Author Correction: Meta-analyses of sulodexide and other drugs in prevention and treatment of post-thrombotic syndrome

Correction to: Eur Rev Med Pharmacol Sci 2022; 26 (24): 9372-9381. DOI: 10.26355/eurrev_202212_30688-PMID: 36591846-published online on December 21, 2022. After publication, the authors found a typo in the discussion section. The sentence to amend is the following one: ·       In meta-analyses of observational studies, we found a low incidence of PTS, with 9% of patients presenting PTS among patients receiving sulodexide and a 50% reduction in the risk of PTS in patients receiving rivaroxaban. The "9%" in the sentence below should be changed to "15%" (in order to align the Discussion section with the Results section and the Abstract. There are amendments to this paper. The Publisher apologizes for any inconvenience this may cause. https://www.europeanreview.org/article/30688.

Meta-analyses of sulodexide and other drugs in prevention and treatment of post-thrombotic syndrome

OBJECTIVE

Post-thrombotic syndrome (PTS) is a common chronic complication of deep vein thrombosis. Elastic compression (ECS) is the common pillar for PTS prevention and treatment, while the pharmacological approach for PTS includes direct oral anticoagulants (DOACs) and venoactive drugs (VADs) for prevention and treatment, respectively. Sulodexide can be used both in long-term prevention and in the treatment of PTS. To better understand the efficacy of the main drugs used in the prevention (sulodexide or DOACs) and treatment of PTS (sulodexide or VADs), pairwise meta-analyses of observational studies and RCTs were conducted.

MATERIALS AND METHODS

A literature search in MEDLINE, Embase, and Cochrane Library for observational studies and RCTs was performed. Incidence of PTS, reduction in PTS signs or symptoms and proportion of patients with complete venous ulcers healing were the primary outcomes for prevention and treatment of PTS, respectively. Fixed and Random effect model meta-analyses were performed. Heterogeneity and publication bias were assessed. R® software was used for the analysis.

RESULTS

893 articles were identified during the search. 8 observational studies (6 for DOACs and 2 for sulodexide) and 2 RCTs for sulodexide, out of the 11 studies included in the qualitative synthesis, were included for the prevention and treatment of PTS, respectively. Meta-analyses of observational studies showed an overall incidence of PTS of 15% (95% CI, 11-19) for sulodexide, and a 50% reduction of PTS signs and/or symptoms for rivaroxaban compared to warfarin (OR, 0.50; 95% CI, 0.38-0.65). The overall estimate of the two sulodexide RCTs showed a significant improvement in complete ulcer healing, with an OR of 2.32 (95% CI, 1.49-3.63).

CONCLUSIONS

In prevention of PTS, sulodexide and rivaroxaban showed a low incidence and reduced risk of PTS respectively, while in PTS treatment, sulodexide was significantly effective in the complete ulcers healing. These results confirm the need to move from the traditional single-pillar approach with elastic compression stockings to a more effective multi-pillar approach, tailoring the treatment to each individual patient.

Feasibility of volumetric expansion of molten chlorides by conventional pushrod dilatometry

This study is a short communication on progress made in the adaptation of conventional push-rod dilatometry for the measurement of volumetric expansion of liquid salts up to 1300 K. A new crucible design is offered as a practical solution for measurement of liquid salts by this method. Proof-of-concept measurements of the volumetric expansion of sodium chloride (NaCl) are compared to the available data in literature. Measurement of the coefficient of thermal expansion (CTE) of solid NaCl compared favorably to the available data in literature, confirming both magnitude and trend. The average CTE of NaCl (solid) was $$\overline{\alpha }_{{{\text{NaCl}}\;{\text{Solid}}}} = 5.63 \cdot 10^{ - 5} {\raise0.7ex\hbox{$1$} \!\mathord{\left/ {\vphantom {1 K}}\right.\kern-\nulldelimiterspace} \!\lower0.7ex\hbox{$K$}}$$ α ¯ NaCl Solid = 5.63 · 10 - 5 1 K . The volumetric expansion of liquid NaCl was measured as $$\beta_{{{\text{NaCl}}\;{\text{Liquid}}}} \approx 3.96 \cdot 10^{ - 5} 1/K$$ β NaCl Liquid ≈ 3.96 · 10 - 5 1 / K and is essentially constant from the melt point to 1300 K. The volumetric expansion produced by this method is in reasonable agreement with the available published data and previous measurements made by the authors by neutron radiographic technique.

Risk for post-thrombotic syndrome after lower-limb deep vein thrombosis: location of the thrombus or residual thrombi?

BACKGROUND

Many works aimed to determine factors that influence the onset of postthrombotic syndrome after an acute episode of deep venous thrombosis. We aimed to compare the prognostic value of the most proximal extent of thrombus (proximal and distal DVT) versus the residual thrombosis as identified by venous ultrasonography performed during follow-up.

METHOD

We conducted a retrospective study of prospectively collected 1183 consecutive cohort patients in the RIETE registry after a first episode of deep venous thrombosis and assessed for postthrombotic syndrome after 12 months.

RESULTS

Multivariate analysis revealed that: residual thrombosis (OR 1.40; 95% CI 0,88-2,21), the presence of cancer (OR 1.38; 95% CI: 0,64-2,97), immobility (OR 1.31; 95% CI 0,70-2,43) and estrogen-containing drugs use (OR 2.08, 95% CI 0,63-6,83), all had a predictive value for the occurrence of PTS.

CONCLUSION

Our study results revealed that ultrasound finding of residual thrombosis is more predictive than proximal location of thrombus for postthrombotic syndrome after episode of deep venous thrombosis. Real life data from a large group of patients from the RIETE registry substantiates that.

Outcomes in patients with acute pulmonary embolism and patent foramen ovale: Findings from the RIETE registry

INTRODUCTION

An increased risk of ischemic stroke in patients with acute pulmonary embolism (PE) and patent foramen ovale (PFO) was reported but few data exist regarding prognostic outcomes of those patients.

