About Additional Risk Factors
BMI > 40 – One additional point (BMI >25=1; BMI.40=2)
Individuals who are physically fit or athletes but very large are not exempt from this risk factor. The stress on the cardiovascular system due to their size and bulk can result in cardiac hypertrophy, hypertension, valvular disease related to heart strain, sleep apnea, and diabetes requiring insulin. A linear increase in VTE events is seen with increased weight and those with a BMI >35 experience a sixfold increase in these events. The VTE risk increases further with a BMI> 40.
Sixfold: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3769947/
Free article, link as reference with abstract below
BMI>40: https://pubmed.ncbi.nlm.nih.gov/12020191/
Abstract
Background: The association between traditional cardiovascular risk factors and risk of venous thromboembolism (VTE) has not been extensively examined in prospective studies.
Methods: To determine whether atherosclerotic risk factors are also associated with increased incidence of VTE, we conducted a prospective study of 19 293 men and women without previous VTE in 6 US communities between 1987 and 1998.
Results: There were 215 validated VTE events (1.45 per 1000 person-years) during a median of 8 years of follow-up. The age-adjusted hazard ratio was 1.4 (95% confidence interval [CI], 1.1-1.9) for men vs women, 1.6 (95% CI, 1.2-2.2) for blacks vs whites, and 1.7 (95% CI, 1.5-2.0) per decade of age. Cigarette smoking, hypertension, dyslipidemia, physical inactivity, and alcohol consumption were not associated with risk of VTE. Age-, race-, and sex-adjusted hazard ratios for body mass index categories (calculated as the weight in kilograms divided by the height in meters squared) of less than 25, 25 to less than 30, 30 to less than 35, 35 to less than 40, and 40 or more were 1.0, 1.5, 2.2, 1.5, and 2.7, respectively (P<.001 for the trend). Diabetes was also associated with an increased risk of VTE (adjusted hazard ratio, 1.5 [95% CI, 1.0-2.1]).
Conclusions: Our data showing no relationship of some arterial risk factors with VTE corroborate the view that the etiology of VTE differs from atherosclerotic cardiovascular disease. In addition, the findings suggest a hypothesis that avoidance of obesity and diabetes or vigilance in prophylaxis in patients with those conditions may prevent some venous thromboses.
BLOOD TRANSFUSION – (1 point)
The infusion of 1-2 unit of blood >28 days old increases the DVT rate and mortality in trauma patients. The incidence of DVT is increased in ventral hernia, and bariatric surgery patients and receiving blood transfusions and many of these events up to 50% occur following discharge. VTE rates in cancer patients are higher when they receive RBC transfusions.
Patients: https://pubmed.ncbi.nlm.nih.gov/19772604/
Abstract
Introduction: In critically ill patients the relationship between the storage age of red blood cells (RBCs) transfused and outcomes are controversial. To determine if duration of RBC storage is associated with adverse outcomes we studied critically ill trauma patients requiring transfusion.
Methods: This retrospective cohort study included patients with traumatic injuries transfused >or=5 RBC units. Patients transfused >or= 1 unit of RBCs with a maximum storage age of up to 27 days were compared with those transfused 1 or more RBC units with a maximum storage age of >or= 28 days. These study groups were also matched by RBC amount (+/- 1 unit) transfused. Primary outcomes were deep vein thrombosis and in-hospital mortality.
Results: Two hundred and two patients were studied with 101 in both decreased and increased RBC age groups. No differences in admission vital signs, laboratory values, use of DVT prophylaxis, blood products or Injury Severity Scores were measured between study groups. In the decreased compared with increased RBC storage age groups, deep vein thrombosis occurred in 16.7% vs 34.5%, (P = 0.006), and mortality was 13.9% vs 26.7%, (P = 0.02), respectively. Patients transfused RBCs of increased storage age had an independent association with mortality, OR (95% CI), 4.0 (1.34 – 11.61), (P = 0.01), and had an increased incidence of death from multi-organ failure compared with the decreased RBC age group, 16% vs 7%, respectively, (P = 0.037).
