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BMJ (Clinical Research Ed.) Jul 2019To determine the rate of a first recurrent venous thromboembolism (VTE) event after discontinuation of anticoagulant treatment in patients with a first episode of... (Meta-Analysis)
Meta-Analysis
Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis.
OBJECTIVES
To determine the rate of a first recurrent venous thromboembolism (VTE) event after discontinuation of anticoagulant treatment in patients with a first episode of unprovoked VTE, and the cumulative incidence for recurrent VTE up to 10 years.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES
Medline, Embase, and the Cochrane Central Register of Controlled Trials (from inception to 15 March 2019).
STUDY SELECTION
Randomised controlled trials and prospective cohort studies reporting symptomatic recurrent VTE after discontinuation of anticoagulant treatment in patients with a first unprovoked VTE event who had completed at least three months of treatment.
DATA EXTRACTION AND SYNTHESIS
Two investigators independently screened studies, extracted data, and appraised risk of bias. Data clarifications were sought from authors of eligible studies. Recurrent VTE events and person years of follow-up after discontinuation of anticoagulant treatment were used to calculate rates for individual studies, and data were pooled using random effects meta-analysis. Sex and site of initial VTE were investigated as potential sources of between study heterogeneity.
RESULTS
18 studies involving 7515 patients were included in the analysis. The pooled rate of recurrent VTE per 100 person years after discontinuation of anticoagulant treatment was 10.3 events (95% confidence interval 8.6 to 12.1) in the first year, 6.3 (5.1 to 7.7) in the second year, 3.8 events/year (95% confidence interval 3.2 to 4.5) in years 3-5, and 3.1 events/year (1.7 to 4.9) in years 6-10. The cumulative incidence for recurrent VTE was 16% (95% confidence interval 13% to 19%) at 2 years, 25% (21% to 29%) at 5 years, and 36% (28% to 45%) at 10 years. The pooled rate of recurrent VTE per 100 person years in the first year was 11.9 events (9.6 to 14.4) for men and 8.9 events (6.8 to 11.3) for women, with a cumulative incidence for recurrent VTE of 41% (28% to 56%) and 29% (20% to 38%), respectively, at 10 years. Compared to patients with isolated pulmonary embolism, the rate of recurrent VTE was higher in patients with proximal deep vein thrombosis (rate ratio 1.4, 95% confidence interval 1.1 to 1.7) and in patients with pulmonary embolism plus deep vein thrombosis (1.5, 1.1 to 1.9). In patients with distal deep vein thrombosis, the pooled rate of recurrent VTE per 100 person years was 1.9 events (95% confidence interval 0.5 to 4.3) in the first year after anticoagulation had stopped. The case fatality rate for recurrent VTE was 4% (95% confidence interval 2% to 6%).
CONCLUSIONS
In patients with a first episode of unprovoked VTE who completed at least three months of anticoagulant treatment, the risk of recurrent VTE was 10% in the first year after treatment, 16% at two years, 25% at five years, and 36% at 10 years, with 4% of recurrent VTE events resulting in death. These estimates should inform clinical practice guidelines, enhance confidence in counselling patients of their prognosis, and help guide decision making about long term management of unprovoked VTE.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42017056309.
Topics: Anticoagulants; Humans; Recurrence; Risk Assessment; Time; Venous Thromboembolism; Withholding Treatment
PubMed: 31340984
DOI: 10.1136/bmj.l4363 -
Thrombosis Journal Mar 2021COVID-19 appears to be associated with a high risk of venous thromboembolism (VTE). We aimed to systematically review and meta-analyze the risk of clinically relevant...
BACKGROUND
COVID-19 appears to be associated with a high risk of venous thromboembolism (VTE). We aimed to systematically review and meta-analyze the risk of clinically relevant VTE in patients hospitalized for COVID-19.
METHODS
This meta-analysis included original articles in English published from January 1st, 2020 to June 15th, 2020 in Pubmed/MEDLINE, Embase, Web of science, and Cochrane. Outcomes were major VTE, defined as any objectively diagnosed pulmonary embolism (PE) and/or proximal deep vein thrombosis (DVT). Primary analysis estimated the risk of VTE, stratified by acutely and critically ill inpatients. Secondary analyses explored the separate risk of proximal DVT and of PE; the risk of major VTE stratified by screening and by type of anticoagulation.
