Pathophysiological Aspects of Aging in Venous Thromboembolism: An Update

Safety of direct oral anticoagulants reversal agents in older patients: an analysis of individual case safety reports of adverse drug reaction from VigiBase®

BACKGROUND

Real-world data on adverse drug reactions (ADRs) associated with idarucizumab and andexanet alfa are limited.

AIM

This study aimed to assess the frequency, the characteristics and clinical and demographic factors associated with ADRs related to their use.

METHODS

This is a retrospective analysis of ADR reports collected in Vigibase® until May 31, 2023. Multivariable logistic regression estimated reporting odds ratios (RORs) for serious ADRs, death, and thromboembolic events according to demographical and clinical covariates.

RESULTS

A total of 1095 Individual Case Safety Reports (ICSRs) reporting idarucizumab (72%) or andexanet alfa (28%) as suspected/interacting agents were collected. Most of the subjects were males (44.5%), with a median age of 78 years, and exposed to only one suspected/interacting medication (73.6%). ADRs were defined as serious in 88.6% of cases, with a total of 614 (56.1%) fatal cases. Compared to patients without concomitant medications, probability of serious ADRs and death were both higher in those receiving ≥ 5 concomitant medications in the idarucizumab subgroup (ROR 4.04 and 1.66, respectively) and in those receiving 1-4 concomitant medications in the andexanet alfa subgroup (ROR 5.66 and 4.80, respectively). Moreover, the probability of thromboembolic events was significantly lower for subjects aged > 75 years (ROR for 75-84 years 0.55; ROR for ≥ 85 years 0.50).

DISCUSSION

In real-world, ADRs associated with idarucizumab and andexanet alfa use are generally serious, resulting in death in a high percentage of subjects.

CONCLUSION

Clinicians should pay particular attention when managing individuals needing these drugs, especially if vulnerable and requiring polytherapy.

Prediction and Risk Factors of Lower Extremity Deep Vein Thrombosis after Total Joint Arthroplasty

This study was to retrospectively analyze the incidence of deep vein thrombosis (DVT) in patients undergoing total joint arthroplasty (TJA) and analyze the risk factors for DVT. 113 patients with TJA were divided into the DVT group (n = 11) and the non-DVT group (n = 102) according to the postoperative ultrasound diagnosis, and the incidence of DVT after TJA was calculated. Logistic regression was used to analyze the correlation between DVT and patients' age, medical history, surgical factors, blood indexes to identify the risk factors of DVT after TJA. Receiver operator characteristic (ROC) curve was constructed to evaluate the diagnostic accuracy of risk factors for DVT. According to the results of ultrasound examination, DVT occurred in 11 of 113 patients after TJA, and the incidence rate of DVT was 9.73%. Univariate analysis showed that the levels of age, diabetes mellitus, operation time, intraoperative blood loss, intraoperative blood transfusion, antithrombin-Ⅲ (AT-Ⅲ), plasma protein C (PC), soluble platelet endothelial cell adhesion molecules-1 (SPECAM-1) and tissue-type plasminogen activator (t-PA) in the DVT group were significantly different from those in the non-DVT group (P < 0.05). Multivariate analysis showed that combined diabetes, decreased PC and t-PA were risk factors for DVT (P < 0.05). ROC analysis showed that PC combined with t-PA had the highest diagnostic accuracy for DVT. Patients with diabetes mellitus are at high risk for DVT after TJA, the increase of D-dimer, the decrease of PC and t-PA after 24 h of TJA is the the risk factors for DVT occurrence.

Retrospective analysis of the effectiveness and safety of sulodexide for venous thromboembolism prevention in neurosurgical patients

Neurosurgery patients are at high risk of developing venous thromboembolism (VTE) which increases the risk of morbidity and mortality. This study is designed to investigate the effectiveness and safety of sulodexide in combination with routine VTE prophylaxis compared with routine VTE prophylaxis alone for VTE prevention in neurosurgical patients. This retrospective, cohort study included neurosurgical patients received routine VTE prophylaxis (control group) or routine VTE prophylaxis plus sulodexide (experimental group) during hospitalization. Predictors of VTE during hospitalization were determined using multivariable logistic regression. A total of 694 eligible patients were included in this study. The incidence of VTE in the experimental group (4.52%, 10/221) was lower compared with that in the control group (6.98%, 33/473) (P = 0.212). The change from baseline in serum creatinine and blood urea nitrogen of the experimental group was significantly higher compared with that in the control group (both P < 0.05). In elderly patients (>65 years), VTE incidence in the experimental group was 3.51% which was significantly lower than that in the control group (10.8%; P = 0.03) and odd ratio [OR] was 0.3 (95% confidence interval [CI]: 0.07, 0.92). Multivariate logistic regression analysis revealed that use of sulodexide plus routine VTE prophylaxis (OR = 0.172, 95% CI: 0.055, 0.535; P = 0.006) and baseline Glasgow Coma Scale (GCS) score (OR = 0.587, 95% CI: 0.521, 0.792; P < 0.001) were protective factors for VTE risk, and the length of hospital stay (OR = 1.134, 95% CI: 1.021, 1.199; P=0.007) was a risk factor for VTE. Sulodexide in combination with routine VTE prophylaxis effectively reduces the risk of VTE in neurosurgical patients. A high baseline GCS score is a protective factor for VTE, whereas length of hospital stay is a risk factor for VTE.

