Venous thromboembolism: An overview

doi:10.1016/j.jvn.2015.02.001

Journal of Vascular Nursing

Volume 33, Issue 3, September 2015, Pages 95-99

https://doi.org/10.1016/j.jvn.2015.02.001 Get rights and content

Highlights

•
Venous thromboembolism (VTE) is a disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE).
•
VTE is the third most common cardiovascular illness after acute coronary syndrome.
•
The incidence of PE in the United States is estimated to be 1 case per 1,000 people per year.
•
Rudolf Virchow described the pathophysiology of DVT in 1846.

Venous thromboembolism (VTE) is a disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). It is a common, lethal disorder that affects both hospitalized and nonhospitalized patients. PE and DVT are 2 clinical presentations of VTE and share the same predisposing factors. In most cases, PE is a consequence of DVT. This article discusses the predisposing factors, prevalence, and individuals who are at risk of developing this often life-threatening disease.

Section snippets

What is venous thromboembolism?

Editor's Note: This article was submitted and accepted for the recent special issue on venous disease but was inadvertently omitted from the issue.

Venous thromboembolism (VTE) is a disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). It is a common, lethal disorder that affects both hospitalized and nonhospitalized patients. It can reoccur frequently, and unfortunately is often overlooked. It may result in long-term complications including chronic thromboembolic

DVT

The lower extremities are the most common site for a DVT, but other affected locations may include the upper extremities, the mesenteric and pelvic veins, as well as the cerebral veins. A proximal lower extremity DVT (defined as occurring in the popliteal vein and above) is linked to an estimated 50% risk of PE if not treated; approximately 20%-25% of calf vein thrombus propagate (in the absence of treatment) to involve the popliteal vein or above (Figure 1). Approximately 10% of all DVT cases

PE

PE resulting from lower extremity DVT have the potential to lead to a number of physiologic changes secondary to obstruction of the pulmonary arteries (Figure 2). These changes include increased respiratory rate and hyperventilation, impairment of gas exchange owing to impaired perfusion, intrapulmonary shunting leading to hypoxemia, atelectasis, and vasoconstriction resulting from the release of inflammatory mediators (serotonin and thromboxane). In hemodynamically challenged patients, acutely

Prevalence

VTE is the third most common cardiovascular illness after acute coronary syndrome and stroke.⁸ The exact incidence of VTE is unknown; it is believed that there are approximately 1 million cases in the United States each year, many of which represent recurrent disease.⁹ Nearly two-thirds of all VTE events result from hospitalization and approximately 300,000 of these patients die.¹⁰

PE is the third most common cause of hospital-related death and is also the most common preventable cause of

United States statistics

The incidence of PE in the United States is estimated to be 1 case per 1,000 people per year.¹⁵ Studies from 2008 suggest that the increasing use of CT for assessing patients with possible PE has led to an increase in the reported incidence of PE.16, 17

From 1979 to 1998, the age-adjusted death rate for PE in the United States decreased from 191 to 94 deaths per million population.¹⁵ Regional studies covering the years after 1998 found either a slight decrease in the incidence of mortality or no

Predisposing factors

The pathophysiology of DVT was described by Virchow in 1846 as coming from a triad of possible changes in the venous system (Figure 3). The triad includes changes in the constituency of blood (hypercoagulability), changes in the vessel wall (injury), and changes in the pattern of blood flow (venous stasis).²¹ These physiologic changes can occur as a result of pathology, therapies, and treatments. Injury to the vessel wall may occur from trauma, surgery, or invasive treatments. Patients on bed

Venous stasis

Venous stasis leads to accumulation of platelets and thrombin in veins. Increased viscosity may occur owing to polycythemia and dehydration, immobility, increased venous pressure in cardiac failure, or compression of a vein by a tumor.

Hypercoagulable states

The complex and delicate balance between coagulation and anticoagulation is altered by many diseases, by obesity, or by trauma. It can also occur after surgery. Concomitant hypercoagulability may be present in disease states where prolonged venous stasis or injury to veins occurs.

Hypercoagulable state

A hypercoagulable state may be acquired or congenital. Factor V Leiden mutation causing resistance to activated protein C is the most common risk factor. Factor V Leiden mutation is present in ≤5% of the normal population and is the most common cause of familial thromboembolism. Primary or acquired deficiencies in protein C, protein S, and antithrombin III are other risk factors. The deficiency of these natural anticoagulants is responsible for 10% of venous thrombosis in younger people.

