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Isand K, Feelders R, Brue T, Toth M, Deutschbein T, Reincke M, Kršek M, Santos A, Demtröder F, Chabre O, Strasburger CJ, Aulinas Maso A, Volke V, Pereira AM, Lohmann R, Gich Saladich I, Webb SM, Wass J, Valassi E. High prevalence of venous thrombotic events in Cushing's syndrome: data from ERCUSYN and details in relation to surgery. Eur J Endocrinol 2024; 190:75-85. [PMID: 38146835 DOI: 10.1093/ejendo/lvad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the prevalence of venous thromboembolism (VTE) in patients included in the European Registry on Cushing's syndrome (ERCUSYN), compare their clinical characteristics with those who did not develop VTE and identify risk factors for VTE. DESIGN A retrospective observational cohort study. METHODS Data extraction from the registry was taken on February, 7, 2022. At the time there were 2174 patients diagnosed with Cushing's syndrome (CS) and 95 VTEs were reported in the database. RESULTS Of 95 VTE events 70 (74%) were in pituitary-dependent CS patients, 12 (12.5%) in adrenal-dependant CS, 10 (10.5%) in ectopic CS, and 3 (3%) in CS due to other causes. Sex, 24-hour urinary free cortisol (UFC) value at diagnosis, as well as the number of operations remained statistically significant predictors of VTE. Of patients who were treated with at least one surgery, 12 (13%) VTE occurred before and 80 (87%) after the surgery. Nearly half of these VTEs occurred within six months since the operation (36; 45%). Over half of the centers that reported VTE did not routinely anticoagulate CS patients. Anticoagulation schemes varied widely. CONCLUSION Patients with CS have an elevated risk of developing VTE for an extended period of time. From ERCUSYN cohort patients have higher risk for VTE if they need multiple surgeries to treat CS, are males and have high UFC values at the diagnosis of CS. Since there is no agreement on thromboprohpylaxis, a protocol for VTE prevention that is widely adopted appears to be necessary for patients with CS.
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Affiliation(s)
- Kristina Isand
- Institute of Biomedicine and Translational Medicine, University of Tartu, Ülikooli 18, 50090, Tartu, Estonia
| | - Richard Feelders
- Department of Internal Medicine, Section of Endocrinology, ENETS Center of Excellence, Erasmus MC and Erasmus Cancer Institute, 3015 Rotterdam, The Netherlands
| | - Thierry Brue
- Aix Marseille Univ, APHM, INSERM, MMG, Department of Endocrinology Hospital La Conception, MarMaRa Institute, 13305 Marseille, France
| | - Miklos Toth
- Department of Internal Medicine and Oncology, Semmelweis University, 1083 Budapest, Hungary
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, 97080 Würzburg, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ludwig-Maximilians-Universität München, 80336 Munich, Germany
| | - Michal Kršek
- Third Department of Internal Medicine, First Faculty of Medicine, Charles University, General University Hospital, 12808 Prague, Czech Republic
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology, Hospital Sant Pau, Dept Medicine, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, 08025 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), Barcelona, Spain
| | - Frank Demtröder
- Zentrum für Endokrinologie, Diabetologie, Rheumatologie Dr. Demtröder & Kollegen, 44137 Dortmund, Germany
| | - Olivier Chabre
- University Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie CHU Grenoble Alpes, F-38000 Grenoble, France
| | | | - Anna Aulinas Maso
- IIB-Sant Pau and Department of Endocrinology, Hospital Sant Pau, Dept Medicine, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, 08025 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), Barcelona, Spain
| | - Vallo Volke
- Institute of Biomedicine and Translational Medicine, University of Tartu, Ülikooli 18, 50090, Tartu, Estonia
| | - Alberto M Pereira
- Department of Endocrinology & Metabolism, Amsterdam University Medical Center, and University of Amsterdam, 1081 Amsterdam, Netherlands
| | - Rüdiger Lohmann