Conclusions: In trauma patients transfused >/=5 units of RBCs, transfusion of RBCs >or= 28 days of storage may be associated with deep vein thrombosis and death from multi-organ failure.
SMOKING – (1 point)
Smoking is defined as the inhalation of anything that burns, including marijuana, or vaping. Smokers were more likely to develop postoperative VTE than never smokers.
Marijuana: https://pubmed.ncbi.nlm.nih.gov/32209959/
Abstract
Background: Tetrahydrocannabinoids (THC) can modulate the coagulation cascade resulting in hypercoagulability. However, the clinical relevance of these findings has not been investigated. The aim of our study was to evaluate the impact of preinjury marijuana exposure on thromboembolic complications (TEC) in trauma patients.
Methods: We performed a 2-year (2015-2016) analysis of American College of Surgeons Trauma Quality and Improvement Program database and included all adult (≥18 year) trauma patients. Patients were stratified based on preinjury exposure to Marijuana: THC + ve and THC -ve groups. We performed propensity score matching to control for confounding variables: demographics, comorbidities, injury parameters, hospital course, and thromboprophylaxis use. Outcomes were TEC (deep venous thrombosis, pulmonary embolism, stroke, myocardial infarction) and mortality.
Results: Of 593,818 trauma patients, 678 patients were matched (THC + ve: 226 vs. THC -ve: 452). Mean age was 34 ± 15 years, Injury Severity Score was 14 (10-21). There was no difference between the two groups regarding age (p = 0.75), sex (p = 0.99), Injury Severity Score (p = 0.54), spine Abbreviated Injury Scale (AIS) (p = 0.61), head AIS (p = 0.32), extremities AIS (p = 0.38), use of unfractionated heparin (p = 0.54), use of low molecular weight heparin (p = 0.54), and hospital length of stay (p = 0.87). Overall, the rate of TEC was 4.3% and mortality was 4%. Patients in THC + ve group had higher rates of TEC compared with those in THC -ve group (3.5% vs. 1.1%, p = 0.03). The rate of deep venous thrombosis (6.6% vs. 1.8%, p = 0.02) and PE (2.2% vs. 0.2%, p = 0.04) was higher in THC + ve group. However, there was no difference regarding the rate of stroke (p = 0.24), myocardial infarction (p = 0.35) and mortality (p = 0.28).
Conclusion: THC exposure increases the risk of TEC in patients with trauma. Early identification and treatment for TEC is required to improve outcomes in this high-risk subset of trauma patients.
VTE: https://pubmed.ncbi.nlm.nih.gov/23481621/
Abstract
Background: Evidence about the effect of smoking on venous thromboembolism risk, generally and in the postoperative period, is limited and inconsistent. We examined the incidence of venous thromboembolism in relation to smoking habits, both in the absence of surgery and in the first 12 postoperative weeks, in a large prospective study of women in the United Kingdom.
Methods and results: During 6 years’ follow-up of 1 162 718 women (mean age 56 years), 4630 were admitted to hospital for or died of venous thromboembolism. In the absence of surgery, current smokers had a significantly increased incidence of venous thromboembolism compared with never-smokers (adjusted relative risk 1.38, 95% confidence interval 1.28-1.48), with significantly greater risks in heavier than lighter smokers (relative risks 1.47 [95% confidence interval 1.34-1.62] and 1.29 [95% confidence interval 1.17-1.42] for ≥15 versus <15 cigarettes per day). Current smokers were also more likely to have surgery than never-smokers (relative risk 1.12, 95% confidence interval 1.12-1.13). Among women who had surgery, the incidence of venous thromboembolism in the first 12 postoperative weeks was significantly greater in current than never-smokers (relative risk 1.16, 95% confidence interval 1.02-1.30).