Immobilization

Immobilization leads to local venous stasis by accumulation of clotting factors and fibrin, resulting in thrombus formation. The risk of PE increases with prolonged bed rest or immobilization of a limb in a cast. In the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) study, immobilization (usually because of surgery) was the risk factor most commonly found in patients with PE.

Surgery and trauma

A prospective study by Geerts et al²³ indicated that major trauma was associated with a 58% incidence of DVT in the lower extremities and an 18% incidence in proximal veins. Surgical and accidental traumas predispose patients to VTE by activating clotting factors and causing immobility. PE may account for 15% of all postoperative deaths. Leg amputations and hip, pelvic, and spinal surgery are associated with the highest risk.²³ Fractures of the femur and tibia are associated with the highest

Pregnancy

The incidence of thromboembolic disease in pregnancy has been reported to range from 1 case in 200 deliveries to 1 case in 1,400 deliveries (see Epidemiology). Fatal events are rare, with 1-2 cases occurring per 100,000 pregnancies.

Oral contraceptives and estrogen replacement

Estrogen-containing birth control pills have increased the occurrence of VTE in healthy women. The risk is proportional to the estrogen content and is increased in postmenopausal women on hormonal replacement therapy. The relative risk is 3-fold, but the absolute risk is 20-30 cases per 100,000 persons per year.²³

Malignancy

Malignancy has been identified in 17% of patients with VTE. Pulmonary emboli have been reported to occur in association with solid tumors, leukemias, and lymphomas. This is probably independent of the indwelling catheters often used in such patients.²⁴ Neoplasms most commonly associated with PE, in descending order of frequency, are pancreatic carcinoma, bronchogenic carcinoma, and carcinomas of the genitourinary tract, colon, stomach, and breast.²⁴

Conclusion

Although VTE is among the most common preventable causes of death among hospitalized patients in the United States, it unfortunately is often overlooked as a major public health problem and viewed more as a complication of hospitalization for another illness, rather than as a specific disease entity. As vascular nurses, we can continue to educate others so that we can continue to increase the awareness of this potentially life-threatening disease.

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Cited by (23)