- Health Care Consulting GmbH, Lohmann & Birkner Health Care Consulting GmbH, 13407 Berlin, Germany
| | - Ignasi Gich Saladich
- Department of Clinical Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), 08025 Barcelona, Spain
| | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology, Hospital Sant Pau, Dept Medicine, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, 08025 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), Barcelona, Spain
| | - John Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals, OX37LE Oxford, United Kingdom
| | - Elena Valassi
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), Barcelona, Spain
- Endocrinology and Nutrition Department, Germans Trias i Pujol Hospital and Research Institute, Badalona 08916, Spain
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Alsaloum M, Zilinyi RS, Madhavan M, Snyder DJ, Saleem D, Burton JB, Rosenzweig EB, Takeda K, Brodie D, Agerstrand C, Eisenberger A, Kirtane AJ, Parikh SA, Sethi SS. Gender Disparities in Presentation, Management, and Outcomes of Acute Pulmonary Embolism. Am J Cardiol 2023; 202:67-73. [PMID: 37421732 DOI: 10.1016/j.amjcard.2023.06.012] [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: 03/21/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 07/10/2023]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death; however, gender disparities in PE remain understudied. All PE cases at a single institution between January 2013 and June 2019 were retrospectively reviewed. The clinical presentation, treatment modalities, and outcomes were compared between men and women using univariate and multivariate analyses adjusting for differences in baseline characteristics. A total of 1,345 patients were diagnosed with acute PE, of whom 56.3% were women (n = 757). Women had a significantly higher mean body mass index (29.4 vs 28.4) and a higher frequency of hypertension (53% vs 46%) and hormone use (6.6% vs 0%; all p <0.02). Men had a higher frequency of smoking (45% vs 33%, p <0.0001). Women had significantly lower PE severity index classifications (p = 0.0009). The rates of intensive care unit admission, vasopressor requirements, extracorporeal membrane oxygenation cannulation, and mechanical ventilation were similar between the genders. There was no significant difference in the treatment modality used between the genders. Although the risk factors and PE severity index class differed between the genders, there was no significant difference in resource utilization or treatment modality. Gender was also not a significant predictor of in-hospital mortality, moderate or severe bleeding, increased length of stay, or readmission in the study population.
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Affiliation(s)
| | | | | | | | | | | | | | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine
| | - Cara Agerstrand
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine
| | - Andrew Eisenberger
- Division of Hematology and Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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3
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Burns KEA, Heels-Ansdell D, Thabane L, Kahn SR, Lauzier F, Mehta S, Ostermann M, Bhuptani P, Crowther MA, Finfer S, Cook DJ. Sex differences in thromboprophylaxis of the critically ill: a secondary analysis of a randomized trial. Can J Anaesth 2023; 70:1008-1018. [PMID: 37310606 DOI: 10.1007/s12630-023-02457-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 06/14/2023] Open
Abstract