MATERIAL AND METHODS

Using data in the RIETE registry, we compared the characteristics, therapeutic approaches and outcomes of patients with PE according to the presence or absence of PFO.

RESULTS

From August 2016 to January 2020, 4148 patients with acute PE were enrolled. Of these, 2775 (67%) had no transthoracic echocardiogram (TTE), 993 (24%) underwent TTE but had no reported results on PFO. Among the remaining 380 patients, 287 (74%) did not have PFO and 93 (26%) had PFO. Patients with PFO were more likely to have chronic heart failure, prior myocardial infarction or ischemic stroke than those without PFO. Patients with PFO had a higher rate of subsequent ischemic stroke than those without PFO (hazard ratio (HR): 9.28; 95% CI: 1.83-69.1), than those with TTE but no data on PFO (HR: 10.1; 95% CI: 2.56-42.4) or without TTE (HR: 9.78; 95% CI: 3.02-28.4). On multivariable analysis, patients with PFO were at increased risk for subsequent ischemic stroke than those without PFO (HR: 8.96; 95% CI: 1.68-47.7).

CONCLUSIONS

PFO was searched in a minority of patients with an acute PE in real life setting. Subject to possible selection and measurement biases, our results confirmed a higher risk of ischemic stroke in PE patients with PFO compared to those without PFO. This association warrants further investigation before determining the best therapeutic option in patients with acute PE and concomitant PFO.

Renal function improves mortality prediction in acute pulmonary embolism: results of a multicentre cohort study with external validation in the RIETE registry

Background

Renal dysfunction may influence outcomes after pulmonary embolism (PE). We determined the incremental value of adding renal function impairment (estimated glomerular filtration rate, eGFR <60 ml/min/1.73m2) on top of the 2019 ESC prognostic model, for the prediction of 30-day all-cause mortality in acute PE patients from a prospective, multicenter cohort.

Methods and results

We identified which of three eGFR formulae predicted death most accurately. Changes in global model fit, discrimination, calibration and net reclassification index (NRI) were evaluated with addition of eGFR. We prospectively included consecutive adult patients with acute PE diagnosed as per ESC guidelines. Among 1,943 patients, (mean age 67.3±17.1, 50.4% women), 107 (5.5% (95% CI 4.5–6.5%)) died during 30-day follow-up. The eGFRMDRD4 formula was the most accurate for prediction of death. The observed mortality rate was higher for intermediate-low risk (OR 1.8, 95% CI 1.1–3.4) and high-risk PE (OR 10.3, 95% CI 3.6–17.3), and 30-day bleeding was significantly higher (OR 2.1, 95% CI 1.3–3.5) in patients with vs without eGFRMDRD4 <60 ml/min/1.73m2. The addition of eGFRMDRD4 information improved model fit, discriminatory capacity, and calibration of the ESC models. NRI was significantly improved (p<0.001), with 18% reclassification of predicted mortality, specifically in intermediate and high-risk PE. External validation using data from the RIETE registry confirmed our findings (Table).

Conclusion

Addition of eGFRMDRD4-derived renal dysfunction on top of the ESC prognostic algorithm yields significant reclassification of risk of death in intermediate and high-risk PE. Impact on therapy remains to be determined.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): BMS-Pfizer Alliance, Bayer Healthcare

Deep Vein Thrombosis in Europe-Health-Related Quality of Life and Mortality

Objectives:

Deep vein thrombosis (DVT) is a major health-care burden in Europe, but exact estimates are lacking. This study reports results from the PREFER venous thromboembolism (VTE) study concerning health-related quality of life (HrQoL) and mortality of patients with DVT.

Methods:

PREFER VTE was a prospective, observational study, conducted in 7 European countries, designed to provide data concerning treatment patterns, resource utilization, mortality, and QoL. First-time or recurrent patients with DVT were followed at 1, 3, 6, and 12 months. Health-related QoL—as measured by the EuroQoL 5-Dimension 5-Level instrument ( EQ-5D-5L)—was analyzed using Tobit regression with repeated measures, assessing the impact of baseline characteristics stratified by cancer activity. Mortality was analyzed using logistic regression.

Results:

At baseline, patients with DVT had a 0.14 lower EQ-5D-5L index score (0.72 for total sample) compared to the reference UK population (0.85). The EQ-5D-5L index score improved from baseline to 12 months in patients with active cancer (from 0.70 to 0.79) and those without (0.72-0.87); 7.3% died within a year, a 5.2% excess mortality compared to the age- and gender-adfjusted general population. The 12-month mortality rate of DVT varied between 2.9% in the pooled data from Germany, Switzerland, or Austria and 15.4% in Italy. Furthermore, the mortality rate differed between patients with active cancer and those without (42.9% vs 4.7%).

Conclusions:

Deep vein thrombosis is associated with a substantial burden of illness in terms of HrQoL at baseline, which following treatment normalizes after 12 months and has a significant mortality rate. In addition, active cancer has a significant impact on mortality and the HrQoL of patients with DVT.

Pharmacokinetics, safety, and tolerability of four 28-day cycle intramuscular injections for risperidone-ISM 75 mg in patients with schizophrenia: A phase-2 randomized study (PRISMA-2)

Introduction

Risperidone-ISM is a new long acting intramuscular formulation of risperidone, for monthly administration without oral supplementation.

Objective

To characterize the pharmacokinetic of risperidone over multiple intramuscular injections in patients with schizophrenia.

Method

A multicenter, open label, two-arm, parallel design clinical trial was performed. Each patient received 4 intramuscular injections of 75 mg of risperidone-ISM in either, gluteal or deltoid muscle at 28-day intervals.

