Fernando Javier Vázquez

Performance of the Wells score in patients with suspected pulmonary embolism during hospitalization: a delayed-type cross sectional study in a community hospital.

INTRODUCTION The role of the Wells score for patients who develop signs and symptoms of pulmonary embolism (PE) during hospitalization has not been sufficiently validated. The aim of this study is to evaluate the performance of the Wells score for inpatients with suspected PE and to evaluate the prevalence of pulmonary embolism. MATERIALS AND METHODS We conducted a cross sectional study nested in the prospective Institutional Registry of Thromboembolic Disease at Hospital Italiano de Buenos Aires from June 2006 to March 2011. We included patients who developed symptoms of pulmonary embolism during hospitalization. Patients were stratified based on the Wells score as PE likely (>4 points) or PE unlikely (≤4 points). The presence of pulmonary embolism was defined by pre-specified criteria. RESULTS Six hundred and thirteen patients met the inclusion criteria, with an overall prevalence of PE of 36%. Two hundred and nineteen (34%) were classified as PE likely and 394 (66%) as PE unlikely with a prevalence of PE of 66% and 20%, respectively. The Wells score showed a sensitivity of 65 (95% CI 59-72), specificity 81 (95% CI 77-85), positive predictive value 66 (95% CI 60-72) and negative predictive value 80 (95% CI 77-84). CONCLUSIONS The Wells Score is accurate to predict the probability of PE in hospitalized patients and this population had a higher prevalence of PE than other cohorts. However, the score is not sufficiently predictive to rule out a potentially fatal disorder.

Risk of major bleeding in patients receiving vitamin K antagonists or low doses of aspirin. A systematic review and meta-analysis

UNLABELLED Prior meta-analysis and observational studies have suggested that the bleeding risks associated with anticoagulation using vitamin K antagonists (VKA) or aspirin (ASA) are similar. OBJECTIVE The aim of this systematic review was to provide the odds ratios (ORs) of major bleeding, intracranial bleeding or major extra-cranial bleeding of anticoagulation with VKA compared to low doses of ASA. METHODS We conducted a systematic review of Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (RCT). Randomized controlled trials reporting bleeding rates in adult patients randomized to a VKA (INR 2-3) or to ASA alone (<325mg daily). Random effects OR were calculated. RESULTS Fifteen trials reporting the outcome of 2511 participants treated with VKA alone and 2471 treated with ASA alone were included; most common conditions evaluated were non-valvular atrial fibrillation (five trials) and heart failure (three trials). Overall, the use of VKA was associated with an increased risk of major bleeding (OR 1.76 (95% CI 1.33-2.33) when compared to ASA. The OR associated with VKA use for intracranial bleeding and extra-cranial bleeding were 1.74 (95% CI 0.83-3.62) and 1.66 (95% CI 0.94-2.92), respectively. In trials achieving good control of anticoagulation [time in therapeutic range (TTR) >65%], the risk of bleeding with VKA was similar to that of ASA [OR 1.16 (95% CI 0.79-1.71)]. CONCLUSION Contrary to prior reports our results suggest that the risk of major bleeding with the use VKA is higher compared to those of patients treated with ASA alone. However, in patients achieving a good TTR, the risk of major bleeding with VKA or ASA is similar.

Improving Adherence Rate of Extended Prophylaxis for Venous Thromboembolic Disease After Abdominal and Pelvic Oncologic Surgery A Pilot Educational Study

Background: Venous thromboembolic disease (VTE) is higher among patients with cancer. For those undergoing abdominal or pelvic surgery for cancer, it is suggested to extend thromboprophylaxis during 4 weeks with low-molecular-weight heparin over limited-duration of 7 days. There is no published local data from our country about compliance with recommended guidelines of extended prophylaxis (EP) in patients with cancer undergoing surgical procedures. Our aim was to evaluate the adherence rate to extended pharmacological thromboprophylaxis after abdominal–pelvic surgery for cancer, before and after an educational intervention program (EIP) geared toward surgeons. Methods: Prospective cross-sectional study before and after an EIP aimed for surgeons. All consecutive patients older than 65 years who underwent surgery for abdominal–pelvic neoplasm, at the Hospital Italiano de Buenos Aires, Argentina, between September 2013 and May 2014, were evaluated for inclusion. Results: A total of 120 patients were included, 60 before and 60 after the EIP aimed for surgeons. None of the initial 60 patients received EP, while 13 (21.6%) of 60 patients received prophylaxis for 28 days (all with colon or rectal cancer) after the intervention. There were no bleeding or death during 90 days of follow-up, and there were 7 of 120 VTE events, none in the group receiving extended thromboprophylaxis. Conclusion: The EIP for the surgical team significantly improved their adherence but only in the colon–rectal surgeries. The adherence to the recommended guidelines is still low. Reasons could be the subjective perception of elevated bleeding risk and the variable grade of recommendation in different guidelines.