PURPOSE Venous thromboembolism (VTE) is a common complication of critical illness. Sex- or gender-based analyses are rarely conducted and their effect on outcomes is unknown. We assessed for an effect modification of thromboprophylaxis (dalteparin or unfractionated heparin [UFH]) by sex on thrombotic (deep venous thrombosis [DVT], pulmonary embolism [PE], VTE) and mortality outcomes in a secondary analysis of the Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT). METHODS We conducted unadjusted analyses using Cox proportional hazards analysis, stratified by centre and admission diagnostic category, including sex, treatment, and an interaction term. Additionally, we performed adjusted analyses and assessed the credibility of our findings. RESULTS Critically ill female (n = 1,614) and male (n = 2,113) participants experienced similar rates of DVT, proximal DVT, PE, any VTE, ICU death, and hospital death. In unadjusted analyses, we did not find significant differences in treatment effect favouring males (vs females) treated with dalteparin (vs UFH) for proximal leg DVT, any DVT, or any PE, but found a statistically significant effect (moderate certainty) favouring dalteparin in males for any VTE (males: hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.52 to 0.96 vs females: HR, 1.16; 95% CI, 0.81 to 1.68; P = 0.04). This effect remained after adjustment for baseline characteristics (males: HR, 0.70; 95% CI, 0.52 to 0.96 vs females: HR, 1.17; 95% CI, 0.81 to 1.68; P = 0.04) and weight (males: HR, 0.70; 95% CI, 0.52 to 0.96 vs females: HR, 1.20; 95% CI, 0.83 to 1.73; P = 0.03). We did not identify a significant effect modification by sex on mortality. CONCLUSIONS We found an effect modification by sex of thromboprophylaxis on VTE in critically ill patients that requires confirmation. Our findings highlight the need for sex- and gender-based analyses in acute care research.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Francois Lauzier
- Research Center of the CHU de Québec-Université Laval, Population Health and Optimal Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - Pulkit Bhuptani
- Department of Pharmacy, Unity Health Toronto-St. Michael's Hospital, Toronto, ON, Canada
| | - Mark A Crowther
- St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Simon Finfer
- Clinical Trials Unit, The George Institute, Sydney, NSW, Australia
| | - Deborah J Cook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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4
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Vicent L, Martín de la Mota Sanz D, Rosillo N, Peñaloza-Martínez E, Moreno G, Bernal JL, Elola J, Bueno H. Sex differences in temporal trends in main and secondary pulmonary embolism diagnosis and case fatality rates: 2003-2019. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:184-193. [PMID: 35533393 DOI: 10.1093/ehjqcco/qcac020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/11/2022] [Accepted: 04/28/2022] [Indexed: 01/01/2023]
Abstract
AIMS There is controversy regarding the incidence and outcomes of pulmonary embolism (PE) according to sex. Our aim was to address sex differences in temporal trends in main and secondary hospital PE diagnoses, management and case fatality rates (CFR). METHODS AND RESULTS Retrospective analysis of Spain´s National Healthcare System hospital database, years 2003-2019, for patients ≥18 years with main or secondary PE diagnosis. Trends by sex in hospital diagnosis, use of procedures, and CFRs were analysed by joinpoint and Poisson regression models. Of 339 469 PE diagnoses, 52% were in women. Sixty-five percent were main diagnosis, 35.2% secondary. Total annual diagnoses and frequentation rates increased similarly in men and women: average annual percent change (AAPC): 2.0% (95% CI, 1.3-2.6; P < 0.005). Secondary PEs were more common in men (37.8% vs. 32.9%, P < 0.001). Men showed greater comorbidity than women (Charlson index 2.22 ± 0.01 vs. 1.74 ± 0.01, P < 0.001), particularly cancer in the secondary diagnosis group (40.9% vs. 31.6%, P < 0.001). CFRs for PE as main diagnosis were comparable and decreased in parallel in men (from 13.8% in 2003 to 7.3% in 2019) and women (from 13.1% in 2003 to 6.9% in 2019). However, for PE as secondary diagnosis, CFRs remained higher (P < 0.001) in men (from 42.5% in 2003 to 26.2% in 2019) than women (from 34.4% in 2003 to 22.8% in 2019). CONCLUSION PE hospital diagnosis increased significantly between 2003 and 2019 in men and women for both main and secondary diagnosis. Although in-hospital CFR decreased one third still remains very high, especially in men with secondary PE diagnosis.
