Exposure to Air Pollution Increases The Risk of Deep Vein Thrombosis

A Review of Baccarelli et al., by Gregory Piazza, MD

Article: Baccarelli A, Martinelli I, Zanobetti A, et al. Exposure to Particulate Air Pollution and Risk of Deep Vein Thrombosis. Arch Intern Med 2008;168:920-927.

May 14, 2008; 8:04 a.m. (EST): Is exposure to particulate air pollution a risk factor for deep vein thrombosis (DVT)?  This case-control study evaluated 870 DVT patients and 1210 control subjects from the Lombardy region of Italy between 1995 and 2005.  The investigators estimated the exposure to particulate matter less than 10 μm (PM10) in aerodynamic diameter using area-specific mean levels obtained from ambient monitors in the year before development of DVT.  Higher mean PM10 levels in the year before examination were associated with abnormal coagulation testing (shortened prothrombin time) in both cases and controls.  After adjustment for clinical and environmental factors that may have contributed to the risk of DVT, each increase in 10 μg/m3 was associated with a 70% increase in the risk of DVT (odd ratio [OR], 1.70; 95% confidence interval [CI], 1.30 to 2.23; p < 0.001).  A linear relationship of exposure to risk was noted over the observed PM10 range.  Interestingly, the association between PM10 level and risk of DVT was weaker in women (OR, 1.40; 95% CI, 1.02 to 1.92; p = 0.02), especially among those using oral contraceptives or hormone replacement therapy.

Although subject to the limitations of a case-control analysis, this study highlights an important association between risk factors for atherosclerosis and venous thromboembolism (VTE).  Recent data have shown that potent risk factors for arterial thrombosis such as hypertension, obesity, and diabetes, also predispose to VTE.  Previous studies have established air pollution as a risk factor for coronary artery disease and stroke.  This study suggests that air pollution should be added to the growing list of factors that increase the risk of both arterial and venous thrombosis. 

This study also highlights the importance of addressing air pollution as a potentially modifiable risk factor for atherosclerosis and VTE and a public health threat.

Gregory Piazza, M.D.
Venous Thromboembolism Fellow
Brigham and Women’s Hospital, Boston, MA

Global Registry on PMT for Acute PE – Development of a Case Report Form

William T. Kuo, MD, FCCP

Vascular and Interventional Radiology, Stanford University Medical Center, Stanford, CA 94305

INTRODUCTION: The Stanford Division of Vascular and Interventional Radiology has drafted a case report form (CRF) for the Global Registry on Percutaneous Mechanical Thrombectomy (PMT) for Acute Pulmonary Embolism.  This draft serves as an initial template for gathering data relevant to the endovascular treatment of massive PE.

We realize there is no widely accepted protocol for catheter-directed treatment of pulmonary embolism, and the PE management algorithm itself varies among institutions.  Furthermore, existing treatment regimens are continuously evolving with the development of new catheters, devices, and treatment protocols.  Consequently, this Case Report Form has been designed to capture data not only on existing catheter-based methods but also on emerging techniques. 

In the final step of completing this document, and prior to its official launch, we open the CRF via the web to commentary and feedback from all interested participants of the North American Thrombosis Forum (NATF).  We are seeking input from all potential collaborators and investigators.  Acceptable ideas and recommendations by consensus will be incorporated into the CRF and contributors acknowledged. 

As part of a worldwide multidisciplinary effort, our goal is to create an effective web-based registry that will study the effects of PMT for acute PE.  Please contact us with questions, comments, and feedback.  We greatly appreciate your input in the creation of this international registry. 

 

Electronic submission of The Global Registry on Percutaneous Mechanical Thrombectomy (PMT) for Acute Pulmonary Embolism CASE REPORT FORM (CRF) requires Adobe Reader version 7.0 or higher.   Mac Ι PC

Heart Failure in Patients With Deep Vein Thrombosis

Article: Piazza G, Seddighzadeh A, Goldhaber SZ. Heart failure in patients with deep vein thrombosis. Am J Cardiol 2008;101:1056-1059.

ABSTRACT: Patients with heart failure (HF) are particularly vulnerable to the development of venous thromboembolism (VTE) and its related complications of pulmonary embolism and right ventricular failure. To improve our understanding of the clinical characteristics, prophylaxis, and initial management of patients with HF and deep vein thrombosis (DVT), we compared 685 patients with a history of HF with 3,890 patients without HF in a prospective registry of 5,451 consecutive patients with ultrasound-confirmed DVT. We excluded 876 patients for whom data regarding HF status were incomplete. Patients with HF had an increased frequency of co-morbid conditions such as neurologic disease including stroke (33% vs 26%, p = 0.0002), acute lung disease including pneumonia (31% vs 15%, p <0.0001), and acute coronary syndrome (11% vs 4%, p <0.0001) contributing to a higher medical acuity than in patients without HF. Furthermore, patients with HF were more likely to have VTE risk factors of immobilization (53% vs 42%, p <0.0001), acute infection (33% vs 27%, p = 0.01), and chronic obstructive pulmonary disease (29% vs 12%, p <0.0001). Patients with and without HF and DVT had a high frequency of recent hospitalization (48% vs 47%, p = 0.96). Fewer than 1⁄2 of patients with HF (46%) who subsequently developed DVT received any VTE prophylaxis. In conclusion, the combination of higher medical acuity, increased frequency of VTE risk factors, and low rate of VTE prophylaxis presents a “triple threat” to patients with HF.

