ven ous t h romboemboli sm risk in medical patients
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Ven ous T h romboemboli sm Risk in Medical Patients. Dr. H. Gül ÖNGEN İstanbul U niversit y Cerrahpaşa Medical Faculty Pulmonology Department. Epidemiology of VTE In the general population Different countries Recent studies (VITEA, IMPROVE, ENDORSE) Medical VTE risks - PowerPoint PPT PresentationTRANSCRIPT
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Venous Thromboembolism Risk in Medical Patients
Dr. H. Gül ÖNGEN
İstanbul University
Cerrahpaşa Medical Faculty
Pulmonology Department
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• Epidemiology of VTE – In the general population– Different countries
• Recent studies – (VITEA, IMPROVE, ENDORSE)
• Medical VTE risks– Gender and sex– Medical risk factors and their relative weight
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VTE is a multifactorial disease
THROMBOSISA multifactorial accident
Hypertension
Diabetes
Smoking
Age
Pregnancy
Cancer
Antiphospholipids
Congenital thrombophilia
HIT
Acute infections
Hyperlipidaemia Others
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DVT and PE as one disease !
• Symptomatic DVT is often associated with asymptomatic PE.
• Symptomatic PE is often associated with asymptomatic DVT
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Major PE remain undiagnosed untill autopy !
• 1964-1977– Coon1 : % 84– Goldhaber2 : % 70 Mean: % 77
‘PE is most comman preventable cause of death among hospitalized medical patients.’
‘PE is often a cause of unexpected death’1Coon WW.Arch Surg. 1976;111:398-402
2Goldhaber SZ.etal Am J Med.1982;73:822-6
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Epidemiology of VTE
• Mortality Symptomatic PE– initial presentation is death in ¼ of patients1
– Risk of early death among patients with symptomatic PE is 18-fold high compared to patients with DVT alone2
– Risk of death is high among elderly patients
1Heit JA J Thromb Thorombolysis. 2006:21:23-9
2Heit JA.et al.Arch Intern Med. 1999:159:445-53
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Fatal PE among hospitalised patients
Death: (1991-2000)
n=16 104
PE: n=265 (erişkinlerin
%5.2)
Medical patients
n=212 (%80.8)
Acute medical disease n=110 (%51.4)
R Alikhan.et al J Clin Pathol. 2004;57:1254-7
Autopsy:
n=6833 (% 42.4)
Acute infections n=26
(%24)
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Sandler DA, et al. J R Soc Med. 1989;82:203-5.
75%
25%
Medical patients
Surgical patients
VTE: Mortality PE kills 3 times more medical patients than surgical patients.
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VTE is a disease having long term complications and risk of
recurrence.
• % 30 VTE:– Recurrence within 10 years.– Venous stasis syndrome occurs within 20
years.
Heit JA J Thromb Thorombolysis. 2006:21:23-9
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Frequency of VTE• General population• Hospitalized patients (sugical, medical, ICU..)
• Medical outpatients• In special group of patients
– Women taking oral contraseption or HRT– Pregnent women ( pregnancy and the puerperium)– Patients with cancer– Patients with thrombophilia (congenital, acquired)
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Epidemiology of VTE in the general population
Different countries Gender and sex In special groups Recent studies (VITEA, IMPROVE,
ENDORSE) Risk factors and their relative weight
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Epidemiology of VTE in the general population
Different countries Gender and sex In special groups Recent studies (VITEA, IMPROVE,
ENDORSE) Risk factors and their relative weight
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Annual VTE incidence in the USA
Death
Pulmonery Hypertension
Pulmonery Embolism
Post-thrombotic syndrome
Symptomatic DVT
Asymptomatic DVT
60 0001
30 0002
600 0001
800 0003,4
2 million 1
1.Hirsh J. Circulation,19962Pengo V. NEJM, 2004
3 Brandjes DP. Lancet 19974KahnSR. J Gen Intern Med 2000
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• 250 000 incident VTE cases occur annually among US whites
–incidence is similar or higher among African-Americans
–and lower among Asian and native- Americans
•VTE is one of the main cause of maternal death in the western wolrd.
Epidemiology of VTE in the USA
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•Each year > 25 000 people die from VTE acquired in hospital.