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Affiliation(s)
- Lourdes Vicent
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain.,Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | | | - Nicolás Rosillo
- CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain.,Department of Preventive Medicine, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Eduardo Peñaloza-Martínez
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Guillermo Moreno
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain.,Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - José Luis Bernal
- Management Control Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Javier Elola
- Instituto para la Mejora de la Atención Sanitaria (IMAS), Madrid, Spain
| | - Héctor Bueno
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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5
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Deischinger C, Dervic E, Nopp S, Kaleta M, Klimek P, Kautzky-Willer A. Diabetes mellitus is associated with a higher relative risk for venous thromboembolism in females than in males. Diabetes Res Clin Pract 2022; 194:110190. [PMID: 36471550 DOI: 10.1016/j.diabres.2022.110190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/12/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
AIMS The risk for developing venous thromboembolism (VTE) is about equal in both sexes. Research suggests diabetes mellitus (DM) is a risk factor for pulmonary embolism and deep vein thrombosis, both forms of VTE. We aimed at investigating the sex-specific impact of DM on VTE risk. MATERIALS AND METHODS Medical claims data were analyzed in a retrospective, population-level cohort study in Austria between 1997 and 2014. 180,034 patients with DM were extracted and compared to 540,102 sex and age-matched controls without DM in terms of VTE risk and whether specific DM medications might modulate VTE risk. RESULTS The risk to develop VTE was 1.4 times higher amongst patients with DM than controls (95% CI 1.36-1.43, p < 0.001). The association of DM with newly diagnosed VTE was significantly greater in females (OR = 1.52, 95% CI 1.46-1.58, p < 0.001) resulting in a relative risk increase of 1.17 (95% CI 1.11-1.23) across all age groups with a peak of 1.65 (95% CI 1.43-1.89) between 50 and 59 years. Dipeptidyl peptidase 4 inhibitors were associated with a higher risk for VTE amongst female DM patients (OR = 2.3, 95% CI 1.3-4.3, p = 0.0096). CONCLUSION Amongst DM patients, females appear to be associated with a higher relative risk increase in VTE than males, especially during perimenopause.
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Affiliation(s)
- Carola Deischinger
- Department of Internal Medicine III, Clinical Division of Endocrinology and Metabolism, Gender Medicine Unit, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Elma Dervic
- Section for Science of Complex Systems, CeMSIIS, Medical University of Vienna, Spitalgasse 23, Vienna, Austria; Complexity Science Hub Vienna, Josefstädter Straße 39, 1080 Vienna, Austria
| | - Stephan Nopp
- Department of Internal Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Michaela Kaleta
- Section for Science of Complex Systems, CeMSIIS, Medical University of Vienna, Spitalgasse 23, Vienna, Austria; Complexity Science Hub Vienna, Josefstädter Straße 39, 1080 Vienna, Austria
| | - Peter Klimek
- Section for Science of Complex Systems, CeMSIIS, Medical University of Vienna, Spitalgasse 23, Vienna, Austria; Complexity Science Hub Vienna, Josefstädter Straße 39, 1080 Vienna, Austria
| | - Alexandra Kautzky-Willer
- Department of Internal Medicine III, Clinical Division of Endocrinology and Metabolism, Gender Medicine Unit, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; Gender Institute, Gars am Kamp, Austria.
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6
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Sedhom R, Megaly M, Elbadawi A, Yassa G, Weinberg I, Gulati M, Elgendy IY. Sex Differences in Management and Outcomes Among Patients With High-Risk Pulmonary Embolism: A Nationwide Analysis. Mayo Clin Proc 2022; 97:1872-1882. [PMID: 36202496 DOI: 10.1016/j.mayocp.2022.03.022] [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: 11/22/2021] [Revised: 03/13/2022] [Accepted: 03/18/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To examine the sex differences in management and outcomes among patients with high-risk acute pulmonary embolism (PE). PATIENTS AND METHODS The Nationwide Readmissions Database was used to identify hospitalizations with high-risk PE from January 1, 2016, to December 31, 2018. Differences in use of advanced therapies, in-hospital mortality, and bleeding events were compared between men and women. RESULTS A total of 125,901 weighted hospitalizations with high-risk PE were identified during the study period; 46.3% were women (n=58,253). Women were older and had a higher prevalence of several comorbidities and risk factors of PE such as morbid obesity, diabetes mellitus, chronic pulmonary disease, heart failure, and metastatic cancer. Systemic thrombolysis and catheter-directed interventions were more commonly used among women; however, mechanical circulatory support was less frequently used. In-hospital mortality was higher among women in the unadjusted analysis (30.7% vs 27.8%, P<.001) and after propensity score matching (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.08 to 1.25; P<.001), whereas the rates of intracranial hemorrhage and non-intracranial hemorrhage were not different. On multivariate regression analysis, female sex (OR, 1.18; 95% CI, 1.15 to 1.21; P<.001) was independently associated with increased odds of in-hospital mortality. CONCLUSION In this contemporary observational cohort of patients admitted with high-risk PE, women had higher rates of in-hospital mortality despite receiving advanced therapies more frequently, whereas the rate of major bleeding events was not different from men. Efforts are needed to minimize the excess mortality observed among women.