Results

A total of 70 patients were randomized, 67 received at least one dose of study medication. Preliminary data show that mean Cmax of the active moiety was achieved 24-48 hours (Tmax) after each administration and ranged over four consecutive doses from 39.6-53.2 ng/mL and 54.1-61 ng/mL, when given in gluteal or deltoid, respectively. All subjects achieved therapeutic levels (> 7.5 ng/mL for the active moiety) between 2-8 hours after drug administration. The mean concentrations were maintained above therapeutic levels throughout the 4-week dosing period. No significance changes across the study were observed, either on Positive and Negative Syndrome Scale or Extrapyramidal Symptoms Scale. Overall, 63 subjects (94%) experienced at least 1 Treatment Emergent Adverse Event (TEAE) during the study. One serious TEAE (dystonia) was related to study treatment. One death not related to study medication was informed. The most frequently reported TEAEs were hyperprolactinaemia (57.7%) and injection site pain (32.8%).

Conclusions

Risperidone-ISM achieved therapeutic levels from the first hours after drug administration and provided a sustained release throughout the 4-weeks dosing period over multiple intramuscular injections independently of the injection site. Risperidone-ISM was found to be safe and well tolerated.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

D-dimer levels and risk of recurrence following provoked venous thromboembolism: findings from the RIETE registry

BACKGROUND

Patients with venous thromboembolism (VTE) secondary to transient risk factors may develop VTE recurrences after discontinuing anticoagulation. Identifying at-risk patients could help to guide the duration of therapy.

METHODS

We used the RIETE database to assess the prognostic value of d-dimer testing after discontinuing anticoagulation to identify patients at increased risk for recurrences. Transient risk factors were classified as major (postoperative) or minor (pregnancy, oestrogen use, immobilization or recent travel).

RESULTS

In December 2018, 1655 VTE patients with transient risk factors (major 460, minor 1195) underwent d-dimer measurements after discontinuing anticoagulation. Amongst patients with major risk factors, the recurrence rate was 5.74 (95% CI: 3.19-9.57) events per 100 patient-years in those with raised d-dimer levels and 2.68 (95% CI: 1.45-4.56) in those with normal levels. Amongst patients with minor risk factors, the rates were 7.79 (95% CI: 5.71-10.4) and 3.34 (95% CI: 2.39-4.53), respectively. Patients with major risk factors and raised d-dimer levels (n = 171) had a nonsignificantly higher rate of recurrences (hazard ratio [HR]: 2.14; 95% CI: 0.96-4.79) than those with normal levels. Patients with minor risk factors and raised d-dimer levels (n = 382) had a higher rate of recurrences (HR: 2.34; 95% CI: 1.51-3.63) than those with normal levels. On multivariate analysis, raised d-dimers (HR: 1.74; 95% CI: 1.09-2.77) were associated with an increased risk for recurrences in patients with minor risk factors, not in those with major risk factors.

CONCLUSIONS

Patients with raised d-dimer levels after discontinuing anticoagulant therapy for VTE provoked by a minor transient risk factor were at an increased risk for recurrences.

Management of venous thromboembolism in patients with cancer

Current guidelines for anticoagulant therapy do not so far suggest any form of differentiated approach to cancer patients with venous thromboembolism (VTE). This review article provides an overview of the published literature in cancer patients with VTE, mostly using data from the RIETE registry. Our findings provide some insights into what factors may be used to guide physicians in adapting recommended anticoagulant regimens to the individual patient, as oncologists are increasingly doing with cancer treatments. For instance, patients presenting with deep vein thrombosis (DVT) alone might benefit from curtailing treatment intensity as anticoagulant therapy progresses. The site of cancer also needs to be considered. In patients with incidental PE or splanchnic vein thrombosis, we should be more cautious before prescribing anticoagulant therapy. The optimal duration of anticoagulant therapy is unknown.

Comparison of Subcutaneous Unfractionated Heparin with a Low Molecular Weight Heparin (Fragmin®) in Patients with Venous Thromboembolism and Contraindications to Coumarin

Intravenous heparin followed by oral anticoagulant therapy (e. g. with coumarin) is still the most widely used treatment for deep venous thromboembolism. Self-administered subcutaneous injections of heparin have been thought of as a promising alternative to coumarin, but the high doses required for ongoing prophylaxis have raised concerns about the possible development of bone disease. Certainly, long-term heparin therapy has been reported to cause osteoporosis in both laboratory animals and humans.

This study aimed to compare the efficacy and safety of unfractionated (UF) heparin with that of a low molecular weight heparin (Fragmin®, Kabi Pharmacia) in the prevention of recurrent deep venous thrombosis (DVT) and pulmonary embolism (PE) in a consecutive series of patients with contraindications to coumarin therapy. The patients comprised 40 men and 40 women, aged between 19 and 92 years (mean age, 68 years). They had all previously been diagnosed as having acute DVT and had been treated with conventional doses of heparin while in hospital. All patients had at least one of the following conditions: recent blood loss (either spontaneous or during admission while receiving heparin therapy); active gastroduodenal ulcer disease; psychological or physical inability or unwillingness to understand and accept the need for regular laboratory monitoring during coumarin treatment; chronic alcoholism; dementia; pregnancy; recent neurosurgery, and pericardial effusion; or were over 80 years of age. They were randomly allocated to receive either UF heparin, 10,000 IU s.c. b.d., or Fragmin®, 5000 IU anti-Factor Xa s. c. b. d., for a period of 3-6 months.

Two patients taking UF heparin were readmitted to hospital 2 and 3 months after discharge, owing to symptomatic, scintigraphically proven recurrent PE. No patients receiving Fragmin® had recurrent PE. There were 10 reports of minor bleeding: six in patients receiving UF heparin and four in patients on Fragmin®. Furthermore, there were seven cases of spinal fracture: six in patients on UF heparin, and one in a patient taking Fragmin®.