Conclusions: Venous thromboembolism incidence was increased in current smokers, both in the absence of surgery and in the 12 weeks after surgery. Smoking is another factor to consider in the assessment of venous thromboembolism risk in patients undergoing surgery.
DIABETES MELLITUS REQUIRING INSULIN – (1 point)
The overall incidence of DVT and PE was higher in the type 2 diabetes mellitus patients than in the controls. Type 1 and 2 patients are at increased risk for recurrent VTE.
Diabetes mellitus: https://pubmed.ncbi.nlm.nih.gov/26271946/
Abstract
We evaluated the effects of diabetes on the risks of developing deep-vein thrombosis (DVT) and pulmonary embolism (PE) in a nationwide, population-based cohort study in Taiwan. The patients with newly diagnosed type 2 diabetes mellitus (T2DM) were identified, and DM-free controls were randomly selected from the general population and frequency-matched according to age, sex, and index year by using the records of the Longitudinal Health Insurance Database between 2000 and 2011. Both cohorts were followed up until the end of 2011 to measure the incidence of DVT and PE. We analysed the risks of DVT and PE using Cox proportional-hazards regression models. The overall incidence of VTE was higher in the T2DM patients than in the controls (12.0 vs 7.51 per 10,000 person-years). The T2DM patients exhibited a 1.44-fold adjusted hazard ratio (aHR) of VTE development compared with the controls (95% confidence interval [CI] = 1.27-1.63). The risks of DVT (aHR = 1.43, 95% CI = 1.23-1.65) and PE (aHR = 1.52, 95% CI = 1.22-1.90) were greater in the T2DM than those in the controls. The T2DM patients had a substantially higher risk of DVT (aHR = 5.10, 95% CI = 3.12-8.32) and PE (aHR = 7.50, 95% CI = 3.29-17.1) development than the controls did in adults aged 49 years and younger. In conclusion, the longitudinal nationwide cohort study indicated that T2DM patients carried greater risks of developing VTE than did the general population.
VTE: https://pubmed.ncbi.nlm.nih.gov/22560173/
Abstract
Purpose: The majority of epidemiological studies demonstrate an increased risk of venous thromboembolism among diabetic patients. Our aim was to compare clinical characteristics, prophylaxis, treatment, and outcomes of venous thromboembolism in patients with and without previously diagnosed diabetes.
Methods: We studied diabetic patients in the population-based Worcester Venous Thromboembolism Study of 2488 consecutive patients with validated venous thromboembolism.
Results: Of 2488 venous thromboembolism patients, 476 (19.1%) had a clinical history of diabetes. Thromboprophylaxis was omitted in more than one third of diabetic patients who had been hospitalized for non-venous-thromboembolism-related illness or had undergone major surgery within 3 months before diagnosis. Patients with diabetes were more likely than nondiabetic patients to have a complicated course after venous thromboembolism. Patients with diabetes were more likely than patients without diabetes to suffer recurrent deep vein thrombosis (14.9% vs 10.7%) and long-term major bleeding complications (16.4% vs 11.7%) (all P=.01). Diabetes was associated with a significant increase in the risk of recurrent deep vein thrombosis (adjusted odds ratio [AOR] 1.74; 95% confidence interval [CI], 1.21-2.51). Aspirin therapy at discharge (AOR 1.59; 95% CI, 1.1-2.3) and chronic kidney disease (AOR 2.19; 95% CI, 1.44-3.35) were independent predictors of long-term major bleeding.
Conclusion: Patients with diabetes who developed venous thromboembolism were more likely to suffer a complicated clinical course. Diabetes was an independent predictor of recurrent deep vein thrombosis. We observed a low rate of thromboprophylaxis in diabetic patients. Further studies should focus on venous thromboembolism prevention in this vulnerable population.
HUMAN IMMUNODEFICIENCY VIRUS – (1 point)
This disease is characterized by activation of multiple inflammatory, immunologic, and coagulation pathways and as a result these patients are at increased risk of VTE.