RESULTS
In 33 studies (n = 4009 inpatients) with heterogeneous thrombotic risk factors, VTE incidence was 9% (95%CI 5-13%, I = 92.5) overall, and 21% (95%CI 14-28%, I = 87.6%) for patients hospitalized in the ICU. Proximal lower limb DVT incidence was 3% (95%CI 1-5%, I = 87.0%) and 8% (95%CI 3-14%, I = 87.6%), respectively. PE incidence was 8% (95%CI 4-13%, I = 92.1%) and 17% (95%CI 11-25%, I = 89.3%), respectively. Screening and absence of anticoagulation were associated with a higher VTE incidence. When restricting to medically ill inpatients, the VTE incidence was 2% (95%CI 0-6%).
CONCLUSIONS
The risk of major VTE among COVID-19 inpatients is high but varies greatly with severity of the disease. These findings reinforce the need for the use of thromboprophylaxis in all COVID-19 inpatients and for clinical trials testing different thromboprophylaxis regimens in subgroups of COVID-19 inpatients.
TRIAL REGISTRATION
The review protocol was registered in PROSPERO International Prospective Register of Systematic Reviews ( CRD42020193369 ).
PubMed: 33750409
DOI: 10.1186/s12959-021-00266-x -
Journal of Interventional Cardiac... Sep 2023Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF); however, the results are suboptimal for persistent AF. The left... (Review)
Review
Catheter ablation using pulmonary vein isolation with versus without left atrial posterior wall isolation for persistent atrial fibrillation: an updated systematic review and meta-analysis.
BACKGROUND
Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF); however, the results are suboptimal for persistent AF. The left atrial posterior wall (LAPW) is thought to be a major additional area in initiation and perpetuation of persistent AF. Therefore, adjunctive ablation of the posterior wall may reduce AF recurrence in patients with persistent AF.
OBJECTIVE
The objective of this study was to compare outcomes of catheter ablation in patients with persistent AF using PVI alone versus a combination of PVI and LAPW isolation.
METHODS
Literature search was conducted in PubMed, PubMed Central, Scopus, and Embase since inception to February 2023. Screening of studies was done via Covidence software. Risk of bias assessment was done using appropriate tools. Data extraction and a narrative synthesis were carried out accordingly.
RESULTS
Ten studies were included, of which five were randomized controlled trials. PVI with LAPW ablation group had significantly lower recurrence of overall atrial tachyarrhythmia (OR 0.47, CI 0.32-0.70) and AF (OR 0.39, CI 0.23-0.69). In sensitivity analysis, freedom from atrial arrhythmias was noted to be significantly higher in the PVI with LAPW ablation group (OR 2.22, CI 1.36-3.64). However, there was no significant difference in occurrence of atrial flutter (OR 1.36, CI 0.86-2.14) or with periprocedural adverse events (OR 1.10, CI 0.60-1.99).
CONCLUSION
LAPW ablation, in addition to PVI, significantly improves the rates of arrhythmia freedom and reduces the recurrence of overall atrial tachyarrhythmia. There was no significant difference in atrial flutter or periprocedural adverse events.
PubMed: 37773559
DOI: 10.1007/s10840-023-01656-z -
JAMA Jan 2012Symptomatic venous thromboembolism (VTE) after total or partial knee arthroplasty (TPKA) and after total or partial hip arthroplasty (TPHA) are proposed patient safety... (Meta-Analysis)
Meta-Analysis Review
Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review.
CONTEXT
Symptomatic venous thromboembolism (VTE) after total or partial knee arthroplasty (TPKA) and after total or partial hip arthroplasty (TPHA) are proposed patient safety indicators, but its incidence prior to discharge is not defined.
OBJECTIVE
To establish a literature-based estimate of symptomatic VTE event rates prior to hospital discharge in patients undergoing TPHA or TPKA.
DATA SOURCES
Search of MEDLINE, EMBASE, and the Cochrane Library (1996 to 2011), supplemented by relevant articles.
STUDY SELECTION
Reports of incidence of symptomatic postoperative pulmonary embolism or deep vein thrombosis (DVT) before hospital discharge in patients who received VTE prophylaxis with either a low-molecular-weight heparin or a subcutaneous factor Xa inhibitor or oral direct inhibitor of factors Xa or IIa.
