scholarly journals Routine advanced echocardiography in the evaluation of cardiovascular sequelae of COVID19 survivors with elevated cardiovascular biomarkers

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
E Rodenas Alesina ◽  
J Rodriguez-Palomares ◽  
M Oller-Bach ◽  
P Jordan ◽  
C Badia ◽  
...  
Keyword(s):  
Screening Program ◽  
Global Longitudinal Strain ◽  
Tertiary Referral Hospital ◽  
Vein Thrombosis ◽  
Funding Sources ◽  
Major Cardiovascular Events ◽  
And Function ◽  
Cardiovascular Biomarkers ◽  
D Dimer

Abstract Background COVID19 has been related to elevated CVB and biventricular dysfunction during hospitalization. However, it is unknown whether patients with biomarker elevation exhibit long-lasting abnormalities in cardiac function. Purpose To determine, using advanced echocardiography, the prevalence and type of cardiovascular sequelae after COVID19 infection with marked elevation of cardiovascular biomarkers (CVB), and their prognostic implications. Methods All patients admitted from March 1st to May 25th, 2020 to a tertiary referral hospital were included. Patients with cardiovascular disease antecedent, death during admission, or the first 30 days after discharge were excluded. Patients with hs-TnI >45 ng/L, NT-proBNP >300 pg/ml, and D-dimer >8000 ng/ml were separated based on each CVB elevation and matched with COVID controls (three biomarkers within the normal range) based on intensive care requirements and age. Results From a total of 2025 hospitalized COVID19 patients, 80 patients with significantly elevated CVB and 29 controls were finally included. No differences in baseline characteristics were observed among groups, but elevated CVB patients were sicker. Follow-up echocardiograms showed no differences among groups regarding LVEF or RV diameters, but TAPSE was lower if hs-TnI or D-dimer were elevated. Hs-TnI patients also had lower global myocardial work and global longitudinal strain. The presence of an abnormal echocardiogram was more frequent in the elevated CVB group compared to controls (23.8 vs 10.3%, P=0.123) but mainly associated with mild abnormalities in deformation parameters. Management did not change in any case and no major cardiovascular events except deep vein thrombosis occurred after a median follow-up of 7 months (Figure 1). Conclusions Minimal abnormalities in cardiac structure and function are observed in COVID19 survivors without previous cardiovascular diseases who presented a significant CVB rise at admission, with no impact on patient management or short-term prognosis. These results do not support a routine screening program after discharge in this population. FUNDunding Acknowledgement Type of funding sources: None. Figure 1

Impact of rhythm in non-valvular atrial fibrillation on four cardiac chamber deformation imaging

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
P Philabout ◽  
L Soulat-Dufour ◽  
I Benhamou-Tarallo ◽  
S Lang ◽  
S Ederhy ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Cardiac Rhythm ◽  
Longitudinal Strain ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Cardiac Chamber ◽  
Deformation Imaging ◽  
And Function