•Fatal PE is the cause of 10% of deaths duiring hospitalization
•Mortality of VTE is higher than the mortality of AIDS, brest cancer and car accident
www.parliament.uk (2005)
Epidemiology of VTE in UK
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EPI-GETBO Study:
•in the Brest district
•Annual incidence: 1.83/1,000
Oger E Thromb Haemost. 2000
Epidemiology of VTE in France
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DVT PE ± (DVT)
EPI-GETBO Study: Charecteristics of patients with VTE (n=674) and clinical settings at the time of diagnosis
Oger E Thromb Haemost. 2000
Age (years) 66 ±17 77 ± 15
% females % 57 % 61
Clinical settings
•Home % 68 %52
•Medical unit % 8 %34
•Surgical unit % 11 % 5
•Nursing home % 11 % 7
•Others % 2 % 2Geçirilmiş VTE % 27 % 23
Oger E Thromb Haemost. 2000
Epidemiology of VTE in France
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Epidemiology of VTE in the general population
Different countries Gender and sex In special groups Recent studies (VITEA, IMPROVE,
ENDORSE) Risk factors and their relative weight
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An
nu
al in
cid
enc
e / 1
00
000
0
600
1200
0-14
Gender, Age and VTE
Arch Intern Med, 1998;158:585-93
1000
800
400
200
15-19
20-24 30-34 40-44 50-54 60-64 70-74 80-84
25-29 35-39 45-49 55-59 65-69 75-79 >85
age
malefemale
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Pe
r 1
0 0
00
EPI-GETBO Study
Incidence of VTE, including patients diagnosed and managed outside the hospital
0
10
20
30
40
50
60
70
80
0-19 20-39 40-59 60-74 > 74
DVT,maleDVT,femalePE±DVT,malePE±DVT,female
Total of all events:
•1.52 /1 000 / year in male
•2.03 / 1 000 / year in female
Oger E Thromb Haemost. 2000; 83: 657-60.
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Gender and age
0
2
4
6
8
10
12
14
0-19 20-39 40-59 60-74 > 74
femalemale
Oger E Thromb Haemost. 2000; 83: 657-60.
years
inci
den
ce o
f V
TE
per
100
0 p
er a
nn
um
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Age ≤ 80 years ≥ 80 years
(n=10 121) (n=2 890)
Fatal PE (%) 1.1 3.7
Fatal bleeding (%) 0.4 0.8
Major bleeding (%) 212 (2.1) 99 (3.4)
Lopez-Jimetez. Haematologica. 2006; 91: 1046-51.
VTE in the elderly patients: findings from a prospective
registry (RIETE)• 2 890 patients > 80 years old (out of 13 011 patients )
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Epidemiology of VTE in the general population
Different countries Gender and sex In special groups Recent studies (VITEA, IMPROVE,
ENDORSE) Risk factors and their relative weight
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VITAE Study( VTE Impact Assessment Group in Europe)
•Total annual VTE events and mortality from 25 EU countries
→ DVT+ PE : 1.5 million
→VTE mortality: 543.000
→DVT : 684.000
A T Cohen, et al, 2007 (in press)
First large study to evaluate the burden of VTE in 25 European countries.
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VITAE Study( VTE Impact Assessment Group in Europe)
•Results in France
→General population: 60.424.000
→VTE-related deaths: 71.196
→Non-fatal VTE events: 140.000
→Cost (million Euros): 452 (316-621)
A T Cohen, et al, 2006 (in press)
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VITAE Study( VTE Impact Assessment Group in Europe)
•Results:
→ VTE is a major public health problem in EU.
→Given the availibilty of VTE prophlaxis, many of these events and deaths could be prevented
A T Cohen, et al, 2007 (in press)
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ENDORSE ( multinational, cross sectional,
multicentric, observational survey)•Aim→To identify patients at risk of VTE among medical and surgical patients hospitalized in representative hospitals globally and locally throuhout the world.
→To determine the propotion of at risk hospitalpatients who receive effective types of VTE prophylaxis based on consensus guidelines.
ICTH Congress, 6-12 July 2007
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35 ENDORSE Ülkesi
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ENDORSE Countries
• Algeria Algeria • Australia/NZAustralia/NZ• BangladeshBangladesh• BrazilBrazil• BulgariaBulgaria• ColombiaColombia• Czech RepublicCzech Republic• EgyptEgypt• GreeceGreece• Gulf StatesGulf States
• Saudi ArabiaSaudi Arabia• SlovakiaSlovakia• SwitzerlandSwitzerland• Thailand Thailand • TunisiaTunisia• TurkeyTurkey• VenezuelaVenezuela
• Hungary Hungary • India India • IrelandIreland• Israel Israel • MexicoMexico• PakistanPakistan• PolandPoland• PortugalPortugal• RomaniaRomania• RussiaRussia
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ENDORSE: Global data analysis flow
• 35 countries• 165.831 beds in participating hospitals• 99.664 beds in eligible wards• 84.637 patients in eligible wards • 77.738 evaluable patients in eligible wards
• 54.812 patients for VTE risk analysis
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Study Population - TURKEY• 5161 beds in participating hospitals
• 3119 beds in eligible wards
• 2363 patients in eligible wards
• 2066 evaluable patients in eligible wards
• 1809 patients enrolled in eligiable wards
1503 patients for VTE risk analysis
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Turkey (11 sites)
Istanbul (4)
Kocaeli
GaziantepIzmir (2)
Samsun
Kayseri
Antakya-Hatay
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ENDORSE: Selected centers
• Eşrefpaşa Hospital (Izmir)
• Erciyes University, Oncology
Hospital
• Gaziantep University Hospital
• Göztepe Education Hospital
• Vezirköprü State Hospital
(Samsun)
•Anadolu Çınar Hospital(Ist)
•Kocaeli University Hospital
•Şişli Etfal Hospital (Ist)
•Süreyyapaşa Hospital (İst)
•Dr. Suat Seren Hospital
(Izmir)
•Hatay (Private) Hospital
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ENDORSE: Study population - TURKEY
Study population (n=1503) VTE risk analysis patients population
medical (1204) 80%
surgical (299) 20% surgical
medical
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SIRIUS Study:
VTE risk factors in medical patients
Samama, Arch Inter Med. 2000; 160:3415-3420.
