Rate and duration of hospitalisation for acute pulmonary embolism in the real-world clinical practice of different countries : Analysis from the RIETE registry

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Characteristics, treatment patterns and outcomes of patients presenting with venous thromboembolic events after knee arthroscopy in the RIETE Registry

Knee arthroscopy is the most common orthopedic procedure worldwide. While incidence of post-arthroscopy venous thromboembolic events (VTE) is low, treatment patterns and patient outcomes have not been described. Patients from the "Registro Informatizado Enfermedad TromboEmbolica" who had confirmed post-arthroscopy VTE were compared to patients with provoked, post bone-fracture, and to patients with unprovoked VTE. Baseline characteristics, presenting signs and symptoms, treatment and outcomes including recurrent VTE, bleeds or death were compared. A total of 101 patients with post-arthroscopy VTE and 19,218 patients with unprovoked VTE were identified. Post-arthroscopy patients were younger (49.5 vs. 66 years, P\u2009<\u20090.0001) and had less history of VTE [5.9% vs. 20%, OR 0.26 (0.11-0.59)]. Among patients with isolated DVT, there were fewer proximal DVT in the post-arthroscopy group [40% vs. 86%, OR 0.11 (0.06-0.19)]. Treatment duration was shorter in the post-arthroscopy group (174\u2009\ub1\u2009140 vs. 311\u2009\ub1\u2009340 days, P\u2009<\u20090.0001) and more often with DOAC [OR 3.67 (1.95-6.89)]. Recurrent VTE occurred in 6.18 (1.96-14.9) and 11.9 (11.0-12.8) per 100 patient years [HR 0.52 (0.16-1.26)] after treatment in the post-arthroscopy and unprovoked groups, respectively. Recurrent VTE occurred in 5.17 (1.31-14.1) per 100 patient years in a separate post bone-fracture group (n\u2009=\u2009147), also not statistically different than the post-arthroscopy recurrence rate. After anticoagulation cessation, some patients post-knee arthroscopy develop VTE. While our small sample size precludes drawing firm conclusions, this signal should warrant further research into the optimal treatment duration for these patients, as some patients may be at increased risk for long-term recurrence

Correction to: Vena cava filters in patients presenting with major bleeding during anticoagulation for venous thromboembolism (Internal and Emergency Medicine, (2019), 14, 7, (1101-1112), 10.1007/s11739-019-02077-5)

In the original publication, part of the conflict of statement was incorrectly published as “Dr. Bikdeli reports that he was approached by lawyers on behalf of plaintiffs in litigation related to IVC filters”. The correct statement should read as “Dr. Bikdeli reports that he is a consulting expert (on behalf of the plaintiff) for litigation related to a specific type of IVC filters”. In addition, the affiliation of first author was incorrectly published. The corrected affiliation is given in this erratum

Vena cava filters in patients presenting with major bleeding during anticoagulation for venous thromboembolism

The association between inferior vena cava filter (IVC) use and outcome in patients presenting with major bleeding during anticoagulation for venous thromboembolism (VTE) has not been thoroughly investigated. We used the RIETE registry to compare the 30-day outcomes (death, major re-bleeding or VTE recurrences) in VTE patients who bled during the first 3 months of therapy, regarding the insertion of an IVC filter. A propensity score matched (PSM) analysis was performed to adjust for potential confounders. From January 2001 to September 2016, 1065 VTE patients had major bleeding during the first 3 months of anticoagulation (gastrointestinal 370; intracranial 124). Of these, 122 patients (11%) received an IVC filter. Patients receiving a filter restarted anticoagulation later (median, 4 vs. 2 days) and at lower doses (95\u2009\ub1\u200952 IU/kg/day vs. 104\u2009\ub1\u200955 of low-molecular-weight heparin) than those not receiving a filter. During the first 30 days after bleeding (after excluding 246 patients who died within the first 24 h), 283 patients (27%) died, 63 (5.9%) had non-fatal re-bleeding and 19 (1.8%) had recurrent pulmonary embolism (PE). In PSM analysis, patients receiving an IVC filter (n\u2009=\u2009122) had a lower risk for all-cause death (HR 0.49; 95% CI 0.31-0.77) or fatal bleeding (HR 0.16; 95% CI 0.07-0.49) and a similar risk for re-bleeding (HR 0.55; 95% CI 0.23-1.40) or PE recurrences (HR 1.57; 95% CI 0.38-6.36) than those not receiving a filter (n\u2009=\u2009429). In VTE patients experiencing major bleeding during the first 3 months, use of an IVC filter was associated with reduced mortality rates.Clinical Trial Registration NCT02832245