Abstract Background Few studies have assessed the evolution of cardiac chambers deformation imaging in patients with atrial fibrillation (AF) according to cardiac rhythm outcome. Purpose To evaluate cardiac chamber deformation imaging in patients admitted for AF and the evolution at 6-month follow-up (M6). Methods In forty-one consecutive patients hospitalised for AF two-dimensional transthoracic echocardiography was performed at admission (M0) and after six months (M6) of follow up. In addition to the usual parameters of chamber size and function, chamber deformation imaging was obtained including global left atrium (LA) and right atrium (RA) reservoir strain, global left ventricular (LV) and right ventricular (RV) free wall longitudinal strain. Patients were divided into three groups according to their cardiac rhythm at M0 and M6: AF at M0 and sinus rhythm (SR) at M6 (AF-SR) (n=23), AF at M0 and AF at M6 (AF-AF) (n=11), SR at M0 (spontaneous conversion before the first echocardiography exam) and SR in M6 (SR-SR) (n=7) Results In comparison with SR patients (n=7), at M0, AF patients (n=34)) had lower global LA reservoir strain (+5.2 (+0.4 to 12.8) versus +33.2 (+27.0 to +51.5)%; p<0.001), lower global RA reservoir strain (+8.6 (−5.4 to 11.6) versus +24.3 (+12.3 to +44.9)%; p<0.001), lower global LV longitudinal strain (respectively −12.8 (−15.2 to −10.4) versus −19.1 (−21.8 to −18.3)%; p<0.001) and lower global RV longitudinal strain (respectively −14.2 (−17.3 to −10.7) versus −23.8 (−31.1 to −16.2)%; p=0.001). When compared with the AF-SR group at M0 the AF-AF group had no significant differences with regard to global LA and RA reservoir strain, global LV and RV longitudinal strain (Table). Between M0 and M6 there was a significant improvement in global longitudinal strain of the four chambers in the AF-SR group whereas no improvements were noted in the AF-AF and SR-SR group (Figure). Conclusion Initial atrial and ventricular deformations were not associated with rhythm outcome at six-month follow up in AF. The improvement in strain in all four chambers strain suggests global reverse remodelling all cardiac cavities with the restoration of sinus rhythm. Evolution of strain between M0 and M6 Funding Acknowledgement Type of funding source: None

Risk of Venous Thromboembolism Recurrence: High Negative Predictive Value of D-dimer Performed after Oral Anticoagulation Is Stopped

2002 ◽  
Vol 87 (01) ◽  
pp. 7-12 ◽  
Author(s):  
Cristina Legnani ◽  
Benilde Cosmi ◽  
Giuliana Guazzaloca ◽  
Claudia Pancani ◽  
Sergio Coccheri ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Recurrent Events ◽  
Oral Anticoagulant Therapy ◽  
Lower Limbs ◽  
First Episode ◽  
Vein Thrombosis ◽  
D Dimer

SummaryIn some patients with previous venous thromboembolism (VTE) D-dimer levels (D-Dimer) tend to increase after oral anticoagulant therapy (OAT) is stopped. The aim of our study was to evaluate the predictive value of D-Dimer for the risk of VTE recurrence after OAT withdrawal. After a first episode of deep vein thrombosis (DVT) of the lower limbs and/or pulmonary embolism (PE), 396 patients (median age 67 years, 198 males) were followed from the day of OAT discontinuation for 21 months. D-dimer was measured on the day of OAT withdrawal (T1), 3-4 weeks (T2) and 3 months (+/− 10 days, T3) thereafter. The main outcome events of the study were: objectively documented recurrent DVT and/or PE. D-dimer was found to be increased in 15.5%, 40.3% and 46.2% of the patients at T1, T2 and T3, respectively. In 199 (50.2%) patients, D-dimer levels were elevated in at least one measurement. During a follow-up of 628.4 years, 40 recurrences were recorded (10.1% of patients; 6.4% patient-years of follow-up). D-dimer was increased in at least one measurement in 28 of these cases, but remained normal in 11 subjects (three of whom had recurrent events triggered by circumstantial factors, three with malignancyassociated factors) (in one subject D-dimer was not measured). The negative predictive value (NPV) of D-dimer was 95.6% (95% CI 91.6-98.1) at T3 and was even higher (96.7%; 95% CI 92.9-98.8) after exclusion of the six recurrences due to circumstantial factors. Only five idiopathic recurrences occurred in the 186 patients with consistently normal D-dimer. In conclusion, D-dimer has a high NPV for VTE recurrence when performed after OAT discontinuation.

scholarly journals Safety of a strategy combining D-dimer testing and whole-leg ultrasonography to rule out deep vein thrombosis

