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Palareti G, Legnani C, Tosetto A, Poli D, Testa S, Ageno W, Pengo V, Cosmi B, Prandoni P. D-dimer and risk of venous thromboembolism recurrence: Comparison of two studies with similar designs but different laboratory and clinical results. Thromb Res 2024; 238:52-59. [PMID: 38669963 DOI: 10.1016/j.thromres.2024.04.018] [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: 11/15/2023] [Revised: 04/03/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND D-dimer testing may help deciding the duration of anticoagulation in subjects at high risk of venous thromboembolism (VTE) recurrence. Two management studies on this issue have been published (DULCIS in 2014 and APIDULCIS in 2022). They had similar designs but had important different results. Aim of this article is to compare their results. METHODS Both studies were finalized to extend anticoagulation [with vitamin K anticoagulants (VKAs) in DULCIS or apixaban 2.5 mg BID (kindly provided by BMS-Pfizer Collaboration) in APIDULCIS] only in patients with positive D-dimer results. RESULTS More D-dimer assays resulted positive in APIDULCIS than in DULCIS (61.1 % vs 47.7 %, respectively; p < 0.0001). While only 4 (0.5 %) refused low dose apixaban in APIDULCIS, the 22.6 % of patients with positive D-dimer refused to resume VKAs in DULCIS; their rates of recurrence were 187 and 8.8 per 100 person-years, respectively (incidence rate ratio [IRR]: 21.2). The incidence of bleeding was low in those receiving apixaban vs those who resumed VKAs (0.4 vs 2.3 per 100 person-years, respectively; IRR 0.17;). While the recurrence rate was low and similar in the studies in subjects who resumed anticoagulation, it was significantly higher in APIDULCIS than in DULCIS in those who stopped anticoagulation for negative D-dimer (5.6 vs 3.0 per 100 person-years, respectively; IRR 1.9). CONCLUSION The low dose Apixaban for extended VTE treatment is effective and safe, and well accepted by patients. Why subjects who stopped anticoagulation for negative D-dimer had a higher recurrence rate in APIDULCIS than in DULCIS remains to be explained.
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Affiliation(s)
| | | | - Alberto Tosetto
- UOC Ematologia, Centro Malattie Emorragiche e Trombotiche (CMET), AULSS 8 Berica Ospedale S. Bortolo, Vicenza, Italy
| | - Daniela Poli
- Malattie Aterotrombotiche, AOU Careggi, Firenze, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi, UUOO Laboratorio Analisi chimico-cliniche e microbiologiche, ASST Cremona, Cremona, Italy
| | - Walter Ageno
- Dipartimento di Medicina e Chirurgia, Università degli Studi dell'Insubria, UOC Pronto Soccorso, Medicina d'Urgenza e Centro Trombosi ed Emostasi, ASST dei Sette Laghi, Varese, Italy
| | - Vittorio Pengo
- Clinica Cardiologica, Azienda Ospedaliera di Padova, Padova, Italy
| | - Benilde Cosmi
- UO di Angiologia e Malattie della Coagulazione, Dipartimento Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Azienda Ospedaliero Universitaria S. Orsola-Malpighi, I.R.C.C.S., Bologna, Italy
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Burggraaf-van Delft JLI, van Rein N, Bemelmans RHH, van den Berg JWK, Bruggeman CY, Cloos-van Balen M, Coppens M, Eefting M, Ende-Verhaar Y, van Es N, van Guldener C, de Jong WK, Kleijwegt F, Koster T, Kroon C, Kuipers S, Leentjens J, Luijten D, Mairuhu ATA, Meijer K, van de Ree MA, Roos R, Schrover I, Swart-Heikens J, van der Velden AWG, van den Akker-van Marle EM, le Cessie S, Geersing GJ, Middeldorp S, Huisman MV, Klok FA, Cannegieter SC. Tailored anticoagulant treatment after a first venous thromboembolism: protocol of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study - cohort-based randomised controlled trial. BMJ Open 2024; 14:e078676. [PMID: 38521524 PMCID: PMC10961563 DOI: 10.1136/bmjopen-2023-078676] [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: 08/08/2023] [Accepted: 02/06/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Patients with a first venous thromboembolism (VTE) are at risk of recurrence. Recurrent VTE (rVTE) can be prevented by extended anticoagulant therapy, but this comes at the cost of an increased risk of bleeding. It is still uncertain whether patients with an intermediate recurrence risk or with a high recurrence and high bleeding risk will benefit from extended anticoagulant treatment, and whether a strategy where anticoagulant duration is tailored on the predicted risks of rVTE and bleeding can improve outcomes. The aim of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study is to evaluate the outcomes of tailored duration of long-term anticoagulant treatment based on individualised assessment of rVTE and major bleeding risks. METHODS AND ANALYSIS The L-TRRiP study is a multicentre, open-label, cohort-based, randomised controlled trial, including patients with a first VTE. We classify the risk of rVTE and major bleeding using the L-TRRiP and VTE-BLEED scores, respectively. After 3 months of anticoagulant therapy, patients with a low rVTE risk will discontinue anticoagulant treatment, patients with a high rVTE and low bleeding risk will continue anticoagulant treatment, whereas all other patients will be randomised to continue or discontinue anticoagulant treatment. All patients will be followed up for at least 2 years. Inclusion will continue until the randomised group consists of 608 patients; we estimate to include 1600 patients in total. The primary outcome is the combined incidence of rVTE and major bleeding in the randomised group after 2 years of follow-up. Secondary outcomes include the incidence of rVTE and major bleeding, functional outcomes, quality of life and cost-effectiveness in all patients. ETHICS AND DISSEMINATION The protocol was approved by the Medical Research Ethics Committee Leiden-Den Haag-Delft. Results are expected in 2028 and will be disseminated through peer-reviewed journals and during (inter)national conferences. TRIAL REGISTRATION NUMBER NCT06087952.
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Affiliation(s)
| | - Nienke van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Remy H H Bemelmans
- Department of Internal Medicine, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | | | - Coty Y Bruggeman
- Department of Internal Medicine, Martini Ziekenhuis, Groningen, Groningen, The Netherlands
| | - Marissa Cloos-van Balen
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, Zuid-Holland, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, Noord-Holland, The Netherlands
| | - Matthijs Eefting
- Department of Internal Medicine, Ikazia Ziekenhuis, Rotterdam, Zuid-Holland, The Netherlands
| | - Yvonne Ende-Verhaar
- Department of Internal Medicine, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, Noord-Holland, The Netherlands
| | - Coen van Guldener
- Department of Internal Medicine, Amphia Ziekenhuis, Breda, North Brabant, The Netherlands
| | - Wouter K de Jong
- Department of Pulmonology, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Fleur Kleijwegt
- Department of Internal Medicine, Rode Kruis Ziekenhuis, Beverwijk, Noord-Holland, The Netherlands
| | - Ted Koster
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, Zuid-Holland, The Netherlands
| | - Cees Kroon
- Department of Internal Medicine, Ziekenhuis Nij Smellinghe, Drachten, Friesland, The Netherlands
| | - Saskia Kuipers
- Department of Internal Medicine, ADRZ, Goes, Zeeland, The Netherlands
| | - Jenneke Leentjens
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, The Netherlands
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Karina Meijer
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Marcel A van de Ree
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Rick Roos
- Department of Internal Medicine, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Ilse Schrover
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Janneke Swart-Heikens
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | | | | | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Clinical Epidemiology, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Geert-Jan Geersing
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, The Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Affiliation(s)
- Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Peter Verhamme
- KU Leuven Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, Leuven, Belgium
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Chiasakul T, Bauer KA. The dos, don'ts, and nuances of thrombophilia testing. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:593-599. [PMID: 38066917 PMCID: PMC10727021 DOI: 10.1182/hematology.2023000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Considerable progress has been made in elucidating genetic and biologic risk factors for venous thromboembolism (VTE). Despite being able to identify heritable defects in a substantial proportion of patients with VTE, testing has not, in general, proven useful in management. Despite efforts to reduce inappropriate testing, it often falls to the hematologist to consult on patients having undergone thrombophilia testing. Through a series of cases, we discuss how D-dimer testing can be helpful in VTE recurrence risk stratification in younger women as well as how to approach patients with persistently elevated D-dimer levels in the absence of thrombosis. While elevated factor VIII coagulant activity levels are a significant risk factor for a first episode of VTE, its biologic basis is not fully understood, and studies have not shown it to be a useful predictor of recurrence. Abnormal results of genetic tests for methylene tetrahydrofolate reductase or plasminogen activator 1 promoter polymorphisms may be encountered, which carry little if any thrombotic risk and should never be ordered. We also discuss protein S deficiency, the most difficult of the hereditary thrombophilias to diagnose due to a wider "normal" range in the general population as compared with protein C, the presence of both free and bound forms in plasma, and the characteristics of the various assays in use. We also present a rare type of protein C deficiency that can be missed by functional assays using an amidolytic rather than a clotting end point.
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Affiliation(s)
- Thita Chiasakul
- Center of Excellence in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Kenneth A Bauer
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Xu Y, Khan F, Kovacs MJ, Sabri E, Carrier M, Righini M, Kahn SR, Wells PS, Anderson DR, Chagnon I, Crowther MA, White RH, Rodger M, Le Gal G. Serial D-dimers after anticoagulant cessation in unprovoked venous thromboembolism: Data from the REVERSE cohort study. Thromb Res 2023; 231:32-38. [PMID: 37801772 DOI: 10.1016/j.thromres.2023.09.012] [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: 06/16/2023] [Revised: 08/24/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION While several risk stratification tools have been developed to predict the risk of recurrence in patients with an unprovoked venous thromboembolism (VTE), only 1 in 4 patients are categorized as low-risk. Rather than a one-time measure, serial D-dimer assessment holds promise to enhance the prediction of VTE recurrence after oral anticoagulant (OAC) cessation. METHODS Using the REVERSE cohort, we compared VTE recurrence among patients with normal D-dimer levels (<490 ng/mL among males under age 70, <500 ng/mL in others) at OAC cessation and 1-month follow-up, to those with an elevated D-dimer level at either timepoint. We also evaluated VTE recurrence based on absolute increase in D-dimer levels between the two timepoints (e.g., ∆D-dimer) according to quartiles. RESULTS Among 214 patients with serial D-dimer levels measured at OAC cessation and 1-month follow-up, an elevated D-dimer level at either timepoint was associated with a numerically higher risk of recurrent VTE than patients with normal D-dimer levels at both timepoints (6.9 % vs. 4.2 % per year, hazard ratio 1.6; 95 % CI 0.9-2.7). Among women with <2 HERDOO2 criteria, a normal D-dimer level at both timepoints predicted a very low risk of recurrent VTE during follow-up (0.8 % per year, 95 % CI 0.1-2.8). Irrespective of baseline value, recurrent VTE risk was only 3 % per year (95 % CI 1.4-5.6) among patients in the lowest ∆D-dimer quartile. CONCLUSION Serial normal D-dimer levels have the potential to identify patients at a low risk of recurrent VTE. In addition, ∆D-dimer, irrespective of its elevation above cutoff threshold, may predict recurrent VTE.
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Affiliation(s)
- Yan Xu
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada
| | - Faizan Khan
- O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Michael J Kovacs
- Department of Medicine, Western University, London, Ontario, Canada
| | - Elham Sabri
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Righini
- Department of Medicine, University of Geneva, Geneva, Switzerland
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, Canada
| | - Philip S Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard H White
- School of Medicine, University of California Davis, Davis, CA, United States of America
| | - Marc Rodger
- Department of Medicine, University of Geneva, Geneva, Switzerland
| | - Grégoire Le Gal
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
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DeLoughery E, Bannow BS. Anticoagulant therapy for women: implications for menstruation, pregnancy, and lactation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:467-473. [PMID: 36485151 PMCID: PMC9820577 DOI: 10.1182/hematology.2022000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Estrogen exposure, in the setting of pregnancy, the postpartum state, combined hormonal contraceptives (CHCs), or hormone therapy use, has been clearly associated with increased rates of venous thromboembolism (VTE). Although recurrence rates are low in these settings, up to 70% of anticoagulated menstruating individuals experience abnormal or heavy menstrual bleeding (HMB), which commonly results in iron deficiency with or without anemia. Patients taking rivaroxaban appear to experience higher rates of HMB compared with those on apixaban, dabigatran, or warfarin. HMB can often be diagnosed in a single visit with a good menstrual history assessing for factors with a known association with increased or heavy bleeding, such as changing pads or tampons more often than every 2 hours, clots larger than a quarter, and iron deficiency (ferritin <50 ng/mL). HMB can be managed with hormonal therapies, including those associated with VTE risk, such as CHCs and depot-medroxyprogesterone acetate (DMPA). In many cases, continuing CHCs or DMPA while a patient is therapeutically anticoagulated is reasonable, so long as the therapy is discontinued before anticoagulation is stopped. Modification of the anticoagulation regimen, such as decreasing to a prophylactic dose in the acute treatment period, is not currently recommended. For patients who are currently pregnant, low-molecular-weight heparin (LMWH) is still standard of care during pregnancy; routine monitoring of anti-factor Xa levels is not currently recommended. Warfarin or LMWH may be considered in the postpartum setting, but direct-acting oral anticoagulants are currently not recommended for lactating patients.
