Concomitant history of cancer in acute pulmonary embolism is connected with poorer outcome

Purpose: Cancer increases the risk of venous thromboembolism (VTE) substantially. VTE is connected with poorer outcome in cancer patients. The aim of our study was to investigate the impact of cancer on the severity and short-term outcome of pulmonary embolism (PE). Methods: We retrospectively analyzed the data of 182 patients with confirmed PE. PE patients were subdivided in the group with concomitant active cancer disease or history of cancer or in the group without cancer. Groups were compared with Wilcoxon–Mann–Whitney Test. Logistic regression models were calculated to investigate the association between cancer and several parameters such as age and PE severity status as well as the association between in-hospital death and the parameters age, gender, PE severity status and cancer. Results: While 20.3% PE patients reported an active cancer disease or a history of cancer (64.9% female), 79.7% of the PE patients did not (60.7% female). PE patients with cancer were 5 years older (76.0 (65.5/81.0) vs. 71.0 (58.5/80.5) years, P=0.055) and revealed a higher PE severity status in mean (1.91±0.53 vs. 1.67±0.54, P=0.069). Univariate logistic regression models showed an association between cancer and age (OR 1.04, CI 95% (1.01–1.08), P=0.017) as well as cancer and the severity status (OR 2.38 (1.05–5.26), P=0.037). In-hospital death in the early course was strongly connected with the PE severity status (OR 36.60 (2.99–448.68), P=0.0049), but not with cancer (P=0.65). Conclusions: Concomitant history of cancer in acute PE was associated with higher PE severity status and therefore poorer outcome

Atherosclerosis and Its Impact on the Outcomes of Patients with Deep Venous Thrombosis

Introduction: Atherosclerosis and pulmonary embolism (PE) affect cardiovascular mortality substantially. We aimed to investigate the impact of atherosclerosis on the outcomes of patients with deep venous thrombosis (DVT) and to identify the differences in DVT patients with and without PE. Methods: Patients with DVT with and without symptomatic atherosclerosis (defined as coronary artery disease, myocardial infarction and/or peripheral artery disease) as well as with and without PE under oral anticoagulation were enrolled during January 2011–April 2013 and compared. The impact of symptomatic atherosclerosis on several outcomes was analyzed. Results: Overall, 509 DVT patients (70.0 [56.0–77.0] years, 51.9% females) were included in this study. Among them, 179 (36.3%) had symptomatic atherosclerosis and 204 (40.1%) a concomitant PE. DVT patients with symptomatic atherosclerosis were older (74.0 [IQR 65.0–80.0] vs. 63.0 [48.0–75.0] years, p p = 0.0087) and had a higher prevalence of classical CVRF and a higher Charlson comorbidity index (7.00 [5.00–8.00] vs. 4.00 [2.00–6.00], p p = 0.018) and hospitalizations (HR 1.64 [95%CI 1.21–2.21], p = 0.0012) and primary long-term outcome (HR 1.99 [95%CI 1.31–3.04], p = 0.0013) during the 2 years follow-up-period in DVT patients. DVT patients without PE had diabetes mellitus (28.2% vs. 16.3%, p p p < 0.01). Conclusions: Atherosclerosis was associated with isolated DVT (without PE) and increased mortality in DVT patients under oral anticoagulation. The profile of CVRF and comorbidities differed between DVT patients with and without a concomitant PE. In the case of DVT or PE, patients should be screened for concomitant atherosclerotic disease. Clinical Trial Registration: at clinicaltrials with Unique identifier NCT01809015

Quality of oral anticoagulation with phenprocoumon in regular medical care and its potential for improvement in a telemedicine-based coagulation service - results from the prospective, multi-center, observational cohort study thrombEVAL

