J.-L. Bosson

Quantitative high D-dimer value is predictive of pulmonary embolism occurrence independently of clinical score in a well-defined low risk factor population

Summary.  We performed a prospective study to assess whether positive quantitative D‐dimer (DD) levels could be integrated for a selected population in a defined strategy to accurately diagnose pulmonary embolism (PE). For this purpose, 1528 in‐ or outpatients with clinically suspected PE were investigated according to our prescription rules. Clinical probability was defined as low, intermediate or high. Patients in whom DD levels were measured met criteria defined by our previously described decision‐making algorithm: in‐ and outpatients, < 80 years, without surgery in the previous 30 days or active cancer. Nine hundred and twenty‐three patients (60.4%) had quantitative DD measurement using automated latex DD assay (STA‐Liatest D‐Di®). According to our decision‐making algorithm, DD measurement was applied to 70.5% of out‐, and 55.7% of inpatients, and PE diagnosis was ruled out in 49.5% of the 923 patients. This allowed us to confirm prospectively that our specific rules greatly improve the DD testing efficiency. PE was diagnosed in 115 (12.5%) patients. For a 0.5 mg L−1 cut‐off, the test sensitivity was 97.4%, but its specificity was only 56.7%. However, PE prevalence increased gradually with DD levels. The true observed PE prevalence, according to the quantitative assessment of DD levels, differed from that predicted with pretest clinical probability only. Moreover, in this well‐defined patient group, a quantitative DD level > 2 mg L−1 was predictive of PE occurrence independently of the clinical score (odds ratio 6.9, 95% confidence interval 3.7, 12.8). As part of a defined strategy, knowledge of positive DD quantitative value, together with the clinical probability score, improves the PE predictive model. A clinical validation of these results in a follow‐up study would now be necessary before considering the implementation of this strategy into clinical practice.

ICD-10 hospital discharge diagnosis codes were sensitive for identifying pulmonary embolism but not deep vein thrombosis

OBJECTIVE To estimate the sensitivity of International Classification of Diseases, Tenth revision (ICD-10) hospital discharge diagnosis codes for identifying deep vein thrombosis (DVT) and pulmonary embolism (PE). STUDY DESIGN AND SETTING We compared predefined ICD-10 discharge diagnosis codes with the diagnoses that were prospectively recorded for 1,375 patients with suspected DVT or PE who were enrolled at 25 hospitals in France. Sensitivity was calculated as the percentage of patients identified by predefined ICD-10 codes among positive cases of acute symptomatic DVT or PE confirmed by objective testing. RESULTS The sensitivity of ICD-10 codes was 58.0% (159 of 274; 95% CI: 51.9, 64.1) for isolated DVT and 88.9% (297 of 334; 95% CI: 85.6, 92.2) for PE. Depending on the hospital, the median values for sensitivity were 57.7% for DVT (interquartile range, IQR, 48.6-66.7; intracluster correlation coefficient, 0.02; P=0.31) and 88.9% for PE (IQR, 83.3-96.3; intracluster correlation coefficient, 0.11; P=0.03). The sensitivity of ICD-10 codes was lower for surgical patients and for patients who developed PE or DVT while they were hospitalized. CONCLUSION ICD-10 discharge diagnosis codes yield satisfactory sensitivity for identifying objectively confirmed PE. A substantial proportion of DVT cases are missed when using hospital discharge data for complication screening or research purposes.

Superficial vein thrombosis and recurrent venous thromboembolism: a pooled analysis of two observational studies

Summary.  Background:  The management strategies for symptomatic isolated superficial vein thrombosis (SVT) (without concomitant deep vein thrombosis [DVT] or pulmonary embolism [PE]) have yet to achieve widespread consensus. Concerns have been raised regarding the usefulness of prescribing anticoagulant treatments to all patients with isolated SVT. Determining the isolated SVT subgroups who have the highest risks of venous thromboembolism (VTE) recurrence (composite of DVT, PE, and new SVT) may facilitate the identification of patients who are likely to benefit from anticoagulant treatment.