DATA EXTRACTION AND SYNTHESIS
Meta-analysis of randomized clinical trials and observational studies that reported rates of postoperative symptomatic VTE in patients who received recommended VTE prophylaxis after undergoing TPHA or TPKA. Data were independently extracted by 2 analysts, and pooled incidence rates of VTE, DVT, and pulmonary embolism were estimated using random-effects models.
RESULTS
The analysis included 44,844 cases provided by 47 studies. The pooled rates of symptomatic postoperative VTE before hospital discharge were 1.09% (95% CI, 0.85%-1.33%) for patients undergoing TPKA and 0.53% (95% CI, 0.35%-0.70%) for those undergoing TPHA. The pooled rates of symptomatic DVT were 0.63% (95% CI, 0.47%-0.78%) for knee arthroplasty and 0.26% (95% CI, 0.14%-0.37%) for hip arthroplasty. The pooled rates for pulmonary embolism were 0.27% (95% CI, 0.16%-0.38%) for knee arthroplasty and 0.14% (95% CI, 0.07%-0.21%) for hip arthroplasty. There was significant heterogeneity for the pooled incidence rates of symptomatic postoperative VTE in TPKA studies but less heterogeneity for DVT and pulmonary embolism in TPKA studies and for VTE, DVT, and pulmonary embolism in TPHA studies.
CONCLUSION
Using current VTE prophylaxis, approximately 1 in 100 patients undergoing TPKA and approximately 1 in 200 patients undergoing TPHA develops symptomatic VTE prior to hospital discharge.
Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Humans; Incidence; Inpatients; Patient Discharge; Pulmonary Embolism; Randomized Controlled Trials as Topic; Venous Thrombosis
PubMed: 22253396
DOI: 10.1001/jama.2011.2029 -
Research and Practice in Thrombosis and... Jul 2021To improve the quality and accuracy of the patient-reported outcome measures that assess health-related quality of life (HRQoL), guidelines have been developed to... (Review)
Review
To improve the quality and accuracy of the patient-reported outcome measures that assess health-related quality of life (HRQoL), guidelines have been developed to standardize the development and validation process. Considering the increasing importance of HRQoL questionnaires in research, we set out to review the literature and evaluate whether existing questionnaires developed for deep vein thrombosis (DVT) and pulmonary embolism (PE) fulfill state-of-the-art requirements. The literature search was conducted in March 2019 and updated in September 2020. Seven databases were searched. No time limit was set for the search to include all available questionnaires. The inclusion criteria were original publications describing the development of disease-specific HRQoL questionnaires specific to DVT or PE in adults and available in English. The questionnaires were assessed to determine whether they fulfill the requirements in the latest guidelines. A total of 3826 references were identified. After the exclusion process, 15 papers were reviewed in full, of which 7 were included. Four questionnaires were developed for chronic venous disease, two were specific to DVT, and one was specific to PE. Most questionnaires we found in this review, fulfilled some but none fulfilled all recommendations in existing guidelines. Because the development of current available HRQoL questionnaires specific to DVT or PE do not fulfil all recommendations of existing guidelines, there is room for improvements within this field. Such improvements could likely enhance the quality associated with the use of these end points in clinical trials and practice.
PubMed: 34278190
DOI: 10.1002/rth2.12556 -
Thrombosis Research Sep 2018Anticoagulation with unfractionated heparin (UFH) or low molecular weight heparin (LMWH) is the mainstay for the treatment of patients with acute cerebral vein... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Anticoagulation with unfractionated heparin (UFH) or low molecular weight heparin (LMWH) is the mainstay for the treatment of patients with acute cerebral vein thrombosis (CVT) with or without intracranial hemorrhage (ICH).
AIM
We conducted a systematic review and meta-analysis to determine the efficacy and safety of LMWH compared to UFH for the treatment of acute CVT.
METHODS
An electronic search of MEDLINE, Pubmed, CENTRAL and Google Scholar was performed. Randomized controlled trials (RCT) reporting on the efficacy and safety of anticoagulation for acute treatment of CVT were included. Outcomes of interest included mortality, disability, new ICH and pulmonary embolism (PE).