2020 ◽  
Vol 4 (20) ◽  
pp. 5002-5010
Author(s):  
Synne G. Fronas ◽  
Camilla T. Jørgensen ◽  
Anders E. A. Dahm ◽  
Hilde S. Wik ◽  
Jostein Gleditsch ◽  
...  
Keyword(s):  
Deep Vein Thrombosis ◽  
Pretest Probability ◽  
Vein Thrombosis ◽  
Venous Thromboembolic ◽  
Deep Vein ◽  
D Dimer ◽  
Rule Out ◽  
Compression Ultrasonography ◽  
High Pretest Probability

Abstract Guidelines for the diagnostic workup of deep vein thrombosis (DVT) recommend assessing the clinical pretest probability before proceeding to D-dimer testing and/or compression ultrasonography (CUS) if the patient has high pretest probability or positive D-dimer. Referring only patients with positive D-dimer for whole-leg CUS irrespective of pretest probability may simplify the workup of DVT. In this prospective management outcome study, we assessed the safety of such a strategy. We included consecutive outpatients referred to the Emergency Department at Østfold Hospital, Norway, with suspected DVT between February 2015 and November 2018. STA-Liatest D-Di Plus D-dimer was analyzed for all patients, and only patients with levels ≥0.5 µg/mL were referred for CUS. All patients with negative D-dimer or negative CUS were followed for 3 months to assess the venous thromboembolic rate. One thousand three hundred ninety-seven patients were included. Median age was 64 years (interquartile range, 52-73 years), and 770 patients (55%) were female. D-dimer was negative in 415 patients (29.7%) and positive in 982 patients (70.3%). DVT was diagnosed in 277 patients (19.8%). Six patients in whom DVT was ruled out at baseline were diagnosed with DVT within 3 months of follow-up for a thromboembolic rate of 0.5% (95% confidence interval, 0.2-1.2). A simple diagnostic approach with initial stand-alone D-dimer followed by a single whole-leg CUS in patients with positive D-dimer safely ruled out DVT. We consider this strategy to be a valuable alternative to the conventional workup of DVT in outpatients. This trial was registered at www.clinicaltrials.gov as #NCT02486445.

scholarly journals P001: Age-adjusted D-dimer and two-site compression point of care ultrasonography to rule out acute deep vein thrombosis - a pilot study

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S57-S57
Author(s):  
K. Alqaydi ◽  
J. Turner ◽  
L. Robichaud ◽  
D. Hamad ◽  
X. Xue ◽  
...  
Keyword(s):  
Deep Vein Thrombosis ◽  
Point Of Care ◽  
Screening Tools ◽  
Duplex Scan ◽  
Vein Thrombosis ◽  
Wells Score ◽  
Deep Vein ◽  
D Dimer ◽  
Rule Out

Introduction: Deep vein thrombosis (DVT) can lead to significant morbidity and mortality if not diagnosed and treated promptly. Currently, few methods aside from venous duplex scanning can rule out DVT in patients presenting to the Emergency Department (ED). Current screening tools, including the use of the subjective Wells score, frequently leads to unnecessary investigations and anticoagulation. In this study, we sought to determine whether two-site compression point-of-care ultrasound (POCUS) combined with a negative age-adjusted D-dimer test can accurately rule out DVT in ED patients irrespective of the modified Wells score. Methods: This is a single-center, prospective observational study in the ED of the Jewish General Hospital in Montreal. We are recruiting a convenience sample of patients presenting to the ED with symptoms suggestive of DVT. All enrolled patients are risk-stratified using the modified Wells criteria for DVT, then undergo two-site compression POCUS, and testing for age-adjusted D-dimer. Patients with DVT unlikely according to modified Wells score, negative POCUS and negative age-adjusted D-dimer are discharged home and receive a three-month phone follow-up. Patients with DVT likely according to modified Wells score, a positive POCUS or a positive age-adjusted D-dimer, will undergo a venous duplex scan. A true negative DVT is defined as either a negative venous duplex scan or a negative follow-up phone questionnaire for patients who were sent home without a venous duplex scan. Results: Of the 42 patients recruited thus far, the mean age is 56 years old and 42.8% are male. Twelve (28.6%) patients had DVT unlikely as per modified Wells score, negative POCUS and negative age-adjusted D-dimer and were discharged home. None of these patients developed a DVT on three-month follow-up. Thirty patients (71.4%) had either a DVT likely as per modified Wells score, a positive POCUS or a positive age-adjusted D-dimer and underwent a venous duplex scan. Of those, six patients had a confirmed DVT (3 proximal & 3 distal). POCUS detected all proximal DVTs, while combined POCUS and age-adjusted D-dimer detected all proximal and distal DVTs. None of the patients with a negative POCUS and age-adjusted D-dimer were found to have a DVT. Conclusion: Two-site compression POCUS combined with a negative age-adjusted D-dimer test appears to accurately rule out DVT in ED patients without the need for follow-up duplex venous scan. Using this approach would alleviate the need to calculate the Wells score, and also reduce the need for radiology-performed duplex venous scan for many patients.