Review of Piazza et al. Coexisting Heart Failure in DVT Patients

Behnood Bikdeli, MD ('08); Cardiovascular Research Center, Modarres Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran - Special Guest Editor: Gregory Piazza, MD

INTRODUCTION

Heart failure (HF) and VTE have a bidirectional association. Heart failure is associated with a 1.5 fold increase in the risk of VTE. 1 Pulmonary thromboembolism may also lead to new-onset HF or decompensation of known heart failure, and serves as a predictor of mortality in HF patients. 2,3

METHODS

From the 5451 patients with ultrasound-confirmed DVT from the DVT-FREE registry, Piazza et al. compared the baseline characteristics, co-morbidities, risk factors, prophylaxis, and initial treatment of 685 patients with, and 3890 patients without heart failure4. HF diagnosis was designated to symptomatic patients with evidence of left-sided cardiac dysfunction (systolic or diastolic dysfunction, or both). Those without history of clinical HF were classified in the “no- HF” group. 876 patients were excluded due to incomplete data regarding HF.

RESULTS

Compared to those without HF, HF patients were older (median age 75 versus 67 years, P<0.0001), and were more likely to have co-morbid neurologic disease, chronic kidney disease, hypertension, and acute coronary syndromes (p=0.002, p<0.005, p<0.0001 and p<0.001, respectively). Although the frequency of overall obesity was similar (45% in each, p=0.94), HF patients had a higher frequency of BMI>35 (19% versus 14%, P<0.004). Immobility, COPD, and acute infections were more common in HF patients (p<0.0001, p<0.0001, and p<0.01, correspondingly). Both HF and non-HF patients had a high frequency of recent hospitalization prior to developing DVT (48% versus 47%, P=0.96). Dyspnea at presentation, occurred more commonly in HF patients (29% versus 19%, p<0.0001). Although HF patients received VTE prophylaxis more frequently, the overall rate of prophylaxis among HF patients was low (46%).

CONCLUSION & COMMENTS

This study emphasizes the problem of VTE prophylaxis underutilization among HF patients despite a high medical acuity and increased frequency of VTE risk factors.

Piazza et al. included patients with a clinical diagnosis of HF, including patients with left ventricular systolic dysfunction, diastolic dysfunction, or a combination of both.  Because data was not ascertained regarding left ventricular ejection fraction and other objective markers of HF severity, conclusions regarding the impact of different etiologies and severity of HF upon the characteristics, presentation, and prophylaxis of VTE cannot be made.

The prevention of VTE in HF patients has become an important measure of the quality of HF care. Although the ACCP and the International Union of Angiology guidelines recommend using UFH or LMWH for thromboprophylaxis in high-risk HF patients 5,6, such recommendations do not exist in the ACC/AHA 7 or HFSA8  guidelines. This study raises the awareness about the frequency and significance of coexistence of HF and VTE. In conclusion, appropriate thromboprophylaxis should be considered in heart failure.9

References:

1. Beemath A, Stein PD, Skaf E, Al Sibae MR, Alesh I. Risk of venous thromboembolism in patients hospitalized with heart failure. Am J Cardiol 2006; 98:793–795.
2. Piazza G, Goldhaber SZ. The acutely decompensated right ventricle: pathways for diagnosis and management. Chest. 2005; 128(3):1836-52.
3. Darze ES, Latado AL, Guimaraes AG, Guedes RA, Santos AB, de Moura SS, Passos LC. Acute pulmonary embolism is an independent predictor of adverse events in severe decompensated heart failure patients. Chest 2007; 131:1838 –1843.
4. Piazza G, Seddighzadeh A, Goldhaber SZ. Heart failure in patients with deep vein thrombosis. Am J Cardiol. 2008 Apr 1;101(7):1056-9.
5. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism, The Seventh ACCP Conference on Antithrombotic and Antithrombolytic Therapy. Chest 2004; 126:338S-400S.
6. Nicoladies AN, Breddn HK, Fareed J, et al. Prevention of venous thromboembolism. International Consensus Statement. Guidelines complied in accordance with the scientific evidence. Int Angiol 2001; 20:1-37.
7. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). American  College of Cardiology Web Site. Available at: http://www.acc.org/clinical/guidelines/failure//index.pdf
8. Adams KF, Lindenfeld J, Arnold JMO, Baker DW, Barnard DH, Baughman KL, Boehmer JP, Deedwania P, Dunbar SB, Elkayam U, Gheorghiade M, Howlett JG,Konstam MA, Kronenberg MW, Massie BM, Mehra MR, Miller AB, Moser DK, Patterson JH, Rodeheffer RJ, Sackner-Bernstein J, Silver MA, Starling RC, Stevenson LW, Wagoner LE. HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Cardiac Failure 2006;12:e1–e122.
9. Jois-Bilowich P, Michota F, Bartholomew JR, et al. Adhere Scientific Advisory Committee and Investigators. Venous thromboembolism prophylaxis in hospitalized heart failure patients. J Card Fail. 2008 Mar; 14(2):127-32.

