Should all acutely ill medical patients be treated with antithrombotic drugs?

2013 ◽  
Vol 109 (04) ◽  
pp. 589-595 ◽  
Author(s):  
Ludovica Perri ◽  
Lorenzo Loffredo ◽  
Francesco Violi
Keyword(s):  
Heart Failure ◽  
Venous Thrombosis ◽  
Observational Studies ◽  
Risk Profile ◽  
Medical Illness ◽  
Clinical Settings ◽  
Medical Patients ◽  
Antithrombotic Drugs ◽  
Thrombotic Risk ◽  
Acute Infections

SummaryAfter reports from observational studies suggesting an association between acutely ill medical patients and venous thromboembolism (VTE), interventional trials with anticoagulants drugs have demonstrated a significant reduction of VTE during and immediately after hospitalisation. Although several guidelines suggest the clinical relevance of reducing this outcome, there is a low tendency to use anticoagulants in patients hospitalised for acute medical illness. We speculated that such underuse may be dependent on a low perception that patients included in the trials are actually at risk of thromboembolism. Therefore, the aim of this study was to analyse the clinical settings included in the interventional trials and their relationship with thrombotic risk. Analysis of interventional trials revealed that the majority of patients included in the trials (about 80%) were affected by heart failure, acute respiratory syndrome or infections. Among these three illnesses, literature data shows an association with venous thrombosis only in patients with acute infections; this finding was, however, supported only by retrospective study. On the contrary, there is scarce or no evidence that heart failure and acute respiratory syndrome are associated with venous thrombosis. These data underscore the need of better defining the thrombotic risk profile of acutely ill medical patients included in interventional trials with anticoagulants.

Benefit of Fondaparinux in Medical Patients: A Subgroup Analysis.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 4079-4079
Author(s):  
Alexander T. Cohen ◽  
Alexander S. Gallus ◽  
Bruce L. Davidson ◽  
Michael R. Lassen ◽  
Martin H. Prins ◽  
...  
Keyword(s):  
Heart Failure ◽  
Respiratory Disease ◽  
Acute Heart Failure ◽  
Inflammatory Disease ◽  
Subgroup Analysis ◽  
Medical Patient ◽  
P Value ◽  
Medical Illness ◽  
Medical Patients ◽  
Population Variable

Abstract Aim In the ARTEMIS study fondaparinux 2.5mg reduced the overall incidence of venous thromboembolism (VTE) by 47% in general medical patients when compared to placebo. Our aim was to identify which medical patient populations with an acute medical illness or risk factor for VTE benefited from fondaparinux prophylaxis. Method A total of 849 patients were enrolled in 35 centres in 8 countries. Patients were randomised to receive placebo or fondaparinux 2.5mg subcutaneously once daily for 6 to 14 days. 644 (76%) patients were available for assessment of the primary outcome, occurrence of documented VTE between day 1 and day 15. We performed a subgroup analysis of the incidence of VTE in the placebo and fondaparinux 2.5mg treatment groups. The medical illness subgroups analysed were those predefined in the original study: acute heart failure only, respiratory disease only, infectious/inflammatory disease only and more than one disease. Results Conclusion Fondaparinux 2.5mg is superior to placebo in preventing VTE in patients with acute medical illness. Similar point estimates and overlapping confidence intervals indicate that the results are consistent within all the predefined medical illness. Population variable Placebo Fondaparinux 2.5mg Relative risk reduction 95% CI * P Value n/N % n/N % *exact CI for RRR based on standardized statistics and inverting a 2-sided test Acute heart failure (NYHA III/IV) 10/82 12.2 7/78 9.0 26.4% [−78.9%;69.7%] 0.61 Acute respiratory disease only 4/73 5.5 1/63 1.6 71.0% [−86.6%;97.7%] 0.37 Acute infectious/inflammatory disease only 10/88 11.4 4/77 5.2 54.3% [−33.1%;85.0%] 0.17 More than one disease 10/80 12.5 6/103 5.8 53.4% [−21.4%;83.4%] 0.12

scholarly journals Contemporary approach to primary prophylaxis of venous thromboembolism regarding the impact of risk factors on anticoagulation therapy duration