scholarly journals Risk of Deep Vein Thrombosis After Acute Achilles Tendon Rupture: A Secondary Analysis of a Randomized Controlled Trial Comparing Early Controlled Motion of the Ankle Versus Immobilization

2020 ◽  
Vol 8 (4) ◽  
pp. 232596712091590 ◽  
Author(s):  
Kristoffer Weisskirchner Barfod ◽  
Emil Graakjær Nielsen ◽  
Beth Hærsted Olsen ◽  
Pablo Gustavo Vinicoff ◽  
Anders Troelsen ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Achilles Tendon ◽  
Tendon Rupture ◽  
Controlled Trial ◽  
Achilles Tendon Rupture ◽  
Vein Thrombosis ◽  
Randomized Controlled ◽  
Deep Vein ◽  
D Dimer

Background: Immobilization of the ankle joint has been suggested as a key element in the pathogenesis leading to deep vein thrombosis (DVT). Purpose: To investigate whether early controlled ankle motion (ECM) could reduce the incidence of DVT compared with immobilization (IM) in the treatment of acute Achilles tendon rupture. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients aged 18 to 70 years were eligible for inclusion, and treatment was nonoperative. The ECM group performed movements of the ankle 5 times a day from weeks 3 to 8 after rupture. The control group was immobilized for 8 weeks. The outcome measure was DVT diagnosed with color Doppler ultrasound for above- and below-knee DVT at 2 and 8 weeks. The Achilles tendon Total Rupture Score, the heel-rise work test, and the Copenhagen Achilles ultrasonographic Length Measurement were performed at 4-, 6-, and 12-month follow-up. Results: A total of 189 patients were assessed for eligibility from February 2014 to December 2016. Of these, 130 were randomized: 68 patients were allocated to the ECM group and 62 to the IM group. All patients participated in follow-up at 8 weeks assessing for DVT. In total, 62 (47.7%) patients were diagnosed with DVT: 33 of 68 (48.5%) in the ECM group and 28 of 61 (46.8%) in the IM group ( P = .84). DVT did not affect treatment outcomes at 4, 6, and 12 months. D-dimer had low sensitivity (71%) for detecting DVT. Conclusion: We found that 1 in 2 patients presented with DVT in nonoperative treatment of acute Achilles tendon rupture. The ECM protocol revealed no benefit versus IM in reducing the incidence of DVT. DVT did not influence functional and patient-reported outcomes the first year after rupture. D-dimer seems an inappropriate test for detection of DVT in patients with acute Achilles tendon rupture. Registration: NCT02015364 ( ClinicalTrials.gov identifier).

scholarly journals Residual Vein Thrombosis Echogenicity Is Associated to the Risk of DVT Recurrence: A Cohort Study