Comparison of seven prognostic tools to identify low-risk pulmonary embolism in patients aged <50 years

In young patients with acute pulmonary embolism (PE), the predictive value of currently available prognostic tools has not been evaluated. Our objective was to compare prognostic value of 7 available tools (GPS, PESI, sPESI, Prognostic Algorithm, PREP, shock index and RIETE) in patients aged &lt;50 years. We used the RIETE database, including PE patients from 2001 to 2017. The major outcome was 30-day all-cause mortality. Of 34,651 patients with acute PE, 5,822 (17%) were aged &lt;50 years. Of these, 83 (1.4%) died during the first 30 days. Number of patients deemed low risk with tools was: PREP (95.9%), GPS (89.6%), PESI (87.2%), Shock index (70.9%), sPESI (59.4%), Prognostic algorithm (58%) and RIETE score (48.6%). The tools with a highest sensitivity were: Prognostic Algorithm (91.6%; 95% CI: 85.6\u201397.5), RIETE score (90.4%; 95%CI: 84.0\u201396.7) and sPESI (88%; 95% CI: 81\u201395). The RIETE, Prognostic Algorithm and sPESI scores obtained the highest overall sensitivity estimates for also predicting 7- and 90-day all-cause mortality, 30-day PE-related mortality, 30-day major bleeding and 30-day VTE recurrences. The proportion of low-risk patients who died within the first 30 days was lowest using the Prognostic Algorithm (0.2%), RIETE (0.3%) or sPESI (0.3%) scores. In PE patients less 50 years, 30-day mortality was low. Although sPESI, RIETE and Prognostic Algorithm scores were the most sensitive tools to identify patients at low risk to die, other tools should be evaluated in this population to obtain more efficient results

Symptomatic subsegmental versus more central pulmonary embolism: Clinical outcomes during anticoagulation

Background: The optimal therapy of patients with acute subsegmental pulmonary embolism (PE) is controversial. Methods: We used the RIETE (Registro Informatizado Enfermedad TromboEmb\uf3lica) database to compare the rate of symptomatic PE recurrences during anticoagulation in patients with subsegmental, segmental, or more central PEs. Results: Among 15&nbsp;963 patients with a first episode of symptomatic PE, 834 (5.2%) had subsegmental PE, 3797 (24%) segmental, and 11&nbsp;332 (71%) more central PE. Most patients in all subgroups received initial therapy with low-molecular-weight heparin, and then most switched to vitamin K antagonists. Median duration of therapy was 179, 185, and 204&nbsp;days, respectively. During anticoagulation, 183 patients developed PE recurrences, 131 developed deep vein thrombosis (DVT), 543 bled, and 1718 died (fatal PE, 135). The rate of PE recurrences was twofold higher in patients with subsegmental PE than in those with segmental (hazard ratio [HR], 2.13; 95% confidence interval [CI], 1.16-3.85) or more central PE (HR, 1.89; 95% CI, 1.12-3.13). On multivariable analysis, patients with subsegmental PE had a higher risk for PE recurrences than those with central PE (adjusted HR, 1.75; 95% CI, 1.02-3.03). After stratifying patients with subsegmental PE according to ultrasound imaging in the lower limbs, the rate of PE recurrences was similar in patients with DVT, in patients without DVT, and in those with no ultrasound imaging. Conclusions: Our study reveals that the risk for PE recurrences in patients with segmental PE is not lower than in those with more central PE, thus suggesting that the risk of PE recurrences is not influenced by the anatomic location of PE