RESULTS
Overall, 4 RCTs were included in the meta-analysis. Two trials compared anticoagulation (UFH (N = 1) and LMWH (N = 1)) to placebo. The use of anticoagulation therapy was associated with an odd ratio (OR) for mortality and disability of 0.31 (95% confidence interval (CI) 0.07 to 1.45; p = 0.14) and 0.3 (95% CI 0.09 to 1.01; p = 0.05), respectively. Three new ICHs were observed among patients receiving placebo and no patient had a PE complication. The other two trials compared LMWH to UFH. LMWH was associated with an OR for mortality and disability of 0.21 (95% CI 0.02 to 2.44, p = 0.21) and 0.5 (95% CI 0.11 to 2.23; p = 0.36), respectively. There were no new events of ICH or PE.
CONCLUSION
LMWH seems to be safe and effective for the management of acute CVT.
Topics: Acute Disease; Anticoagulants; Heparin; Heparin, Low-Molecular-Weight; Humans; Intracranial Hemorrhages; Intracranial Thrombosis; Pulmonary Embolism; Treatment Outcome; Venous Thrombosis
PubMed: 30056293
DOI: 10.1016/j.thromres.2018.07.023 -
Journal of Thrombosis and Thrombolysis May 2012Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism. The 2009 JUPITER trial showed a significant decrease in DVT in... (Review)
Review
Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism. The 2009 JUPITER trial showed a significant decrease in DVT in non-hyperlipidemic patients, with elevated C-reactive protein (CRP) levels, treated with rosuvastatin. The effects of statins on thrombosis are unclear, prompting this literature review. A literature search was performed (1950 to February 2011) with MEDLINE, EMBASE, and PUBMED databases including the following keywords: "statins", "hydroxymethylglutaryl-CoA reductase inhibitors", "VTE", "PE", "DVT", and either "anti-coagulation" or "inflammation". Editorials, reviews, case reports, meta-analysis and duplicates were excluded. Inflammatory biomarkers of DVT, include interleukin (IL)-6, CRP, IL-8, and monocyte chemotactic protein 1 (MCP-1). Statin therapy reduces IL-6 expression of CRP and MCP-1, usually elevated in VTE. Reduction of IL-6 induced MCP-1 has been linked to vein wall fibrosis, promoting post thrombotic syndrome (PTS) and recurrent DVT in patients. Also, our review suggests that the anti-thrombotic effects are likely exhibited through the anti-inflammatory properties of statins. This work supports that statin therapy has the ability to decrease the incidence and recurrence of VTE and the potential to decrease PTS. This is mainly due to the anti-inflammatory effects of statins and may explain why normolipidemic patients, with elevated CRP, appear to have the greatest reduction in VTE. Given their low risk of bleeding, statins have the potential to serve as a safe adjunctive pharmacological therapy to current treatments in select patients with VTE, however further investigations into this concept are needed and essential.
Topics: C-Reactive Protein; Cytokines; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hydroxymethylglutaryl-CoA Synthase; MEDLINE; Pulmonary Embolism; Venous Thromboembolism; Venous Thrombosis
PubMed: 22278047
DOI: 10.1007/s11239-012-0687-9 -
Circulation. Arrhythmia and... Feb 2014For the past decade, electric pulmonary vein isolation (PVI) has become a procedure implemented worldwide for the treatment of atrial fibrillation. Currently, 2 main... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
For the past decade, electric pulmonary vein isolation (PVI) has become a procedure implemented worldwide for the treatment of atrial fibrillation. Currently, 2 main approaches are used for PVI: ostial isolation of the PVs and wide antral PVI. The aims of this systematic review are to evaluate the relative merits of each technique with a pooled comparative analysis of efficacy and complications.
METHODS AND RESULTS
Studies were identified by searching electronic databases for studies on ostial versus antral PVI. Information was extracted from each included trial. Odds ratio was the primary measure of treatment effect or side effects. The proportion of patients with recurrences of atrial fibrillation or other atrial tachyarrhythmias was evaluated at the end of the follow-up periods in 12 trials, including 1183 patients. The recurrence rate of total supraventricular arrhythmias was significantly lower in wide antral than in segmental PVI group (odds ratio, 0.42; 95% confidence interval, 0.32-0.56; P<0.00001). Atrial fibrillation recurrence was significantly lower in the wide antral group (odds ratio, 0.33; 95% confidence interval, 0.24-0.46; P<0,00001). A trend toward a higher incidence of left atrial tachycardia occurrence in the wide antral circumferential ablation group was detected, which did not reach statistical significance (odds ratio, 1.53; 95% confidence interval, 0.88-2.69; P=0.13).