BACKGROUND: The majority of studies on quality of oral anticoagulation (OAC) therapy with vitamin K-antagonists are performed with short-acting warfarin. Data on long-acting phenprocoumon, which is frequently used in Europe for OAC therapy and is considered to enable more stable therapy adjustment, are scarce. In this study, we aimed to assess quality of OAC therapy with phenprocoumon in regular medical care and to evaluate its potential for optimization in a telemedicine-based coagulation service. METHODS: In the prospective observational cohort study program thrombEVAL we investigated 2,011 patients from regular medical care in a multi-center cohort study and 760 patients from a telemedicine-based coagulation service in a single-center cohort study. Data were obtained from self-reported data, computer-assisted personal interviews, and laboratory measurements according to standard operating procedures with detailed quality control. Time in therapeutic range (TTR) was calculated by linear interpolation method to assess quality of OAC therapy. Study monitoring was carried out by an independent institution. RESULTS: Overall, 15,377 treatment years and 48,955 international normalized ratio (INR) measurements were analyzed. Quality of anticoagulation, as measured by median TTR, was 66.3% (inte rquartile range (IQR) 47.8/81.9) in regular medical care and 75.5% (IQR 64.2/84.4) in the coagulation service (P <0.001). Stable anticoagulation control within therapeutic range was achieved in 63.8% of patients in regular medical care with TTR at 72.1% (IQR 58.3/84.7) as compared to 96.4% of patients in the coagulation service with TTR at 76.2% [(IQR 65.6/84.7); P = 0.001)]. Prospective follow-up of coagulation service patients with pretreatment in regular medical care showed an improvement of the TTR from 66.2% (IQR 49.0/83.6) to 74.5% (IQR 62.9/84.2; P <0.0001) in the coagulation service. Treatment in the coagulation service contributed to an optimization of the profile of time outside therapeutic range, a 2.2-fold increase of stabile INR adjustment and a significant decrease in TTR variability by 36% (P <0.001). CONCLUSIONS: Quality of anticoagulation with phenprocoumon was comparably high in this real-world sample of regular medical care. Treatment in a telemedicine-based coagulation service substantially improved quality of OAC therapy with regard to TTR level, frequency of stable anticoagulation control, and TTR variability. TRIAL REGISTRATION: ClinicalTrials.gov, unique identifier NCT01809015, March 8, 2013. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12916-015-0268-9) contains supplementary material, which is available to authorized users

Telemedicine-Based Specialized Care Improves the Outcome of Anticoagulated Individuals with Venous Thromboembolism-Results from the thrombEVAL Study

Venous thromboembolism (VTE) is a life-threatening disease with risk of recurrence. Oral anticoagulation (OAC) with vitamin K antagonists (VKA) is effective to prevent thromboembolic recurrence. We aimed to investigate the quality of OAC of VTE patients in regular medical care (RMC) compared to a telemedicine-based coagulation service (CS). The thrombEVAL study (NCT01809015) is a prospective, multi-center study to investigate OAC treatment (recruitment: January 2011&ndash;March 2013). Patients were evaluated using clinical visits, computer-assisted personal interviews, self-reported data and laboratory measurements according to standard operating procedures. Overall, 360 patients with VTE from RMC and 254 from CS were included. Time in therapeutic range (TTR) was higher in CS compared to RMC (76.9% (interquartile range [IQR] 63.2&ndash;87.1%) vs. 69.5% (52.3&ndash;85.6%), p &lt; 0.001). Crude rate of thromboembolic events (rate ratio [RR] 11.33 (95% confidence interval [CI] 1.85&ndash;465.26), p = 0.0015), clinically relevant bleeding (RR 6.80 (2.52&ndash;25.76), p &lt; 0.001), hospitalizations (RR 2.54 (1.94&ndash;3.39), p &lt; 0.001) and mortality under OAC (RR 5.89 (2.40&ndash;18.75), p &lt; 0.001) were consistently higher in RMC compared with CS. Patients in RMC had higher risk for primary outcome (clinically relevant bleedings, thromboembolic events and mortality, hazard ratio [HR] 5.39 (95%CI 2.81&ndash;10.33), p &lt; 0.0001), mortality (HR 5.54 (2.22&ndash;13.84), p = 0.00025), thromboembolic events (HR 6.41 (1.51&ndash;27.24), p = 0.012), clinically relevant bleeding (HR 5.31 (1.89&ndash;14.89), p = 0.0015) and hospitalization (HR 1.84 (1.34&ndash;2.55), p = 0.0002). Benefits of CS care were still observed after adjusting for comorbidities and TTR. In conclusion, anticoagulation quality and outcome of VTE patients undergoing VKA treatment was significantly better in CS than in RMC. Patients treated in CS had lower rates of adverse events, hospitalizations and lower mortality. CS was prognostically relevant, beyond providing advantages of improved international ratio (INR) monitoring