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Plessier A, Goria O, Cervoni JP, Ollivier I, Bureau C, Poujol-Robert A, Minello A, Houssel-Debry P, Rautou PE, Payancé A, Scoazec G, Bruno O, Corbic M, Durand F, Vilgrain V, Paradis V, Boudaoud L, de Raucourt E, Roy C, Gault N, Valla D. Rivaroxaban Prophylaxis in Noncirrhotic Portal Vein Thrombosis. NEJM EVIDENCE 2022; 1:EVIDoa2200104. [PMID: 38319842 DOI: 10.1056/evidoa2200104] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: In patients with noncirrhotic chronic portal vein thrombosis (PVT), the benefit of long-term anticoagulation is unknown. We assessed the effects of rivaroxaban on the risk of venous thromboembolism and portal hypertension-related bleeding in such patients. METHODS: In this multicenter, controlled trial, we randomly assigned patients with noncirrhotic chronic PVT without major risk factors for thrombosis to receive either rivaroxaban 15 mg/day or no anticoagulation. The primary end point was 2-year thrombosis-free survival. Secondary end points included the occurrence of site-specific thromboses and major bleeding events. RESULTS: A total of 111 participants were enrolled in the trial, with a mean age of 50.4±13.2 years; 58% of participants were men. An unplanned interim analysis was requested by the independent data safety monitoring board (DSMB) after 10 thrombotic events occurred. The thrombosis incidence rate was 0 per 100 person-years in the rivaroxaban group and 19.71 per 100 person-years (95% confidence interval, 7.49 to 31.92) in the no anticoagulation group (log-rank P=0.0008) after a median follow-up of 11.8 months. Based on the interim analysis, the DSMB recommended switching patients from the no anticoagulation group to anticoagulation. After a median follow-up of 30.3 months (intraquartile range, 24.3 to 47.8), major bleeding occurred in two patients receiving rivaroxaban and in one patient not receiving anticoagulation. No deaths occurred. CONCLUSIONS: After a median follow-up of 11.8 months, among patients with noncirrhotic chronic PVT without major risk factors for thrombosis, daily rivaroxaban reduced the incidence of venous thromboembolism and did not increase major bleeding events. (Funded by grants from the French Ministry of Health and the Association de Malades des Vaisseaux du foie; ClinicalTrials.gov number, NCT02555111.)
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Affiliation(s)
- Aurélie Plessier
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, Filière de Santé des Maladies Rares du Foie, Valdig, ERN RARE-LIVER, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1149
| | - Odile Goria
- Service d'Hépatologie et Gastroentérologie, Hôpital Universitaire Charles Nicolle de Rouen, Rouen, France
| | | | - Isabelle Ollivier
- Service d'Hépatologie et Gastroentérologie, Hôpital Universitaire Côte de la Nacre, Caen, France
| | - Christophe Bureau
- Service d'Hépatologie et Gastroentérologie, Hôpital Universitaire Rangueil Toulouse, Toulouse, France
| | - Armelle Poujol-Robert
- Service d'Hépatologie, Hôpital Saint Antoine Assistance Publique-Hôpitaux de Paris, ERN RARE-LIVER, Paris
| | - Anne Minello
- Service d'Hépatologie et Gastroentérologie, Pôle des Pathologies Digestives, Endocriniennes, Métaboliques et Urologique, Hôpital Universitaire François Mitterrand, Dijon, France
| | | | - Pierre Emmanuel Rautou
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, Filière de Santé des Maladies Rares du Foie, Valdig, ERN RARE-LIVER, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1149
| | - Audrey Payancé
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, Filière de Santé des Maladies Rares du Foie, Valdig, ERN RARE-LIVER, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1149
| | - Giovanna Scoazec
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, Filière de Santé des Maladies Rares du Foie, Valdig, ERN RARE-LIVER, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1149
| | - Onorina Bruno
- Université de Paris, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1149
- Service de Radiologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris
- ERN RARE-LIVER, Clichy, France
| | | | - Francois Durand
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, Filière de Santé des Maladies Rares du Foie, Valdig, ERN RARE-LIVER, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1149
| | - Valérie Vilgrain
- Université de Paris, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1149
- Service de Radiologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris
- ERN RARE-LIVER, Clichy, France
| | - Valérie Paradis
- Service d'Anatomo-Pathologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, ERN RARE-LIVER, Clichy, France
| | - Larbi Boudaoud
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire Beaujon Assistance Publique-Hôpitaux de Paris, ERN RARE-LIVER, Clichy, France
| | - Emmanuelle de Raucourt
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire Beaujon Assistance Publique-Hôpitaux de Paris, ERN RARE-LIVER, Clichy, France
| | - Carine Roy
- Assistance Publique-Hôpitaux de Paris, Direction de la Recherche Clinique et de l'Innovation, Unité de Recherche Clinique Paris Nord, Hôpital Bichat, Paris
- Institut National de la Santé et de la Recherche Médicale CIC-EC1425, Hôpital Bichat, Paris
| | - Nathalie Gault
- Institut National de la Santé et de la Recherche Médicale CIC-EC1425, Hôpital Bichat, Paris
- Assistance Publique-Hôpitaux de Paris Nord-Université de Paris, Département Epidémiologie Biostatistiques et Recherche Clinique, Hôpital Beaujon, Clichy, France
| | - Dominique Valla
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, Filière de Santé des Maladies Rares du Foie, Valdig, ERN RARE-LIVER, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1149
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D-dimer and reduced-dose apixaban for extended treatment after unprovoked venous thromboembolism: the Apidulcis study. Blood Adv 2022; 6:6005-6015. [PMID: 35914222 PMCID: PMC9691910 DOI: 10.1182/bloodadvances.2022007973] [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: 04/28/2022] [Accepted: 07/11/2022] [Indexed: 12/14/2022] Open
Abstract
D-dimer assay is used to stratify patients with unprovoked venous thromboembolism (VTE) for the risk of recurrence. However, this approach was never evaluated since direct oral anticoagulants are available. With this multicenter, prospective cohort study, we aimed to assess the value of an algorithm incorporating serial D-dimer testing and administration of reduced-dose apixaban (2.5 mg twice daily) only to patients with a positive test. A total of 732 outpatients aged 18 to 74 years, anticoagulated for ≥12 months after a first unprovoked VTE, were included. Patients underwent D-dimer testing with commercial assays and preestablished cutoffs. If the baseline D-dimer during anticoagulation was negative, anticoagulation was stopped and testing repeated after 15, 30, and 60 days. Patients with serially negative results (286 [39.1%]) were left without anticoagulation. At the first positive result, the remaining 446 patients (60.9%) were given apixaban for 18 months. All patients underwent follow-up planned for 18 months. The study was interrupted after a planned interim analysis for the high rate of primary outcomes (7.3%; 95% confidence interval [CI], 4.5-11.2), including symptomatic proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) recurrence, death for VTE, and major bleeding occurring in patients off anticoagulation vs that in those receiving apixaban (1.1%; 95% CI, 0.4-2.6; adjusted hazard ratio [HR], 8.2; 95% CI, 3.2-25.3). In conclusion, in patients anticoagulated for ≥1 year after a first unprovoked VTE, the decision to further extend anticoagulation should not be based on D-dimer testing. The results confirmed the high efficacy and safety of reduced-dose apixaban against recurrences. This trial was registered at www.clinicaltrials.gov as #NCT03678506.
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Investigation of the ongoing pulmonary defects with perfusion-single photon emission computed tomography/computed tomography in patients under anticoagulant therapy for coronavirus disease 2019–induced pulmonary embolism. Nucl Med Commun 2022; 43:978-986. [DOI: 10.1097/mnm.0000000000001595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Limperger V, Torge A, Kiesau B, Langer F, Kenet G, Mesters R, Juhl D, Stoll M, Shneyder M, Kowalski D, Bajorat T, Rocke A, Kuta P, Lasarow L, Spengler D, Junker R, Nowak-Göttl U. Validation of a predictive model for identifying an increased risk for recurrence in adolescents and young adults with a first provoked thromboembolism. Blood Cells Mol Dis 2022; 94:102651. [PMID: 35051688 DOI: 10.1016/j.bcmd.2022.102651] [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: 11/12/2021] [Accepted: 01/08/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND To develop and validate a predictive model to determinate patients at increased risk to suffer from recurrence following a first provoked deep vein thrombosis (VTE). METHODS Predictive variables, i.e. male sex [1 point], inherited thrombophilia (IT) status (none [0 points], single [1 point], combined variants [2 points]), blood group non-0, and age at first VTE onset were included into a risk assessment model, which was derived in 511 patients and then validated in 509 independent subjects. RESULTS VTE recurrence risk score (maximum 4 points, range 0-3) was below two for patients scored as low-risk (LRS) and ≥2 for patients at high-risk (HRS). Within a median time of 3 years after withdrawal of anticoagulation (AC) recurrence rate in LRG (derivation) was 11.8% versus 26.0% in HRS (p < 0.001). In the validation cohort within 2.2 years the recurrence rate was 9.8% in LRS versus 30.1% in HRS (p < 0.001). In multivariable analysis adjusted for age at first VTE and blood group the recurrent risk in HRS was significantly increased compared with the LRS (derivation: hazard/95% confidence interval: 3.7/1.75-7.91; validation: 4.7/2.24-9.81; combined 5.2/1.92-13.9). Model specificity (sensitivity) was 79.0% (52.0%) in the derivation cohort compared with 78.0% (43.0%) in the validation group. In conclusion, in the prediction model presented here the risk of VTE recurrence was associated with male gender and combined ITs. Based on the negative predictive value calculated the model may identify patients with a first provoked VTE not being at risk for recurrence.
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Affiliation(s)
- Verena Limperger
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
| | - Antje Torge
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
| | - Bettina Kiesau
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
| | - Florian Langer
- Department of Hematology & Oncology, Univ. Hospital Hamburg, Germany
| | - Gili Kenet
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Centre, Tel-Hashomer, Israel; The Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Israel
| | - Rolf Mesters
- Department of Medicine/Hematology & Oncology, Univ. Hospital Münster, Germany
| | - David Juhl
- Institute of Transfusion Medicine, Univ. Hospital Kiel & Lübeck, Germany
| | - Monika Stoll
- Institute of Human Genetics, Westfälische-Wilhelms-University, Münster, Germany; Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands
| | - Maria Shneyder
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
| | - Dorothee Kowalski
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
| | - Tido Bajorat
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
| | - Angela Rocke
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
| | - Piotr Kuta
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
| | - Livia Lasarow
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
| | - Dietmar Spengler
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
| | - Ralf Junker
- Institute of Clinical Chemistry, Univ. Hospital Kiel & Lübeck, Germany
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Reda S, Thiele Serra E, Müller J, Hamedani NS, Oldenburg J, Pötzsch B, Rühl H. Increased Prevalence of Elevated D-Dimer Levels in Patients on Direct Oral Anticoagulants: Results of a Large Retrospective Study. Front Cardiovasc Med 2022; 9:830010. [PMID: 35433891 PMCID: PMC9008253 DOI: 10.3389/fcvm.2022.830010] [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: 12/06/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
Elevated D-dimer levels during anticoagulant therapy with vitamin K antagonists (VKA) are associated with an increased risk of thrombosis. It has been hypothesized that elevated D-dimer levels in patients receiving direct oral anticoagulants (DOACs) also indicate an increased risk of thrombosis recurrence, but data on the distribution of D-dimer levels in patients with VTE on DOACs are sparse. In the present study we retrospectively analyzed D-dimer levels in patients taking DOACs after first or recurrent venous thrombosis (n = 1,716, 1,126 thereof rivaroxaban, 481 apixaban, 62 edoxaban, and 47 dabigatran). Patients on VKA (n = 402) served as control group. Thrombotic events in the study population were categorized into distal deep venous thrombosis (DVT, n = 552 patients), distal DVT with pulmonary embolism (PE, n = 166), proximal DVT (n = 685), proximal DVT with PE (n = 462), PE without DVT (n = 522), DVT of the upper extremity (n = 78), cerebral venous sinus thrombosis (CVST, n = 48), and other venous thrombosis (n = 74). In VKA users a median D-dimer level of 0.20 mg/l was observed. In patients on DOACs D-dimer levels were significantly higher, with 0.26 mg/l for rivaroxaban, 0.31 mg/l for apixaban (P < 10−16 each), 0.24 mg/l for edoxaban (P = 2 × 10−5), and 0.25 mg/l for dabigatran (P = 4 × 10−4). These differences in comparison to patients on VKA treatment could not be explained by the patients' age, sex, body mass index, and type of thrombosis as these characteristics did not differ significantly between cohorts. Moreover, the prevalence of D-dimer levels above age-adjusted cut-offs [≥0.50 mg/l in ≤50-year-old patients, ≥(age × 0.01) mg/l in >50-year-old patients] was higher in patients on rivaroxaban (13.9%, RR 1.74, 95% CI 1.21–2.50), apixaban (17.0%, RR 2.14, 95% CI 1.45–3.15) and dabigatran (23.4%, RR 2.94, 95% CI 1.59–5.44) than in patients on VKA (8.0%). In patients on edoxaban D-dimer levels above the reference range were observed in 14.5%, but no statistical significance was reached in comparison to the VKA cohort. In conclusion, the obtained data suggest, that the type of oral anticoagulant should be considered in the clinical assessment of D-dimer levels in thrombosis patients. Further studies are warranted to evaluate a potential association between elevated D-dimer levels and thrombosis risk in patients on DOACs.
