongoing, multicenter, observational registry of consecutive outpatients with coronary artery disease, cerebrovascular disease, or peripheral artery disease. We retrospectively examined the influence of concomitant use of PPIs on outcome in patients receiving clopidogrel.

RESULTS

As of March 2009, 1222 patients were using clopidogrel: 595 had coronary artery disease, 329 cerebrovascular disease, and 298 had peripheral artery disease. Of these, 519 (42%) were concomitantly using PPIs. Over a mean follow-up of 15 months, 131 patients (11%) had 139 subsequent ischemic events: myocardial infarction 44, ischemic stroke 40, and critical limb ischemia 55. Seventeen of them (13%) died within 15 days of the subsequent event. PPI users had a higher incidence of myocardial infarction (rate ratio, 2.5; 95% confidence interval [CI], 1.3-4.8), ischemic stroke (rate ratio, 1.9; 95% CI, 1.03-3.7), and a nonsignificantly higher rate of critical limb ischemia (rate ratio, 1.6; 95% CI, 0.95-2.8) than nonusers. On multivariate analysis, concomitant use of clopidogrel and PPIs was independently associated with an increased risk for subsequent ischemic events both in the whole series of patients (hazard ratio, 1.8; 95% CI, 1.1-2.7) and in those with cerebrovascular disease or peripheral artery disease (hazard ratio, 1.5; 95% CI, 1.01-2.4).

CONCLUSIONS

In patients with established arterial disease, concomitant use of PPIs and clopidogrel was associated with a nearly doubling of the incidence of subsequent myocardial infarction or ischemic stroke. This higher incidence persisted after multivariate adjustment.

Differences in cardiovascular mortality in smokers, past-smokers and non-smokers: findings from the FRENA registry

BACKGROUND

The influence of smoking on outcome in patients with coronary artery disease (CAD) is controversial. Even less is known about its influence in patients with cerebrovascular (CVD), or peripheral artery (PAD) disease.

PATIENTS AND METHODS

FRENA is an ongoing, observational registry of consecutive outpatients with symptomatic CAD, CVD, or PAD. We reviewed their cardiovascular mortality according to smoking status.

RESULTS

As of May 2008, 2501 patients had been enrolled in FRENA. Of these, 439 (18%) were current smokers, 1086 (43%) past-smokers, 976 (39%) had never smoked. Current- and past-smokers were 10 years younger, more often males, and more likely to have chronic lung disease, but had diabetes, hypertension, heart failure, or renal insufficiency less often than non-smokers. Over a mean follow-up of 14 months, 123 patients died (cardiovascular death, 68). On univariate analysis, current smokers had a significantly lower rate of cardiovascular death: 1.1 (95% CI: 0.4-2.4) per 100 patient-years in current smokers; 1.9 (95% CI: 1.2-2.8) in past-smokers; 3.5 (95% CI: 2.5-4.7) in non-smokers, with no differences between patients with CAD, CVD or PAD. Mean age at cardiovascular death was 82+/-6.4; 70+/-9.9 and 67+/-15 years, respectively. On multivariate analysis, smoking status was not independently associated with a lower risk for cardiovascular death.

CONCLUSIONS

Current and past-smokers with CAD, CVD or PAD had a less than half cardiovascular mortality than those who never smoked, but this may be explained by the confounding effect of additional variables. They died over 10 years younger than non-smokers.

Body mass index and outcome in patients with coronary, cerebrovascular, or peripheral artery disease: findings from the FRENA registry

Background

The relationship between body mass index (BMI) and mortality in patients with established arterial disease remains controversial.

Methods

FRENA is an ongoing, observational registry of consecutive outpatients with coronary artery disease (CAD), cerebrovascular disease, or peripheral artery disease (PAD). We examined the prognostic importance of accepted BMI categories on outcome among patients in the FRENA registry.

Results

In April 2008, 2274 patients (mean age, 66 years) had been enrolled, of whom 14 (0.6%) were underweight; 533 (23%) normal; 1051 (46%) overweight; and 676 (30%) were obese. Over a mean follow-up of 14 months, the incidence of major cardiovascular events (myocardial infarction, ischemic stroke, or critical limb ischemia) per 100 patient-years was: 7.1 [95% confidence interval (CI): 0.4–35]; 11 (95% CI: 8.4–14); 6.9 (95% CI: 5.6–8.5); and 8.5 (95% CI: 6.6–11), respectively. Their cardiovascular mortality was: 7.1 (95% CI: 0.4–35); 4.1 (95% CI: 5.9–11); 1.3 (95% CI: 0.9–2.3); and 1.5 (95% CI: 1.4–3.5), respectively. On multivariate analysis, the hazard ratio for cardiovascular mortality was: 2.2 (95% CI: 0.3–17); 1.0 (reference); 0.37 (95% CI: 0.20–0.69); and 0.37 (95% CI: 0.18–0.73), respectively. Survival benefit was only found in patients with CAD or PAD. Weight loss had little influence on outcome.

Conclusion

Patients with CAD or PAD (not those with cerebrovascular disease) have an inverse correlation between BMI and cardiovascular mortality, even after adjusting for confounding variables.

Clinical Outcome in Patients With Peripheral Artery Disease and Renal Artery Stenosis

Background: There is controversy on the influence of renal artery stenosis on outcome in patients with peripheral artery disease. Patients and Methods: The 12-month impact of renal artery stenosis on declining renal function, control of hypertension, and incidence of major cardiovascular events in 100 consecutive patients undergoing angiography for peripheral artery disease was evaluated. Results: A total of 60 patients had renal artery stenosis: 32 mild, 16 moderate, and 12 severe stenosis. There were no significant differences in either the decline of renal function (2.7 ± 18% vs 0.9 ± 16%), control of hypertension (139 ± 16 vs 139 ± 22 mm Hg) or number of antihypertensive drugs (1.8 ± 1.0 vs 1.6 ± 0.8). Patients with renal artery stenosis had an increased incidence of major cardiovascular events (odds ratio: 2.3; 95% confidence interval: 1.03-5.4), but on multivariate analysis its influence disappeared. Conclusions: Patients with peripheral artery disease having renal artery stenosis had similar decline of renal function and control of hypertension. They had an increased incidence of major cardiovascular events, but it may be explained by the confounding effect of additional variables.