2017 ◽  
Vol 24 (3) ◽  
pp. 477-482 ◽  
Author(s):  
Bruna M. Mazetto ◽  
Fernanda L. A. Orsi ◽  
Sandra A. F. Silveira ◽  
Luis F. Bittar ◽  
Mariane M. C. Flores-Nascimento ◽  
...  
Keyword(s):  
Deep Vein Thrombosis ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Late Complication ◽  
Predictive Marker ◽  
Predictive Markers ◽  
Vein Thrombosis ◽  
Deep Vein ◽  
D Dimer

Although deep vein thrombosis (DVT) recurrence is a common late complication of the disease, there are few predictive markers to risk-stratify patients long-term after the thrombotic event. The accuracy of residual vein thrombosis (RVT) in this context is controversial, possibly due to a lack of a standardized methodology. The objective of the study was to evaluate the accuracy of RVT echogenicity as a predictive marker of late DVT recurrence. To evaluate the accuracy of RVT echogenicity as a predictive marker of late DVT recurrence. This prospective study included patients with history of DVT in the past 33 months. Ultrasound examination was performed to detect the presence of RVT, and its echogenicity was determined by calculating the grayscale median (GSM) of the images. Blood samplings were taken for plasma D-dimer levels. Patients were followed-up for 28 months and the primary end point was DVT recurrence. Deep vein thrombosis recurrence was confirmed or excluded by ultrasound during the follow-up. Fifty-six patients were included, of which 10 presented DVT recurrence during the follow-up. D-dimer levels above 630 ng/mL conferred higher risk for recurrence with a negative predictive value of 94%. The absence of RVT was a protective marker for recurrence with a negative predictive value of 100%. Also, the presence of hypoechoic RVT, determined by GSM values below 24, positively predicted 75% of DVT recurrences. Our results suggest that the persistence of RVT and, particularly, the presence of hypoechoic thrombi (GSM < 24) are predictive markers of the risk of DVT recurrence. Residual vein thrombosis echogenicity, by GSM analysis, could represent a new strategy for the evaluation of recurrence risk in patients with DVT.

Abstract 40: Duration of Prediabetes is Associated with Subclinical Atherosclerosis and Cardiac Dysfunction in Middle-Age: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Circulation ◽  
2017 ◽  
Vol 135 (suppl_1) ◽  
Author(s):  
Jared P Reis ◽  
Norrina B Allen ◽  
Michael P Bancks ◽  
Jeffrey J Carr ◽  
Cora E Lewis ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Cardiac Dysfunction ◽  
Middle Age ◽  
Subclinical Atherosclerosis ◽  
Global Longitudinal Strain ◽  
Oral Glucose ◽  
Cardiac Structure ◽  
Cvd Risk ◽  
And Function

Background: A prolonged duration of diabetes has been shown to be independently associated with incident cardiovascular disease (CVD). Whether duration of prediabetes is similarly associated with CVD is unknown. We sought to determine whether the duration of prediabetes during young adulthood is associated with the presence of coronary artery calcified plaque (CAC) and cardiac structure/function in middle-age. Methods: Participants were 3244 white and black adults aged 18-30 years without prediabetes or diabetes at baseline (1985-86) or diabetes during follow-up in the multicenter community-based CARDIA Study. Prediabetes was defined at follow-up examinations 7, 10, 15, 20, and 25 years after baseline as fasting glucose 100-125 mg/dL, 2-hour oral glucose tolerance 140-199 mg/dL or HbA1c 5.7-6.4%. Presence of CAC was measured by computed tomography at follow-up years 15, 20, and 25. Measures of cardiac structure and function were obtained from echocardiography performed at year 25. Results: Of the 3244 individuals, 1561 (48.2%) developed prediabetes during follow-up. Among those who developed prediabetes, the median (IQR) duration was 10 (5-12) years. After adjustment for age, sex, race, education, study center, and CVD risk factors, the hazard ratio for the presence of CAC was 1.21 times higher for each 10-year increase in duration of prediabetes (95% CI: 1.06, 1.37). Duration of prediabetes was also associated with worse global longitudinal strain (per 10 years: 0.2%; 95% CI: 0.1, 0.4; P=.005), e′ (-0.2 cm/s; 95% CI: -0.3, -0.1; P < .001), and E/e′ ratio (0.113; 95% CI: -0.007, 0.233; P=.06) ( Table ). These results did not differ significantly by race or sex. Conclusions: Exposure to a longer duration of prediabetes is associated with subclinical atherosclerosis and cardiac dysfunction in middle-age. Further research is needed to better understand the pathophysiology of these relationships.