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12
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Alexander P, Visagan S, Issa R, Gorantla VR, Thomas SE. Current Trends in the Duration of Anticoagulant Therapy for Venous Thromboembolism: A Systematic Review. Cureus 2021; 13:e18992. [PMID: 34853735 PMCID: PMC8608253 DOI: 10.7759/cureus.18992] [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] [Accepted: 10/23/2021] [Indexed: 01/15/2023] Open
Abstract
Anticoagulation therapy is the first line and drug of choice for both the treatment and prophylaxis of venous thromboembolism (deep vein thrombosis and/or pulmonary embolism). Anticoagulation drugs, ranging from different preparations of heparin, warfarin, and newer direct oral drugs such as rivaroxaban and dabigatran, work mainly by inhibiting important factors and enzymes in the coagulation cascade by preventing fibrin formation, platelet aggregation, and clot assembly. With recurrent thrombosis and embolisms being a feared complication for many physicians treating such cases, anticoagulation is often extended beyond the initial three- to six-month acute phase after an incident of venous thromboembolism. For some groups of patients, anticoagulation needs to be offered indefinitely to decrease the risk of a recurrent thrombosis. However, this concomitantly increases obvious and dangerous adverse effects such as increased risk of hemorrhage, as the ability to clot is hindered. This tradeoff between recurrent venous thromboembolism and bleeding is what underscores the controversy of the clinical question: for how long should anticoagulation be administered for venous thromboembolism? This review analyzes the use of anticoagulants in different types of venous thromboembolism and remarks on current consensus and trends on the length of anticoagulation treatment. We are doing so while acknowledging that venous thromboembolism management is an active area of research that is rapidly evolving. A literature search was performed looking at recent studies on anticoagulant administration for the treatment of venous thromboembolism with a focus on varying durations and patient populations. Factors that affect clinical decisions of duration are also elucidated. The most clinically relevant anticoagulants were discussed and their effects on the risk of recurrent thrombosis and embolism, and the risk of bleeding in relation to other drugs were analyzed. Ultimately, this article discussed patterns of anticoagulant treatments duration and which patient groups are likely to benefit the most from certain durations, shedding light on the ambiguity in how physicians should approach administering anticoagulation therapy over time for a broad range of presentations of venous thromboembolism.
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Affiliation(s)
- Peter Alexander
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Shakthi Visagan
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Reem Issa
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | | | - Sneha E Thomas
- Internal Medicine, University of Maryland Medical Center, Baltimore, USA
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13
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Khan F, Rahman A, Tritschler T, Carrier M, Kearon C, Weitz JI, Schulman S, Couturaud F, Becattini C, Agnelli G, Brighton T, Lensing AW, Pinede L, Parpia S, Geersing GJ, Takada T, Bradbury C, Andreozzi GM, Palareti G, Prandoni P, Buller HR, Mallick R, Hutton B, Thavorn K, Le Gal G, Rodger M, Fergusson DA. Long-term risk of major bleeding after discontinuing anticoagulation for unprovoked venous thromboembolism: a systematic review and meta-analysis. Thromb Haemost 2021; 122:1186-1197. [PMID: 34753191 DOI: 10.1055/a-1690-8728] [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 The long-term risk of major bleeding after discontinuing anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. OBJECTIVES To determine the incidence of major bleeding up to 5 years after discontinuing anticoagulation for a first unprovoked VTE. METHODS We searched MEDLINE, EMBASE, and Cochrane CENTRAL (from inception to January 2021) to identify relevant randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding after discontinuing anticoagulation in patients with a first unprovoked VTE who had completed ≥3 months of initial treatment. Unpublished data on major bleeding events and person-years were obtained from authors of included studies to calculate study-level incidence rates. Random-effects meta-analysis was used to pool results across studies. RESULTS Of 1123 records identified by the search, 20 studies (17 RCTs) and 8740 patients were included in the analysis. During 13 011 person-years of follow-up after discontinuing anticoagulation, the pooled incidence of major bleeding (n=41) and fatal bleeding (n=7) per 100 person-years was 0.35 (95% confidence interval [CI], 0.20-0.54) and 0.09 (95% CI, 0.05-0.15). The 5-year cumulative incidence of major bleeding was of 1.0% (95% CI, 0.4%-2.4%). The case-fatality rate of major bleeding after discontinuing anticoagulation was 19.9% (95% CI, 10.6%-31.1%). CONCLUSIONS Patients with a first unprovoked VTE have a non-trivial risk of major bleeding once anticoagulants are discontinued. Estimates from this study can help clinicians counsel patients about the incremental risk of major bleeding with extended anticoagulation to guide decision making about treatment duration for unprovoked VTE.
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Affiliation(s)
- Faizan Khan
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Tobias Tritschler
- Department of General Internal Medicine, Bern University Hospital, Bern, Switzerland
| | - Marc Carrier
- Department of Medicine. University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada.,The Thrombosis and Atherosclerosis Research Institute, Hamilton, Canada
| | | | - Francis Couturaud
- Department of internal medicine and chest diseases, Brest University Hospital Centre, Brest, France
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine,Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine,Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Timothy Brighton
- Prince of Wales Hospital and Community Health Services, Randwick, Australia
| | | | - Laurent Pinede
- Infirmerie Protestante de Lyon, Caluire et Cuire, France
| | | | | | | | - Charlotte Bradbury
- University of Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland
| | | | | | | | - H R Buller
- Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | | | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kednapa Thavorn
- ICES @uOttawa, University of Ottawa Faculty of Medicine, Ottawa, Canada
| | - Grégoire Le Gal
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa, Canada.,Université de Bretagne Occidentale, Brest, France.,INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, Saint Etienne, France
| | - Marc Rodger
- Medicine, McGill University, Montreal, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada
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14
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Khan F, Tritschler T, Kimpton M, Wells PS, Kearon C, Weitz JI, Büller HR, Raskob GE, Ageno W, Couturaud F, Prandoni P, Palareti G, Legnani C, Kyrle PA, Eichinger S, Eischer L, Becattini C, Agnelli G, Vedovati MC, Geersing GJ, Takada T, Cosmi B, Aujesky D, Marconi L, Palla A, Siragusa S, Bradbury CA, Parpia S, Mallick R, Lensing AWA, Gebel M, Grosso MA, Shi M, Thavorn K, Hutton B, Le Gal G, Rodger M, Fergusson D. Long-term risk of recurrent venous thromboembolism among patients receiving extended oral anticoagulant therapy for first unprovoked venous thromboembolism: A systematic review and meta-analysis. J Thromb Haemost 2021; 19:2801-2813. [PMID: 34379859 DOI: 10.1111/jth.15491] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The long-term risk for recurrent venous thromboembolism (VTE) during extended anticoagulation for a first unprovoked VTE is uncertain. OBJECTIVES To determine the incidence of recurrent VTE during extended anticoagulation of up to 5 years in patients with a first unprovoked VTE. METHODS MEDLINE, EMBASE, and the Cochrane CENTRAL were searched to identify randomized trials and prospective cohort studies reporting recurrent VTE among patients with a first unprovoked VTE who were to receive anticoagulation for a minimum of six additional months after completing ≥3 months of initial treatment. Unpublished data on number of recurrent VTE and person-years, obtained from authors of included studies, were used to calculate study-level incidence rate, and random-effects meta-analysis was used to pool results. RESULTS Twenty-six studies and 15 603 patients were included in the analysis. During 11 631 person-years of follow-up, the incidence of recurrent VTE and fatal pulmonary embolism per 100 person-years was 1.41 (95% CI, 1.03-1.84) and 0.09 (0.04-0.16), with 5-year cumulative incidences of 7.1% (3.0%-13.2%) and 1.2% (0.4%-4.6%), respectively. The incidence of recurrent VTE was 1.08 (95% CI, 0.77-1.44) with direct oral anticoagulants and 1.55 (1.01-2.20) with vitamin K antagonists. The case-fatality rate of recurrent VTE was 4.9% (95% CI, 2.2%-8.7%). CONCLUSIONS In patients with a first unprovoked VTE, the long-term risk of recurrent VTE during extended anticoagulation is low but not negligible. Thus, clinicians and patients should be aware of this risk and take appropriate and timely action in case of suspicion of recurrent VTE. Estimates from this study can be used to advise patients on what to expect while receiving extended anticoagulation, and estimate the net clinical benefit of extended treatment to guide long-term management of unprovoked VTE.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Miriam Kimpton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Philip S Wells
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, OK, USA
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Brest University Hospital, Brest, France
| | | | | | | | - Paul A Kyrle
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sabine Eichinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Lisbeth Eischer
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Benilde Cosmi
- Department of Specialty, Diagnostic and Experimental Medicine, Division of Angiology and Blood Coagulation, S. Orsola Malpighi University Hospital, Bologna, Italy
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Letizia Marconi
- Department of Surgical, Medical and Molecular Pathology, and Critical Care, University of Pisa, Pisa, Italy
| | - Antonio Palla
- Department of Surgical, Medical and Molecular Pathology, and Critical Care, University of Pisa, Pisa, Italy
| | - Sergio Siragusa
- Department Pro.Mi.Se., University of Palermo, Palermo, Italy
| | | | - Sameer Parpia
- Departments of Oncology, and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | | | - Minggao Shi
- Daiichi-Sankyo Pharma Development, Basking Ridge, NJ, USA
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gregoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Marc Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Dean Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
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National guidelines on the management of venous thromboembolism: Joint guideline of the Turkish Society of Cardiovascular Surgery, National Society of Vascular and Endovascular Surgery, and Phlebology Society. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:562-576. [PMID: 35096459 PMCID: PMC8762899 DOI: 10.5606/tgkdc.dergisi.2021.22121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/06/2021] [Indexed: 11/29/2022]
Abstract
These evidence-based guidelines from the Turkish Society of Cardiovascular Surgery, National Society of Vascular and Endovascular Surgery, and Phlebology Society intend to support clinicians in best decisions regarding the treatment of venous thromboembolism (VTE). The Editor was selected by the three national societies and was tasked with the recruitment of the recognized panel. All financial support was solely derived from the sponsoring societies without the direct involvement of industry or other external stakeholders. The panel prioritized clinical questions and outcomes according to their importance for clinicians in terms of VTE. The panel agreed on 42 recommendations under 15 headings for the diagnosis, initial management, secondary prevention of VTE, and treatment of recurrent VTE events. Important recommendations included the use of ultrasonography, preference for home treatment over hospital treatment for uncomplicated VTE, preference for direct oral anticoagulants (DOACs) over vitamin K antagonists for primary treatment of cancer and non-cancer-related VTE, extended or indefinite anticoagulation with DOACs in selected high-risk patients. Early catheter-directed thrombectomy was recommended in only young symptomatic patients with a diagnosis of fresh iliofemoral deep vein thrombosis.