2014 ◽  
Vol 142 (3-4) ◽  
pp. 249-256
Author(s):  
Nebojsa Antonijevic ◽  
Ljubica Jovanovic ◽  
Valentina Djordjevic ◽  
Ivana Zivkovic ◽  
Miodrag Vukcevic ◽  
...  
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Venous Thromboembolism ◽  
Anticoagulation Therapy ◽  
Chronic Obstructive ◽  
Medical Illness ◽  
Medical Patients ◽  
Class Iii ◽  
Vte Prophylaxis ◽  
The Impact

Adequate thromboprophylaxis primarily requires timely detection of reversible and irreversible risk factors of venous thromboembolism (VTE) and their categorization. It is important to note that the highest percentage of VTE episodes occur in non-surgical (medical) patients and that VTE develops in a large number of surgical patients upon hospital discharge; this emphasizes the need for adequate VTE prevention in inflammatory diseases, acute medical illness and other medical diseases as well as for prolonging and optimizing the anticoagulant regimen after surgical intervention in the primary VTE prophylaxis. As almost completely unrecognized and neglected major risk factors of VTE in clinical practice, we particularly point out the chronic obstructive pulmonary disease (COPD) and heart failure, especially in NYHA functional class III and IV patients with significantly reduced left heart ventricle. It is necessary to raise clinicians? awareness of a potential danger from wrongly and one-sidedly interpreted dyspnea and coughing signs in patients with COPD as typical symptoms of basic respiratory disease as well as from ascribing the signs of disease aggravation in heart failure patients exclusively to cardial status worsening, neglecting the possibility of having unrecognized and untreated pulmonary embolism at issue. Contemporary way of life enhances the development of new VTE risk factors such as traveler?s thrombosis, in particular during long-haul flights as well as in individuals sitting at a computer for prolonged periods (e-thrombosis). Determining and recognizing VTE risk factors, especially those formerly neglected nonsurgical ones and simultaneous presence of multiple risk factors within a given period is required for defining an adequate anticoagulant regimen in primary VTE prophylaxis for surgical and non-surgical (medical) patients.

692 A novel prognostic index including comorbidities for stable heart failure validated in different clinical settings

2006 ◽  
Vol 5 (1) ◽  
pp. 156-156
Author(s):  
M SENNI ◽  
G SANTILLI ◽  
P PARRELLA ◽  
R DEMARIA ◽  
G ALARI ◽  
...  
Keyword(s):  
Heart Failure ◽  
Prognostic Index ◽  
Clinical Settings

scholarly journals Incidence of thrombotic complications in COVID-19

2021 ◽  
Author(s):  
William J. Jenner ◽  
Diana A. Gorog
Keyword(s):  
Intensive Care Unit ◽  
Observational Studies ◽  
Severity Of Illness ◽  
Controlled Trials ◽  
Thrombotic Risk ◽  
Randomized Controlled ◽  
Hospitalised Patients ◽  
High Incidence ◽  
Thrombotic Complications ◽  
Asymptomatic Individuals

AbstractA high incidence of thrombosis in hospitalised patients with COVID-19 was identified early during the pandemic. Accurately quantifying thrombotic risk may assist prognosis and guide appropriate thromboprophylaxis. Observational studies have estimated the rate of thrombosis in both hospitalised and non-hospitalised patients with COVID-19, and how this corresponds to the severity of illness. In this review, we provide an overview of the incidence and prevalence of arterial and venous thrombotic events in patients with COVID-19 and highlight the limitations in the studies to date. Asymptomatic individuals with COVID-19 and those with mild symptoms are at very low risk of thrombotic complications. However, rates of thrombosis are substantially increased in hospitalised patients, and are strikingly high in those patients who are critically-ill requiring treatment on the intensive care unit and especially those requiring extracorporeal membrane oxygenation. Clinicians managing such patients need to be aware of these risks and take appropriate steps with respect to thromboprophylaxis and heightened clinical vigilance. Large prospective observational studies will more accurately quantify thrombotic rate, and randomized controlled trials are currently investigating optimal thromboprophylactic strategies.