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Affiliation(s)
- Ramy Sedhom
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Michael Megaly
- Division of Cardiology, Henry Ford Hospital, Detroit, MI, USA
| | - Ayman Elbadawi
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - George Yassa
- Department of Medicine, Ascension Macomb-Oakland Hospital, Warren, MI, USA
| | - Ido Weinberg
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Martha Gulati
- Division of Cardiology, University of Arizona-College of Medicine, Phoenix, AZ, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA.
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7
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Lui B, Wee B, Lai J, Khattak Z, Kwok A, Donarelli C, Ho P, Lim HY. A ten-year review of the impact of the transition from warfarin to direct oral anticoagulant - Has venous thromboembolism treatment become safer? Thromb Res 2022; 219:112-120. [PMID: 36162254 DOI: 10.1016/j.thromres.2022.09.006] [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: 04/06/2022] [Revised: 08/20/2022] [Accepted: 09/09/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The introduction of direct oral anticoagulants (DOAC) has resulted in a paradigm shift in the management of venous thromboembolism (VTE). We evaluate the impact of the transition to DOAC, over the last decade, on overall VTE clinical outcomes including in first unprovoked major VTEs. METHOD A retrospective analysis of all VTE admissions in non-cancer patients from January 2011 to December 2020 at Northern Health, Victoria, Australia. "Warfarin era" included events that occurred between January 2011 and December 2014 and "DOAC era" from January 2016. RESULTS There were 2687 cases involving 2508 patients (45.9 % males; median age 63 years). 98 % were symptomatic and 1261 events (47 %) were unprovoked. 1003 events occurred during the warfarin era (79 % warfarin, 6 % DOAC) and 1479 during the DOAC era (18 % warfarin, 70 % DOAC). While recurrent thrombosis during the acute phase of treatment was comparable, there were fewer recurrences during the long-term preventative phase of treatment in the DOAC era compared to warfarin era (HR 0.602, 95 % CI: 0.393-0.924, p0.020). Clinically significant bleeding events were lower in the DOAC era (HR 0.623, 95 % CI: 0.395-0.985, p = 0.043). A subanalysis of first unprovoked major VTE events (n = 602) demonstrated a significant reduction in recurrent VTE during the long-term preventative phase of treatment in the DOAC era (HR 0.296, 95 % CI: 0.097-0.901, p = 0.032) with no difference in clinically significantly bleeding rates (HR 0.529, 95 % CI 0.219-1.280, p = 0.158) between the eras. CONCLUSION Treatment outcomes for VTE appear to have improved over time with reduced rate of thrombotic and clinically significant bleeding complications in the DOAC era.
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Affiliation(s)
- Brandon Lui
- Department of Haematology, Northern Health, Epping, VIC, Australia.