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16
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Khan F, Tritschler T, Kimpton M, Wells PS, Kearon C, Weitz JI, Büller HR, Raskob GE, Ageno W, Couturaud F, Prandoni P, Palareti G, Legnani C, Kyrle PA, Eichinger S, Eischer L, Becattini C, Agnelli G, Vedovati MC, Geersing GJ, Takada T, Cosmi B, Aujesky D, Marconi L, Palla A, Siragusa S, Bradbury CA, Parpia S, Mallick R, Lensing AWA, Gebel M, Grosso MA, Thavorn K, Hutton B, Le Gal G, Fergusson DA, Rodger MA. Long-Term Risk for Major Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism : A Systematic Review and Meta-analysis. Ann Intern Med 2021; 174:1420-1429. [PMID: 34516270 DOI: 10.7326/m21-1094] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The long-term risk for major bleeding in patients receiving extended (beyond the initial 3 to 6 months) anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. PURPOSE To determine the incidence of major bleeding during extended anticoagulation of up to 5 years among patients with a first unprovoked VTE, overall, and in clinically important subgroups. DATA SOURCES MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to 23 July 2021. STUDY SELECTION Randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding among patients with a first unprovoked VTE who were to receive oral anticoagulation for a minimum of 6 additional months after completing at least 3 months of initial anticoagulant treatment. DATA EXTRACTION Two reviewers independently abstracted data and assessed study quality. Unpublished data required for analyses were obtained from authors of included studies. DATA SYNTHESIS Among the 14 RCTs and 13 cohort studies included in the analysis, 9982 patients received a vitamin K antagonist (VKA) and 7220 received a direct oral anticoagulant (DOAC). The incidence of major bleeding per 100 person-years was 1.74 events (95% CI, 1.34 to 2.20 events) with VKAs and 1.12 events (CI, 0.72 to 1.62 events) with DOACs. The 5-year cumulative incidence of major bleeding with VKAs was 6.3% (CI, 3.6% to 10.0%). Among patients receiving either a VKA or a DOAC, the incidence of major bleeding was statistically significantly higher among those who were older than 65 years or had creatinine clearance less than 50 mL/min, a history of bleeding, concomitant use of antiplatelet therapy, or a hemoglobin level less than 100 g/L. The case-fatality rate of major bleeding was 8.3% (CI, 5.1% to 12.2%) with VKAs and 9.7% (CI, 3.2% to 19.2%) with DOACs. LIMITATION Data were insufficient to estimate incidence of major bleeding beyond 1 year of extended anticoagulation with DOACs. CONCLUSION In patients with a first unprovoked VTE, the long-term risks and consequences of anticoagulant-related major bleeding are considerable. This information will help inform patient prognosis and guide decision making about treatment duration for unprovoked VTE. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research. (PROSPERO: CRD42019128597).
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Affiliation(s)
- Faizan Khan
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Tobias Tritschler
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T., D.A.)
| | - Miriam Kimpton
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Philip S Wells
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Clive Kearon
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (C.K., J.I.W.)
| | - Jeffrey I Weitz
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (C.K., J.I.W.)
| | - Harry R Büller
- Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (H.R.B.)
| | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, Oklahoma (G.E.R.)
| | | | | | - Paolo Prandoni
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Gualtiero Palareti
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Cristina Legnani
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Paul A Kyrle
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | - Sabine Eichinger
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | - Lisbeth Eischer
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | | | | | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (G.G., T.T.)
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (G.G., T.T.)
| | - Benilde Cosmi
- Sant'Orsola-Malpighi University Hospital, Bologna, Italy (B.C.)
| | - Drahomir Aujesky
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T., D.A.)
| | | | | | | | | | - Sameer Parpia
- McMaster University, Hamilton, Ontario, Canada (S.P.)
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (R.M.)
| | | | | | | | - Kednapa Thavorn
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Brian Hutton
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Gregoire Le Gal
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Dean A Fergusson
- University of Ottawa, Ottawa Hospital Research Institute, and The Ottawa Hospital, Ottawa, Ontario, Canada (D.A.F.)
| | - Marc A Rodger
- Ottawa Hospital Research Institute, Ottawa, Ontario, and McGill University, Montreal, Quebec, Canada (M.A.R.)
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Factors affecting the recurrence in patients with venous thromboembolism: A retrospective cohort study. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:384-390. [PMID: 34589258 PMCID: PMC8462109 DOI: 10.5606/tgkdc.dergisi.2021.20679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/13/2020] [Indexed: 11/29/2022]
Abstract
Background
The aim of the study was to evaluate the frequency of recurrence and the risk factors for recurrence in patients who were diagnosed with venous thromboembolism.
Methods
Between January 2005 and January 2015, a total of 412 venous thromboembolism patients (164 males, 248 females; mean age: 53.5±16.6 years; range: 19 to 95 years) were retrospectively analyzed. The demographics, underlying risk factors, comorbidities, imaging findings, and treatment data of the patients were recorded.
Results
At least one transient/permanent risk factor was found in 341 (82.7%) of the index events, and the other 71 (17.2%) were idiopathic. Recurrence developed in 76 (18.4%) of the patients. The duration of the treatment in the first event was significantly longer in recurrent cases (p=0.007). The recurrence rate in patients diagnosed with only deep vein thrombosis or patients diagnosed with pulmonary thromboembolism + deep vein thrombosis was significantly higher than the patients diagnosed with only pulmonary thromboembolism (24% vs. 14.2%, respectively; p=0.007). The rate of idiopathic venous thromboembolism was higher in recurrent cases than in non-recurrent cases (26.3% vs. 15.2%, respectively; p=0.028). At the end of the first year, the mean D-dimer levels were higher in recurrent cases (p=0.034). Hereditary risk factors were also higher in recurrent cases (39.5% vs. 19.3%, respectively; p=0.031). There was no significant correlation between recurrence and mortality.
Conclusion
The presence of deep vein thrombosis, idiopathic events, high D-dimer levels at the end of the first year and hereditary risk factors seem to be associated with recurrence.
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Di Minno MND, Calcaterra I, Papa A, Lupoli R, Di Minno A, Maniscalco M, Ambrosino P. Diagnostic accuracy of D-Dimer testing for recurrent venous thromboembolism: A systematic review with meta-analysis.: VTE recurrence and D-dimer. Eur J Intern Med 2021; 89:39-47. [PMID: 33933338 DOI: 10.1016/j.ejim.2021.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/02/2021] [Accepted: 04/07/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Venous thromboembolism (VTE) recurrence is a major concern after a first symptomatic episode, potentially impacting survival and healthcare needs in community, hospital and rehabilitation settings. We evaluated the association of D-Dimer positivity after oral anticoagulant therapy (OAT) discontinuation with VTE recurrence. METHODS PubMed, Web of Science, Scopus and EMBASE databases were systematically searched. Differences were expressed as Odds Ratio (OR) with 95% confidence intervals (95%CI). Pooled sensitivity, specificity, positive (PLR) and negative likelihood ratio (NLR), and summary ROC (sROC) curve were calculated. RESULTS Twenty-six articles on 10,725 VTE patients showed that the absolute risk of recurrence was 16.1% (95%CI: 13.2%-19.5%) among 4,049 patients with a positive D-Dimer and 7.4% (95%CI: 6.0%-9.0%) in 6,676 controls (OR: 2.1, 95%CI: 1.7-2.8, P<0.001), with an attributable risk of 54.0%. sROC curve of the association between positive D-Dimer and recurrence showed a diagnostic AUC of 63.8 (95%CI: 60.3-67.4), with a pooled sensitivity of 54.3% (95%CI: 51.3%-57.3%), specificity of 64.2% (95%CI: 63.2-65.1), PLR of 1.53 (95%CI: 1.37-1.72), and NLR of 0.71 (95%CI: 0.60-0.84). Subgroup and meta-regression analyses suggested that a positive D-Dimer may have a higher discriminatory ability for patients with provoked events, confirmed by better pooled diagnostic indexes for recurrence and a diagnostic AUC of 70.6 (95%CI: 63.8-77.4). Regression models showed that the rate of OAT resumption after the evidence of D-Dimer positivity was inversely associated with VTE recurrence (Z-score: -3.91, P<0.001). CONCLUSIONS D-Dimer positivity after OAT may identify VTE patients at higher risk of recurrence, with a better diagnostic accuracy for provoked events.
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Affiliation(s)
| | - Ilenia Calcaterra
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Antimo Papa
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Roberta Lupoli
- Department of Molecular Medicine and Medical Biotechnology Federico II University, Naples, Italy
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19
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Jang YS, Lee ES, Kim YK. Venous thromboembolism associated with combined oral contraceptive use: a single-institution experience. Obstet Gynecol Sci 2021; 64:337-344. [PMID: 33794564 PMCID: PMC8290149 DOI: 10.5468/ogs.20374] [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: 12/05/2020] [Revised: 02/15/2021] [Accepted: 03/23/2021] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE Combined oral contraceptives (COCs) are used for various reasons. However, venous thromboembolism (VTE), a significant side effect, can be fatal. This study reports the first case series in Korea involving patients with COC-associated VTE registered at a university hospital. METHODS This study recruited 13 patients diagnosed with COC-associated VTE between June 2006 and May 2018. Risk factors, including age, body mass index, smoking habits, estrogen dosage, type of progestin, and duration of COC use, were evaluated. RESULTS Among patients with VTE, 9 showed pulmonary embolism (PE) concomitant with deep vein thrombosis (DVT). However, the remaining patients showed DVT (1 patient), PE (1 patient), and cerebral venous thrombosis (2 patients). The median duration between the onset of symptoms and a hospital visit was 3 days, and it sometimes took as long as 32 days. Among the 10 patients with PE, 1 high-risk group and 2 intermediate-high risk groups were treated with tissue plasminogen activators before anticoagulants. There were no cases of recurrence among patients who continued to take anticoagulants for 3 months. CONCLUSION These findings emphasize that healthcare professionals who prescribe or dispense COCs to women must inform them of the risk of VTE, including the risk factors, differences in risk depending on the type of progestin present in the product, and pertinent signs and symptoms. Efforts should also be made to inform patients of VTE, even through information campaigns such as brochures. Most importantly, women should remain alert for signs and symptoms of VTE when using COCs.
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Affiliation(s)
- Yong-Su Jang
- Department of Obstetrics and Gynecology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Eun Sil Lee
- Department of Obstetrics and Gynecology, Soonchunhyang University College of Medicine, Seoul,
Korea
| | - Yang-Ki Kim
- Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul,
Korea
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20
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Aziz D, Skeith L, Rodger MA, Sabri E, Righini M, Kovacs MJ, Carrier M, Kahn SR, Wells PS, Anderson DR, Chagnon I, Solymoss S, Crowther MA, White RH, Le Gal G. Long-term risk of recurrent venous thromboembolism after a first contraceptive-related event: Data from REVERSE cohort study. J Thromb Haemost 2021; 19:1526-1532. [PMID: 33724705 DOI: 10.1111/jth.15303] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 02/28/2021] [Accepted: 03/05/2021] [Indexed: 08/31/2023]
Abstract
INTRODUCTION The risk of recurrent venous thromboembolism (VTE) after combined oral contraceptive (COC) use is variably reported. We assessed the long-term risk of recurrent VTE in women on COC at the time of a first VTE, in comparison to women without COC use. Our secondary aim assessed the impact of COC use on the recurrent VTE risk in high-risk and low-risk hyperpigmentation, edema, or redness in either leg; D-dimer level ≥250 μg/L; obesity with body mass index ≥30; or older age, ≥65 years (HERDOO2) subgroups. METHODS The REVERSE cohort study derived the HERDOO2 clinical decision rule to predict recurrent VTE in patients who discontinued anticoagulation after 5-7 months for a first unprovoked VTE. Incidence rates of recurrent VTE among women with and without COC exposure were calculated as the number of recurrent VTE over the number of person-years of follow-up, and Cox proportional hazards model was used to compare risks between groups. RESULTS The risk of recurrent VTE among COC users was 1.1% (95% confidence interval [CI] 0.3-2.9) per patient-year as compared with 3.2% per patient-year (95% CI 2.4-4.3) among nonusers (hazard ratio 0.37; 95% CI 0.1-1.0). Women who were COC users and high risk by HERDOO2 score had a recurrence rate of 3.5% (95% CI 0.4-12.5) compared with 6.1% (95% CI 4.3-8.5) among women who were non-COC users and at high risk by HERDOO2 score (HR 0.6, 95% CI 0.1-2.5). CONCLUSIONS Women who were COC users at the time of an otherwise unprovoked VTE event had a lower VTE recurrence rate during long-term follow-up, compared with nonusers. The use of HERDOO2 rule may help identify higher risk women with COC use.