We conclude that fixed doses of both UFH and Fragmin® appear to be quite effective and safe for use in patients with a high risk of bleeding. In our experience, however, UF heparin is associated with an unacceptably high incidence of spinal fracture.

Prognosis of venous thromboembolism in orthopaedic surgery or trauma patients and use of thromboprophylaxis

BACKGROUND

There is scarce evidence about the prognosis of venous thromboembolism in patients undergoing orthopedic surgery and in patients suffering non-surgical trauma.

METHODS

We used the RIETE database (Registro Informatizado de pacientes con Enfermedad Trombo Embólica) to compare the prognosis of venous thromboembolism and the use of thromboprophylaxis in patients undergoing different orthopedic procedures and in trauma patients not requiring surgery.

RESULTS

From March 2001 to March 2015, a total of 61,789 patients were enrolled in RIETE database. Of these, 943 (1.52%) developed venous thromboembolism after elective arthroplasty, 445 (0.72%) after hip fracture, 1,045 (1.69%) after non-major orthopedic surgery and 2,136 (3.46%) after non-surgical trauma. Overall, 2,283 patients (50%) initially presented with pulmonary embolism. Within the first 90 days of therapy, 30 patients (0.66%; 95% CI 0.45-0.93) died from pulmonary embolism. The rate of fatal pulmonary embolism was significantly higher after hip fracture surgery (n = 9 [2.02%]) than after elective arthroplasty (n = 5 [0.53%]), non-major orthopedic surgery (n = 5 [0.48%]) or non surgical trauma (n = 11 [0.48%]). Thromboprophylaxis was more commonly used for hip fracture (93%) or elective arthroplasty (94%) than for non-major orthopedic surgery (71%) or non-surgical trauma (32%). Major bleeding was significantly higher after hip fracture surgery (4%) than that observed after elective arthroplasty (1.6%), non-major orthopedic surgery (1.5%) or non-surgical trauma (1.4%).

CONCLUSIONS

Thromboprophylaxis was less frequently used in lower risk procedures despite the absolute number of fatal pulmonary embolism after non-major orthopedic surgery or non-surgical trauma, exceeded that observed after high risk procedures.

Randomised Phase II Feasibility Trial of Image-guided External Beam Radiotherapy With or Without High Dose Rate Brachytherapy Boost in Men with Intermediate-risk Prostate Cancer (CCTG PR15/ NCT01982786)

AIMS

We conducted a multicentre feasibility study to assess the ability to randomise patients between image-guided radiotherapy (IGRT) and IGRT + high dose rate (HDR) brachytherapy boost and to adhere to appropriate radiation quality assurance standards.

MATERIALS AND METHODS

The primary end point was to determine the ability to randomise 60 patients over an 18 month period. Arm 1 (IGRT) patients received 78 Gy in 39 fractions or 60 Gy in 20 fractions (physician's preference), whereas arm 2 (IGRT + HDR) received 37.5 Gy in 15 fractions with HDR boost of 15 Gy. The secondary end points included >grade 3 acute genitourinary and gastrointestinal toxicity, using Common Terminology Criteria for Adverse Events version 4.0 at 3 months, validation of a prospectively defined radiation oncology quality assurance to assess treatment compliance. All analyses were descriptive; no formal comparisons between treatment arms were carried out.

RESULTS

Between April 2014 and September 2015, 57 National Comprehensive Cancer Network (NCCN)-defined intermediate-risk prostate cancer patients were randomised between IGRT alone (arm 1; n = 29) and IGRT plus HDR brachytherapy boost (arm 2; n = 28). Overall, 93% received the treatment as randomised. There were four patients (one on IGRT arm 1 and three patients on the IGRT + HDR arm 2) who were treated differently from randomisation assignment. For the 29 patients receiving IGRT (arm 1), there were 14 cases reported with minor deviations and three with major deviations. For patients on IGRT + HDR (arm 2), there were 18 cases reported with minor deviations and two with major deviations. At 3 months in the IGRT group (arm 1), one patient reported grade 3 diarrhoea, whereas in the IGRT + HDR group (arm 2), two patients reported grade 3 haematuria. No other gastrointestinal and genitourinary toxicities were reported.

CONCLUSION

The pilot study showed the feasibility of randomisation between treatment with IGRT alone versus IGRT + HDR boost. Treatment compliance was good, including adherence to quality assurance standards.

[Venous thromboembolic disease: Comparison of management practices in France, Italy and Spain]

BACKGROUND

Many national and international guidelines have been established for venous thromboembolic disease (VTE). Homogeneous management practices could be expected in the different European countries. To verify this hypothesis, we compared practices in France, Italy and Spain.

METHOD

We used data from the international RIETE registry to compare VTE management between France, Italy and Spain.

RESULTS

From 2001 January to 2011 January, patients were consecutively included in France (n=1548), Italy (n=2083) and Spain (29,824). All patients received anticoagulant treatment. Low molecular-weight heparin (LMWH) was the most frequently used drug as initial therapy in all three countries, but unfractionated heparin (UFH) was more frequently used in France and Italy than in Spain. In France, the proportion of patients receiving LMWH was lower than the proportion of patients with active cancer (cancer 22.5 %, long-term treatment with LMWH 17.4 %). A vena cava filter was significantly more frequently used in France (5.5 % in France, 3.2 % in Italy and 2 % in Spain, P<0.0001). High bleeding risk because of surgery with recent thromboembolic disease was the most frequent indication in France and Italy for vena cava filter placement (36.4 %, and 31.3 %, respectively).

CONCLUSION

Despite the publication of national and international guidelines, VTE management differs among the three major European countries included in the RIETE registry, France, Italy and Spain.

Outcome of Patients with Venous Thromboembolism and Factor V Leiden or Prothrombin 20210 Carrier Mutations During the Course of Anticoagulation

BACKGROUND

Individuals with factor V Leiden or prothrombin G20210A mutations are at a higher risk to develop venous thromboembolism. However, the influence of these polymorphisms on patient outcome during anticoagulant therapy has not been consistently explored.