Active Tuberculosis and Venous Thromboembolism: Association According to International Classification of Diseases, Ninth Revision Hospital Discharge Diagnosis Codes

BACKGROUND Infections are risk factors for venous thromboembolism (VTE), especially if severe and acute. The role of chronic infections such as active tuberculosis is ill defined, although several case reports and small series have suggested an association between tuberculosis and VTE. METHODS Using data from the Premier Perspective database (27 659 947 admissions), we performed a multivariate analysis to assess the specific VTE risk associated with tuberculosis. The analysis was adjusted on classic risk factors for VTE. RESULTS The prevalence of VTE among patients with active tuberculosis was 2.07% (95% confidence interval [CI], 1.62%-2.59%). In a multivariate analysis model, adults with active tuberculosis had a greater risk of VTE than those without (odds ratio, 1.55 [95% CI, 1.23-1.97], P < .001), close to the previously reported risk associated with neoplasia. No particular link was found between pulmonary tuberculosis and pulmonary embolism, or between extrapulmonary tuberculosis and deep vein thrombosis. This may suggest the preponderant role of a systemic hypercoagulable state over an intrathoracic venous compression mechanism. In-hospital mortality of patients with both active tuberculosis and VTE (11/72 [15%]) was higher than mortality of patients with only active tuberculosis (92/3413 [2.7%]) or only VTE (5062/199 480 [2.5%]) (P < .001). Pulmonary embolism was more frequent in black patients, suggesting that this population, which is also more likely to suffer from tuberculosis, should be followed carefully. CONCLUSIONS Tuberculosis must be considered as a pertinent risk factor for VTE and should be included in thromboembolism risk evaluation similar to any acute and severe infection.

Clinical presentation and mortality in pulmonary embolism: The Optimev study

AIMS To describe the clinical presentation and 3-month mortality in recognized forms of venous thromboembolism (VTE). METHODS All 8256 patients referred to 359 vascular physicians for clinical suspicion of VTE were included over a 15-month period in France. Subjects without a confirmed diagnosis of VTE served as controls. Risk factors, clinical presentation and estimated 3-month survival for each form of VTE were evaluated. RESULTS Of 5889 patients, 426 had pulmonary embolism (PE) with deep vein thrombosis (DVT), 148 had PE without DVT, and 5315 had no VTE. 2350 patients with other VTE events (DVT and superficial vein thrombosis) and 17 other patients were excluded of the analysis. PE without DVT patients presented differently for risk factors in the univariate analysis. Three-month mortality was 4.0% for controls, 12.9% for PE with DVT, and 4.6% for PE without DVT. Compared with controls, only PE with DVT patients (adjusted hazard ratio: 2.6 95% CI [1.4-4.7]) were at increased risk of mortality. CONCLUSIONS PE without DVT is not associated with a higher 3-month mortality compared to controls, in contrast to PE with DVT. When diagnosing PE in patients, the clinical significance of an associated DVT is important.

Graduated compression stocking thromboprophylaxis for elderly inpatients

AbstractBACKGROUND: Graduated compression stockings (GCS) are often used for deep vein thrombosis prophylaxis in nonsurgical patients, although evidence on their effectiveness is lacking in this setting. OBJECTIVE: To determine whether prophylaxis with GCS is associated with a decrease in the rate of deep vein thrombosis in nonsurgical elderly patients. METHODS: Using original data from 2 multicenter nonrandomized studies, we performed multivariable and propensity score analyses to determine whether prophylaxis with GCS reduced the rate of deep vein thrombosis among 1,310 postacute care patients 65 years or older. The primary outcome was proximal deep vein thrombosis detected by routine compression ultrasonography performed by registered vascular physicians. RESULTS: Proximal deep vein thrombosis was found in 5.7% (21/371) of the GCS users and in 5.2% (49/939) of the GCS nonusers (odds ratio [OR], 1.09; 95% confidence interval [CI], 0.64–1.84). Although adjusting for propensity score eliminated all differences in baseline characteristics between users and nonusers, the OR for proximal deep vein thrombosis associated with GCS remained nonsignificant in propensity-stratified (adjusted OR, 1.11; 95% CI, 0.59–2.10) and propensity-matched (conditional OR, 0.92; 95% CI, 0.42–2.02) analysis. Similar figures were observed for distal and any deep vein thrombosis. The rates of deep vein thrombosis did not differ according to the length of stockings. CONCLUSIONS: Prophylaxis with GCS is not associated with a lower rate of deep vein thrombosis in nonsurgical elderly patients in routine practice. Randomized studies are needed to assess the efficacy of GCS when properly used in this setting.