VTE: https://pubmed.ncbi.nlm.nih.gov/30566969/
Abstract
The number of people infected with human immunodeficiency virus (HIV) is rapidly increasing and the majority of those infected are living in sub-Saharan Africa. Some hallmarks of HIV are inflammation and upregulation of inflammatory markers. A pathological coagulation system may accompany these inflammatory changes and potentially result in venous thromboembolism such as a deep vein thrombosis (DVT). In this review, the authors describe the inflammatory profile in HIV, the treatment regimens currently in place in South Africa, and in particular how HIV affects the hematological system, with specific focus on platelets, red blood cells (RBCs; erythrocytes), and fibrin(ogen). They also discuss the presence of DVT in HIV, focus on screening tests, and suggest a more proactive approach to track the inflammatory profile of HIV patients, by specifically using parameters that might point to pathological coagulation; these should involve platelet, RBC, and fibrin(ogen) analysis. They conclude by suggesting that including coagulation function tests to study the effect of treatment interventions would improve outcomes in these individuals, as it could help in the diagnosis of thromboembolic disease. Furthermore, this approach could streamline treatment strategies due to improved monitoring. A better understanding of hypercoagulability of HIV-infected patients is therefore urgently needed. In conclusion, the authors suggest a panel of pathology tests that should be considered as standard procedures when HIV is present.
CHEMOTHERAPY – (1 point)
VTE incidence is increased in patients treated with chemotherapy. Incidental VTE is a relative common finding in patients with solid tumors, especially in the first months of chemotherapy. Patients with multiple myeloma are at an increased risk of venous thromboembolism (VTE), especially when treated with thalidomide and lenalidomide, in combination with dexamethasone and/or chemotherapy. Neoadjuvant therapy for cancer is associated with an increased risk of VTE. Current ASCO guidelines address the use of chemotherapy in a wide variety of clinical scenarios in patients with cancer.
Chemotherapy: https://pubmed.ncbi.nlm.nih.gov/16388837/
Abstract
Venous thromboembolism (VTE) is a frequent and potentially life-threatening complication associated with hematological and solid tumor malignancies. In patients with cancer, VTE portends a poor prognosis; in fact, only 12% of those who suffer an event will survive beyond one year. There are several different risk factors for the development of VTE in cancer patients that are well-described in the literature. One that has become increasingly recognized over the past two decades is the independent risk factor of chemotherapy. The annual incidence of VTE in patients receiving chemotherapy is estimated at 11%. This risk can climb to 20% or higher depending on the type of drug(s) being administered. In addition to chemotherapy, there are many other anti-neoplastic and supportive therapies that are also associated with an increased risk for the development of VTE. At present, several original basic science studies and clinical trials are underway in an effort to enhance our understanding of the mechanisms by which different chemotherapeutic agents can generate a prothrombotic state. The purpose of this article is to review the pertinent literature related to VTE in malignancy, and more specifically, chemotherapy and other cancer-related treatments associated with VTE.
Chemotherapy: https://pubmed.ncbi.nlm.nih.gov/20806119/
Abstract
While the association between cancer and symptomatic venous thromboembolism (VTE) is well established, the incidence and risk factors for incidental VTE in cancer patients remain unclear. The medical records of 1,921 consecutive cancer patients starting chemotherapy from January 2003 up to March 2009 were identified. Patients with a positive history of VTE were excluded. Pre-existing signs of VTE, kind and stage of malignancy, first and subsequent lines of chemotherapy, and all follow-up computed tomography (CT) scans were analysed. The primary outcome was incidental VTE. Overall, there were 101 (5.3%) VTE, 62 (3.2%) incidental and 39 (2.0%) symptomatic during a median of eight months (range 3-72). The incidence on CT scans was 0.58% (95%CI: 0.44-0.74). Incidental VTE included 24 pulmonary embolism, 28 deep venous thrombosis of the extremities, and 10 thromboses of the cava or splanchnic veins. Half of the incidental VTE occurred in the first 3-6 months of chemotherapy with a relatively higher incidence in gynecological and lung cancers. The presence of metastases, high leukocyte count, and platin-based chemotherapy increased the risk up to three-fold. All patients with incidental VTE regardless the location received half to full therapeutic doses of low-molecular-weight heparin for a minimum of three months. In summary, incidental VTE is a relative common finding in patients with solid tumours, especially in the first months of chemotherapy. Further research is needed to understand the natural history of incidental thrombosis in order to develop adequate management guidelines.
