Glucocorticoid use and risk of first and recurrent venous thromboembolism: self-controlled case-series and cohort study

Glucocorticoid treatment increases venous thromboembolism (VTE) risk. Whether this is due to the medication or the underlying disease, or affects the risk of VTE recurrence, has been difficult to determine. The aim of our present study was to quantify the risk for first and recurrent VTE associated with oral glucocorticoids use, considering the underlying disease. A total of 2547 patients with VTE from the Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis (MEGA) study were linked to the Dutch Pharmaceutical Statistics register. The risk of first VTE during periods of exposure with oral glucocorticoids was estimated by the self-controlled case series method and that of recurrent VTE was examined in a cohort design. The incidence rate ratio (IRR) of first VTE in the period of glucocorticoid treatment was 3 center dot 51 [95% confidence interval (CI) 2 center dot 55-4 center dot 80]. This IRR was 2 center dot 53 (95% CI 1 center dot 10-5 center dot 72) in the week before treatment started, 5 center dot 28 (95% CI 2 center dot 89-9 center dot 53) in the first 7 days of treatment, remained elevated afterwards and decreased to 1 center dot 55 (95% CI 0 center dot 85-3 center dot 12) after 6 months, as compared to unexposed periods. The hazard ratio for recurrence was 2 center dot 72 (95% CI 1 center dot 64-4 center dot 78) in treatment periods as compared with no treatment. The increased risk of VTE associated with oral glucocorticoid treatment is due to a combined effect of the treatment and the underlying disease, remaining high during the first months of prescription.Clinical epidemiolog

Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis

AimsRisk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations.Methods and resultsAn individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value ConclusionThe present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study.Thrombosis and Hemostasi

Towards optimal use of antithrombotic therapy of people with cancer at the end of life: a research protocol for the development and implementation of the SERENITY shared decision support tool Thrombosis Research

Background: Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs. Methods: The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe.Results: SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life. Conclusions: We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers

Strategies in suspected venous thrombo-embolism in primary care

This thesis describes strategies for managing suspected venous thrombo-embolism (VTE) in a primary care setting. VTE, compromising deep vein thrombosis (DVT) and pulmonary embolism (PE) is a relatively common condition with an annual incidence of around 2-3 cases per 1000 persons. Most patients with signs and symptoms suggestive for acute VTE are first presented in primary care. In that domain, the primary care physician has to decide if additional testing is needed to confirm or refute a diagnosis. As signs and symptoms of acute VTE can be relatively mild, it is an easy diagnosis to miss. Consequently, the PCP is frequently confronted with a difficult dilemma in these patients: refer all patients would imply not missing a case but also would yield a very low proportion of actually confirmed cases (only around 10%); yet not referring a patients always poses a certain risk of missing acute – and possibly fatal – VTE. This thesis predominantly focuses on tools available to PCPs to help them with this difficult dilemma. In summary, these tools encompass a combination of clinical characteristics (summarized in a clinical decision rule) and D-dimer testing (degradation products of fibrin). In this thesis, it is concluded that in patients with a low risk of having acute VTE (as based on a low score on a clinical decision rule), a negative D-dimer test can safely exclude both DVT and PE. Moreover, such an approach is also feasible and safe if performed by PCPs in primary care. For PCPs the use of a point-of-care D-dimer test is also a safe and convenient approach. These tests provide results within 10 minutes, thereby enabling a safe exclusion of acute VTE during the consultation of the patient

[Added value of clopidogrel in cardiology and neurology]

Item does not contain fulltext- Platelet aggregation inhibitors reduce the risk of complications during and after acute coronary syndromes and after a TIA or stroke.- Acetylsalicylic acid plays a major role in secondary prevention; the combination of acetylsalicylic acid and a platelet ADP receptor antagonist, such as clopidogrel, may have added value.- In percutaneous coronary intervention, dual platelet inhibition appears to be effective in the prevention of stent thrombosis.- Long-term (> 1 year) use of dual platelet inhibition has an unfavourable risk-benefit profile, partly due to an increase in the number of bleeding events, particularly in the stomach.- The use of the combination of acetylsalicylic acid and clopidogrel may be helpful after a TIA or minor stroke, but further research is needed to identify the group of patients for whom this combination would be applicable.- This article provides an overview of the modern cardiological and neurological indications for platelet inhibition as well as the risk factors for severe bleeding events when using dual antiplatelet therapy

[The antithrombotic jungle: an overview of the recent literature]

Physicians encounter patients who use antithrombotics in virtually every area of medical specialisation. As antithrombotic use is often chronic, it is important for medication monitoring that physicians have sufficient knowledge of the latest developments, even if they do not prescribe antithrombotics themselves. The risk of thrombosis must be weighed against the risk of bleeding in every patient who is eligible to be treated with antithrombotics. In this article we describe the main indications for treatment with antithrombotics based on articles published within the past five years

[The antithrombotic jungle: an overview of the recent literature]

Item does not contain fulltextPhysicians encounter patients who use antithrombotics in virtually every area of medical specialisation. As antithrombotic use is often chronic, it is important for medication monitoring that physicians have sufficient knowledge of the latest developments, even if they do not prescribe antithrombotics themselves. The risk of thrombosis must be weighed against the risk of bleeding in every patient who is eligible to be treated with antithrombotics. In this article we describe the main indications for treatment with antithrombotics based on articles published within the past five years