Immune-metabolome response to an acute exercise exertion reveals dysfunctional metabolic recovery in heart failure

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
N Kraenkel ◽  
A Koc ◽  
S Kaczmarek ◽  
K Lehnert ◽  
I Urbaneck ◽  
...  
Keyword(s):  
Heart Failure ◽  
T Cells ◽  
Cardiovascular Risk ◽  
Nk Cells ◽  
Cardiopulmonary Exercise Testing ◽  
Risk Profile ◽  
Left Ventricular ◽  
Metabolic Parameters ◽  
Control Group ◽  
Cardiovascular Risk Profile

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): BMBF Background Patients with heart failure with reduced ejection fraction (HFrEF) have an increased inflammatory load and impaired cardiac oxidative lipid phosphorylation. Early dysregulations of pathophysiological alterations may not be detectable if patients are assessed under resting conditions. Purpose We exposed HFrEF patients to a physical exertion challenge by cardiopulmonary exercise testing (CPET) and determined inflammatory and metabolic parameters before, during and 2 hours after the test. Methods A symptom-limited CPET was performed in participants with HFrEF (n = 16) and age and sex matched controls (CON, n = 13). In addition to clinical and physiological parameters, we assessed blood counts of leukocyte subtypes, their morphology, aggregation with platelets and microvesicle release, as well as plasma cytokines and metabolites at baseline (T1), immediately after CPET (T2), and after 2 hours of rest (T3). Inflammatory and metabolic parameters were measured using the ThermoFischer ProcartaPlex Human Inflammation-Panel and Biocrates MxP® Quant 500 kit, respectively. Non-parametric tests were chosen and all multiple tests were adjusted by the Benjamini-Hochberg method. Results Cardiovascular risk profile of HFrEF and CON was similar. In agreement with the definition for HFrEF, these patients had a lower EF and a greater left ventricular enddiastolic diameter compared to CON. There were no differences between groups for leukocyte, cytokine or metabolic parameters at T1. Immediately after CPET, 20 parameters were significantly increased in both groups, including an increase of lactate, natural killer (NK) and NK T cell blood counts. In addition, 131 inflammatory and metabolic parameters were upregulated only in HFrEF, as compared to only 17 in CON. In HFrEF-platelet aggregates with NK cells, CD8+ cytotoxic T cells and "classical" CD14++CD16-monocytes, 58 different phosphatidylcholines and 21 triglycerides were upregulated immediately after exercise. At T3 almost all altered parameters returned to baseline in CON while in HFrEF blood counts and morphological markers of inflammatory effector cell types, including NK cells, CD8+ T cells and neutrophils, as well as genomic nuclear DNA, an indicator of cell death, remained elevated. Moreover, several triglycerides did not return to baseline in HFrEF after a 2-hour resting period. In these patients, but not in CON, the different lipids (i.e. phosphatidylcholine, triglycerides) strongly correlated with pro-inflammatory cytokines and NK cells. Conclusion Our data support the concept of impaired fatty acid utilization and inflammation-mediated metabolic dysregulation in HFrEF. However, the correlations between metabolic and inflammatory parameters were not detected at baseline in comparison to a control group with similar cardiovascular risk profile. Therefore, investigating patients in response to a physical or metabolic challenge might reveal early pathological changes.