Risk of venous thromboembolic disease and adequacy of prophylaxis in hospitalized patients in Argentina: a multicentric cross-sectional study

BackgroundVenous thromboembolic disease (VTE) is associated with high morbi-mortality. Adherence rate to the recommendations of antithrombotic prophylaxis guidelines (ATPG) is suboptimal. The aim of this study was to describe the adequacy of antithrombotic prophylaxis (ATP) in hospitalized patients as the initial stage of a program designed to improve physician adherence to –ATP recommendations in Argentina.MethodsThis study was a multicenter, cross-sectional study that included 28 Institutions throughout 5 provinces in Argentina.Results1315 patients were included, 729 (55.4%) were hospitalized for medical (clinical) reasons, and 586 (44.6%) for surgical reasons. Adequate ATP was provided to 66.9% of the patients and was more frequent in surgical (71%) compared to clinical (63.6%) subjects (p < 0.001). Inadequate ATP resulted from underuse in 76.6% of the patients. Among clinical, 203 (16%) had increased bleeding risk and mechanical ATP was used infrequently.ConclusionsThe adequacy of ATP was better in low VTE risk clinical and surgical patients and high VTE risk in orthopedic patients. There was worse adequacy in high risk patients (with active neoplasm) and in those with pharmacological ATP contraindications, in which the use of mechanical methods was scarce. The adequacy of ATP was greater at institutions with < 150 beds compared with larger institutions. This is the first multicentric study reporting ATP in Argentina. Understanding local characteristics of medical performance within our territory is the first step in order to develop measures for improving ATP in our environment.

The outcome of pulmonary vein thrombosis in non-surgical patients. A systematic review and case report

The outcome of pulmonary vein thrombosis in non-surgical patients. A systematic review and case report -

Aspirin Compared to Low Intensity Anticoagulation in Patients with Non-Valvular Atrial Fibrillation. A Systematic Review and Meta-Analysis

Background Despite its lack of efficacy, aspirin is commonly used for stroke prevention in atrial fibrillation. Since prior studies have suggested a benefit of low-intensity anticoagulation over aspirin in the prevention of vascular events, the aim of this systematic review was to compare the outcomes of patients with non-valvular atrial fibrillation treated with low-intensity anticoagulation with Vitamin K antagonists or aspirin. Methods We conducted a systematic review searching Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials, from 1946 to October 14th, 2015. Randomized controlled trials were included if they reported the outcomes of patients with non-valvular atrial fibrillation treated with a low-intensity anticoagulation compared to patients treated with aspirin. The primary outcome was a combination of ischemic stroke or systemic embolism. The random-effects model odds ratio was used as the outcome measure. Results Our initial search identified 6309relevant articles of which three satisfied our inclusion criteria and were included. Compared to low-intensity anticoagulation, aspirin alone did not reduce the incidence of ischemic stroke or systemic embolism OR 0.94 (95% CI 0.57–1.56), major bleeding OR 1.06 (95% CI 0.42–2.62) or vascular death OR 1.04 (95% CI 0.61–1.75). The use of aspirin was associated with a significant increase in all-cause mortality OR 1.66 (95% CI 1.12–2.48). Conclusion In patients with non-valvular atrial fibrillation, aspirin provides no benefits over low-intensity anticoagulation. Furthermore, the use of aspirin appears to be associated with an increased risk in all-cause mortality. Our study provides more evidence against the use aspirin in patients with non-valvular atrial fibrillation.

Antiphospholipid antibodies and lower extremity peripheral arterial disease - a systematic review and meta-analysis

BACKGROUND Despite being an important risk factor for venous thromboembolism and ischaemic stroke, the role of antiphospholipid antibodies in patients with peripheral arterial disease remains a matter of debate. The aim of this study was to evaluate the association of persistently elevated antiphospholipid antibodies and lower extremity peripheral arterial disease. METHODS We conducted a systematic review of electronic databases including MEDLINE, EUROPUBMED and EMBASE to assess the prevalence of antiphospholipid antibodies in patients with lower extremity peripheral arterial disease. Case-control studies were included if they reported the prevalence of antiphospholipid antibodies in patients with lower extremity peripheral arterial disease. Two reviewers (FV and EG) independently assessed the eligibility of all articles. The primary outcome measure was the odds ratio (OR) for the prevalence of antiphospholipid antibodies patients with lower extremity peripheral arterial disease, along with the corresponding 95 % confidence intervals (CIs). RESULTS Our initial electronic search identified 128 relevant abstracts, of which two studies were included. Antiphospholipid antibodies were found in 50/571 patients with lower extremity peripheral arterial disease and 13/490 of the controls, OR 3.32 (95 % CI = 1.49 to 7.4). In those with critical limb ischaemia, the prevalence of antiphospholipid antibodies was elevated compared to controls, pooled OR 4.78 (95 % CI = 2.37 to 9.65). CONCLUSIONS Our systematic review and meta-analysis suggests that the prevalence of persistently elevated levels of antiphospholipid antibodies is increased in patients with lower extremity peripheral diseases when compared to healthy controls, especially in those with critical limb ischaemia.