METHODS

We used the Registro Informatizado de Enfermedad TromboEmbólica database to compare rates of venous thromboembolism recurrence and bleeding events occurring during the anticoagulation course in factor V Leiden carriers, prothrombin mutation carriers, and noncarriers.

RESULTS

Between March 2001 and December 2015, 10,139 patients underwent thrombophilia testing. Of these, 1384 were factor V Leiden carriers, 1115 were prothrombin mutation carriers, and 7640 were noncarriers. During the anticoagulation course, 160 patients developed recurrent deep vein thrombosis and 94 patients developed pulmonary embolism (16 died); 154 patients had major bleeding (10 died), and 291 patients had nonmajor bleeding. On multivariable analysis, factor V Leiden carriers had a similar rate of venous thromboembolism recurrence (adjusted hazard ratio [HR], 1.16; 95% confidence interval [CI], 0.82-1.64), half the rate of major bleeding (adjusted HR, 0.50; 95% CI, 0.25-0.99) and a nonsignificantly lower rate of nonmajor bleeding (adjusted HR, 0.66; 95% CI, 0.43-1.01) than noncarriers. Prothrombin mutation carriers and noncarriers had a comparable rate of venous thromboembolism recurrence (adjusted HR, 1.00; 95% CI, 0.68-1.48), major bleeding (adjusted HR, 0.75; 95% CI, 0.42-1.34), and nonmajor bleeding events (adjusted HR, 1.10; 95% CI, 0.77-1.57).

CONCLUSIONS

During the anticoagulation course, factor V Leiden carriers had a similar risk for venous thromboembolism recurrence and half the risk for major bleeding compared with noncarriers. This finding may contribute to decision-making regarding anticoagulation duration in selected factor V Leiden carriers with venous thromboembolism.

Once versus twice daily enoxaparin for the initial treatment of acute venous thromboembolism

Essentials In venous thromboembolism (VTE), it is uncertain if enoxaparin should be given twice or once daily. We compared the 15- and 30-day outcomes in VTE patients on enoxaparin twice vs. once daily. Patients on enoxaparin once daily had fewer major bleeds and deaths than those on twice daily. The rate of VTE recurrences was similar in both subgroups.

SUMMARY

Background In patients with acute venous thromboembolism (VTE), it is uncertain whether enoxaparin should be administered twice or once daily. Methods We used the RIETE Registry data to compare the 15- and 30-day rates of VTE recurrence, major bleeding and death between patients receiving enoxaparin twice daily and those receiving it once daily. We used propensity score matching to adjust for confounding variables. Results The study included 4730 patients: 3786 (80%) received enoxaparin twice daily and 944 once daily. During the first 15 days, patients on enoxaparin once daily had a trend towards more VTE recurrences (odds ratio [OR], 1.79; 95% confidence interval [CI], 0.55-5.88), fewer major bleeds (OR, 0.42; 95% CI, 0.17-1.08) and fewer deaths (OR, 0.32; 95% CI, 0.13-0.78) than those on enoxaparin twice daily. At day 30, patients on enoxaparin once daily had more VTE recurrences (OR, 2.5; 95% CI, 1.03-5.88), fewer major bleeds (OR, 0.40; 95% CI, 0.17-0.94) and fewer deaths (OR, 0.58; 95% CI, 0.33-1.00). On propensity analysis, patients on enoxaparin once daily had fewer major bleeds at 15 (hazard ratio [HR], 0.30; 95% CI, 0.10-0.88) and at 30 days (HR, 0.16; 95% CI, 0.04-0.68) and also fewer deaths at 15 (HR, 0.37; 95% CI, 0.14-0.99) and at 30 days (HR, 0.19; 95% CI, 0.07-0.54) than those on enoxaparin twice daily. Conclusions Our findings confirm that enoxaparin prescribed once daily results in fewer major bleeds than enoxaparin twice daily, as suggested in a meta-analysis of controlled clinical trials.

The Clinical Course of Venous Thromboembolism May Differ According to Cancer Site

BACKGROUND

We hypothesized that the clinical course of venous thromboembolism in patients with active cancer may differ according to the specificities of primary tumor site.

AIM AND METHODS

We used data from RIETE (international registry of patients with venous thromboembolism) to compare the clinical venous thromboembolism-related outcomes during the course of anticoagulation in patients with one of the 4 more frequent cancers (breast, prostate, colorectal, or lung cancer).

RESULTS

As of September 2014, 3947 cancer patients were recruited, of whom 938 had breast, 629 prostate, 1189 colorectal, and 1191 lung cancer. Overall, 55% had metastatic disease (42%, 36%, 53%, and 72%, respectively). During the course of anticoagulant therapy (mean duration, 139 days), the rate of thromboembolic recurrences was similar to the rate of major bleeding in patients with breast (5.6 [95% confidence interval (CI), 3.8-8.1] vs 4.1 [95% CI, 2.7-5.9] events per 100 patient-years) or colorectal cancer (10 [95% CI, 7.6-13] vs 12 [95% CI, 9.4-15] per 100 patient-years). In contrast, in patients with prostate cancer, the rate of venous thromboembolic recurrences was half the rate of major bleeding (6.9 [95% CI, 4.4-10] vs 13 [95% CI, 9.2-17] events per 100 patient-years), whereas in those with lung cancer, the rate of thromboembolic recurrences was twofold higher than the rate of major bleeding (27 [95% CI, 22-23] vs 11 [95% CI, 8.6-15] per 100 patient-years).

CONCLUSIONS

Significant differences in the clinical profile of venous thromboembolic-related outcomes were observed according to the site of cancer. These findings suggest the development of cancer-specific anticoagulant strategies as an area for further research.