Real-life Use of Anticoagulants in Venous Thromboembolism With a Focus on Patients With Exclusion Criteria for Direct Oral Anticoagulants

We assessed the real-life use of direct oral anticoagulants (DOACs) in patients with venous thromboembolism (VTE) and exclusion criteria for randomized trials. From 2013 to 2016, 3,578 of 18,853 patients (19%) had exclusion criteria. Irrespective of which anticoagulant was chosen, they had more VTE recurrences (hazard ratio (HR): 3.10; 95% confidence interval (CI): 2.47\u20133.88), major bleeds (HR: 4.10; 95% CI: 3.38\u20134.96), and deaths (HR: 9.47; 95% CI: 8.46\u201310.6) than those without exclusion criteria. During initial therapy, no patient with exclusion criteria on DOACs (n = 115) recurred, but those on rivaroxaban bled less often (adjusted HR: 0.18; 95% CI: 0.04\u20130.79) than those on unfractionated heparin (n = 224) and similar to those (n = 3,172) on low-molecular-weight (LMWH) heparin. For long-term therapy, patients on rivaroxaban (n = 151) had nonsignificantly fewer VTE recurrences (adjusted HR: 0.74; 95% CI: 0.08\u20131.32) and major bleeds (adjusted HR: 0.41; 95% CI: 0.15\u20131.15) than those on LMWH (n = 2,071). The efficacy and safety of DOACs were similar to standard therapy

Treatment of Right Heart Thrombi Associated with Acute Pulmonary Embolism

Background Evidence-based recommendations do not adequately address the treatment of right heart thrombi in patients who present with acute symptomatic pulmonary embolism. Methods This study included patients who had acute pulmonary embolism associated with right heart thrombi and participated in the Registro Informatizado de la Enfermedad TromboEmb\uf3lica registry. We assessed the effectiveness of anticoagulation versus reperfusion treatment for the outcomes of all-cause mortality, pulmonary embolism\u2013related mortality, recurrent venous thromboembolism, and major bleeding rates through 30 days after initiation of pulmonary embolism treatment. We used propensity score matching to adjust for the likelihood of receiving reperfusion treatment. Results Of 325 patients with pulmonary embolism and right heart thrombi, 255 (78%; 95% confidence interval, 74-83) received anticoagulation and 70 (22%; 95% confidence interval, 17-26) also received reperfusion treatment. Propensity score\u2013matched pairs analyses did not detect a statistically lower risk of all-cause death (6.2% vs 14%, P&nbsp;= .15) or pulmonary embolism\u2013related mortality (4.7% vs 7.8%; P&nbsp;= .47) for reperfusion compared with anticoagulation. Of the patients who received reperfusion treatment, 6.2% had a recurrence during the study follow-up period, compared with 0% of those who received anticoagulation (P&nbsp;= .049). The incidence of major bleeding events was not statistically different between the 2 treatment groups (3.1% vs 3.1%; P&nbsp;= 1.00). Conclusions In patients with pulmonary embolism and right heart thrombi, no significant difference was found between reperfusion therapy and anticoagulant therapy for mortality and bleeding. The risk of recurrences was significantly higher for reperfusion therapy compared with anticoagulation. Right heart thrombi may not warrant riskier interventions than standard anticoagulation

Predictors of active cancer thromboembolic outcomes: RIETE experience of the Khorana score in cancer-associated thrombosis