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Affiliation(s)
- David Aziz
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Leslie Skeith
- Division of Hematology & Hematological Malignancies, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marc A Rodger
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Michael J Kovacs
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
| | - Marc Carrier
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Philip S Wells
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - David R Anderson
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Isabelle Chagnon
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Susan Solymoss
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Mark A Crowther
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard H White
- Department of Medicine, UC Davis School of Medicine, Sacramento, California, USA
| | - Grégoire Le Gal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Internal Medicine and Chest Diseases, Brest University Hospital, Université de Brest, Brest, France
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21
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Which patients are at high risk of recurrent venous thromboembolism (deep vein thrombosis and pulmonary embolism)? Blood Adv 2021; 4:5595-5606. [PMID: 33170937 DOI: 10.1182/bloodadvances.2020002268] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/24/2020] [Indexed: 12/14/2022] Open
Abstract
Recurrent venous thromboembolism (VTE, or deep vein thrombosis and pulmonary embolism) is associated with mortality and long-term morbidity. The circumstances in which an index VTE event occurred are crucial when personalized VTE recurrence risk is assessed. Patients who experience a VTE event in the setting of a transient major risk factor (such as surgery associated with general anesthesia for >30 minutes) are predicted to have a low VTE recurrence risk following discontinuation of anticoagulation, and limited-duration anticoagulation is generally recommended. In contrast, those patients whose VTE event occurred in the absence of risk factors or who have persistent risk factors have a higher VTE recurrence risk. Here, we review the literature surrounding VTE recurrence risk in a range of clinical conditions. We describe gender-specific risks, including VTE recurrence risk following hormone- and pregnancy-associated VTE events. Finally, we discuss how the competing impacts of VTE recurrence and bleeding have shaped international guideline recommendations.
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22
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Individualised Risk Assessments for Recurrent Venous Thromboembolism: New Frontiers in the Era of Direct Oral Anticoagulants. HEMATO 2021. [DOI: 10.3390/hemato2010003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality and is associated with high recurrence rates. The introduction of direct oral anticoagulants (DOACs) in the 2010s has changed the landscape of VTE management. DOACs have become the preferred anticoagulant therapy for their ease of use, predictable pharmacokinetics, and improved safety profile. Increasingly, guidelines have recommended long term anticoagulation for some indications such as following first unprovoked major VTE, although an objective individualised risk assessment for VTE recurrence remains elusive. The balance of preventing VTE recurrence needs to be weighed against the not insignificant bleeding risk, which is cumulative with prolonged use. Hence, there is a need for an individualised, targeted approach for assessing the risk of VTE recurrence, especially in those patients in whom the balance between benefit and risk of long-term anticoagulation is not clear. Clinical factors alone do not provide the level of discrimination required on an individual level. Laboratory data from global coagulation assays and biomarkers may provide enhanced risk assessment ability and are an active area of research. A review of the prediction models and biomarkers for assessing VTE recurrence risk is provided, with an emphasis on contemporary developments in the era of DOACs and global coagulation assays.
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23
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Weitz JI, Prandoni P, Verhamme P. Anticoagulation for Patients with Venous Thromboembolism: When is Extended Treatment Required? TH OPEN 2020; 4:e446-e456. [PMID: 33376944 PMCID: PMC7758152 DOI: 10.1055/s-0040-1721735] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/05/2020] [Indexed: 12/21/2022] Open
Abstract
The need for extended venous thromboembolism (VTE) treatment beyond 3 to 6 months is usually determined by balancing the risk of recurrence if treatment is stopped against the risk of bleeding from continuing treatment. The risk of recurrence, and in turn the decision to extend, can be determined through the nature of the index event. Patients with VTE provoked by surgery or trauma (major transient risk factors) are recommended to receive 3 months of anticoagulation therapy because their risk of recurrence is low, whereas patients with VTE provoked by a major persistent risk factor, such as cancer, or those considered to have “unprovoked” VTE, are recommended to receive an extended duration of therapy based on an established high risk of recurrence. Nonetheless, recent evidence and new guidance identify that this approach fails to consider patients with risk factors classed as minor transient (e.g., impaired mobility and pregnancy) or minor persistent (e.g., inflammatory bowel disease and congestive heart disease). Indeed, the risk of recurrence with respect to VTE provoked by minor persistent risk factors has been demonstrated to be not dissimilar to that of VTE without identifiable risk factors. This review provides an overview of the available data on the risk of recurrence according to the underlying cause of VTE, a critical evaluation of evidence from clinical studies on the available anticoagulants for extended VTE treatment, models of risk prediction for recurrent VTE and bleeding, and guidance on how to apply the evidence in practice.
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Affiliation(s)
- Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada
| | - Paolo Prandoni
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padua, Italy
| | - Peter Verhamme
- Vascular Medicine and Haemostasis, Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
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24
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Áinle FN, Kevane B. Which patients are at high risk of recurrent venous thromboembolism (deep vein thrombosis and pulmonary embolism)? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:201-212. [PMID: 33275736 PMCID: PMC7727525 DOI: 10.1182/hematology.2020002268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Recurrent venous thromboembolism (VTE, or deep vein thrombosis and pulmonary embolism) is associated with mortality and long-term morbidity. The circumstances in which an index VTE event occurred are crucial when personalized VTE recurrence risk is assessed. Patients who experience a VTE event in the setting of a transient major risk factor (such as surgery associated with general anesthesia for >30 minutes) are predicted to have a low VTE recurrence risk following discontinuation of anticoagulation, and limited-duration anticoagulation is generally recommended. In contrast, those patients whose VTE event occurred in the absence of risk factors or who have persistent risk factors have a higher VTE recurrence risk. Here, we review the literature surrounding VTE recurrence risk in a range of clinical conditions. We describe gender-specific risks, including VTE recurrence risk following hormone- and pregnancy-associated VTE events. Finally, we discuss how the competing impacts of VTE recurrence and bleeding have shaped international guideline recommendations.
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Affiliation(s)
- Fionnuala Ní Áinle
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- Department of Hematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland; and
- Irish Network for VTE Research
| | - Barry Kevane
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland; and
- Irish Network for VTE Research
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25
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O’Rourke E, Toolan S, Bedos A, Tierney A, Jennings C, O’Neill A, Áinle FN, Kevane B. “What will happen in the future?” A personal VTE journey. THROMBOSIS UPDATE 2020. [DOI: 10.1016/j.tru.2020.100013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Hernigou P, Housset V, Pariat J, Dubory A, Flouzat Lachaniette CH. Total hip arthroplasty for sickle cell osteonecrosis: guidelines for perioperative management. EFORT Open Rev 2020; 5:641-651. [PMID: 33204507 PMCID: PMC7608517 DOI: 10.1302/2058-5241.5.190073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The prognosis of sickle cell disease (SCD) has greatly improved in recent years, resulting in an increased number of patients reporting musculoskeletal complications such as osteonecrosis of the femoral head. Total hip arthroplasty (THA) can be utilized to alleviate the pain associated with this disease. Although it is well known that hip arthroplasty for avascular necrosis (AVN) in SCD may represent a challenge for the surgeon, complications are frequent, and no guidelines exist to prevent these complications. Because patients with SCD will frequently undergo THA, we thought it necessary to fulfil the need for guidance recommendations based on experience, evidence and agreement from the literature. For all these reasons this review proposes guidelines that provide clinicians with a document regarding management of patients with SCD in the period of time leading up to primary THA. The recommendations provide guidance that has been informed by the clinical expertise and experience of the authors and available literature. Although this is not a systematic review since some papers may have been published in languages other than English, our study population consisted of 5,868 patients, including 2,126 patients with SCD operated on for THA by the senior author in the same hospital during 40 years and 3,742 patients reported in the literature.
Cite this article: EFORT Open Rev 2020;5:641-651. DOI: 10.1302/2058-5241.5.190073
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Affiliation(s)
| | - Victor Housset
- Hôpital Henri Mondor, University Paris East, Paris, France
| | - Jacques Pariat
- Hôpital Henri Mondor, University Paris East, Paris, France
| | - Arnaud Dubory
- Hôpital Henri Mondor, University Paris East, Paris, France
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27
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Thomas W, Mindlina I, MacDonald S, Besser M. Does age‐adjusted D‐dimer have a role in assessment of VTE recurrence rates? Comment. Int J Lab Hematol 2020; 42:e240-e242. [DOI: 10.1111/ijlh.13294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Will Thomas
- Department of Haematology Cambridge University Hospitals NHS Foundation TrustCambridge Biomedical Campus Cambridge UK
| | - Irina Mindlina
- Clinical School University of CambridgeCambridge Biomedical Campus Cambridge UK
| | - Stephen MacDonald
- Department of Haematology Cambridge University Hospitals NHS Foundation TrustCambridge Biomedical Campus Cambridge UK
| | - Martin Besser
- Department of Haematology Cambridge University Hospitals NHS Foundation TrustCambridge Biomedical Campus Cambridge UK
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28
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Galanaud J, Sevestre M, Pernod G, Genty C, Richaud C, Rolland C, Weber L, Kahn SR, Quéré I, Bosson J. Epidemiology and 3-year outcomes of combined oral contraceptive-associated distal deep vein thrombosis. Res Pract Thromb Haemost 2020; 4:1216-1223. [PMID: 33134787 PMCID: PMC7590310 DOI: 10.1002/rth2.12409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Distal deep vein thrombosis (infrapopliteal DVT without proximal DVT or pulmonary embolism [PE]) generally shares the same triggering risks factors as proximal DVT. In women of childbearing age, a frequent triggering risk factor is the use of combined oral contraceptive (COC) pills. However, data on the epidemiology and long-term outcomes of COC-associated distal DVT are lacking. OBJECTIVES To assess the epidemiology and long-term outcomes of COC-associated distal DVT. METHODS Using data from the OPTIMEV (Optimisation de l'Interrogatoire dans l'évaluation du risque thrombo-Embolique Veineux [Optimization of Interrogation in the Assessment of Thromboembolic Venous Risk]) multicenter cohort study of patients with objectively confirmed venous thromboembolism (VTE) enrolled between 2004 and 2006, we assessed in nonpregnant or postpartum women aged ≤ 50 years without cancer or history of VTE (i) proportion of COC-associated distal DVTs among women with distal DVTs and among women with COC-associated VTEs (distal DVT, proximal DVT, or PE) and (ii) 3-year incidence of death, bleeding, and VTE recurrence. RESULTS COC-associated distal DVTs (n = 54) represented 43.9% of all distal DVTs and 51.9% of COC-associated VTEs. All but one woman with a COC-associated distal DVT received therapeutic anticoagulation for a median of 3 months. At 3-year follow-up, all women with COC-associated distal DVTs were alive, and none had bled during anticoagulant treatment or had experienced a DVT or PE recurrence after stopping anticoagulants. Similar results were found in patients with COC-associated proximal DVT and PE: The VTE recurrence rate was 1.7% per patient-year (PY) and 0% PY, respectively, and there were no deaths or major bleeds in either group. CONCLUSIONS Distal DVT was the most frequent clinical presentation of COC-associated VTE and had similarly favorable long-term outcomes as other COC-associated VTE.
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Affiliation(s)
- Jean‐Philippe Galanaud
- Department of Vascular Medicine and Clinical Investigation CentreMontpellier University HospitalMontpellierFrance
- Department of MedicineSunnybrook Health Sciences CentreUniversity of TorontoTorontoONCanada
| | | | - Gilles Pernod
- Department of Public HealthCNRSGrenoble‐Alpes University Hospital and TIMC‐IMAGUniversity Grenoble AlpesGrenobleFrance
- Department of Vascular MedicineGrenoble‐Alpes University HospitalGrenobleFrance
| | - Céline Genty
- Department of Public HealthCNRSGrenoble‐Alpes University Hospital and TIMC‐IMAGUniversity Grenoble AlpesGrenobleFrance
| | - Cécile Richaud
- Department of Vascular MedicineGrenoble‐Alpes University HospitalGrenobleFrance
| | - Carole Rolland
- Department of Public HealthCNRSGrenoble‐Alpes University Hospital and TIMC‐IMAGUniversity Grenoble AlpesGrenobleFrance
| | - Laurence Weber
- Vascular Medicine PhysicianAvignon HospitalAvignonFrance
| | - Susan R. Kahn
- Department of MedicineMcGill UniversityMontrealQCCanada
- Centre for Clinical EpidemiologyJewish General HospitalMontrealQCCanada
| | - Isabelle Quéré
- Department of Vascular Medicine and Clinical Investigation CentreMontpellier University HospitalMontpellierFrance
| | - Jean‐Luc Bosson
- Department of Public HealthCNRSGrenoble‐Alpes University Hospital and TIMC‐IMAGUniversity Grenoble AlpesGrenobleFrance
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Desch KC, Ozel AB, Halvorsen M, Jacobi PM, Golden K, Underwood M, Germain M, Tregouet DA, Reitsma PH, Kearon C, Mokry L, Richards JB, Williams F, Li JZ, Goldstein D, Ginsburg D. Whole-exome sequencing identifies rare variants in STAB2 associated with venous thromboembolic disease. Blood 2020; 136:533-541. [PMID: 32457982 PMCID: PMC7393257 DOI: 10.1182/blood.2019004161] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/12/2020] [Indexed: 12/13/2022] Open
Abstract
Deep vein thrombosis and pulmonary embolism, collectively defined as venous thromboembolism (VTE), are the third leading cause of cardiovascular death in the United States. Common genetic variants conferring increased varying degrees of VTE risk have been identified by genome-wide association studies (GWAS). Rare mutations in the anticoagulant genes PROC, PROS1 and SERPINC1 result in perinatal lethal thrombosis in homozygotes and markedly increased VTE risk in heterozygotes. However, currently described VTE variants account for an insufficient portion of risk to be routinely used for clinical decision making. To identify new rare VTE risk variants, we performed a whole-exome study of 393 individuals with unprovoked VTE and 6114 controls. This study identified 4 genes harboring an excess number of rare damaging variants in patients with VTE: PROS1, STAB2, PROC, and SERPINC1. At STAB2, 7.8% of VTE cases and 2.4% of controls had a qualifying rare variant. In cell culture, VTE-associated variants of STAB2 had a reduced surface expression compared with reference STAB2. Common variants in STAB2 have been previously associated with plasma von Willebrand factor and coagulation factor VIII levels in GWAS, suggesting that haploinsufficiency of stabilin-2 may increase VTE risk through elevated levels of these procoagulants. In an independent cohort, we found higher von Willebrand factor levels and equivalent propeptide levels in individuals with rare STAB2 variants compared with controls. Taken together, this study demonstrates the utility of gene-based collapsing analyses to identify loci harboring an excess of rare variants with functional connections to a complex thrombotic disease.