FOTROCAN Delphi consensus statement regarding the prevention and treatment of cancer-associated thrombosis in areas of uncertainty and low quality of evidence

INTRODUCTION

Decision-making in cancer-related venous thromboembolism (VTE) is often founded on scant lines of evidence and weak recommendations. The aim of this work is to evaluate the percentage of agreement surrounding a series of statements about complex, clinically relevant, and highly uncertain aspects to formulate explicit action guidelines.

MATERIALS AND METHODS

Opinions were based on a structured questionnaire with appropriate scores and were agreed upon using a Delphi method. Questions were selected based on a list of recommendations with low evidence from the Spanish Society of Oncology Clinical Guideline for Thrombosis. The questionnaire was completed in two iterations by a multidisciplinary panel of experts in thrombosis.

RESULTS

Of the 123 statements analyzed, the panel concurred on 22 (17%) and another 81 (65%) were agreed on by qualified majority, including important aspects of long-term and prolonged anticoagulation, major bleeding and rethrombosis management, treatment in special situations, catheter-related thrombosis and thromboprophylaxis. Among them, the panelists agreed the incidental events should be equated to symptomatic ones, long-term and extended use of full-dose low-molecular weight heparin, and concluded that the Khorana score is not sensitive enough to uphold an effective thromboprophylaxis strategy.

CONCLUSION

Though the level of consensus varied depending on the scenario presented, overall, the iterative process achieved broad agreement as to the general treatment principles of cancer-associated VTE. Clinical validation of these statements in genuine practice conditions would be useful.

Acute pulmonary embolism detection with ventilation/perfusion SPECT combined with full dose CT: What is the best option?

AIM

To compare diagnostic accuracy of Ventilation/Perfusion (V/P) single-photon emission computed tomography (SPECT) combined with simultaneous full-dose CT with a hybrid SPECT/CT scanner versus planar ventilation/perfusion (V/P) SPECT and CT angiography (CTA) in patients suspected with acute pulmonary embolism (PE).

METHODS

Between 2009 and 2011, consecutive patients suspected of acute PE were referred for V/P SPECT/CT (reviewed board approved study). A contrast agent was administered to patients who had no contraindications. Non-contrast V/P SPECT/CT was performed on the remaining patients. All patients were followed-up for at least 3 months.

RESULTS

A total of 314 patients were available during the study period, with the diagnosis of PE confirmed in 70 (22.29%) of them. The overall population sensitivity and specificity was 90.91% and 92.44%, respectively for V/P SPECT, 80% and 99.15%, respectively, for CTA, and 95.52% and 97.08% for V/P SPECT/CT. SPECT/CT performed better than V/P SPECT (AUC differences=0.0419, P=0.0043, 95% CI; 0.0131-0.0706) and CTA (AUC differences=0.0681, P=0.0208, 95% CI; 0.0103-0.1259)). Comparing imaging modalities when contrast agent could be administered, sensitivity and specificity increased and V/P SPECT/CT was significantly better than CTA (AUC differences=0.0681, P=0.0208, 95% CI; 0.0103-0.1259) and V/P SPECT (AUC differences=0.0659, P=0.0052, 95% CI; 0.0197-0.1121). In case of non-contrast enhancement, there was non-significant increase of specificity. Secondary findings on CT impacted patient management in 14.65% of cases.

CONCLUSION

Our study shows that combined V/P SPECT/CT scanning has a higher diagnostic accuracy for detecting acute PE than V/P SPECT and CTA alone. When feasible, V/P SPECT/CT with contrast enhancement is the best option.

A Prospective Study of the Long-Term Efficacy of Two Different Venoactive Drugs in Patients with Post-Thrombotic Syndrome

Objective:

In an open cross-over study, the effect of two different venoactive drugs was prospectively studied in a series of patients with post-thrombotic syndrome.

Design:

Prospective, open cross-over study.

Patients:

Twenty-nine patients with established unilateral deep venous insufficiency of at least 12 months duration, and a history of venography-proven deep venous thrombosis in the affected leg.

Interventions:

On entering the study, patients were randomly assigned to receive either Hidrosmina (Venosmil, FAES SA, Spain) 600 mg daily, or 0-(β-hydroxyethyl)-rutosides (Venoruton, Zyma SA, Switzerland) 900 mg daily. The drugs were taken for 6 months. At the end of this period, the drug was discontinued, and patients taking Hidrosmina changed to rutosides, or vice versa, for a further 6-month period. Finally, both drugs were discontinued, and patients were re-examined 3 and 6 months later.

Results:

During the first 6-month period, 12 out of 29 patients showed reduced tiredness and/or pain in the leg in comparison to the control visit. Furthermore, a slight reduction was found in mean circumferences of both the ankle and calf during this study period. During the second 6-month period of therapy, six additional patients improved their subjective symptoms, but there were three patients in whom these symptoms had increased. Six months after discontinuation of therapy, subjective symptoms increased in 10 out of 29 patients, and mean circumferences of both the ankle and calf returned to baseline values.

Conclusions:

In this pilot study our findings demonstrate that venoactive drugs may improve both objective and subjective symptoms in patients with post-thrombotic syndrome, and that these effects disappear after drug therapy is discontinued.

Prevention of Post-Thrombotic Syndrome with Hidrosmina: A Prospective Pilot Study

Objective:

In a previous study we demonstrated the beneficial effect of some venoactive drugs when administered to patients with established post-thrombotic syndrome (PTS). The aim of the present study was to assess prospectively the efficacy of one of such drugs in preventing the development of PTS signs.

Design:

Prospective, randomized, open study.

Patients:

100 consecutive patients with a first episode of deep vein thrombosis (DVT), whose diagnosis had been verified with either venography or real-time ultrasonography, were entered in the study.