Deep Vein Thrombosis Diagnosis with D-Dimer Adjusted to Clinical Probability

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 20-20
Author(s):  
Kerstin de Wit ◽  
Sameer Papira ◽  
Sam Schulman ◽  
Fred Spencer ◽  
Sangita Sharma ◽  
...  
Keyword(s):  
Ultrasound Imaging ◽  
Anticoagulant Therapy ◽  
Diagnostic Testing ◽  
Diagnostic Algorithm ◽  
Advisory Board ◽  
Vein Thrombosis ◽  
Wells Score ◽  
Deep Vein ◽  
D Dimer

Introduction Diagnostic testing for deep vein thrombosis (DVT) is a multi-step and time-consuming process. Testing starts with clinical pretest probability (C-PTP) assessment. A negative D-dimer in combination with low C-PTP is widely used to exclude DVT; otherwise ultrasound imaging is required. When proximal vein ultrasound is used, a repeat ultrasound after a week is usually required to exclude DVT in moderate or high C-PTP patients. Ultrasound imaging is costly and can introduce delays. The goal of this study was to evaluate the safety and efficiency of a diagnostic algorithm for DVT that was designed to minimize the need for ultrasound imaging by using C-PTP-based D-dimer thresholds to exclude DVT (the 4D algorithm), rather than a standard fixed D-dimer cut-off value. Methods Consenting patients were enrolled in a Canadian prospective multicentre management study. Outpatients with symptoms or signs of DVT were eligible to be included in this study. Physicians used the 9-item Wells score to categorize the patient's C-PTP as low (Wells score, -2 to 0), moderate (1 or 2), or high (≥3). Patients with low C-PTP and a D-dimer &lt;1,000 ng/mL or with a moderate C-PTP and a D-dimer &lt;500 ng/mL underwent no further diagnostic testing for DVT and did not receive anticoagulant therapy. All other patients underwent proximal vein ultrasound. Patients with a single negative ultrasound but very high D-dimer (low or moderate C-PTP with D-dimer ≥3000 ng/mL, high C-PTP with D-dimer ≥1500 ng/mL) had a second proximal venous ultrasound one week later. The primary outcome was symptomatic, objectively verified, venous thromboembolism (VTE), which included proximal DVT or pulmonary embolism. All patients were followed for 90 days. A sample size of 1500 was required to establish 4D algorithm safety (90-day post-test probability of VTE &lt;2%). Results From April 2014 through March 2020, a total of 1512 patients were enrolled and analyzed. The mean age was 60 years and 58% were female. Overall, 173 (11%) had DVT on initial or serial diagnostic testing (168 had DVT on ultrasound imaging on the day of presentation and 5 had DVT on repeat ultrasound imaging at one week). Of all 1298 patients (86% of total) who did not have DVT (at either initial presentation or at scheduled repeat ultrasound imaging) and who did not receive anticoagulant therapy, 7 had VTE during follow-up (0.5%, 95% confidence interval (CI): 0.3 to 1.1%). In the 579 patients who had low (378 patients) or moderate (201 patients) C-PTP and negative D-dimer results (i.e. &lt;1000 or &lt;500 ng/mL respectively) and who did not receive anticoagulant therapy, 2 had VTE during follow-up (0.4%, 95% CI: 0.1 to 1.3%). In the 572 patients with a single negative ultrasound who were low or moderate C-PTP with D-dimer &lt;3000 ng/mL (423 patients), or high C-PTP with D-dimer &lt;1500 ng/mL (149 patients) and who did not receive anticoagulant therapy, 3 had VTE during follow-up (0.5%, 95% CI: 0.2 to 1.5%). The difference in the mean number of ultrasound examinations with the 4D algorithm (0.72) compared with the conventional algorithm (1.36) was -0.64 (95% CI, -0.68 to -0.61), corresponding to a 47% relative reduction (1083 ultrasound scans performed with the 4D algorithm compared with 2053 ultrasound scans required for the conventional algorithm). Conclusions The 4D diagnostic algorithm ruled out DVT safely while substantially reducing the requirement for ultrasound imaging. Disclosures Wu: BMS-pfizer: Honoraria, Other: advisory board; leo pharma: Other: advisory board; Pfizer: Honoraria; Servier: Other: advisory board.