Utilization outcomes of direct oral anticoagulants in Medicare patients
2023, Research in Social and Administrative Pharmacy
To compare the adherence, persistence, discontinuation and switching rates of direct oral anticoagulants (DOACs) for Medicare patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE).
This was retrospective observational cohort study design. Medicare Part D claims files were used for the study duration (2015–2018). Inclusion-exclusion criteria were applied to identify the NVAF and VTE sample using dabigatran, rivaroxaban, apixaban, edoxaban and warfarin during the identification period (2016–2017). Outcomes of adherence, persistence, time to non-persistence and time to discontinuation were assessed in those who did not switch the index drug in the follow-up period (365 days from the index date). Switching rates were assessed in those who switched the index drug at least once in the aforementioned follow-up period. Descriptive statistics were conducted for all the outcomes, and comparisons were made using t-tests, chi-square, and ANOVA. Logistic regression was conducted to compare the odds of being adherent and the odds of switching in NVAF and VTE patient cohorts.
Of all the DOACs, patients with NVAF or VTE were most adherent to apixaban (PDC = 76.88). Among all the DOACs, non-persistence and discontinuation rates were highest for warfarin. Majority of the switches were reported from dabigatran to other DOAC and to apixaban from other DOAC. Despite the better utilization outcomes reported for apixaban users, Medicare plans covered rivaroxaban favorably. It was associated with the lowest mean amount paid by the patient (NVAF: $76; VTE: $59), and the highest mean amount paid by the plans (NVAF: $359; VTE: $326).
Medicare plans need to consider adherence, persistence, discontinuation and switching rates of DOACs to make the coverage decisions.
Cerebral venous thrombosis in adults: A case series of 35 patients from a tertiary hospital
2023, Revista Clinica Espanola
Describir las características basales, de presentación clínica, de imagen y evolución e identificar potenciales factores pronósticos en una cohorte de pacientes con trombosis venosa cerebral (TVC).
Estudio observacional retrospectivo, unicéntrico, que incluye a pacientes adultos con diagnóstico de TVC desde enero 2016 hasta diciembre 2020. Las variables fueron recogidas a través de la historia clínica electrónica.
Se incluyeron 35 pacientes con una edad media al diagnóstico de 50,3 (± 17,8) años, siendo la mayoría mujeres (74,4%). El 95% de los pacientes presentaba al menos un factor de riesgo para el desarrollo de TVC. El 97,1% recibió tratamiento anticoagulante con heparinas en la fase aguda, en su mayoría heparina de bajo peso molecular (75%). El evento compuesto (muerte, ingreso en unidad de cuidados intensivos, National institute of Health Stroke Scale al alta > 3, recurrencia de TVC, hemorragia mayor, o la presencia de complicaciones) en las primeras dos semanas ocurrió en el 28,6%. El seguimiento medio fue de 3,3 años, durante el cual el 14,3% falleció (solo un paciente en relación con la TVC), un paciente presentó hemorragia mayor y ningún paciente presentó recurrencia de TVC.
En nuestra cohorte, la TVC afectó con mayor frecuencia a mujeres jóvenes, y ocurrió en pacientes con al menos un factor de riesgo para TVC. La presencia de edema en la tomografía computarizada y el tratamiento con corticosteroides asociaron un peor pronóstico a corto plazo. Se observó un buen pronóstico a largo plazo en términos de mortalidad, recurrencia y sangrado.
To describe the baseline characteristics, clinical presentation, imaging tests and outcomes, and identify potential prognostic factors in a cohort of patients diagnosed with cerebral venous thrombosis (CVT).
This retrospective, single-center, observational study included adult patients diagnosed with CVT from January 2016 to December 2020. The variables were reviewed using electronic medical records.
A total of 35 patients were included, with a median age at diagnosis of 50.3 (± 17.8) years, and the majority being women (74.4%). Nearly 95% of the patients presented at least one risk factor for the development of CVT. Heparins were used for the acute phase in 97.1% of cases, with 75% of those being low molecular weight heparins. During the first two weeks, a compound event (death, intensive care unit admission, National Institute of Health Stroke Scale at discharge >3, CVT recurrence, major bleeding, or the presence of complications) occurred in 28.6% of patients (10 patients). Over the mean follow-up period of 3.3 years, 14.3% of the patients died (with only one death attributed to CVT), one patient experienced major bleeding, and no patients had a recurrence of CVT.
In our cohort, CVT predominantly affected young women with at least one risk factor for its development. The presence of edema on CT and corticosteroid treatment were associated with a poor short-term prognosis. However, we observed a favorable long-term prognosis in terms of mortality, recurrence, and bleeding.
Venous thromboembolism in patients with COVID-19. A prevalent and a preventable complication of the pandemic
2021, Journal of Interventional Medicine
Citation Excerpt :
VTE is a name given to a group of coagulation disorders, which comprise deep vein thrombosis and pulmonary embolism (PE). Deep vein thrombosis is a phenomenon of the formation of blood clots in the deep veins of the lower limbs, but may also occur in other parts of the body.21,22 Venous thrombosis consists of the so-called Virchow’s triad, which comprises irregular blood flow, blood coagulation disorders, and vessel wall abnormalities.