• Pregnancy 11.41 (1.40-93.29)• Deterioration of general state 5.75 (2.20-15.01)• Immobilisation 5.61 (2.30-13.67)• Long-duration travel (>5-6hr) 2.35 (1.45-3.80)• Infectious disease* 1.95 (1.31-2.92)
Worsening Factors
• History of DVT/PE * 15.6 (6.77-35.89)
• Venous insufficiency 4.45 (3.10-6.38)
• Chronic heart failure 2.93 (1.55-5.56)
• Obesity ( BMI> 30 kg/m2 ) 2.49 (1.88-3.87)
• > 3 months pregnancy
• Prolonged standing ( > 6 hours /day)
Intrinsic Factors
Risk OD CI
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IMPROVE Study: International Medical Prevention Registry on
Venous Thromboembolism
J Thromb Haemost 2003;(suppl)
0
10
20
30
40
50
cardiac n=254)
Pulmonery ( n=348)
Neurological ( n=208)
Cancer ( n=104)
50 %19 45
%13
46%22
24%23
Pa
tie
nts
in p
rop
hy
lax
sis
(%)
Primary reason of admission
70 % of medical patients with
acute diseases do not receive
any prophylaxis
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Goldhaber SZ, et al. Chest. 2000;118:1680-4.
43%
16%10%
9%
8%14% Medical
General surgery
Medical oncology
Orthopedi
Thoracic surgery
Others
VTE: According to the wards
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MAJOR MEDICAL RISK FACTORS?
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Major VTE risk factors
age
Immobiliztion
Cancer
Pregnancy/postpartum
Oral contraception
Hormone RT
Antiphospholipid sendr.
Myeloporoliferative
sndr.
Hyperhomocysteinemia
Increased levels of:
•Factor VII
•Fibrinogen
•Factor XI
•Factor IX
Franco RT, Hum Genet. 2001;109:369-84.
Deficiency in AT
Deficiency in ProteinC
Deficiency in Protein S
Factor V Leiden
Protrombin gene mut.
Deficiency in
Fibrinogen, Plasminojen
Inherited Acquired Inher./Acquir.
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The range of risk of VTE according to clinical situation
Risk Factors Risk*
Recent operation 3-21.7
Non-surgical hospitalization /immobilization 5.7-11.1
Congestive heart failure 1.4-9.6
Venous insufficiency 0.9-4.2
Cancer and chemotherapy 6.5
Myocardial infarction 5.9
Ischaemic stroke 2.0-3.0
Malignancy 2.4-5.6 Venous catheter 5.6-6.0
Samama MM,et al. Heamatologica,2003;88
• *Risk includes odds ratio, relative risk, ralative hazard, and hazard ratio
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Range of VTE Risk
Risk Factors Risk*
Age 1.8-14.8
Hyperhomocystenaemia 7.1
Obesity 1.0-4.5
Oral contraception 1.7-4.7
Personel history of VTE 5.9
Secondery antiphospholipid syndrome 4.3
Samama MM,et al. Heamatologica,2003;88
*Risk, odd ratio, relatif risk, ralatif hazard, ve hazard ratio’yu kapsar
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Risk Factors Risk*
Smoking 1.0-3.3
Hormone replacement therapy 2.1-2.7
Black ethnicity 1.4
Male 0.6-1.4
Family history of VTE 3.3-3.4
Samama MM,et al. Heamatologica,2003;88
Range of VTE Risk
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Combination of Risk Factors
•Combination of hereditary and/ or acquired risk factors
•Multiplication effct of combination of risk factors
•Mathematical models are very rare.
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Risk assessment in medical patients?
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Risk assessment in medical patients?
Lutz L, et al. Med Welt, 2002
No risk dehydratation > 60 age Thrombophlia polisitemia pregnancy history ofVTE varikosis nephrotic synd. Active cancer family his. VTE myoloprolipheratiph s. or obesity kateg.1 >2 risk Kateg. 1 > 3r
Kateg. 2 >2r
Predisposing risks
0 1 2 3
•Ischaemic stroke •COPD, acute repr. Failu. + ventilation support•Myocardial infarction
•Heart failure•COPD, acute repr. Failu. + no ventilation support•Sepsis•Infection/acute inflam.disease:confined to bed•Infection/acute inflam.disease:not confined to bed•Venous catheter•No risk
Exposed risks(acute risks)
3
2
1
0
0
1
2
3
0 1 2 3
High Risk
Low Risk
x
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Risk assessment in medical patients
• Stroke• Congestive
h. failure• Acute respir.
failure• Infections• Acute MI
• Immobilization• Malignanacy • Chemoterapy
• History of VTE
• Advabced age > 65
• Obesity• Coagulation
disorders
At least 1 At least 2At least 1+ 1 minor risk
Major Risks Minor Risks Additional Risks
Nicolaides AN et al. International Consensus Statement. Int Angiol 2006; 25: 101-61.