Biological Aging and Venous Thromboembolism: A Review of Telomeres and Beyond

Although venous thromboembolism (VTE) is the third most common cardiovascular disease, and the risk of VTE increases sharply with advancing age, approximately 40% of VTE cases are currently classified as unprovoked, highlighting the importance of risk factor research. While chronological aging is associated with the risk of VTE, the association with biological aging remains unclear. Biological aging is highly complex, influenced by several dysregulated cellular and biochemical mechanisms. In the last decade, advancements in omics methodologies provided insights into the molecular complexity of biological aging. Techniques such as high-throughput genomics, epigenomics, transcriptomics, proteomics, and metabolomics analyses identified and quantified numerous epigenetic markers, transcripts, proteins, and metabolites. These methods have also revealed the molecular alterations organisms undergo as they age. Despite the progress, there is still a lack of consensus regarding the methods for assessing and validating these biomarkers, and their application lacks standardization. This review gives an overview of biomarkers of biological aging, including telomere length, and their potential role for VTE. Furthermore, we critically examine the advantages and disadvantages of the proposed methods and discuss possible future directions for investigating biological aging in VTE.

Apelin-13 as a novel diagnostic laboratory biomarker in thromboembolic disorders: a review of literature with prospective insights

Thromboembolic disorders, including deep vein thrombosis (DVT) and pulmonary embolism (PE), are major global health concerns, causing significant morbidity and mortality. Early diagnosis is crucial for effective treatment and improved patient outcomes. Recent research has identified Apelin-13, a bioactive peptide in the apelin family, as a promising diagnostic biomarker for Thromboembolic disorders. Apelin-13 supports vascular health by regulating protease balance through plasminogen activator inhibitors and modulating endothelial cell function. Additionally, it plays a vital role in coagulation, with elevated levels associated with an increased risk of clot formation, suggesting its utility in predicting thrombosis risk, particularly in preoperative evaluations. Findings indicate that the Apelin-13 pathway shows significant promise as a biomarker for Thromboembolic disorders, underscoring its potential therapeutic applications and the need for further investigation. This review synthesizes current literature on thromboembolic disorders and associated laboratory biomarkers, with a particular focus on Apelin-13. It examines Apelin-13's role in disease mechanisms, its physiological functions, and its potential as a diagnostic biomarker in thromboembolic conditions.

Resistin and In-Hospital Mortality in Patients with Acute Ischemic Stroke: A Prospective Study

Background/Objectives: Understanding the prognostic factors of acute ischemic stroke (AIS) is essential for improving patient outcomes. The aim of this study was to establish the predictive role of plasmatic resistin and leptin on short-term mortality in adult patients with a first episode of AIS. Methods: This study enrolled 277 patients who were consecutively hospitalized for AIS. Demographic data, cardiovascular risk, comorbidities, and laboratory tests were collected. Death was noted if it occurred during hospitalization. Results: Death was recorded in 33 (11.9%) patients. Conducting multivariate analysis, the following variables were independent variables associated with in-hospital mortality: a resistin value of >11 ng/mL (OR 10.81 (95%CI 2.31;50.57), p = 0.002), a lesion volume of >18.8 mL (OR 4.87 (95%CI 1.87;12.67), p = 0.001), a NIHSS score of >7 (OR 5.88 (95%CI 2.01;17.16), p = 0.001), and the presence of IHD (OR 4.33 (95%CI 1.66;11.27), p = 0.003). This study has some limitations: single-center design (which may affect the generalizability of the results) and the potential impact of the COVID-19 pandemic on patient outcomes. Conclusions: This study demonstrated that resistin is a significant predictor of in-hospital mortality in AIS patients. Other established factors, such as a high NIHSS score, large lesion volume, and the presence of IHD, were reaffirmed as important predictors.

