Thrombosis Update最新文献

Aim

The risk of venous thromboembolism (VTE) and arterial thrombosis events (ATE) and potential corresponding risk factors were assessed in patients with cancer diagnosed with COVID-19.

Methods

Adults with cancer treated in community health systems who were diagnosed with COVID-19 in 2020 were evaluated for absolute risk (risk) of ATE and VTE. Thrombotic events were ascertained in the 90-day window starting with COVID-19 diagnosis (index). ICD codes defined baseline comorbidities, COVID-19, and thrombotic events.

Results

7591 patients were included with median age of 67, 6% with cardiovascular disease (CVD), 4% with prior VTE, and 24% were hospitalized at index. Risk of ATE and VTE were 2.1% (95%CI: 1.8, 2.5) and 3.2% (95%CI: 2.8, 3.6), respectively. Patients with CVD had increased risk [ATE: 20.1% (95%CI: 16.7, 24.1); VTE: 4.9% (95%CI: 3.3, 7.3)] as did patients with prior VTE [ATE: 3.8% (95%CI: 2.2, 6.6; VTE: 20.5% (95%CI: 16.4, 25.3)] and patients hospitalized with ventilator support [(ATE: 5.7% (95%CI: 2.6, 11.8; VTE: 6.6% (95%CI: 3.2, 13.0)]. Incidence rates for ATE and VTE were 0.094 and 0.141 per person-year, respectively.

Conclusions

This study of cancer patients, conducted in a time period prior to vaccine availability, found patients with CVD, prior VTE, and with higher severity of COVID-19 were at increased risk for ATE and VTE. Identifying patients most at risk can help to target interventions.

Background

The use of anticoagulant medications is complex and prone to inappropriate prescribing that impacts patient safety. Anticoagulation stewardship is a growing field that requires more focus and attention.

Aim

This review aimed to retrieve and synthesise the available research studies on the clinical and economic value of Anticoagulation Stewardship Programmes (ASPs) in line with the Anticoagulation Forum Core Elements of Anticoagulation Stewardship.

Methods

A comprehensive electronic literature search was conducted using three databases (Cochrane Central Register of Controlled Trials (CENTRAL), Embase and PubMed) from inception up to and including January 2023. Inclusion criteria were primary research studies where the purpose of the study was any hospital ASP intervention applicable to optimising antithrombotic drug use, across all anticoagulation medications and in adult hospital inpatients.

Results

A total of 787 records were identified after duplicates were removed. Twenty-eight papers were included in this review. Twenty-four of these studies were single-centre studies; four of these studies were multi-centre studies. Eleven studies took a prospective approach, fifteen took a retrospective approach and two were quasi-experimental studies. Interventions implemented by either multidisciplinary ASP teams or pharmacist-led anticoagulation services included the provision of education to healthcare professionals and patients, undertaking medication reviews and implementing guidelines and protocols, and interventions to facilitate transitions of care. Clinical benefits to patients and cost savings were observed across many studies.

Conclusion

Implementing multidisciplinary ASP teams and pharmacist-led anticoagulation services is associated with an overall improvement in the safe use of anticoagulation among hospital patients. Studies identified incorporated some of the core elements of ASP, however further work and research are necessary to standardise the adoption and implementation of ASP and ensure that it is prioritised among healthcare professionals, in the healthcare setting, and among health systems and policy-makers.

Objective

The purpose of our study was to examine risk factors for venous thromboembolism (VTE) and VTE associated mortality in elderly acute lymphocytic leukemia (ALL) patients receiving different treatment options.

Methods

We analyzed data from the United States SEER-Medicare database (2007–2015) for patients ≥65 years diagnosed with ALL. Data were stratified by treatment options into three groups as chemotherapy: the use of antimetabolites, anthracyclines, alkylating agents or vinca alkaloids; other treatment: the use of corticosteroids/tyrosine kinase inhibitors without chemotherapy; and no treatment. Logistic regression was used to examine risk factors for VTE and Cox proportional regression was used to evaluate Hazard Ratios (HRs) for the effect of VTE on mortality in ALL patients.

Results

In a cohort of 1088 elderly ALL patients, 17.4 % patients had a diagnosis of VTE. VTE was diagnosed in 27.7 % of 159 patients who received chemotherapy, 16.2 % of 328 patients who received other treatment, and 15.3 % of 601 patients who did not receive any treatment (p < 0.001). Adjusted odds of VTE were 1.59 (95 % CI, 1.02–2.48) in patients who received chemotherapy, and OR_a = 0.88 (95 % CI, 0.60–1.30) in those who received other treatment, compared to those who did not receive any treatment. VTE was not associated with the risk of death in ALL patients (HR_a = 0.85, 95 % CI, 0.70–1.02).

Conclusion

Our study identified VTE risk factors and the effect of VTE on mortality in elderly ALL patients with and without treatment.