Interventions:

In addition to anticoagulant therapy, and immediately prior to discharge, patients were randomly allocated to receive Hidrosmina (Venosmil, FAES, Spain) 600 mg daily or no additional treatment. Each patient was followed-up in our outpatient clinic at 4-monthly intervals for a 3-year period. At each visit, patients were carefully examined for the presence of oedema, pigmentation, induration and ulceration. A simple scoring system, as reported by the SVS and the ISCS, was used to assess the severity of symptoms and signs.

Results:

After excluding 17 patients with recurrent DVT, there remained 83 patients, 10 of whom had bilateral DVT. No signs of PTS were found during the 3-year period in 65 out of 93 limbs (70%). Class 1 signs were found in 21 out of 93 limbs (23%), class 2 in 6 out of 93 limbs (6%) and class 3 signs in one limb. PTS was more commonly found in patients in whom DVT had involved the popliteal vein (20/50 vs. 8/43; p < 0.05). Furthermore, PTS developed in 7 out of 46 limbs (15%) in patients taking Hidrosmina vs. 21 out of 47 limbs (45%) in patients not taking the drug ( p < 0.005).

Conclusions:

In this pilot study our findings demonstrate that long-term therapy with Hidrosmina may be useful in preventing the development of PTS signs.

Risk of recurrent venous thromboembolism and major hemorrhage in cancer-associated incidental pulmonary embolism among treated and untreated patients: a pooled analysis of 926 patients

ESSENTIALS: We performed a pooled analysis of 926 patients with cancer-associated incidental pulmonary embolism (IPE). Vitamin K antagonists (VKA) are associated with a higher risk of major hemorrhage. Recurrence risk is comparable after subsegmental and more proximally localized IPE. Our results support low molecular weight heparins over VKA and similar management of subsegmental IPE.

BACKGROUND

Incidental pulmonary embolism (IPE) is defined as pulmonary embolism (PE) diagnosed on computed tomography scanning not performed for suspected PE. IPE has been estimated to occur in 3.1% of all cancer patients and is a growing challenge for clinicians and patients. Nevertheless, knowledge about the treatment and prognosis of cancer-associated IPE is scarce. We aimed to provide the best available evidence on IPE management.

METHODS

Incidence rates of symptomatic recurrent venous thromboembolism (VTE), major hemorrhage, and mortality during 6-month follow-up were pooled using individual patient data from studies identified by a systematic literature search. Subgroup analyses based on cancer stage, thrombus localization, and management were performed.

RESULTS

In 926 cancer patients with IPE from 11 cohorts, weighted pooled 6-month risks of recurrent VTE, major hemorrhage and mortality were 5.8% (95% confidence interval [CI] 3.7-8.3%), 4.7% (95% CI 3.0-6.8%), and 37% (95% CI 28-47%). VTE recurrence risk was comparable under low molecular weight heparins (LMWH) and vitamin K antagonists (VKAs) (6.2% vs. 6.4%; hazard ratio [HR] 0.9; 95% CI 0.3-3.1), while 12% in untreated patients (HR 2.6; 95% CI 0.91-7.3). Risk of major hemorrhage was higher under VKAs than under LMWH (13% vs. 3.9%; HR 3.9; 95% CI 1.6-10). VTE recurrence risk was comparable in patients with an subsegmental IPE and those with a more proximally localized IPE (HR 1.1; 95% CI 0.50-2.4).

CONCLUSION

These results support the current recommendation to anticoagulate cancer-associated IPE with LMWH and argue against different management of subsegmental IPE.

A prognostic score to identify low-risk outpatients with acute deep vein thrombosis in the upper extremity

BACKGROUND

No studies have identified which patients with upper-extremity deep vein thrombosis (DVT) are at low risk for adverse events within the first week of therapy.

METHODS

We used data from Registro Informatizado de la Enfermedad TromboEmbólica to explore in patients with upper-extremity DVT a prognostic score that correctly identified patients with lower limb DVT at low risk for pulmonary embolism, major bleeding, or death within the first week.

RESULTS

As of December 2014, 1135 outpatients with upper-extremity DVT were recruited. Of these, 515 (45%) were treated at home. During the first week, three patients (0.26%) experienced pulmonary embolism, two (0.18%) had major bleeding, and four (0.35%) died. We assigned 1 point to patients with chronic heart failure, creatinine clearance levels 30-60 mL min(-1) , recent bleeding, abnormal platelet count, recent immobility, or cancer without metastases; 2 points to those with metastatic cancer; and 3 points to those with creatinine clearance levels < 30 mL min(-1) . Overall, 759 (67%) patients scored ≤ 1 point and were considered to be at low risk. The rate of the composite outcome within the first week was 0.26% (95% confidence interval [CI] 0.004-0.87) in patients at low risk and 1.86% (95% CI 0.81-3.68) in the remaining patients. C-statistics was 0.73 (95% CI 0.57-0.88). Net reclassification improvement was 22%, and integrated discrimination improvement was 0.0055.

CONCLUSIONS

Using six easily available variables, we identified outpatients with upper-extremity DVT at low risk for adverse events within the first week. These data may help to safely treat more patients at home.

Treatment of venous thromboembolism in cancer patients with dalteparin for up to 12 months: the DALTECAN Study

BACKGROUND

Treatment of venous thromboembolism (VTE) in patients with cancer has a high rate of recurrence and bleeding complications. Guidelines recommend low-molecular-weight heparin (LMWH) for at least 3-6 months and possibly indefinitely for patients with active malignancy. There are, however, few data supporting treatment with LMWH beyond 6 months. The primary aim of the DALTECAN study (NCT00942968) was to determine the safety of dalteparin between 6 and 12 months in cancer-associated VTE.

METHODS

Patients with active cancer and newly diagnosed VTE were enrolled in a prospective, multicenter study and received subcutaneous dalteparin for 12 months. The rates of bleeding and recurrent VTE were evaluated at months 1, 2-6 and 7-12.