Epidemiology, Etiology, and Pathophysiology of Pulmonary Embolism

Over the last 20 years, there has been a progressive increase in the incidence of pulmonary embolism (PE) diagnosis in the United States, Europe, and Australia. Increased use of computed tomography pulmonary angiography has likely contributed in part to this rising incidence. However, it is pertinent to note that the burden of comorbidities associated with PE, such as malignancy, obesity, and advanced age, has also increased over the past 20 years. Time-trend analysis in North American, European, and Asian populations suggests that mortality rates associated with PE have been declining. The reported improved survival rates in PE over the past 20 years are likely, at least in part, to be the result of better adherence to guidelines, improved risk stratification, and enhanced treatment. Factors contributing to the development of venous thromboembolism (VTE) include stasis of blood, hypercoagulability, endothelial injury, and inflammation. In 70 to 80% of cases of PE, the thrombi embolizes from the proximal deep veins of the lower extremities and pelvis. Strong risk factors for VTE include lower extremity fractures and surgeries, major trauma, and hospitalization within the previous 3 months for acute myocardial infarction or heart failure with atrial fibrillation. Acute PE causes several pathophysiological responses including hypoxemia and right ventricle (RV) failure. The latter is a result of pulmonary artery occlusion and associated vasoconstriction. Hemodynamic compromise from RV failure is the principal cause of poor outcome in patients with acute PE.

Oral anticoagulant therapy in older adults

Patients aged ≥65 years not only account for the majority of patients with atrial fibrillation (AF) and venous thromboembolism (VTE), they are also at a higher risk of morbidity, mortality, and undertreatment than younger patients. Several age-related physiological changes with effects on drug pharmacokinetics/-dynamics and blood vessel fragility as well as the higher prevalence of geriatric conditions such as frailty, multimorbidity, polypharmacy, fall risk, dementia, and malnutrition make older persons more vulnerable to disease- and anticoagulation-related complications. Moreover, because older patients with AF/VTE are underrepresented in oral anticoagulation (OAC) trials, evidence on OAC in older adults with AF/VTE is mainly based on subgroup analyses from clinical trials and observational studies. A growing body of such limited evidence suggests that direct oral anticoagulants (DOACs) may be superior in terms of efficacy and safety compared to vitamin K antagonists in older persons with AF/VTE and that specific DOACs may have a differing risk-benefit profile. In this narrative review, we summarize the evidence on epidemiology of AF/VTE, impact of age-related physiological changes, efficacy/safety of OAC, specifically considering individuals with common geriatric conditions, and review OAC guideline recommendations for older adults with AF/VTE. We also propose a research agenda to improve the evidence basis on OAC older individuals with AF/VTE, including the conduct of advanced age-specific and pragmatic studies using less restrictive eligibility criteria and patient-reported health outcomes, in order to compare the effectiveness and safety of different DOACs, and investigate lower-dose regimens and optimal OAC durations in older patients.

Venous thromboembolism: diagnostic advances and unaddressed challenges in management

PURPOSE OF REVIEW

This review summarizes recent advances in developing targeted diagnostics for venous thromboembolism (VTE) and unaddressed knowledge gaps in patient management. Without addressing these critical data needs, the morbidity in VTE patients will persist.

RECENT FINDINGS

Recent studies investigating plasma protein profiles in VTE patients have identified key diagnostic targets to address the currently unmet need for low-cost, confirmatory, point-of-care VTE diagnostics. These studies and a growing body of evidence from animal model studies have revealed the importance of inflammatory and vascular pathology in driving VTE, which are currently unaddressed targets for VTE therapy. To enhance the translation of preclinical animal studies, clinical quantification of thrombus burden and comparative component analyses between modeled VTE and clinical VTE are necessary.

SUMMARY

Lead candidates from protein profiling of VTE patients' plasma offer a promising outlook in developing low cost, confirmatory, point-of-care testing for VTE. Additionally, addressing the critical knowledge gap of quantitatively measuring clinical thrombi will allow for an array of benefits in VTE management and informing the translatability of experimental therapeutics.

Analysis of Sex Hormones, Insulin Dosage, and Risk Factors Associated With Male Diabetic Patients

The purpose of this study is to assess the influence of sex hormones and other indicators on risk factors for hypercoagulable states in male patients with type 2 diabetes mellitus. Ninety-two diabetic patients were divided into two groups based on testosterone levels: T1 group (testosterone <12 mmol/L) and T2 group (testosterone >12 mmol/L). Fifty-four non-diabetic patients were used as the control group. Sex hormone index, glucose, insulin, C-peptide, 24-h urinary free cortisol, thromboelastography, and insulin resistance index were measured by radioimmunoassay. Testosterone was lower in the diabetic men than in the control group (12.02 vs 14.77, p < .05), and was inversely related to blood coagulation status, blood glucose level, and cortisol level. Body mass index was positively correlated with estradiol and insulin resistance index. Testosterone was independently associated with the clotting process after controlling for age. Low testosterone is a risk factor for hypercoagulable state in diabetic men. Elevated estradiol and insulin resistance are influential factors for increased body mass index.