Disease burden and unmet needs for prevention of venous thromboembolism in medically ill patients in Europe show underutilisation of preventive therapies

2011 ◽  
Vol 106 (10) ◽  
pp. 600-608 ◽  
Author(s):  
Sharon Welner ◽  
Maria Kubin ◽  
Kerstin Folkerts ◽  
Sylvia Haas ◽  
Hanane Khoury
Keyword(s):  
Venous Thromboembolism ◽  
Care Delivery ◽  
Risk Groups ◽  
Considerable Proportion ◽  
Medical Illness ◽  
Medical Patients ◽  
Vte Prophylaxis ◽  
Medically Ill ◽  
Medical Inpatients ◽  
Clear Identification

SummaryIt was the aim of this review to assess the incidence of venous thromboembolism (VTE) and current practice patterns for VTE prophylaxis among medical patients with acute illness in Europe. A literature search was conducted on the epidemiology and prophylaxis practices of VTE prevention among adult patients treated in-hospital for major medical conditions. A total of 21 studies with European information published between 1999 and April 2010 were retrieved. Among patients hospitalised for an acute medical illness, the incidence of VTE varied between 3.65% (symptomatic only over 10.9 days) and 14.9% (asymptomatic and symptomatic over 14 days). While clinical guidelines recommend pharmacologic VTE prophylaxis for patients admitted to hospital with an acute medical illness who are bedridden, clear identification of specific risk groups who would benefit from VTE prophylaxis is lacking. In the majority of studies retrieved, prophylaxis was under-used among medical inpatients; 21% to 62% of all patients admitted to the hospital for acute medical illnesses did not receive VTE prophylaxis. Furthermore, among patients who did receive prophylaxis, a considerable proportion received medication that was not in accord with guidelines due to short duration, suboptimal dose, or inappropriate type of prophylaxis. In most cases, the duration of VTE prophylaxis did not exceed hospital stay, the mean duration of which varied between 5 and 11 days. In conclusion, despite demonstrated efficacy and established guidelines supporting VTE prophylaxis, utilisation rates and treatment duration remain suboptimal, leaving medical patients at continued risk for VTE. Improved guideline adherence and effective care delivery among the medically ill are stressed.

Polymorphisms in the protein C gene as risk factor for venous thrombosis

2009 ◽  
Vol 101 (01) ◽  
pp. 62-67 ◽  
Author(s):  
Carine Doggen ◽  
Hans Vos ◽  
Pieter Reitsma ◽  
Frits Rosendaal ◽  
Elisabeth Pomp
Keyword(s):  
Oral Contraceptive ◽  
Venous Thrombosis ◽  
Protein C ◽  
Contraceptive Use ◽  
Factor V Leiden ◽  
Factor V ◽  
Thrombotic Risk ◽  
Control Subjects ◽  
Oral Contraceptive Use ◽  
Increased Risk

SummaryProtein C is an important inhibitor of blood coagulation. We investigated the effect of two polymorphisms within the promoter region of the protein C gene (C/T at position 2405 and A/G at position 2418) on risk of venous thrombosis and on plasma protein C levels. In addition the combined effect of the two polymorphisms with factor V Leiden and oral contraceptive use was investigated. Previous studies on these polymorphisms were small and were not able to investigate synergistic effects. In the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA study), protein C levels were determined in 2,043 patients with venous thrombosis and 2,857 control subjects, and the two polymorphisms in 4,285 patients and 4,863 control subjects. The CC/GG genotype was associated with the lowest protein C levels. Compared to carriers of the TT/AA genotype – a genotype associated with higher protein C levels – the risk of venous thrombosis in CC/GG carriers was 1.3-fold increased (95% confidence interval 1.09–1.48). The combination of factor V Leiden with the CC/GG genotype led to a 4.7-fold increased risk, compared to non-carriers with the TT/AA genotype. Oral contraceptive use together with the CC/ GG genotype resulted in a 5.2-fold increased risk. In conclusion, the CC/GG genotype is associated with lower levels of protein C and an elevated risk of venous thrombosis compared to the TT/AA genotype. There is no clear synergistic effect of the CC/ GG genotype with factor V Leiden or oral contraceptive use on thrombotic risk.

scholarly journals Family Caregiving for Individuals With Heart Failure: A Scientific Statement From the American Heart Association