Pulmonary embolism is a common disease associated with significant morbidity and mortality. Existing validated risk stratification tools have enabled the rapid identification of patients with low versus high-risk pulmonary embolism. Intermediate-high risk pulmonary embolism is defined as pulmonary embolism with haemodynamic stability, evidence of right ventricular dysfunction and elevated cardiac biomarkers. The therapeutic management of intermediate-high risk pulmonary embolism in the acute setting is challenging as these patients are often unwell, but do not fulfil criteria for high-risk pulmonary embolism. Although current guidelines recommend prompt first-line treatment with systemic anticoagulation and monitoring for deterioration, alternative strategies are being increasingly considered in this cohort. These include systemic or catheter-directed thrombolysis, surgical embolectomy, and mechanical circulatory support. In this case series, we discuss three cases of intermediate-high risk pulmonary embolism with a focus on multidisciplinary decision making in clinical management. Following on from this, we provide a brief narrative review of the current literature and guidelines surrounding this topic, considering the risks and benefits of alternative therapy options on patient outcomes.

Aims

The identification of venous thromboembolism (VTE) using administrative databases is frequently required for reporting and research. The accuracy of International Classification of Diseases 10th revision (ICD-10) codes for VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE), remains unclear. We examined the accuracy of ICD-10 codes for identifying VTE in adult and pediatric inpatients and outpatients.

Methods

For this systematic review and meta-analysis, we searched MEDLINE, EMBASE, Web of Science, CENTRAL, Epistemonikos and McMaster Superfilters from inception to July 25, 2023 for studies evaluating the sensitivity, specificity, positive predictive value (PPV), and/or negative predictive value (NPV) of ICD-10 codes for VTE in any anatomical location. We assessed risk of bias using QUADAS and certainty of evidence using GRADE. We calculated pooled sensitivity and specificity with 95% confidence intervals (CI) using a random-effects model.

Results

We included 24 studies in the qualitative synthesis and 7 in the meta-analysis. Pooled sensitivity for any VTE based on ICD-10 codes was 72% (95% CI 60–85%, low certainty); pooled specificity was 82% (95% CI 76–88%, low certainty). The PPV for ICD-10 VTE codes ranged from 0% to 100% (median: 80%) while the NPV ranged from 95.4% to 100% (median: 100%). ICD-10 codes for PE had a higher pooled sensitivity (91%) than for DVT (58%).

Conclusion

ICD-10 codes have moderate-to-high sensitivity and specificity for the identification of VTE in electronic databases. The certainty of evidence is low due to inconsistency and risk of bias. Further robust studies validating ICD-10 VTE codes are needed to improve reporting and better understand coding limitations.

Background

Venous thromboembolism (VTE) remains one of the leading causes of morbidity and mortality during pregnancy and the postpartum period. Despite that, the prevention and management of VTEs in pregnant patients is an area of great debate.

Objectives

The aim of this systematic review was to evaluate the risk of VTE recurrence during pregnancy for pregnant patients with prior personal history of VTE and the effect of LMWH on such risk.

Methods

MEDLINE and EMBASE were searched between January 2000 to December 2022. We included studies that evaluated pregnant patients with previous personal history of VTE and assessed VTE recurrence with or without thromboprophylaxis. A meta-analysis of proportions was done through a Freeman–Tukey transformation using random effect models.

Results

30 studies were included in this systematic review. The studies included 5075 pregnant patients with a previous history of DVT or PE. We found a wide variability in thromboprophylaxis strategies. The estimated pooled proportions of VTE recurrence were 2.5% (95% CI 1.8–3.3) in patients who were consistently on anticoagulation during pregnancy (pre- and post-partum), 4.7% (95% CI 1.8–8.8) in patients who received anticoagulation in the postpartum period only, and 13.6% (95% CI 6.5 to 22.8) in patients who were not on anticoagulation.

Conclusions

In patients with a previous VTE history receiving prophylactic anticoagulation (either both pre- and post-partum or post-partum only), the estimates of VTE recurrence were lower than for patients who did not receive prophylaxis, however, a direct comparison was not possible. The optimal thromboprophylaxis strategy remains unknown.

Thrombosis is a common and serious event in cancer patients. While risk factors are well established in solid tumors and have lead to guidance regarding prophylaxis, similar data and recommendations are lacking for patients with hematologic malignancies. Likewise treatment for established venous thrombosis in cancer patients has shifted from low molecular weight heparin to direct oral anticoagulants (DOACs) based on favorable outcomes with the latter drugs in most tumor types while hematologic malignancies remain understudied and the appropriateness of DOAC use in these patients is less certain. Reasons for the knowledge gaps that have developed regarding management of thrombosis in hematologic malignancies include their relative rarity compared to solid organ cancer making large scale trials difficult to complete, and the particular nature of blood cancers and their treatment giving rise frequently to severe thrombocytopenia which is typically regarded as an exclusion from clinical trials.

In this review we discuss landmark studies and other available literature regarding management of thromboembolism in hematologic malignancies and highlight unique features of these diseases and their treatment in this context.

Hospitalisation with an acute medical illness represents a significant risk factor for venous thromboembolism. Identification of patients at high risk of VTE at hospital admission and provision of appropriate thromboprophylaxis is a key intervention to improve patient safety during hospitalisation. The successful implementation of a systematic approach to VTE prevention in England highlights the effectiveness of this approach. However, the optimal strategy for identification of at-risk patients enabling targeted thromboprophylaxis provisions remains uncertain and many VTE events occur despite provision of appropriate thromboprophylaxis. In this narrative review, we discuss the pros and cons of commonly utilised VTE risk assessment tools for acutely ill medical patients, the current controversies in optimal dosing and duration of thromboprophylaxis and highlight special patient populations where further research is required.