178 Fatal Cases of Pulmonary Embolism in a Medical Department

Nielsen, Hans Kræmmer; Bechgaard, P; Nielsen, Peter From; Husted, Steen; Geday, E

doi:10.1111/j.0954-6820.1981.tb11606.x

Cited by 23 publications

(5 citation statements)

References 13 publications

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“…1 The incidence of deep vein thrombosis has been reported to range from 10% to 26% among general medical patients, and 75% of fatal pulmonary embolisms occur in nonsurgical patient populations. 2,3 Recent evidence suggests that higher rates of VTE prophylaxis in the absence of formal VTE risk stratification may not lead to reduced VTE rates. 4 National quality organizations in the United States have opted for a group risk assessment and thromboprophylaxis strategy in the hospitalized medical patient 5,6 ; however, recent international guideline statements have stressed the need for individualized VTE risk assessment through the use of VTE risk assessment models (RAMs) in the acutely ill medical patient population.…”

mentioning

confidence: 99%

External Validation of the Risk Assessment Model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for Medical Patients in a Tertiary Health System

Rosenberg

Eichorn

Alarcon

et al. 2014

JAHA

124

164

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BackgroundHospitalized medical patients are at risk for venous thromboembolism (VTE). Universal application of pharmacological thromboprophylaxis has the potential to place a large number of patients at increased bleeding risk. In this study, we aimed to externally validate the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE risk assessment model in a hospitalized general medical population.Methods and ResultsWe identified medical discharges that met the IMPROVE protocol. Cases were defined as hospital‐acquired VTE and confirmed by diagnostic study within 90 days of index hospitalization; matched controls were also identified. Risk factors for VTE were based on the IMPROVE risk assessment model (aged >60 years, prior VTE, intensive care unit or coronary care unit stay, lower limb paralysis, immobility, known thrombophilia, and cancer) and were measured and assessed. A total of 19 217 patients met the inclusion criteria. The overall VTE event rate was 0.7%. The IMPROVE risk assessment model identified 2 groups of the cohort by VTE incidence rate: The low‐risk group had a VTE event rate of 0.42 (95% CI 0.31 to 0.53), corresponding to a score of 0 to 2, and the at‐risk group had a VTE event rate of 1.29 (95% CI 1.01 to 1.57), corresponding to a score of ≥3. Low‐risk status for VTE encompassed 68% of the patient cohort. The area under the receiver operating characteristic curve was 0.702, which was in line with the derivation cohort findings.ConclusionsThe IMPROVE VTE risk assessment model validation cohort revealed good discrimination and calibration for both the overall VTE risk model and the identification of low‐risk and at‐risk medical patient groups, using a risk score of ≥3. More than two thirds of the entire cohort had a score ≤2.

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mentioning

confidence: 99%

External Validation of the Risk Assessment Model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for Medical Patients in a Tertiary Health System

Rosenberg

Eichorn

Alarcon

et al. 2014

JAHA

124

164

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“…A high proportion of patients with autopsy-verified FPE had underlying terminal illnesses (e.g., FPE rates in two large autopsy series: 95% (169/178 [30]) and 96.5% (1,867/1,934 [31])). Since surgeons try to avoid performing elective operations on terminally ill people and medical services frequently care for terminally ill patients, the low FPE rate in surgical RCTs and high rate in acute medical patients makes sense.…”

Section: Problems With Anticoagulant Treatment For Vtementioning

confidence: 99%

“…Again, in the late 1940s, incidence of FPE at autopsy was <1% versus almost 8% by the early 1970s [30] (Fig. 2).…”

Section: Diet and Vtementioning

confidence: 99%

Diet as prophylaxis and treatment for venous thromboembolism?

Cundiff

Agutter²,

Malone³

et al. 2010

Theor Biol Med Model

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BackgroundBoth prophylaxis and treatment of venous thromboembolism (VTE: deep venous thrombosis (DVT) and pulmonary emboli (PE)) with anticoagulants are associated with significant risks of major and fatal hemorrhage. Anticoagulation treatment of VTE has been the standard of care in the USA since before 1962 when the U.S. Food and Drug Administration began requiring randomized controlled clinical trials (RCTs) showing efficacy, so efficacy trials were never required for FDA approval. In clinical trials of 'high VTE risk' surgical patients before the 1980s, anticoagulant prophylaxis was clearly beneficial (fatal pulmonary emboli (FPE) without anticoagulants = 0.99%, FPE with anticoagulants = 0.31%). However, observational studies and RCTs of 'high VTE risk' surgical patients from the 1980s until 2010 show that FPE deaths without anticoagulants are about one-fourth the rate that occurs during prophylaxis with anticoagulants (FPE without anticoagulants = 0.023%, FPE while receiving anticoagulant prophylaxis = 0.10%). Additionally, an FPE rate of about 0.012% (35/28,400) in patients receiving prophylactic anticoagulants can be attributed to 'rebound hypercoagulation' in the two months after stopping anticoagulants. Alternatives to anticoagulant prophylaxis should be explored.Methods and FindingsThe literature concerning dietary influences on VTE incidence was reviewed. Hypotheses concerning the etiology of VTE were critiqued in relationship to the rationale for dietary versus anticoagulant approaches to prophylaxis and treatment.Epidemiological evidence suggests that a diet with ample fruits and vegetables and little meat may substantially reduce the risk of VTE; vegetarian, vegan, or Mediterranean diets favorably affect serum markers of hemostasis and inflammation. The valve cusp hypoxia hypothesis of DVT/VTE etiology is consistent with the development of VTE being affected directly or indirectly by diet. However, it is less consistent with the rationale of using anticoagulants as VTE prophylaxis. For both prophylaxis and treatment of VTE, we propose RCTs comparing standard anticoagulation with low VTE risk diets, and we discuss the statistical considerations for an example of such a trial.ConclusionsBecause of (a) the risks of biochemical anticoagulation as anti-VTE prophylaxis or treatment, (b) the lack of placebo-controlled efficacy data supporting anticoagulant treatment of VTE, (c) dramatically reduced hospital-acquired FPE incidence in surgical patients without anticoagulant prophylaxis from 1980 - 2010 relative to the 1960s and 1970s, and (d) evidence that VTE incidence and outcomes may be influenced by diet, randomized controlled non-inferiority clinical trials are proposed to compare standard anticoagulant treatment with potentially low VTE risk diets. We call upon the U. S. National Institutes of Health and the U.K. National Institute for Health and Clinical Excellence to design and fund those trials.

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“…14 The risk of recurrent VTE continues for up to 90 days after hospitalization. 15,16 Approximately 60% of VTE events 17 and 75% of autopsyconfirmed fatal PE [18][19][20][21] occur in nonsurgical patients. More importantly, PE and proximal DVT are occurring more frequently in medical patients than in surgical patients.…”

Section: Introductionmentioning

confidence: 99%