A Negative D-dimer Excludes Recurrent Deep Vein Thrombosis: Results of a Multicentre Management Study.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 698-698 ◽  
Author(s):  
Shannon Bates ◽  
Clive Kearon ◽  
Susan Kahn ◽  
Jim A. Julian ◽  
Mark A. Crowther ◽  
...  
Keyword(s):  
Deep Vein Thrombosis ◽  
High Sensitivity ◽  
Vein Thrombosis ◽  
Recurrent Deep Vein Thrombosis ◽  
Clinically Significant ◽  
Suspected Recurrence ◽  
Lost To Follow Up ◽  
Deep Vein ◽  
D Dimer

Abstract The high frequency of residual radiologic abnormalities after initial deep vein thrombosis (DVT) makes management of patients with suspected recurrence difficult. D-dimer (DD) and serial compression ultrasonography (CUS) of the proximal veins have a high sensitivity and negative predictive value (NPV) in suspected first DVT. We hypothesized that it would be safe to withhold anticoagulation in patients with suspected recurrence who had a negative sensitive DD or negative serial CUS when DD testing was positive. In a multicentre prospective cohort study, patients underwent DD testing with an immunoturbidometric assay (MDA DD). If the DD was negative (<0.5 ug fibrinogen equivalent units [FEU]/mL), patients had no further testing. If the DD was positive, CUS was performed and, if normal, repeated after 1–3 and 7–10 days. Patients with a positive DD and abnormal CUS at presentation were managed as per their treating physician. Patients were followed for 3 months to detect venous thromboembolism (VTE) and suspected VTE were adjudicated centrally. Of the 504 patients enrolled in this study, 14 were subsequently deemed ineligible and 2 patients were lost to follow-up. The overall prevalence of confirmed recurrent DVT at presentation or during follow-up was 17%. 230 patients had a negative DD at presentation and, of the 227 evaluable patients, 4 had definite confirmed VTE (NPV of DD = 98%; 95% Confidence Interval [CI], 96–99%). Of the 135 patients with a positive DD and normal initial CUS, serial CUS was negative in 129 cases. Of these patients, 3 had definite VTE during follow-up (NPV of serial CUS in patients with positive DD = 98%; 95% CI, 93–99%). These results suggest that a negative MDA DD result excludes clinically significant recurrent DVT and that anticoagulants can also be safely withheld in patients with negative serial CUS, even if their DD is positive. This simple diagnostic approach can be used to safely manage approximately 70% of patients with suspected recurrent DVT.