| | - Benjamin Wee
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | - Jeffrey Lai
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | - Zille Khattak
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | - Anna Kwok
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | | | - Prahlad Ho
- Department of Haematology, Northern Health, Epping, VIC, Australia; Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Hui Yin Lim
- Department of Haematology, Northern Health, Epping, VIC, Australia; Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
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8
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Hisatake S, Ikeda T, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Mo M, Yamazaki T, Okumura Y, Hirayama A. Rivaroxaban Treatment for Patients With Unprovoked or Provoked Venous Thromboembolism ― Subanalysis of the J’xactly Study ―. Circ Rep 2022; 4:490-498. [PMID: 36304427 PMCID: PMC9535131 DOI: 10.1253/circrep.cr-22-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 11/09/2022] Open
Abstract
Background: The efficacy and safety of direct oral anticoagulants (DOACs) in patients with unprovoked venous thromboembolism (VTE) remain unclear. Methods and Results: In this subanalysis of the J’xactly study, a multicenter prospective observational study, we evaluated the safety and effectiveness of rivaroxaban in patients with acute VTE according to unprovoked (n=388) or provoked (n=557) VTE status. Median follow-up was 21.2 months. Compared with patients in the provoked group, patients in the unprovoked group were younger, less likely to be female, and had higher body weight. The incidence of symptomatic VTE recurrence was significantly higher in the unprovoked than provoked VTE group (3.54% vs. 1.77% per patient-year; P=0.032). There was no significant difference in the incidence of major bleeding events between rivaroxaban-treated patients with unprovoked and provoked VTE (2.31% vs. 3.75% per patient-year; P=0.289). Although the proportion of patients with a body mass index (BMI) ≥25 kg/m2
who were non-users of antiplatelet agents was higher in the unprovoked VTE group, there was no interaction effect (BMI: 4.58% vs. 1.55% per patient-year [P=0.040; P for interaction=0.361]; concomitant antiplatelet agent non-users: 3.65% vs. 1.72% per patient-year [P=0.028; P for interaction=0.627]). Conclusions: This subanalysis suggests the safety and effectiveness of rivaroxaban in patients with unprovoked VTE. In such patients, DOAC discontinuation should be considered carefully, particularly in those not using antiplatelet agents and those with a high BMI.
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Affiliation(s)
- Shinji Hisatake
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital
| | | | | | | | - Hideaki Maeda
- Division of Cardiovascular Surgery, Nihon University School of Medicine
| | | | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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9
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Bikdeli B, Piazza G, Jimenez D, Muriel A, Wang Y, Khairani CD, Rosovsky RP, Mehdipoor G, O'Donoghue ML, Spagnolo P, Dreyer RP, Bertoletti L, López-Jiménez L, Núñez MJ, Blanco-Molina Á, Bates SM, Gerhard-Herman M, Goldhaber SZ, Monreal M, Krumholz HM. Sex Differences in PrEsentation, Risk Factors, Drug and Interventional Therapies, and OUtcomes of Elderly PatientS with Pulmonary Embolism: Rationale and design of the SERIOUS-PE study. Thromb Res 2022; 214:122-131. [DOI: 10.1016/j.thromres.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022]
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10
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Giustozzi M, Valerio L, Agnelli G, Becattini C, Fronk EM, Klok FA, Konstantinides SV, Vedovati MC, Cohen AT, Barco S. Sex-specific differences in the presentation, clinical course, and quality of life of patients with acute venous thromboembolism according to baseline risk factors. Insights from the PREFER in VTE. Eur J Intern Med 2021; 88:43-51. [PMID: 33810940 DOI: 10.1016/j.ejim.2021.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Sex and the presence of specific provoking risk factors, along with age, influence the presentation and prognosis of venous thromboembolism (VTE). We investigated the presentation, course and quality of life in women and men with acute VTE classified according to their VTE provoking factors. METHODS PREFER in VTE is an international, non-interventional registry of patients with a first episode of acute symptomatic VTE. Baseline provoking factors were classified as follows: major transient, minor transient, active cancer, and none identifiable. The primary outcome was recurrent VTE. Quality of life and treatment satisfaction were secondary outcomes. RESULTS Of 3,455 patients with acute VTE, 1,623 (47%) were women. The mean age at the time of VTE was 61 (SD 18) in women, 60 (SD 15) in men. The distribution of provoking risk factors was similar between sexes, despite a tendency for higher frequency of minor and major transient risk factors in women, and cancer or unprovoked VTE in men. At 12-month follow-up, VTE recurrence was reported in 74 (6.5%) women and 80 (6.4%) men (absolute risk difference -0.1%, 95% CI -1.9%; +2.1%). In patients with unprovoked VTE, the VTE recurrence rate was 38/612 (6.2%) in women and 53/798 (6.6%) in men (absolute risk difference -0.4, 95% CI -3.0; +2.1%). Multivariable Cox regressions confirmed the absence of sex differences. Quality of life and treatment satisfaction scores one year after VTE were lower in women than in men irrespective of the provoking risk factors (p<0.001 for both scores). CONCLUSIONS Despite differences in the provoking risk factors for VTE, women and men had a similar rate VTE recurrence at one year. After acute VTE, women had lower quality of life and treatment satisfaction scores.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy.