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Affiliation(s)
| | - Ayse B Ozel
- Department of Human Genetics, University of Michigan, Ann Arbor, MI
| | - Matt Halvorsen
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Marine Germain
- INSERM UMR_S 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | - David-Alexandre Tregouet
- INSERM UMR_S 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | - Pieter H Reitsma
- Einthoven Laboratory for Experimental Vascular and Regenerative Medicine, Leiden, The Netherlands
| | - Clive Kearon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lauren Mokry
- Department of Medicine, Human Genetics, Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - J Brent Richards
- Department of Medicine, Human Genetics, Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Frances Williams
- Department of Twin Research and Genetic Epidemiology, Kings College London, London, United Kingdom
| | - Jun Z Li
- Department of Human Genetics, University of Michigan, Ann Arbor, MI
| | - David Goldstein
- Columbia University, Institute for Genomic Medicine, New York, NY; and
| | - David Ginsburg
- Department of Pediatrics and
- Department of Human Genetics, University of Michigan, Ann Arbor, MI
- Department of Internal Medicine, Howard Hughes Medical Institute, University of Michigan, Ann Arbor, MI
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30
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Single-Drug Approach with Edoxaban is Effective for Resolving Non-Acute Cancer-Associated Venous Thrombosis: A Single-Arm Retrospective Analysis. Cancers (Basel) 2020; 12:cancers12071711. [PMID: 32605234 PMCID: PMC7407992 DOI: 10.3390/cancers12071711] [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: 05/03/2020] [Revised: 06/19/2020] [Accepted: 06/24/2020] [Indexed: 12/21/2022] Open
Abstract
Recently, cancer-related venous thromboembolism (VTE) has been termed "cancer-associated thrombosis (CAT)" and is the focus of current research. We retrospectively investigated the efficacy of a single-drug approach with edoxaban for the treatment of non-acute CAT. Thirty-two non-acute CAT patients who received edoxaban were analyzed. The primary endpoint of this analysis was the thrombus disappearance rate at the first evaluation. Secondary endpoints included progression/recurrence of VTE, major bleeding, and D-dimer levels. The thrombus disappearance rate was 62.5%. Therefore, the null hypothesis for the primary endpoint (thrombus disappearance rate of ≤32.0%) was rejected (p = 0.00038) based on the rate of the previous study as the historical control. Recurrent VTE and major bleeding occurred in two patients each. After the start of treatment with edoxaban, a significant difference in D-dimer levels was observed (p = 0.00655). We demonstrated that a single-drug approach with edoxaban is a potential treatment option for non-acute CAT.
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31
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Geersing GJ, Hendriksen JMT, Zuithoff NPA, Roes KC, Oudega R, Takada T, Schutgens REG, Moons KGM. Effect of tailoring anticoagulant treatment duration by applying a recurrence risk prediction model in patients with venous thromboembolism compared to usual care: A randomized controlled trial. PLoS Med 2020; 17:e1003142. [PMID: 32589630 PMCID: PMC7319277 DOI: 10.1371/journal.pmed.1003142] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 06/03/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with unprovoked (i.e., without the presence of apparent transient risk factors such as recent surgery) venous thromboembolism (VTE) are at risk of recurrence if anticoagulants are stopped after 3-6 months, yet their risk remains heterogeneous. Thus, prolonging anticoagulant treatment should be considered in high-risk patients, whereas stopping is likely preferred in those with a low predicted risk. The Vienna Prediction Model (VPM) could aid clinicians in estimating this risk, yet its clinical effects and external validity are currently unknown. The aim of this study was to investigate the clinical impact of this model on reducing recurrence risk in patients with unprovoked VTE, compared to usual care. METHODS AND FINDINGS In a randomized controlled trial, the decision to prolong or stop anticoagulant treatment was guided by predicted recurrence risk using the VPM (n = 441), which was compared with usual care (n = 442). Patients with unprovoked VTE were recruited from local thrombosis services in the Netherlands (in Utrecht, Harderwijk, Ede, Amersfoort, Zwolle, Hilversum, Rotterdam, Deventer, and Enschede) between 22 July 2011 and 30 November 2015, with 24-month follow-up complete for all patients by early 2018. The primary outcome was recurrent VTE during 24 months of follow-up. Secondary outcomes included major bleeding and clinically relevant non-major (CRNM) bleeding. In the total study population of 883 patients, mean age was 55 years, and 507 (57.4%) were men. A total of 96 recurrent VTE events (10.9%) were observed, 46 in the intervention arm and 50 in the control arm (risk ratio 0.92, 95% CI 0.63-1.35, p = 0.67). Major bleeding occurred in 4 patients, 2 in each treatment arm, whereas CRNM bleeding occurred in 20 patients (12 in intervention arm versus 8 in control arm). The VPM showed good discriminative power (c-statistic 0.76, 95% CI 0.69-0.83) and moderate to good calibration, notably at the lower spectrum of predicted risk. For instance, in 284 patients with a predicted risk of >2% to 4%, the observed rate of recurrence was 2.5% (95% CI 0.7% to 4.3%). The main limitation of this study is that it did not enroll the preplanned number of 750 patients in each study arm due to declining recruitment rate. CONCLUSIONS Our results show that application of the VPM in all patients with unprovoked VTE is unlikely to reduce overall recurrence risk. Yet, in those with a low predicted risk of recurrence, the observed rate was also low, suggesting that it might be safe to stop anticoagulant treatment in these patients. TRIAL REGISTRATION Netherlands Trial Register NTR2680.
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Affiliation(s)
- Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- * E-mail:
| | - Janneke M. T. Hendriksen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nicolaas P. A. Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kit C. Roes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Biostatistics Research Group, Department of Health Evidence, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
| | - Ruud Oudega
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Roger E. G. Schutgens
- Van Creveld Clinic, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Karel G. M. Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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32
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Affiliation(s)
- Hyangkyoung Kim
- Division of Vascular Surgery, Department of Surgery, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
| | - Sang Seob Yun
- Division of Vascular and Transplant Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
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33
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Retrospective review of d-dimer testing for venous thrombosis recurrence risk stratification: is this a useful test in the real world? J Thromb Thrombolysis 2020; 49:562-571. [DOI: 10.1007/s11239-020-02101-y] [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] [Indexed: 10/24/2022]
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34
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Palareti G, Legnani C, Antonucci E, Cosmi B, Poli D, Testa S, Tosetto A, Ageno W, Falanga A, Ferrini PM, Pengo V, Prandoni P. D-dimer testing, with gender-specific cutoff levels, is of value to assess the individual risk of venous thromboembolic recurrence in non-elderly patients of both genders: a post hoc analysis of the DULCIS study. Intern Emerg Med 2020; 15:453-462. [PMID: 31691119 PMCID: PMC7165144 DOI: 10.1007/s11739-019-02216-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/11/2019] [Indexed: 12/17/2022]
Abstract
Male patients, especially the young, are at a higher risk of recurrent venous thromboembolism (RVTE) than females. Recent scientific reports show the use of D-dimer does not help predict RVTE risk in males. In the present report, we reviewed the data obtained in the DULCIS study (main report published in Blood 2014), focusing on D-dimer results recorded in non-elderly patients of both genders included in the study, and their relationship with RVTE events occurring during follow-up. Using specifically designed cutoff values for positive/negative interpretation, serial D-dimer measurements (performed during warfarin treatment and up to 3 months after discontinuation of anticoagulation) in 475 patients (males 57.3%) aged ≤ 65 years were obtained. D-dimer resulted positive in 46.3% and 30.5% of males and females, respectively (p = 0.001). Following management procedure, anticoagulation was stopped in 53.7% of males and 69.5% of females, who had persistently negative D-dimer results. The rate of subsequent recurrent events was 1.7% (95% CI 0.5-4.5%) and 0.4% (95% CI 0-2.5%) patient-years in males and females, respectively, with upper limits of confidence intervals always below the level of risk considered acceptable by international scientific societies for stopping anticoagulation (< 5%). In conclusion, using sensitive quantitative assays with specifically designed cutoff values and serial measurements during and after discontinuation of anticoagulation, D-dimer testing is useful to predict the risk of RVTE and is of help in deciding the duration of anticoagulation in both male and female adult patients aged up to 65 years.
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Affiliation(s)
- Gualtiero Palareti
- Fondazione Arianna Anticoagulazione, Via Paolo Fabbri 1/3, 40138, Bologna, Italy.
| | - Cristina Legnani
- Fondazione Arianna Anticoagulazione, Via Paolo Fabbri 1/3, 40138, Bologna, Italy
| | - Emilia Antonucci
- Fondazione Arianna Anticoagulazione, Via Paolo Fabbri 1/3, 40138, Bologna, Italy
| | - Benilde Cosmi
- Department of Angiology and Blood Coagulation, S. Orsola Malpighi University Hospital, Bologna, Italy
| | - Daniela Poli
- Thrombosis Center, Dipartimento Oncologico AOU Careggi, Firenze, Italy
| | - Sophie Testa
- Hemostasis and Thrombosis Center, AO Istituti Ospitalieri di Cremona, Cremona, Italy
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Anna Falanga
- Thrombosis and Hemostasis Center, Department of Immunohematology and Transfusion Medicine, Bergamo, Italy
| | - Piera Maria Ferrini
- Thrombosis and Hemostasis Center, Department of Internal Medicine, Parma, Italy
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiologic, Thoracic and Vascular Sciences, Università di Padova, Padova, Italy
| | - Paolo Prandoni
- Fondazione Arianna Anticoagulazione, Via Paolo Fabbri 1/3, 40138, Bologna, Italy
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35
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Abenante A, Zuretti F, Dedionigi C, Tangianu F, Dentali F. D-dimer testing to assess the individual risk of venous thromboembolic recurrence in non-elderly patients of both genders: follow the rules! Intern Emerg Med 2020; 15:369-370. [PMID: 31813090 DOI: 10.1007/s11739-019-02249-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 11/27/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Alessia Abenante
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Francesca Zuretti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Cristina Dedionigi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Flavio Tangianu
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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36
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Fernandes CJ, Calderaro D, Piloto B, Hoette S, Jardim CVP, Souza R. Extended anticoagulation after venous thromboembolism: should it be done? Ther Adv Respir Dis 2020; 13:1753466619878556. [PMID: 31558116 PMCID: PMC6767720 DOI: 10.1177/1753466619878556] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Most physicians understand venous thromboembolism (VTE) to be an acute and
time-limited disease. However, pathophysiological and epidemiological data
suggest that in most patients VTE recurrence risk is not resolved after the
first 6 months of anticoagulation. Recurrence rates are high and potentially
life-threatening. In these cases, it would make sense to prolong anticoagulation
for an undetermined length of time. However, what about the bleeding rates,
induced by prolonged anticoagulation? Would they not outweigh the benefit of
reducing the VTE recurrent risk? How long should anticoagulation be continued,
and should all patients suffering from VTE be provided with extended
anticoagulation? This review will address the most recent data concerning
extended anticoagulation in VTE secondary prophylaxis. The reviews of this paper are available via the supplementary material
section.