Challenges in Coagulation Management in Neurosurgical Diseases: A Scoping Review, Development, and Implementation of Coagulation Management Strategies

Bleeding and thromboembolic (TE) complications in neurosurgical diseases have a detrimental impact on clinical outcomes. The aim of this study is to provide a scoping review of the available literature and address challenges and knowledge gaps in the management of coagulation disorders in neurosurgical diseases. Additionally, we introduce a novel research project that seeks to reduce coagulation disorder-associated complications in neurosurgical patients. The risk of bleeding after elective craniotomy is about 3%, and higher (14-33%) in other indications, such as trauma and intracranial hemorrhage. In spinal surgery, the incidence of postoperative clinically relevant bleeding is approximately 0.5-1.4%. The risk for TE complications in intracranial pathologies ranges from 3 to 20%, whereas in spinal surgery it is around 7%. These findings highlight a relevant problem in neurosurgical diseases and current guidelines do not adequately address individual circumstances. The multidisciplinary COagulation MAnagement in Neurosurgical Diseases (COMAND) project has been developed to tackle this challenge by devising an individualized coagulation management strategy for patients with neurosurgical diseases. Importantly, this project is designed to ensure that these management strategies can be readily implemented into healthcare practices of different types and with sustainable integration.

Soluble endothelial protein C receptor is an independent predictor of venous thromboembolism after severe injury: Secondary analysis of a prospective cohort study

BACKGROUND

Venous thromboembolism is a leading cause of morbidity after trauma. Endothelial cells are essential regulators of coagulation. Although endothelial cell dysregulation is widely reported after trauma, the link between endothelial injury and venous thromboembolism has not been reported.

METHODS

We conducted a secondary analysis of the Pragmatic Randomized Optimal Platelets and Plasma Ratios study. Deaths from hemorrhage or within 24 hours were excluded. Venous thromboembolism was diagnosed by duplex ultrasound or chest computed tomography. Endothelial markers soluble endothelial protein c receptor, thrombomodulin, and syndecan-1 were measured in plasma by enzyme-linked immunosorbent assay and compared over the first 72 hours from admission using the Mann-Whitney test. Multivariable logistic regression assessed the adjusted effects of endothelial markers on venous thromboembolism risk.

RESULTS

Of 575 patients enrolled, 86 developed venous thromboembolism (15%). The median time to venous thromboembolism was 6 days ([Q1, Q3], [4, 13]). No differences were identified in demographics or injury severity. Soluble endothelial protein c receptor, thrombomodulin, and syndecan-1 showed significant increases over time among patients who developed venous thromboembolism compared to those who did not. Using the last available values, patients were stratified into high and low-soluble endothelial protein c receptor, thrombomodulin, and syndecan-1 groups. Multivariable analyses revealed an independent association between elevated soluble endothelial protein c receptor and venous thromboembolism risk (odds ratio 1.63; 95% confidence interval 1.01, 2.63; P = .04). Cox proportional hazards modeling demonstrated a strong yet nonsignificant trend between elevated soluble endothelial protein c receptor and time to venous thromboembolism.

CONCLUSION

Plasma markers of endothelial injury, particularly soluble endothelial protein c receptor, are strongly associated with trauma-related venous thromboembolism. Therapeutics targeting endothelial function could mitigate the incidence of venous thromboembolism after trauma.

Chronic Venous Insufficiency With Emphasis on the Geriatric Population

The underpinning of Chronic Venous Insufficiency (CVI) is valvular dysfunction, which manifests on a spectrum depending on the severity of insufficiency and duration of the disease. The mainstay of treatment relies on compression therapy of a proper type and intensity. In older adults, special consideration must be taken during the patient encounter to account for age-related factors. This review discusses the clinical presentation, diagnosis, and mimicking of CVI, focusing mainly on older adults. The epidemiology, risk factors, disease burden, and grave complications -- such as thrombosis and ulceration, are reviewed. The physiological impacts of CVI are described, providing the background for treatment strategies, including non-invasive, medical, and surgical therapies. The findings show advanced age to be an important risk factor contributing to CVI and that other age-related factors add to the risk of severe complications. Clinical assessments combined with objective measurements that assess localized skin water using tissue dielectric constant values or whole limb assessments may aid in the differential diagnosis. Furthermore, understanding the mechanism of action of compression therapy, the mainstay of CVI treatment, and its physiological impacts, allows for its informed use in geriatric patients with increased risks of potential compression-related side effects.