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy
| | | | - Frederikus A Klok
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Maria Cristina Vedovati
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy
| | - Alexander T Cohen
- Guy's and St Thomas' NHS Foundation Trust, King's College London, Department of Haematology, London, United Kingdom
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
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11
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Dubois-Silva Á, Barbagelata-López C, Piñeiro-Parga P, Francisco I, Falgá C, Tirado R, Suriñach JM, Vela JR, Mella C, Quere I, Siniscalchi C, Monreal M. Prognostic Significance of Concomitant Superficial Vein Thrombosis in Patients with Deep Vein Thrombosis of the Lower Limbs. Thromb Haemost 2021; 121:1650-1659. [PMID: 33677826 DOI: 10.1055/a-1414-5055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The prognostic significance of concomitant superficial vein thrombosis (SVT) in patients with lower-limb deep vein thrombosis (DVT) has not been consistently evaluated. METHODS We used the RIETE (Registro Informatizado de Enfermedad TromboEmbólica) registry to compare the rates of subsequent pulmonary embolism (PE), recurrent DVT, major bleeding or death in patients with lower-limb DVT, according to the presence or absence of concomitant SVT. RESULTS From March 2015 to May 2020, there were 8,743 patients with lower-limb DVT. Of these, 745 (8.5%) had concomitant SVT. Most patients (97.4% in both subgroups) received anticoagulant therapy (median duration: 138 vs. 147 days). During follow-up (median: 193 vs. 210 days), 156 (1.8%) patients developed subsequent PE, 336 (3.8%) had recurrent DVT, 201 (2.3%) had major bleeding and 844 (9.7%) died. Patients with concomitant SVT had a higher rate of subsequent PE (rate ratio [RR]: 2.11; 95% confidence interval [95%CI]: 1.33-3.24) than those with isolated DVT, with no significant differences in the rates of recurrent DVT (RR: 0.80; 95%CI: 0.50-1.21), major bleeding (RR: 0.77; 95%CI: 0.41-1.33) or death (RR: 0.81; 95%CI: 0.61-1.06). On multivariable analysis, patients with DVT and SVT concomitantly were at increased risk of subsequent PE during anticoagulation (adjusted hazard ratio [HR]: 2.23; 95%CI: 1.22-4.05) and also during the entire follow-up period (adjusted HR: 2.33; 95%CI: 1.49-3.66). CONCLUSION Patients with lower-limb DVT and SVT concomitantly are at increased risk of developing PE. Further studies are needed to externally validate our findings and to determine if these patients could benefit from a different management strategy.