FINDINGS

Of 334 patients enrolled, 185 and 109 completed 6 and 12 months of therapy; 49.1% had deep vein thrombosis (DVT); 38.9% had pulmonary embolism (PE); and 12.0% had both on presentation. The overall frequency of major bleeding was 10.2% (34/334). Major bleeding occurred in 3.6% (12/334) in the first month, and 1.1% (14/1237) and 0.7% (8/1086) per patient-month during months 2-6 and 7-12, respectively. Recurrent VTE occurred in 11.1% (37/334); the incidence rate was 5.7% (19/334) for month 1, 3.4% (10/296) during months 2-6, and 4.1% (8/194) during months 7-12. One hundred and sixteen patients died, four due to recurrent VTE and two due to bleeding.

CONCLUSION

Major bleeding was less frequent during dalteparin therapy beyond 6 months. The risk of developing major bleeding complications or VTE recurrence was greatest in the first month of therapy and lower over the subsequent 11 months.

A prognostic score to identify low-risk outpatients with acute deep vein thrombosis in the lower limbs

BACKGROUND

No prior studies have identified which patients with deep vein thrombosis in the lower limbs are at a low risk for adverse events within the first week of therapy.

METHODS

We used data from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) to identify patients at low risk for the composite outcome of pulmonary embolism, major bleeding, or death within the first week. We built a prognostic score and compared it with the decision to treat patients at home.

RESULTS

As of December 2013, 15,280 outpatients with deep vein thrombosis had been enrolled. Overall, 5164 patients (34%) were treated at home. Of these, 12 (0.23%) had pulmonary embolism, 8 (0.15%) bled, and 4 (0.08%) died. On multivariable analysis, chronic heart failure, recent immobility, recent bleeding, cancer, renal insufficiency, and abnormal platelet count independently predicted the risk for the composite outcome. Among 11,430 patients (75%) considered to be at low risk, 15 (0.13%) suffered pulmonary embolism, 22 (0.19%) bled, and 8 (0.07%) died. The C-statistic was 0.61 (95% confidence interval [CI], 0.57-0.65) for the decision to treat patients at home and 0.76 (95% CI, 0.72-0.79) for the score (P = .003). Net reclassification improvement was 41% (P < .001). Integrated discrimination improvement was 0.034 for the score and 0.015 for the clinical decision (P < .001).

CONCLUSIONS

Using 6 easily available variables, we identified outpatients with deep vein thrombosis at low risk for adverse events within the first week. These data may help to safely treat more patients at home. This score, however, should be validated.

Trend and seasonality in hospitalizations for pulmonary embolism: a time-series analysis

BACKGROUND

The existence of seasonal variability in patients with acute pulmonary embolism (PE) has been debated for years, with contradictory results. The aim of this study was to identify the trend and possible existence of a seasonal pattern in hospitalizations for PE in Spain.

METHODS

We analyzed the hospital discharge database of the Spanish National Health System from 2001 to 2010. Patients aged > 14 years diagnosed with PE were selected and a time series was constructed considering mean daily admissions for PE by month. The trend and seasonality factor of the series were determined using time-series analysis, and time-series modeling was used for analysis. Exponential smoothing models and the autoregressive integrated moving average test were used to generate a predictive model.

RESULTS

From 2001 to 2010, there were 162,032 diagnoses of PE (5.07 per 1000 hospitalizations). In 105,168 cases, PE was the reason for admission. The PE diagnosis rate ranged from 4.14 per 1000 in 2001 to 6.56 per 1000 in 2010; and hospital admissions due to PE ranged from 2.67 to 4.28 per 1000 hospital discharges. Time-series analysis showed a linear increase in the incidence and a significant seasonal pattern with 17% more admissions in February and 12% fewer in June-July with respect to the central tendency (difference from February to June, 29%).

CONCLUSIONS

The incidence of hospitalizations for PE showed a linear increase and a seasonal pattern, with the highest number of admissions in winter and the lowest number in summer.

Prognostic significance of tricuspid annular displacement in normotensive patients with acute symptomatic pulmonary embolism

BACKGROUND

Tricuspid annular plane systolic excursion (TAPSE) is an emerging prognostic indicator in patients with acute symptomatic pulmonary embolism (PE).

METHODS AND RESULTS

We prospectively examined 782 normotensive patients with PE who underwent echocardiography in a multicenter study. As compared with patients with a TAPSE of > 1.6 cm, those with a TAPSE of ≤ 1.6 cm had increased systolic pulmonary artery pressure (53.7 ± 16.7 mmHg vs. 40.0 ± 15.5 mmHg, P < 0.001), right ventricle (RV) end-diastolic diameter (3.5 ± 0.8 cm vs. 3.0 ± 0.6 cm, P < 0.001), and RV to left ventricle end-diastolic diameter ratio (1.0 ± 0.3 vs. 0.8 ± 0.2, P < 0.001), and a higher prevalence of RV free wall hypokinesis (68% vs. 11%, P < 0.001). Patients with a TAPSE of ≤ 1.6 cm at the time of PE diagnosis were significantly more likely to die from any cause (hazard ratio [HR] 2.3; 95% confidence interval [CI] 1.2-4.7; P = 0.02) and from PE (HR 4.4; 95% CI 1.3-15.3; P = 0.02) during follow-up. In an external validation cohort of 1326 patients with acute PE enrolled in the international multicenter Registro Informatizado de la Enfermedad TromboEmbólica, a TAPSE of ≤ 1.6 cm remained a significant predictor of all-cause mortality (HR 2.1; 95% CI 1.3-3.2; P = 0.001) and PE-specific mortality (HR 2.5; 95% CI 1.2-5.2; P = 0.01).

CONCLUSIONS

In normotensive patients with PE, TAPSE reflects right ventricular function. For these patients, TAPSE is independently predictive of survival.