About Behnood Bikdeli, M.D. (`08): Behnood Bikdeli is student of medicine, research fellow, and student section director of Modarres Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences (SBMU). He won the award of “Best Research Paper” at the seventh Annual Research Seminar of Iranian Medical Sciences Students and was twice named as the best student researcher at SBMU in 2006 and 2007. He has also headed development of adapted cardiovascular clinical practice guidelines on VTE, Heart failure, and CPR for generalists in collaboration with the World Health Organization in Iran. Recently, he has been working to build an international consensus for development of heart failure clinical practice guidelines for the generalists and family physicians, in addition to contributing to research projects on atherosclerosis, thromboembolism, and atrial fibrillation.  

NATF Traveling Fellowship Program: APPLICATION DEADLINE IS JULY 15, 2008

With the goal of exploring the cross-disciplinary diagnosis, treatment, education, and research related to thrombosis, the NATF Traveling Fellowship Program is an annual scientific exchange opportunity for physicians (either Junior Faculty or physicians-in-training), scientists, nurses, or pharmacists.  NATF will provide an award equivalent to $5,000 for lodging and travel for one Fellow selected to visit a North American thrombosis research and education center of his or her choice for up to 10-30 days.

The NATF Traveling Fellow will:

• Work on a joint project with hosting center
• Contribute to the development of a cross-disciplinary approach for the research, diagnosis, treatment, and education thrombosis
• View research facilities and thrombosis diagnosis, treatment, and prevention methods
• Participate in scientific symposia with members of the NATF Board and Scientific Advisory Committee
• Free participation in the 2008 North American Thrombosis Forum Thrombosis Summit (Boston, MA, September 27, 2008) attended by cross-disciplinary medical and scientific leaders
• Present learnings gained through NATF Traveling Fellowship at the Fall 2009 North American Thrombosis Forum Thrombosis Summit
• Serve as an NATF Ambassador

To learn more about the NATF Traveling Fellowship or to apply, please click here.

Benefits of the NATF Traveling Fellowship

• Foster an exchange of scientific information, stimulate research and expanded education, and develop friendships among leaders in thrombosis research, treatment, and patient education
• Serve as a bridge that may be used to forge the future of thrombosis treatment and prevention that includes a cross-disciplinary approach
• Provide a stimulus for leadership by recognizing young medical personnel or scientists with the potential for nationally lowering the rate of life-threatening thrombotic episodes through education, research, and prevention

NATF Committment to Future Leaders

The NATF Traveling Fellowship Program was conceptualized to allow scientists and health professionals (MD, DO, PhD, RN, or PharmD) the opportunity to expand their fund of knowledge, as well as build positive and enduring relationships with others concerned with thrombotic disorders. NATF recognizes the vital impact training programs have on the future of thrombosis research, diagnosis, treatment, and prevention.

Application Requirements

• The Fellow will be selected by the NATF Advisory Committee, Chaired by Dr. Arthur A. Sasahara, MD, Professor of Medicine, Emeritus, Harvard Medical School, and NATF Director.
• The fellowship will be granted based on a demonstrated commitment to excellence in education, research, or clinical practice.
• 3 Letters of reference are required.
• Applicants must be practicing in North America:  Application Deadline is July 15, 2008

The North American Thrombosis Forum is a 501(c)(3) nonprofit organization that focuses on unmet needs and issues related to thrombosis and cardiovascular diseases such as deep vein thrombosis, pulmonary embolism, myocardial infarction, peripheral arterial occlusive disease, and stroke. The five areas of major focus are: 1) basic translational research, 2) clinical research, especially diagnosis and therapy, 3) prevention and education, 4) public policy, and 5) advocacy. NATF's legacy will be to improve patient care, outcomes, and public health by supporting thrombosis-related programs, such as novel research projects, innovative educational programs, public policy initiatives, regulatory issues and advocacy, and to broaden training opportunities for scientists and health professionals (physicians, nurses, pharmacists).

Our offices are located at 1620 Tremont Street, Suite 3022; Roxbury Crossing, MA 02120.  For general information, please call (617) 525-8326 or email: info@NATFonline.org.

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