Prevalence and Geographical Variation of Prothrombin G20210A Mutation in Patients with Cerebral Vein Thrombosis: A Systematic Review and Meta-Analysis

Objectives To compare the prevalence of prothrombin G20210A in patients with objectively confirmed cerebral vein or cortical vein thrombosis against healthy controls, and evaluate geographical variations. Design Systematic review and meta-analysis of case control studies. Methods We conducted a systematic review of electronic databases including MEDLINE and EMBASE. The main outcome was the prevalence of prothrombin G20210A in patients with objectively confirmed cerebral vein or cortical vein thrombosis; we also analyzed individual country variations in the prevalence. The random-effects model OR was used as the primary outcome measure. Results In total 19 studies evaluated 868 cases of cerebral venous thrombosis and 3981 controls. Prothrombin G20210A was found in 103/868 of the patients with cerebral venous thrombosis and 105/3999 of the healthy controls [random effects pooled OR 5.838, 95% CI 3.96 to 8.58; I217.9%]. The prevalence of prothrombin G20210A was significantly elevated in Italian studies (OR 9.69), in Brazilian studies (OR 7.02), and in German studies (OR 3.77), but not in Iranian studies (OR 0.98). Conclusion Prothrombin G20210A is significantly associated with cerebral venous thrombosis when compared to healthy controls, although this association is highly dependent on the country of origin.

Wells Score and Poor Outcomes Among Adult Patients With Subsegmental Pulmonary Embolism A Cohort Study

Introduction: Since the introduction of computed tomography pulmonary angiography, isolated subsegmental pulmonary embolism has become a commonly recognized clinical problem, but its clinical relevance remains unclear. The objective of the present study was to evaluate the extent to which the simplified Wells score discriminates between patients with varying levels of risk of complications after presenting with subsegmental pulmonary embolism. Materials and Methods: Retrospective cohort study. Patients included had subsegmental pulmonary embolism (1 or multiple emboli limited to subsegmental arteries). Primary explanatory variable was the simplified Wells score, categorized as high (>4) or low (≤4). The primary outcome was time to death or new venous thromboembolism. Kaplan-Meier techniques and Cox regression analysis were used to compare the survival experience of patients with high versus low Wells score with and without adjustment for active malignancy, age, Charlson score, previous venous thromboembolism, and previous major surgery in the last 30 days. Main Results: Seventy-nine patients with subsegmental pulmonary embolism were included. Patients with a high Wells score had a 4-fold increased risk of the composite outcome (hazard ratio = 4.2, 95% confidence interval [CI] = 2.0-8.9, P < .001). Other covariates significantly associated with increased risk in univariate analyses included active malignancy, a low serum albumin, and an increased Charlson score. In multivariate Cox regression analyses adjusting for these other factors, a high Wells score remained significant (hazard ratio 5.5, 95% CI 2.4-12.6, P < .001). Conclusion: High Wells score is associated with death or new venous thromboembolism during follow-up among patients with subsegmental pulmonary embolism. Clinical trial registration: ClinicalTrials.gov number, NCT01372514.

Predictive score for estimating cancer after venous thromboembolism: a cohort study

BackgroundVenous thromboembolism (VTE) has been associated with a higher risk of developing malignancy and mortality, and patients with VTE may therefore benefit from increased surveillance. We aimed to construct a clinical predictive score that could classify patients with VTE according to their risk for developing these outcomes.MethodsObservational cohort study using an existing clinical registry in a tertiary academic teaching hospital in Buenos Aires, Argentina. 1264 adult patients greater than 17 years of age presented new VTE between June 2006 and December 2011 and were included in the registry. We excluded patients with previous or incident cancer, those who died during the first month, and those with less than one year of follow up (< 5%). 540 patients were included. Primary outcome was new cancer diagnosis during one year of follow-up, secondary composite outcome was any new cancer diagnosis or death. The score was developed using a multivariable logistic regression model to predict cancer or death.ResultsDuring follow-up, one-quarter (26.4%) of patients developed cancer (9.2%) or died (23.7%). Patients with the primary outcome had more comorbidities, were more likely to have previous thromboembolism and less likely to have recent surgery. The final score developed for predicting cancer alone included previous episode of VTE, recent surgery and comorbidity (Charlson comorbidity score), [AUC of 0.75 (95% CI 0.66-0.84) and 0.79 (95% CI 0.63-0.95) in the derivation and validation cohorts, respectively]. The version of this score developed to predict cancer or death included age, albumin level, comorbidity, previous episode of VTE, and recent surgery [AUC = 0.72 (95% CI 0.66-0.78) and 0.71 (95% CI 0.63-0.79) in the derivation and validation cohorts, respectively].ConclusionsA simple clinical predictive score accurately estimates patients’ risk of developing cancer or death following newly diagnosed VTE. This tool could be used to help reassure low risk patients, or to identify high-risk patients that might benefit from closer surveillance and additional investigations.Trial registrationClinicalTrials.gov: NCT01372514.