Long‐term outcomes of cancer‐related isolated distal deep vein thrombosis: the OPTIMEV study

Essentials Clinical significance of cancer‐related isolated distal deep vein thrombosis (iDDVT) is unknown. We studied patients with iDDVT, with and without cancer, and proximal DVT with cancer. Cancer‐related iDDVT patients have a much poorer prognosis than iDDVT patients without cancer. Cancer‐related iDDVT patients have a similar prognosis to cancer‐related proximal DVT patients.

Maladie thromboembolique veineuse chez la personne âgée : résultat d’un programme d’amélioration de la qualité de la prévention☆

INTRODUCTION Venous thromboembolism is highly prevalent in the elderly population. However, this age group often receives inadequate thromboprophylaxis because of concerns about bleeding risk, denying patients the benefit of proven antithrombotic regimens. Besides, there is a lack of data in non-surgical patients in postacute care facilities. METHODS A multifaceted intervention program addressing venous thromboembolism prophylaxis has been conducted and evaluated in 50 postacute care facilities. Data were collected in two cross-sectional, epidemiologic studies of 1664 patients aged 65 years or older, including a systematic venous complete compression ultrasound. RESULTS Despite the fact that 56% of patients received pharmacologic prophylaxis, the prevalence of asymptomatic deep venous thromboses (DVT) was 15%. Specific risk factors in this population have been identified: dependence in basic activities of daily living (ADLs), a higher timed Up and Go test score and the presence of pressure ulcers. Implantation of a multifaceted program was followed by a reduction in DVT prevalence (OR=0.58, CI95%, 0.40-0.83). Implication of nurses and physical therapists was associated with an increase in patients mobilization (62% versus 37%, p<0.01). Nevertheless, we were unable to find any efficacy of medical compression in venous thomboembolism prevention for medical patients. CONCLUSION This project shows the high prevalence of venous thromboembolism in postacute care facilities and enhances the need for a multidisciplinary approach to this disease.

High percentage of non-diagnostic compression ultrasonography results and the diagnosis of ipsilateral recurrent proximal deep vein thrombosis: a rebuttal: Letters to the Editor

See also Tan M, Velthuis SI, Westerbeek RE, van Rooden CJ, van der Meer FJ, Huisman MV. High percentage of non‐diagnostic compression ultrasonography results and the diagnosis of ipsilateral recurrent proximal deep vein thrombosis. J Thromb Haemost 2010; 8: 848–50; Tan M, Huisman MV. High percentage of non‐diagnostic compression ultrasonography results and the diagnosis of ipsilateral recurrent proximal deep vein thrombosis: reply to a rebuttal. This issue, pp 417–8.

More on: asymptomatic thrombophilia—a family affair

*Haemostasis Unit, CHU Grenoble, France; Department of Medical Genetics, CHU Grenoble, France; Centre of Clinical Investigations,CHU Grenoble, France; and §Angiology Unit, CHU Grenoble, FranceTo cite this article: Pernod G, Jouk PS, Bosson JL, Carpentier PH, Polack B. More on: asymptomatic thrombophilia—a family affair. J ThrombHaemost 2005; 3: 1329–30.See also Spencer FA, Goldberg RJ. Asymptomatic thrombophilia—a family affair. J Thromb Haemost 2005; 3: 457–9; Vossen CY, Conard J,Fontcuberta J, Makris M, van der Meer FJM, Pabinger I, Palareti G, Preston FE, Scharrer I, Souto JC, Svensson P, Walker ID, Rosendaal FR. Risk of afirst venous thrombotic event in carriers of a familial thrombophilic defect. The European Prospective Cohort on Thrombophilia (EPCOT). J ThrombHaemost 2005; 3: 459–64.