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Affiliation(s)
- Caio J Fernandes
- Cardiopulmonary Department, Heart Institute, University of Sao Paulo Medical School, 44, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, 05403-000, Brazil.,Cancer Institute, University of Sao Paulo Medical School, 251, Dr. Arnaldo Avenue, Sao Paulo, SP, Brazil.,Sirio Libanes Hospital, 115, Adma Jafet St, Sao Paulo, SP, Brazil
| | - Daniela Calderaro
- Cardiopulmonology Department, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.,Sirio Libanes Hospital, Sao Paulo, SP, Brazil
| | - Bruna Piloto
- Cardiopulmonology Department, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.,Sirio Libanes Hospital, Sao Paulo, SP, Brazil
| | - Susana Hoette
- Cardiopulmonology Department, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Carlos Vianna Poyares Jardim
- Cardiopulmonology Department, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.,Sirio Libanes Hospital, Sao Paulo, SP, Brazil
| | - Rogério Souza
- Cardiopulmonology Department, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.,Sirio Libanes Hospital, Sao Paulo, SP, Brazil
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Gong X, Lei X, Huang Z, Song Y, Wang Q, Qian J, Ge J. D-Dimer Level Predicts Angiographic No-Reflow Phenomenon After Percutaneous Coronary Intervention Within 2-7 Days of Symptom Onset in Patients with ST-Segment Elevation Myocardial Infarction. J Cardiovasc Transl Res 2020; 14:728-734. [PMID: 32212039 DOI: 10.1007/s12265-020-09991-6] [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: 09/10/2019] [Accepted: 03/11/2020] [Indexed: 10/24/2022]
Abstract
It remains uncertain whether plasma D-dimer level can predict no-reflow in patients with STEMI who had pPCI after 48 h of symptom onset. This study retrospectively enrolled 229 consecutive patients who had pPCI for acute STEMI within 2-7 days of symptom onset between January 2008 and December 2018. Patients were divided into no-reflow group (TIMI flow grade 0-2) and reflow group (TIMI flow grade 3). Predictors of no-reflow were assessed by univariate and multivariate binary logistic regression analyses. Plasma D-dimer level can independently predict no-reflow in patients with STEMI who had pPCI within 2-7 days of symptom onset (OR 2.52 per 1 mg/L increase, 95% CI 1.16-5.47, p = 0.019). This finding indicated that pPCI may be safe and feasible for STEMI patients within 2-7 days of symptom onset with low D-dimer level. Graphical Abstract Plasma D-dimer level can independently predict no-reflow in patients with STEMI who had pPCI within 2-7 days of symptom onset. pPCI may be safe and feasible for STEMI patients within 2-7 days of symptom onset with low D-dimer level.
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Affiliation(s)
- Xue Gong
- Department of Cardiology, DeltaHealth Hospital, Shanghai, China.,Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Xiaoting Lei
- Department of Cardiology, No. 1 Hospital of Tianshui City, Tianshui, Gansu Province, China
| | - Zheyong Huang
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Yanan Song
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Qibing Wang
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Juying Qian
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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38
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Bradbury C, Buckley T, Sun YZ, Rose P, Fitzmaurice D. Patients with high levels of circulating endothelial progenitor cells (EPC) following at least three months of anticoagulation for unprovoked venous thromboembolism (VTE) are at low risk of recurrent VTE-Results from the ExACT randomised controlled trial. EClinicalMedicine 2019; 17:100218. [PMID: 31891148 PMCID: PMC6933150 DOI: 10.1016/j.eclinm.2019.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND There is clinical need for a laboratory biomarker to identify patients who, following an unprovoked venous thrombosis (VTE), are at low VTE recurrence risk and can discontinue anticoagulation after a limited treatment duration (3-6 m). This secondary analysis of the ExACT study aimed to evaluate whether quantitation of peripheral blood endothelial progenitor cells (EPCs) could improve prediction of VTE recurrence risk. METHODS The ExACT study was a non-blinded, multicentre RCT comparing extended vs discontinued anticoagulation following a first unprovoked VTE. Adult patients were eligible if they had completed ≥3 months anticoagulation and remained anticoagulated. The primary outcome was time to first recurrent VTE from randomisation. Blood samples were taken at baseline and results correlated with clinical outcome over 2 years follow up. (Trial registration: ISRCTN:73819751 and EUDRACT:2101-022119-20). FINDINGS 281 patients were recruited, randomised (between July 2011 and February 2015) and followed up for 24 months (Male:Female 2:1, mean age 63). Of these, 273 patients were included in the final analysis. Blood samples were received at baseline for Full Blood Count(n = 216), d-dimers(n = 205) and endothelial progenitor cell (EPC) quantitation by flow cytometry(n = 193). VTE recurrence was lower in the extended vs discontinued anticoagulation arms (5% vs 23%, HR 0.20(95%CI:0.09-0.46,p < 0.001)). Level of EPCs were lower in patients who later developed VTE recurrence (43.41 ± 7.69 cells/ml vs 87.1 ± 7.15 cells/ml, p = 0.02). Survival free from VTE recurrence was significantly improved in patients with EPCs ≥ 100 cells/ml vs EPCs < 100 cells/ml (HR 0.10(95%CI:0.01-0.75,p = 0.025)). INTERPRETATION If confirmed, EPC quantitation may represent a novel biomarker that identifies patients at low VTE recurrence risk who are suitable for limited duration anticoagulation.
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Affiliation(s)
- Charlotte Bradbury
- School of Cellular and Molecular Medicine, University of Bristol, United Kingdom
- University Hospitals Bristol, United Kingdom
- Corresponding author.
| | | | | | - Peter Rose
- University Hospitals Coventry and Warwickshire, United Kingdom
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39
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Bradbury C, Fletcher K, Sun Y, Heneghan C, Gardiner C, Roalfe A, Hardy P, McCahon D, Heritage G, Shackleford H, Hobbs FR, Fitzmaurice D. A randomised controlled trial of extended anticoagulation treatment versus standard treatment for the prevention of recurrent venous thromboembolism (VTE) and post-thrombotic syndrome in patients being treated for a first episode of unprovoked VTE (the ExACT study). Br J Haematol 2019; 188:962-975. [PMID: 31713863 DOI: 10.1111/bjh.16275] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/06/2019] [Indexed: 12/19/2022]
Abstract
Venous thromboembolism (VTE) is prevalent and impactful, with a risk of death, morbidity and recurrence. Post-thrombotic syndrome (PTS) is a common consequence and associated with impaired quality of life (QoL). The ExACT study was a non-blinded, prospective, multicentred randomised controlled trial comparing extended versus limited duration anticoagulation following a first unprovoked VTE (proximal deep vein thrombosis or pulmonary embolism). Adults were eligible if they had completed ≥3 months anticoagulation (remaining anticoagulated). The primary outcome was time to first recurrent VTE from randomisation. The secondary outcomes included PTS severity, bleeding, QoL and D-dimers. Two-hundred and eighty-one patients were recruited, randomised and followed up for 24 months (mean age 63, male:female 2:1). There was a significant reduction in recurrent VTE for patients receiving extended anticoagulation [2·75 vs. 13·54 events/100 patient years, adjusted hazard ratio (aHR) 0·20 (95% confidence interval (CI): 0·09 to 0·46, P < 0·001)] with a non-significant increase in major bleeding [3·54 vs. 1·18 events/100 patient years, aHR 2·99 (95% CI: 0·81-11·05, P = 0·10)]. Outcomes of PTS and QoL were no different between groups. D-dimer results (on anticoagulation) did not predict VTE recurrence. In conclusion, extended anticoagulation reduced VTE recurrence but did not reduce PTS or improve QoL and was associated with a non-significant increase in bleeding. Results also suggest very limited clinical utility of D-dimer testing on anticoagulated patients.
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Affiliation(s)
- Charlotte Bradbury
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Kate Fletcher
- Institute of Applied Health Research, The University of Birmingham, Birmingham, UK
| | - Yongzhong Sun
- Institute of Applied Health Research, The University of Birmingham, Birmingham, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Chris Gardiner
- Haemostasis Research Unit (HRU), Department of Haematology, University College London, London, UK
| | - Andrea Roalfe
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Pollyanna Hardy
- Institute of Applied Health Research, The University of Birmingham, Birmingham, UK
| | - Debbie McCahon
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gail Heritage
- Institute of Applied Health Research, The University of Birmingham, Birmingham, UK
| | - Helen Shackleford
- Institute of Applied Health Research, The University of Birmingham, Birmingham, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - David Fitzmaurice
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
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40
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Couturaud F, Girard P, Laporte S, Sanchez O. [What duration of anticoagulant treatment for PE/proximal DVT?]. Rev Mal Respir 2019; 38 Suppl 1:e99-e112. [PMID: 31711819 DOI: 10.1016/j.rmr.2019.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- F Couturaud
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; EA3878-GETBO, CIC Inserm1412, département de médecine interne et pneumologie, centre hospitalo-universitaire de Brest, université de Bretagne occidentale, 29200 Brest, France
| | - P Girard
- Institut du thorax-Curie-Montsouris, l'institut mutualiste Montsouris, 75014 Paris, France
| | - S Laporte
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; SAINBOIS U1059 équipe DVH, Unité de recherche clinique, Inserm, innovation, pharmacologie, CHU de Saint-Étienne, université Jean-Monnet, université de Lyon, hôpital du Nord, 42000 Saint-Étienne, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Service de pneumologie et soins intensifs, université de Paris, AH-HP, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Innovations thérapeutiques en hémostase, Inserm UMRS 1140, 75006 Paris, France.
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Who should get long-term anticoagulant therapy for venous thromboembolism and with what? Blood Adv 2019; 2:3081-3087. [PMID: 30425073 DOI: 10.1182/bloodadvances.2018020230] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 05/24/2018] [Indexed: 12/27/2022] Open
Abstract
After an initial 3 to 6 months of anticoagulation for venous thromboembolism (VTE), clinicians and patients face an important question: "Do we stop anticoagulants or continue them indefinitely?" The decision is easy in some scenarios (eg, stop in VTE provoked by major surgery). In most scenarios, which are faced on a day-to-day basis in routine practice, it is a challenging decision because of uncertainty in estimates in the long-term risks (principally major bleeding) and benefits (reducing recurrent VTE) and the tight trade-offs between them. Once the decision is made to continue, the next question to tackle is "Which anticoagulant?" Here again, it is a difficult decision because of the uncertainty with regard to estimates of efficacy and the safety of anticoagulant options and the tight trade-offs between choices. We conclude with the approach that we take in our clinical practice.
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Brunson A, Keegan T, Mahajan A, White R, Wun T. High incidence of venous thromboembolism recurrence in patients with sickle cell disease. Am J Hematol 2019; 94:862-870. [PMID: 31074115 DOI: 10.1002/ajh.25508] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/07/2022]
Abstract
Previous reports show increased incidence of venous thromboembolism [VTE, deep-vein thrombosis (DVT) and pulmonary embolus (PE)] in sickle cell disease (SCD) patients. The incidence, time course, and risk factors for VTE recurrence have been less well described. We determined the cumulative incidence of first VTE recurrence and bleeding in a cohort of SCD patients with incident VTE. Risk factors for recurrence and bleeding were also determined using multivariable Cox regression models, adjusting for gender, race/ethnicity, era of incident VTE, location and hospitalization-associated status of incident VTE, and SCD-related complications. Results are presented as adjusted hazard ratios (HR) and 95% confidence intervals (CI). Among 877 SCD patients with an incident VTE, the 1-year and 5-year cumulative incidence of recurrence was 13.2% (95% CI 11.0%-15.5%) and 24.1% (95% CI 21.2%-27.1%). Risk factors for VTE recurrence included more severe SCD (HR = 2.41; CI: 1.67-3.47), lower extremity DVT as the incident event (HR = 1.64; CI: 1.17-2.30), and pneumonia/acute chest syndrome (HR = 1.68; CI: 1.15-2.45). The cumulative incidence of bleeding was 4.9% (CI 3.5%-6.4%) at 6 months and 7.9% (CI: 6.2%-9.8%) at 1 year. More severe SCD (HR = 1.61; CI: 1.11-2.35) was associated with bleeding. The high incidence of VTE recurrence in patients with SCD suggests that extended anticoagulation may be indicated; however, this must be weighed against a relatively high risk of bleeding. Prospective, randomized studies of anticoagulation in SCD patients with VTE are needed.