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Affiliation(s)
- Álvaro Dubois-Silva
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña, Servizo Galego de Saúde, A Coruña, Spain.,Universidade da Coruña, A Coruña, Spain
| | - Cristina Barbagelata-López
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña, Servizo Galego de Saúde, A Coruña, Spain
| | - Patricia Piñeiro-Parga
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña, Servizo Galego de Saúde, A Coruña, Spain
| | - Iria Francisco
- Department of Internal Medicine, Hospital Universitari de Girona Dr. Josep Trueta, Gerona, Spain
| | - Conxita Falgá
- Department of Internal Medicine, Hospital de Mataró, Barcelona, Spain
| | - Raimundo Tirado
- Department of Internal Medicine, Hospital Infanta Margarita, Córdoba, Spain
| | - José María Suriñach
- Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Jerónimo Ramón Vela
- Department of Internal Medicine, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Carmen Mella
- Department of Internal Medicine, Complejo Hospitalario Universitario de Ferrol, A Coruña, Spain
| | - Isabelle Quere
- Department of Vascular Medicine, Hôpital Saint Eloi, Montpellier, France
| | | | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Universidad Autónoma de Barcelona, Spain
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12
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Jarman AF, Mumma BE, Singh KS, Nowadly CD, Maughan BC. Crucial considerations: Sex differences in the epidemiology, diagnosis, treatment, and outcomes of acute pulmonary embolism in non-pregnant adult patients. J Am Coll Emerg Physicians Open 2021; 2:e12378. [PMID: 33532761 PMCID: PMC7839235 DOI: 10.1002/emp2.12378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/30/2020] [Accepted: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
Acute pulmonary embolism (PE) affects over 600,000 Americans per year and is a common diagnostic consideration among emergency department patients. Although there are well-documented differences in the diagnosis, treatment, and outcomes of cardiovascular conditions, such as ischemic heart disease and stroke, the influence of sex and gender on PE remains poorly understood. The overall age-adjusted incidence of PE is similar in women and men, but women have higher relative rates of PE during early and mid-adulthood (ages 20-40 years); whereas, men have higher rates of PE after age 60 years. Women are tested for PE at far higher rates than men, yet women who undergo computed tomography pulmonary angiography are ultimately diagnosed with PE 35%-55% less often than men. Among those diagnosed with PE, women are more likely to have severe clinical features, such as hypotension and signs of right ventricular dysfunction. When controlled for PE severity, women are less likely to receive reperfusion therapies, such as thrombolysis. Finally, women have more bleeding complications for all types of anticoagulation. Further investigation of possible sex-specific diagnostic and treatment algorithms is necessary in order to more accurately detect and treat acute PE in non-pregnant adults.
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Affiliation(s)
- Angela F. Jarman
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Bryn E. Mumma
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Kajol S. Singh
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Craig D. Nowadly
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Brandon C. Maughan
- Department of Emergency MedicineOregon Health and Science UniversityPortlandOregonUSA
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13
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Pribish AM, Beyer SE, Krawisz AK, Weinberg I, Carroll BJ, Secemsky EA. Sex differences in presentation, management, and outcomes among patients hospitalized with acute pulmonary embolism. Vasc Med 2020; 25:541-548. [PMID: 33203347 DOI: 10.1177/1358863x20964577] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
While the presence of gender disparities in cardiovascular disease have been described, there is a paucity of data regarding the impact of sex in acute pulmonary embolism (PE). We identified all patients admitted to a tertiary care hospital with acute PE between August 1, 2012 through July 1, 2018. We stratified the presenting characteristics, management, and outcomes between women and men. Of the 2031 patients admitted with acute PE, 1081 (53.2%) were women. Women were more likely to present with dyspnea (59.8% vs 52.0%, p < 0.001) and less likely to present with hemoptysis (1.9% vs 4.0%, p = 0.01). Women were older (63.8 ± 17.4 years vs 62.3 ± 15.0 years, p = 0.04), but had lower rates of myocardial infarction, liver disease, smoking history, and prior DVT. PE severity was similar between women and men (massive: 4.9% vs 3.6%; submassive: 43.9% vs 41.8%; p = 0.19), yet women were more likely to present with normal right ventricular size on a surface echocardiogram (63.2% vs 54.8%, p = 0.01). In unadjusted analyses, women were less likely to survive to discharge (92.4% vs 94.7%, p = 0.04), but after adjustment, there was no sex-based survival difference. There were no sex differences in the PE-related diagnostic studies performed, use of advanced therapies, or short-term outcomes, before and after adjustment (p > 0.05 for all). In this large PE cohort from a tertiary care institution, women had different comorbidity profiles and PE presentations compared with men. Despite these differences, there were no sex disparities in PE management or outcomes.
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Affiliation(s)
- Abby M Pribish
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sebastian E Beyer
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Anna K Krawisz
- Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ido Weinberg
- Harvard Medical School, Boston, MA, USA.,Divison of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Brett J Carroll
- Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric A Secemsky
- Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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