Multiple myeloma: https://pubmed.ncbi.nlm.nih.gov/21232658/
Abstract
Patients with multiple myeloma are at an increased risk of venous thromboembolism (VTE), especially when treated with the immunomodulatory drugs, thalidomide and lenalidomide, in combination with dexamethasone and/or chemotherapy. Several studies have shown that patients with multiple myeloma precursor disease (monoclonal gammopathy of undetermined significance [MGUS]) also have a higher risk of thrombosis compared to the general population. The underlying mechanisms for the hypercoagulable state are not completely understood. In this review, we discuss risk factors for thrombosis in multiple myeloma, as well as prophylactic strategies, the evidence for thrombosis among patients with MGUS, and proposed mechanisms for the hypercoagulability.
Neoadjuvant therapy: https://pubmed.ncbi.nlm.nih.gov/29754426/
Abstract
Essentials Cancer patients are at risk for venous thromboembolism (VTE). The risk of VTE in less advanced stage cancer on neoadjuvant chemotherapy is unclear. In over 7800 patients, we found a 7% pooled incidence of VTE during neoadjuvant therapy. Highest VTE rates were observed in patients with bladder and esophageal cancer.
Summary: Background Venous thromboembolism (VTE) is a frequent complication in cancer patients receiving adjuvant treatment. The risk of VTE during neoadjuvant chemo-radiotherapy remains unclear. Objectives This systematic review evaluated the incidence of VTE in patients with cancer receiving neoadjuvant treatment. Methods MEDLINE and EMBASE databases were searched from inception to October 2017. Search results were supplemented with screening of conference proceedings of the American Society of Clinical Oncology (2009-2016) and the International Society of Thrombosis and Haemostasis (2003-2016). Two review authors independently screened titles and abstracts, and extracted data onto standardized forms. Results Twenty-eight cohort studies (7827 cancer patients, range 11 to 1398) were included. Twenty-five had a retrospective design. Eighteen cohorts included patients with gastrointestinal cancer, representing over two-thirds of the whole study population (n = 6002, 78%). In total, 508 of 7768 patients were diagnosed with at least one VTE during neoadjuvant treatment, for a pooled VTE incidence of 7% (95% CI, 5% to 10%) in the absence of substantial between-study heterogeneity. Heterogeneity was not explained by site of cancer or study design characteristics. VTE presented as pulmonary embolism in 22% to 96% of cases (16 cohorts), and it was symptomatic in 22% to 100% of patients (11 cohorts). The highest VTE rates were observed in patients with bladder (10.6%) or esophageal (8.4%) cancer. Conclusions This review found a relatively high incidence of VTE in cancer patients receiving neoadjuvant therapy in the presence of some between-study variation, which deserves further evaluation in prospective studies.
Scenarios: https://pubmed.ncbi.nlm.nih.gov/31381464/
Abstract
Purpose: To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer
Methods: PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed.
Results: The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE.
Recommendations: Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.Additional information is available at www.asco.org/supportive-care-guidelines.
Length of Surgery Greater than 2 hours (not including Joint Replacement Surgery which is 5 points listed separately) – (1 point)
- Identifying Patients at High Risk for Venous Thromboembolism Requiring Treatment After Outpatient Surgery
- Borow M Prevention of DVT 5 methods of treatment