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Affiliation(s)
- Ann Brunson
- Center for Oncology and Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, UC Davis School of Medicine, Sacramento, California
| | - Theresa Keegan
- Center for Oncology and Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, UC Davis School of Medicine, Sacramento, California
| | - Anjlee Mahajan
- Center for Oncology and Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, UC Davis School of Medicine, Sacramento, California
| | - Richard White
- Division of General Internal Medicine, UC Davis School of Medicine, Sacramento, California
| | - Ted Wun
- Center for Oncology and Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, UC Davis School of Medicine, Sacramento, California
- UC Davis Clinical and Translational Science Center, Sacramento, California
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43
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Khan F, Rahman A, Carrier M, Kearon C, Weitz JI, Schulman S, Couturaud F, Eichinger S, Kyrle PA, Becattini C, Agnelli G, Brighton TA, Lensing AWA, Prins MH, Sabri E, Hutton B, Pinede L, Cushman M, Palareti G, Wells GA, Prandoni P, Büller HR, Rodger MA. Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis. BMJ 2019; 366:l4363. [PMID: 31340984 PMCID: PMC6651066 DOI: 10.1136/bmj.l4363] [Citation(s) in RCA: 148] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To determine the rate of a first recurrent venous thromboembolism (VTE) event after discontinuation of anticoagulant treatment in patients with a first episode of unprovoked VTE, and the cumulative incidence for recurrent VTE up to 10 years. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, and the Cochrane Central Register of Controlled Trials (from inception to 15 March 2019). STUDY SELECTION Randomised controlled trials and prospective cohort studies reporting symptomatic recurrent VTE after discontinuation of anticoagulant treatment in patients with a first unprovoked VTE event who had completed at least three months of treatment. DATA EXTRACTION AND SYNTHESIS Two investigators independently screened studies, extracted data, and appraised risk of bias. Data clarifications were sought from authors of eligible studies. Recurrent VTE events and person years of follow-up after discontinuation of anticoagulant treatment were used to calculate rates for individual studies, and data were pooled using random effects meta-analysis. Sex and site of initial VTE were investigated as potential sources of between study heterogeneity. RESULTS 18 studies involving 7515 patients were included in the analysis. The pooled rate of recurrent VTE per 100 person years after discontinuation of anticoagulant treatment was 10.3 events (95% confidence interval 8.6 to 12.1) in the first year, 6.3 (5.1 to 7.7) in the second year, 3.8 events/year (95% confidence interval 3.2 to 4.5) in years 3-5, and 3.1 events/year (1.7 to 4.9) in years 6-10. The cumulative incidence for recurrent VTE was 16% (95% confidence interval 13% to 19%) at 2 years, 25% (21% to 29%) at 5 years, and 36% (28% to 45%) at 10 years. The pooled rate of recurrent VTE per 100 person years in the first year was 11.9 events (9.6 to 14.4) for men and 8.9 events (6.8 to 11.3) for women, with a cumulative incidence for recurrent VTE of 41% (28% to 56%) and 29% (20% to 38%), respectively, at 10 years. Compared to patients with isolated pulmonary embolism, the rate of recurrent VTE was higher in patients with proximal deep vein thrombosis (rate ratio 1.4, 95% confidence interval 1.1 to 1.7) and in patients with pulmonary embolism plus deep vein thrombosis (1.5, 1.1 to 1.9). In patients with distal deep vein thrombosis, the pooled rate of recurrent VTE per 100 person years was 1.9 events (95% confidence interval 0.5 to 4.3) in the first year after anticoagulation had stopped. The case fatality rate for recurrent VTE was 4% (95% confidence interval 2% to 6%). CONCLUSIONS In patients with a first episode of unprovoked VTE who completed at least three months of anticoagulant treatment, the risk of recurrent VTE was 10% in the first year after treatment, 16% at two years, 25% at five years, and 36% at 10 years, with 4% of recurrent VTE events resulting in death. These estimates should inform clinical practice guidelines, enhance confidence in counselling patients of their prognosis, and help guide decision making about long term management of unprovoked VTE. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017056309.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alvi Rahman
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Marc Carrier
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Ottawa Blood Disease Centre, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University, and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Sam Schulman
- Department of Medicine, McMaster University, and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Brest University Hospital, Brest, France
| | - Sabine Eichinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Paul A Kyrle
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | | | | | - Martin H Prins
- Department of Epidemiology and Technology Assessment, University of Maastricht, Maastricht, Netherlands
| | - Elham Sabri
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Laurent Pinede
- Department of Internal Medicine, Infirmerie Protestante, Caluire-Lyon, France
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | | | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Marc A Rodger
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Ottawa Blood Disease Centre, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
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Kearon C, Parpia S, Spencer FA, Schulman S, Stevens SM, Shah V, Bauer KA, Douketis JD, Lentz SR, Kessler CM, Connors JM, Ginsberg JS, Spadafora L, Julian JA. Long-term risk of recurrence in patients with a first unprovoked venous thromboembolism managed according to d-dimer results; A cohort study. J Thromb Haemost 2019; 17:1144-1152. [PMID: 31033194 DOI: 10.1111/jth.14458] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/17/2019] [Indexed: 11/26/2022]
Abstract
Essentials Long-term recurrence risk after a first unprovoked VTE with negative d-dimer levels is uncertain. Anticoagulation was stopped if d-dimer was negative, and was continued if d-dimer was positive. Five years after stopping anticoagulants, recurrent VTE was 30% in men and 17% in women. Negative d-dimers do not justify stopping anticoagulants in most men but appear to in most women. BACKGROUND The long-term risk of recurrence in patients with a first unprovoked venous thromboembolism (VTE) who have negative d-dimer results is uncertain. OBJECTIVES To determine this risk, including in subgroups based on sex. PATIENTS AND METHODS ln a prospective interventional cohort study of 410 patients with a first unprovoked VTE, anticoagulants were stopped if d-dimer was negative on therapy and 1 month after stopping therapy. Other patients remained on anticoagulant therapy. We previously reported findings after a mean of 2.2 years. The current report includes 3 years of additional follow-up in 293 of these patients. RESULTS During a median follow-up of 5.0 years, recurrent VTE after stopping therapy in response to negative d-dimer testing was 5.1% (95% confidence interval [CI], 3.6-6.5) per patient-year overall, 7.5% (95% CI, 5.5-10.0) in men, 3.8% (95% CI, 2.0-6.6) in women with VTE not associated with estrogens, and 0.4% (95% CI, 0.0-2.3) in women with VTE associated with estrogens (P < 0.001 for three-group comparison). Risk of recurrence at 5 years was 21.5% (95% CI, 16.4-26.5) overall, 29.7% (95% CI, 22.1-37.3) in men, 17.0% (95% CI, 8.1-25.9) in non-estrogen women, and 2.3% (95% CI, 0.0-6.8) in estrogen women. CONCLUSION The long-term risk of recurrence in patients with a first unprovoked VTE who have negative d-dimer results is not low enough to justify stopping anticoagulant therapy in men, but appears to be low enough in women for many to choose stopping therapy (ClinicalTrials.gov; NCT00720915).
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Affiliation(s)
- Clive Kearon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Scott M Stevens
- Department of Medicine, Intermountain Medical Center, Murray, Utah
| | - Vinay Shah
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Kenneth A Bauer
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Steven R Lentz
- Department of Medicine, University of Iowa, Iowa City, Iowa
| | - Craig M Kessler
- Department of Medicine, Georgetown University, Washington, District of Columbia
| | - Jean M Connors
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | - Jim A Julian
- Department of Oncology, McMaster University, Hamilton, ON, Canada
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Johnson ED, Schell JC, Rodgers GM. The D-dimer assay. Am J Hematol 2019; 94:833-839. [PMID: 30945756 DOI: 10.1002/ajh.25482] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 03/26/2019] [Accepted: 04/01/2019] [Indexed: 12/21/2022]
Abstract
D-dimer is an indirect marker of fibrinolysis and fibrin turnover; this molecule exhibits unique properties as a biological marker of hemostatic abnormalities as well as an indicator of intravascular thrombosis. D-dimer is a soluble fibrin degradation product that results from the systematic degradation of vascular thrombi through the fibrinolytic mechanism. Because of this, the D-dimer serves as a valuable marker of activation of coagulation and fibrinolysis in a number of clinical scenarios. Most commonly, D-dimer has been extensively investigated for excluding the diagnosis of venous thromboembolism (VTE) and is used routinely for this indication. In addition, D-dimer has been evaluated for determining the optimal duration of anticoagulation in VTE patients, for diagnosing and monitoring disseminated intravascular coagulation, and for monitoring other conditions in which the patient is at high risk of bleeding or thrombosis. Limitations of the assay include D-dimer elevation in a constellation of clinical scenarios (age, pregnancy, and cancer) and lack of clinical standardization.
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Affiliation(s)
- Eric D. Johnson
- Division of Hematology and Hematologic MalignanciesUniversity of Utah Health Sciences Center Salt Lake City Utah
| | - John C. Schell
- Department of Internal MedicineUniversity of Utah School of Medicine Salt Lake City Utah
| | - George M. Rodgers
- Division of Hematology and Hematologic MalignanciesUniversity of Utah Health Sciences Center Salt Lake City Utah
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Lobastov KV. [Contemporary approaches to determine the duration of anticoagulant therapy for venous thromboembolism]. Khirurgiia (Mosk) 2019:94-103. [PMID: 31169827 DOI: 10.17116/hirurgia201905194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The review is devoted to the issue of optimal duration of anticoagulant therapy for venous thromboembolic complications (VTEC) using oral anticoagulants (OAC). These drugs are characterized by higher safety in comparison with vitamin K antagonists and make it possible to increase the duration of treatment for not only spontaneous thrombosis (with high risk of recurrence), but also thrombosis provoked by minor persistent and transient risk factors of VTEC. Efficacy and safety of prolonged treatment of VTEC using OAC was analyzed. Different classifications of primary thrombotic episode depending on risk of subsequent recurrence are presented. Moreover, scales for individual assessment of risk of recurrent thrombosis after anticoagulant therapy cancellation and risk of bleeding in case of continued treatment are given. Outcomes of long-term administration of rivaroxaban for VTEC are analyzed. It was concluded that OAC are safe for prolonged management of primary thrombotic episode. However, overall duration of treatment should be determined considering individual balance of benefits and risks.
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Affiliation(s)
- K V Lobastov
- Pirogov Russian National Research Medical University, Moscow, Russia
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47
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Bevacizumab Plus Direct Oral Anticoagulant Therapy in Ovarian Cancer Patients with Distal Deep Vein Thrombosis. Clin Drug Investig 2019; 39:395-400. [PMID: 30737671 DOI: 10.1007/s40261-019-00757-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Administration of bevacizumab to ovarian cancer patients with distal deep vein thrombosis (DVT) is problematic because of lack of evidence about the likely outcomes. We conducted a preliminary study in ovarian cancer patients with DVT who received bevacizumab combined with a direct oral anticoagulant (DOAC). METHODS We retrospectively investigated patients with advanced or recurrent epithelial ovarian cancer and distal DVT diagnosed by ultrasonography who underwent chemotherapy containing bevacizumab (15 mg/kg every 3 weeks) combined with DOAC therapy. RESULTS Bevacizumab was administered to 88 patients, including 7 patients (7.9%) receiving concomitant DOAC therapy for distal DVT. In these 7 patients, the median body mass index was 21.3 kg/m2, median D-dimer level at diagnosis of DVT was 4.3 µg/mL, and median duration of DOAC therapy was 8 months. Adverse events during DOAC therapy were grade 1 epistaxis and grade 1 hemorrhoidal bleeding in one patient each. DVT resolved in four patients and was unchanged in three patients, with no central progression or secondary thromboembolism. CONCLUSION In ovarian cancer patients who have distal DVT, bevacizumab can possibly be administered safely when combined with a DOAC. To confirm this finding, further investigation on a larger scale will be required.
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Abstract
Venous thromboembolism (VTE) includes pulmonary embolism (PE) and deep vein thrombosis. PE is the third most common cause of cardiovascular death worldwide after stroke and heart attack. Management of PE has evolved recently with the availability of local thrombolysis; mechanical extraction devices; hemodynamic support devices, like extracorporeal membrane oxygenation; and surgical embolectomy. There has been development of multidisciplinary PE response teams nationwide to optimize the care of patients with VTE. This review describes the epidemiology of PE, discusses diagnostic strategies and current and emerging treatments for VTE, and considers post-PE follow-up care.
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Affiliation(s)
- Eno-Obong Essien
- Division of Internal Medicine Residency Program, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Parth Rali
- Division of Thoracic Surgery and Medicine, Pulmonary Embolism Response Team (PERT), Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140, USA.
| | - Stephen C Mathai
- John Hopkins Hospital, 830 East Monument Street, 1830 Building 5th Floor Pulmonary, Baltimore, MD 21287, USA
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Risk of Recurrent Venous Thromboembolism After an Initial Episode: Risk Stratification and Implications for Long-term Treatment. Curr Cardiol Rep 2019; 21:24. [PMID: 30828779 DOI: 10.1007/s11886-019-1111-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW Venous thromboembolism (VTE) is a common condition with significant associated morbidity and mortality. Recurrent VTE after an initial episode is a preventable medical condition. The following review discusses data supporting recurrence risk estimates after an initial VTE episode as well as treatment strategies to mitigate risk of recurrent VTE. RECENT FINDINGS This review particularly highlights methods for stratifying the risk of recurrent VTE and recent studies that have evaluated direct oral anticoagulants for the prevention of recurrent VTE. Risk assessment for VTE recurrence should guide anticoagulation duration. In patients who present with unprovoked VTE events, there remains a high risk of recurrence that is significantly mitigated with extended duration anticoagulation with either a vitamin K antagonist or direct oral anticoagulant.
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