158sinoneEven though the Khorana risk score (KRS) has been validated to predict against the development of VTE among patients with cancer, it has a low positive predictive value. It is also unknown whether the score predicts outcomes in patients with cancer with established VTE. We selected a cohort of patients with active cancer from the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry to assess the prognostic value of the KRS at inception in predicting the likelihood of VTE recurrences, major bleeding and mortality during the course of anticoagulant therapy. We analysed 7948 consecutive patients with cancer-associated VTE. Of these, 2253 (28 %) scored 0 points, 4550 (57 %) 1-2 points and 1145 (14 %) scored ≥points. During the course of anticoagulation, amongst patient with low, moderate and high risk KRS, the rate of VTE recurrences was of 6.21 (95 %CI: 4.99-7.63), 11.2 (95 %CI: 9.91-12.7) and 19.4 (95 %CI: 15.4-24.1) events per 100 patient-years; the rate of major bleeding of 5.24 (95 %CI: 4.13-6.56), 10.3 (95 %CI: 9.02-11.7) and 19.4 (95 %CI: 15.4-24.1) bleeds per 100 patient-years and the mortality rate of 25.3 (95 %CI: 22.8-28.0), 58.5 (95 %CI: 55.5-61.7) and 120 (95 %CI: 110-131) deaths per 100 patient-years, respectively. The C-statistic was 0.53 (0.50-0.56) for recurrent VTE, 0.56 (95 %CI: 0.54-0.59) for major bleeding and 0.54 (95 %CI: 0.52-0.56) for death. In conclusion, most VTEs occur in patients with low or moderate risk scores. The KRS did not accurately predict VTE recurrence, major bleeding, or mortality among patients with cancer-associated thrombosis.noneTafur A.J.; Caprini J.A.; Cote L.; Trujillo-Santos J.; del Toro J.; Garcia-Bragado F.; Tolosa C.; Barillari G.; Visona A.; Monreal M.; Adarraga M.D.; Aibar M.A.; Alfonso M.; Arcelus J.I.; Ballaz A.; Barba R.; Barron M.; Barrn-Andres B.; Bascunana J.; Blanco-Molina A.; Canas I.; Chic N.; del Pozo R.; Diaz-Pedroche M.C.; Diaz-Peromingo J.A.; Falga C.; Fernandez-Aracil C.; Fernandez-Capitan C.; Fidalgo M.A.; Font C.; Font L.; Gallego P.; Garcia I.; Garcia M.A.; Garcia-Rodenas M.; Gavin O.; Gomez C.; Gomez V.; Gonzalez J.; Grau E.; Grimon A.; Guijarro R.; Guirado L.; Gutierrez J.; Hernandez-Comes G.; Hernandez-Blasco L.; Jara-Palomares L.; Jaras M.J.; Jimenez D.; Jimenez J.; Joya M.D.; Llamas P.; Lobo J.L.; Lopez P.; Lopez-Jimenez L.; Lopez-Reyes R.; Lopez-Saez J.B.; Lorente M.A.; Lorenzo A.; Lumbierres M.; Marchena P.J.; Martin-Martos F.; Mellado M.; Nieto J.A.; Nieto S.; Nunez A.; Nunez M.J.; Otalora S.; Otero R.; Ovejero A.; Pedrajas J.M.; Perez G.; Perez-Ductor C.; Peris M.L.; Pons I.; Porras J.A.; Reig O.; Riera-Mestre A.; Riesco D.; Rivas A.; Rodriguez M.; Rodriguez-Davila M.A.; Rosa V.; Ruiz-Artacho P.; Ruiz-Gimenez N.; Sahuquillo J.C.; Sala-Sainz M.C.; Samperiz A.; Sanchez-Martinez R.; Sanz O.; Soler S.; Sopena B.; Surinach J.M.; Torres M.I.; Uresandi F.; Usandizaga E.; Valero B.; Valle R.; Vela J.; Velez-Mendizabal E.; Vidal G.; Vila M.; Villalobos