CONCLUSIONS
Our primary finding is that PVI performed with a wide antral approach is more effective than ostial PVI in achieving freedom from total atrial tachyarrhythmia recurrence at long-term follow-up.
Topics: Atrial Fibrillation; Catheter Ablation; Chi-Square Distribution; Humans; Odds Ratio; Pulmonary Veins; Recurrence; Risk Factors; Tachycardia, Supraventricular; Time Factors; Treatment Outcome
PubMed: 24385448
DOI: 10.1161/CIRCEP.113.000922 -
Thrombosis Research Nov 2013Patients with acute deep vein thrombus (DVT) can safely be treated as outpatients. However the role of outpatient treatment in patients diagnosed with a pulmonary... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Patients with acute deep vein thrombus (DVT) can safely be treated as outpatients. However the role of outpatient treatment in patients diagnosed with a pulmonary embolism (PE) is controversial. We sought to determine the safety of outpatient management of patients with acute symptomatic PE.
MATERIALS AND METHODS
A systematic literature search strategy was conducted using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and all EBM Reviews. Pooled proportions for the different outcomes were calculated.
RESULTS
A total of 1258 patients were included in the systematic review. The rate of recurrent venous thromboembolism (VTE) in patients with PE managed as outpatients was 1.47% (95% CI: 0.47 to 3.0%; I(2): 65.4%) during the 3 month follow-up period. The rate of fatal PE was 0.47% (95% CI: 0.16 to 1.0%; I(2): 0%). The rates of major bleeding and fatal intracranial hemorrhage were 0.81% (95% CI: 0.37 to 1.42%; I(2): 0%) and 0.29% (95% CI: 0.06 to 0.68%; I(2): 0%), respectively. The overall 3 month mortality rate was 1.58% (95% CI: 0.71 to 2.80%; I(2): 45%). The event rates were similar if employing risk stratification models versus using clinical gestalt to select appropriate patients for outpatient management.
CONCLUSIONS
Independent of the risk stratification methods used, the rate of adverse events associated with outpatient PE treatment seems low. Based on our systematic review and pooled meta-analysis, low-risk patients with acute PE can safely be treated as outpatients if home circumstances are adequate.
Topics: Ambulatory Care; Hemorrhage; Humans; Outpatients; Pulmonary Embolism; Recurrence; Treatment Outcome; Venous Thromboembolism
PubMed: 24035045
DOI: 10.1016/j.thromres.2013.08.012 -
Current Cardiology Reviews 2017Pulmonary vein isolation (PVI) is an accepted treatment strategy for catheter ablation (CA) of paroxysmal atrial fibrillation (PAF). In this study, we aimed to assess... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pulmonary vein isolation (PVI) is an accepted treatment strategy for catheter ablation (CA) of paroxysmal atrial fibrillation (PAF). In this study, we aimed to assess the short, mid- and long-term outcome of PVI as a sole treatment strategy for PAF.
METHODS
Six bibliographic electronic databases were searched to identify all published relevant studies until December 14, 2015. Search of the scientific literature was performed for studies describing outcomes with mean follow-up > 24 months after PAF ablation. Only articles with 1, 3 or 5-year follow up were included, from the same group of investigators.
RESULTS
Of the 2398 references reviewed for eligibility, 13 articles (enrolling a total of 1774 patients) were included in the final analysis. Pooled analysis showed that the 12- and 62 -month success rate of a single CA procedure was 78% (95% CI 0.76% to 0.855) and 59% (95% CI 0.56% to 0.64%), respectively. The results did not differ by type of CA performed. Major complications mentioned in the enrolled studies were cerebrovascular event, pericardial tamponade and PV stenosis.
CONCLUSION
There is a progressive and significant decline in freedom from AF between 1, 3 and 5- year after successful PVI in patients with PAF. Our analysis suggests that a high short-time success rate after PVI does not necessarily result in high chronic success rate.
Topics: Atrial Fibrillation; Catheter Ablation; Follow-Up Studies; Heart Conduction System; Humans; Pulmonary Veins; Tachycardia, Paroxysmal; Time Factors; Treatment Outcome
PubMed: 28124593
DOI: 10.2174/1573403X13666170117125124