Circulation ◽  
2020 ◽  
Vol 141 (22) ◽  
Author(s):  
Lisa Kitko ◽  
Colleen K. McIlvennan ◽  
Julie T. Bidwell ◽  
J. Nicholas Dionne-Odom ◽  
Shannon M. Dunlay ◽  
...  
Keyword(s):  
Heart Failure ◽  
Family Caregiving ◽  
Heart Association ◽  
Well Being ◽  
Clinical Settings ◽  
Financial Health ◽  
Future Directions ◽  
Scientific Statement ◽  
The Relationship ◽  
Health And Well Being

Many individuals living with heart failure (HF) rely on unpaid support from their partners, family members, friends, or neighbors as caregivers to help manage their chronic disease. Given the advancements in treatments and devices for patients with HF, caregiving responsibilities have expanded in recent decades to include more intensive care for increasingly precarious patients with HF—tasks that would previously have been undertaken by healthcare professionals in clinical settings. The specific tasks of caregivers of patients with HF vary widely based on the patient’s symptoms and comorbidities, the relationship between patient and caregiver, and the complexity of the treatment regimen. Effects of caregiving on the caregiver and patient range from physical and psychological to financial. Therefore, it is critically important to understand the needs of caregivers to support the increasingly complex medical care they provide to patients living with HF. This scientific statement synthesizes the evidence pertaining to caregiving of adult individuals with HF in order to (1) characterize the HF caregiving role and how it changes with illness trajectory; (2) describe the financial, health, and well-being implications of caregiving in HF; (3) evaluate HF caregiving interventions to support caregiver and patient outcomes; (4) summarize existing policies and resources that support HF caregivers; and (5) identify knowledge gaps and future directions for providers, investigators, health systems, and policymakers.

HOSPITAL Score, LACE Index and LACE+ Index as predictors of 30-day readmission in patients with heart failure

2019 ◽  
Vol 25 (5) ◽  
pp. 166-167 ◽  
Author(s):  
Abdisamad M Ibrahim ◽  
Cameron Koester ◽  
Mohammad Al-Akchar ◽  
Nitin Tandan ◽  
Manjari Regmi ◽  
...  
Keyword(s):  
Heart Failure ◽  
Length Of Stay ◽  
Patient Population ◽  
Prediction Models ◽  
Hospital Admissions ◽  
Diastolic Heart Failure ◽  
Hospital Readmissions ◽  
Medical Patients ◽  
Readmission Rates ◽  
C Statistic

This study aimed to evaluate the accuracy of the HOSPITAL Score (Haemoglobin level at discharge, Oncology at discharge, Sodium level at discharge, Procedure during hospitalization, Index admission, number of hospital admissions, Length of stay) LACE index (Length of stay, Acute/emergent admission, Charlson comorbidy index score, Emerency department visits in previous 6 months) and LACE+ index in predicting 30-day readmission in patients with diastolic dysfunction. Heart failure remains one of the most common hospital readmissions in adults, leading to significant morbidity and mortality. Different models have been used to predict 30-day hospital readmissions. All adult medical patients discharged from the SIU School of Medicine Hospitalist service from 12 June 2016 to 12 June 2018 with an International Classification of Disease, 10th Revision, Clinical Modification diagnosis of diastolic heart failure were studied retrospectively to evaluate the performance of the HOSPITAL Score, LACE index and LACE+ index readmission risk prediction tools in this patient population. Of the 730 patient discharges with a diagnosis of heart failure with preserved ejection fraction (HFpEF), 692 discharges met the inclusion criteria. Of these discharges, 189 (27%) were readmitted to the same hospital within 30 days. A receiver operating characteristic evaluation showed C-statistic values to be 0.595 (95% CI 0.549 to 0.641) for the HOSPITAL Score, 0.551 (95% CI 0.503 to 0.598) for the LACE index and 0.568 (95% CI 0.522 to 0.615) for the LACE+ index, indicating poor specificity in predicting 30-day readmission. The result of this study demonstrates that the HOSPITAL Score, LACE index and LACE+ index are not effective predictors of 30-day readmission for patients with HFpEF. Further analysis and development of new prediction models are needed to better estimate the 30-day readmission rates in this patient population.

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