A.; Xifre B.; Vanassche T.; Verhamme P.; Yoo H.H.B.; Wells P.; Hirmerova J.; Maly R.; Salgado E.; Bertoletti L.; Bura-Riviere A.; Falvo N.; Farge-Bancel D.; Hij A.; Mahe I.; Moustafa F.; Braester A.; Brenner B.; Tzoran I.; Antonucci G.; Bilora F.; Bortoluzzi C.; Brandolin B.; Bucherini E.; Candeloro G.; Cattabiani C.; Ciammaichella M.; Dentali F.; Di Micco P.; Duce R.; Giorgi-Pierfranceschi M.; Grandone E.; Imbalzano E.; Lessiani G.; Maida R.; Mastroiacovo D.; Pace F.; Parisi R.; Pellegrinet M.; Pesavento R.; Pinelli M.; Poggio R.; Prandoni P.; Quintavalla R.; Rocci A.; Tiraferri E.; Tonello D.; Tufano A.; Visona A.; Gibietis V.; Skride A.; Vitola B.; Bosevski M.; Zdraveska M.; Bounameaux H.; Mazzolai L.Tafur, A. J.; Caprini, J. A.; Cote, L.; Trujillo-Santos, J.; del Toro, J.; Garcia-Bragado, F.; Tolosa, C.; Barillari, G.; Visona, A.; Monreal, M.; Adarraga, M. D.; Aibar, M. A.; Alfonso, M.; Arcelus, J. I.; Ballaz, A.; Barba, R.; Barron, M.; Barrn-Andres, B.; Bascunana, J.; Blanco-Molina, A.; Canas, I.; Chic, N.; del Pozo, R.; Diaz-Pedroche, M. C.; Diaz-Peromingo, J. A.; Falga, C.; Fernandez-Aracil, C.; Fernandez-Capitan, C.; Fidalgo, M. A.; Font, C.; Font, L.; Gallego, P.; Garcia, I.; Garcia, M. A.; Garcia-Rodenas, M.; Gavin, O.; Gomez, C.; Gomez, V.; Gonzalez, J.; Grau, E.; Grimon, A.; Guijarro, R.; Guirado, L.; Gutierrez, J.; Hernandez-Comes, G.; Hernandez-Blasco, L.; Jara-Palomares, L.; Jaras, M. J.; Jimenez, D.; Jimenez, J.; Joya, M. D.; Llamas, P.; Lobo, J. L.; Lopez, P.; Lopez-Jimenez, L.; Lopez-Reyes, R.; Lopez-Saez, J. B.; Lorente, M. A.; Lorenzo, A.; Lumbierres, M.; Marchena, P. J.; Martin-Martos, F.; Mellado, M.; Nieto, J. A.; Nieto, S.; Nunez, A.; Nunez, M. J.; Otalora, S.; Otero, R.; Ovejero, A.; Pedrajas, J. M.; Perez, G.; Perez-Ductor, C.; Peris, M. L.; Pons, I.; Porras, J. A.; Reig, O.; Riera-Mestre, A.; Riesco, D.; Rivas, A.; Rodriguez, M.; Rodriguez-Davila, M. A.; Rosa, V.; Ruiz-Artacho, P.; Ruiz-Gimenez, N.; Sahuquillo, J. C.; Sala-Sainz, M. C.; Samperiz, A.; Sanchez-Martinez, R.; Sanz, O.; Soler, S.; Sopena, B.; Surinach, J. M.; Torres, M. I.; Uresandi, F.; Usandizaga, E.; Valero, B.; Valle, R.; Vela, J.; Velez-Mendizabal, E.; Vidal, G.; Vila, M.; Villalobos, A.; Xifre, B.; Vanassche, T.; Verhamme, P.; Yoo, H. H. B.; Wells, P.; Hirmerova, J.; Maly, R.; Salgado, E.; Bertoletti, L.; Bura-Riviere, A.; Falvo, N.; Farge-Bancel, D.; Hij, A.; Mahe, I.; Moustafa, F.; Braester, A.; Brenner, B.; Tzoran, I.; Antonucci, G.; Bilora, F.; Bortoluzzi, C.; Brandolin, B.; Bucherini, E.; Candeloro, G.; Cattabiani, C.; Ciammaichella, M.; Dentali, F.; Di Micco, P.; Duce, R.; Giorgi-Pierfranceschi, M.; Grandone, E.; Imbalzano, E.; Lessiani, G.; Maida, R.; Mastroiacovo, D.; Pace, F.; Parisi, R.; Pellegrinet, M.; Pesavento, R.; Pinelli, M.; Poggio, R.; Prandoni, P.; Quintavalla, R.; Rocci, A.; Tiraferri, E.; Tonello, D.; Tufano, A.; Visona, A.; Gibietis, V.; Skride, A.; Vitola, B.; Bosevski, M.; Zdraveska, M.; Bounameaux, H.; Mazzolai, L