Measurement of Thrombin Generation Is a Positive Predictive Biomarker of V enous Thromboembolism (VTE) in Metastatic Cancer Patients Enrolled in the Hypercan Study

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 654-654 ◽  
Author(s):  
Anna Falanga ◽  
Marina Marchetti ◽  
Cristina Verzeroli ◽  
Cinzia Giaccherini ◽  
Giovanna Masci ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Healthy Subjects ◽  
Metastatic Cancer ◽  
Breast Cancer Patients ◽  
Vein Thrombosis ◽  
Kaplan Meier ◽  
Cancer Types ◽  
D Dimer

Abstract Introduction The HYPERCAN study is an ongoing prospective Italian multicenter trial (Thromb.Res. 2014, Suppl 2, 182), designed to evaluate the role of laboratory hypercoagulation screening to predict early diagnosis (in healthy subjects), or prognosis and response to therapy in patients with either limited or metastatic cancers. Four cancer types are included, i.e. non-small cell lung [NSCL], gastric, colorectal, and breast cancers. The occurrence of clinically manifest VTE events, confirmed by objective diagnostic tests, is also recorded. Patients are followed up for 5 years or death. Aim In a group of patients with metastatic cancer enrolled in the HYPERCAN program, we wanted to evaluate the role of thrombin generation assay (TG), fibrinogen, and D-dimer levels in predicting the occurrence of VTE in the follow up. Methods As of June 2015, overall 831 patients with metastatic cancer have been enrolled. According to protocol, blood samples from these patients are collected at enrollment (baseline), after 3 and 6 chemotherapy cycles, and at end of treatment, or earlier if cancer disease progression. We measured the levels of TG, fibrinogen, and D-dimer in the baseline citrated plasma samples from the first 281 patients enrolled into the study (158 M/123 F; median age 64 years, range 32-84; NSCL = 56.2%, gastric = 11.1%, colorectal = 14.6%, breast = 18.1%). TG was measured by the Calibrated automated thrombogram (CAT assay, STAGO, France) at 5pM TF and results expressed as endogenous thrombin potential (ETP), fibrinogen and D-dimer were measured by commercial assays (Q.F.A. Thrombin; D-dimer HS; Werfen, Italy). Cut-off values were established by ROC curves; Kaplan Meier analysis was performed to define the VTE risk. Results Overall the patient baseline ETP values as well as the fibrinogen and D-Dimer levels were significantly greater than those of a control group of healthy subjects (p<0.0001). Among the cancer types, ETP values were highest in patients with NSCL cancer, and lowest in those with gastric cancer (1899±517 nM*min vs 1622±550 nM*min; p=0.024). D-dimer and fibrinogen levels were greatest in gastric (801±186 ng/ml) and NSCL (484±190 mg/dl) cancers, respectively, and were both lowest in breast cancer patients. After a median follow up of 473 days, overall 37 VTE events were recorded in 36 patients: 16 pulmonary embolism (PE), 16 deep vein thrombosis (DVT), 3 superficial vein thrombosis, and 1 PE + DVT. Of these events, 69% occurred in NSCL, 17% in colon, 8.5% in gastric, and 5.5% in breast cancer patients. Median time to VTE was 5 months from enrollment, >80% of VTE developed during chemotherapy. Baseline ETP levels were significantly higher in patients with VTE than in patients without VTE (2020±618 nM*min vs 1799±467 nM*min; p=0.017). Univariate analysis (Kaplan-Meier) showed that patients with ETP>1750 nM*min had about 3-fold higher risk of developing VTE than those with ETP<1750 nM*min (HR:2.841, 95% CI 1.42-5.69 p=0.002). ETP predictive value remained significant by multivariate analysis after correction for age, gender, and tumor site (HR: 2.341, 95% CI 1.15-4.75, p=0.019). Differently, the baseline levels of D-dimer and fibrinogen did not significantly predict for VTE. Conclusions These results reveal that ETP is a valuable marker in predicting VTE in metastatic cancer patients, therefore it can help to optimize the identification of the high risk subjects, which remains an important challenge and may improve the design of interventional studies of efficacy and safety of primary thromboprophylaxis in cancer patients during chemotherapy. Project funded by AIRC "5xMILLE" n. 12237 grant from the "Italian Association for Cancer Research (AIRC)". Disclosures Santoro: Celgene: Research Funding.

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