Coronavirus disease 2019 or most commonly known as COVID-19 is a trending global infectious disease which a few months ago was affirmed as a global health emergency or a pandemic by the WHO Emergency Committee. The common symptoms manifested in this pandemic disease are high grade fever, cough, fatigue, shortness of breath and flu like symptom which can evolve into severe respiratory disorders such as pneumonia, acute respiratory distress syndrome (ARDS) and/or end-organ failure. Factors that contribute to the severity or high mortality rate in COVID-19 include old age, comorbidities like hypertension, diabetes, hyperlipidaemia, neutrophilia, and organ and coagulation dysfunction. Disseminated intravascular coagulation and other various coagulopathies including Venous thromboembolism have known to become a major contributing factor to high mortality rate. Venous thromboembolism is a disease which is a combination of deep vein thrombosis and pulmonary embolism. Prophylactic anticoagulation in patients prone to or with a pre-existing history of venous thromboembolism is associated with decreased mortality in severe COVID-19 pneumonia. This review article focuses upon COVID-19 and increased incidence of venous thromboembolism in patients infected by COVID-19 along with the role it has in high mortality rate in COVID-19 patients.
Antiphospholipid antibodies are not elevated in patients with severe COVID-19 pneumonia and venous thromboembolism
2020, Thrombosis Research
Incidence of asymptomatic deep vein thrombosis in patients with COVID-19 pneumonia and elevated D-dimer levels
2020, Thrombosis Research
Citation Excerpt :
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are the main manifestations of venous thromboembolism (VTE). DVT and PE share common risk factors and, in most cases, PE is a consequence of DVT [1]. D-dimer is a product of degradation of fibrin acting as a surrogate marker for fibrinolysis and is usually elevated in thrombotic events [2].
An increased risk of venous thromboembolism (VTE) in patients with COVID-19 pneumonia admitted to intensive care unit (ICU) has been reported. Whether COVID-19 increases the risk of VTE in non-ICU wards remains unknown. We aimed to evaluate the burden of asymptomatic deep vein thrombosis (DVT) in COVID-19 patients with elevated D-dimer levels.
In this prospective study consecutive patients hospitalized in non-intensive care units with diagnosis of COVID-19 pneumonia and D-dimer > 1000 ng/ml were screened for asymptomatic DVT with complete compression doppler ultrasound (CCUS). The study was approved by the Institutional Ethics Committee.
The study comprised 156 patients (65.4% male). All but three patients received standard doses of thromboprophylaxis. Median days of hospitalization until CCUS was 9 (IQR 5–17). CCUS was positive for DVT in 23 patients (14.7%), of whom only one was proximal DVT. Seven patients (4.5%) had bilateral distal DVT. Patients with DVT had higher median D-dimer levels: 4527 (IQR 1925-9144) ng/ml vs 2050 (IQR 1428-3235) ng/ml; p < 0.001. D-dimer levels > 1570 ng/ml were associated with asymptomatic DVT (OR 9.1; CI 95% 1.1–70.1). D-dimer showed an acceptable discriminative capacity (area under the ROC curve 0.72, 95% CI 0.61–0.84).
In patients admitted with COVID-19 pneumonia and elevated D-dimer levels, the incidence of asymptomatic DVT is similar to that described in other series. Higher cut-off levels for D-dimer might be necessary for the diagnosis of DVT in COVID-19 patients.
Trends in vena cava filter insertions and “prophylactic” use
2018, Journal of Vascular Surgery: Venous and Lymphatic Disorders
Prophylactic vena cava filter (VCF) use in patients without venous thromboembolism is common practice despite ongoing controversy. Thorough analysis of the evolution of this practice is lacking. We describe trends in VCF use and identify events associated with changes in practice.
Using the National Inpatient Sample, we conducted a retrospective observational study of U.S. adult hospitalizations from 2000 to 2014. Trends in prophylactic VCF insertion were analyzed both across the entire study population and within subgroups according to trauma status and type of concurrent surgery. Annual percentage change (APC) was calculated, and trends were analyzed using Poisson regression.
Among 461,904,314 adult inpatients (median [interquartile range] age, 58.1 [38.5-74.3] years; 39.6% male), the incidence of VCF insertion increased rapidly at first (from 0.19% to 0.35%; APC, 11.2%; 95% confidence interval [CI], 10.3%-12.2%; P < .001), then at a slower rate after the publication of the Prévention du Risque d'Embolie Pulmonaire par Interruption Cave 2 (PREPIC2) trial in 2005 (from 0.35% to 0.42%; APC, 4.4%; 95% CI, 2.8%-6.0%; P < .001), and it began decreasing after the 2010 Food and Drug Administration (FDA) safety alert (from 0.42% to 0.32%; APC, −5.5%; 95% CI, −6.5% to −4.6%; P < .001). The percentage of total VCFs that had a prophylactic indication increased quickly before publication of the PREPIC2 trial (APC, 19.5%; 95% CI, 17.9%-21.0%; P < .001), increased at a slower rate after publication in 2005 (APC, 4.4%; 95% CI, 2.6%-6.2%; P < .001), and dropped after the FDA safety alert, stabilizing at 18.5% for the last 3 years (APC, −0.3%; 95% CI, −2.2% to 1.7%; P = .8). Subgroups most associated with prophylactic VCF insertion were operative trauma (odds ratio [OR], 10.9; 95% CI, 10.2-11.7), orthopedic surgery (OR, 4.7; 95% CI, 4.3-5.2), and neurosurgical procedures (OR, 3.9; 95% CI, 3.6-4.2). All groups except orthopedic surgery experienced a deceleration in prophylactic VCF growth after the publication of PREPIC2. Meanwhile, the FDA safety alert was associated with a decrease in prophylactic VCF insertions for all groups except other major surgery.
Whereas publication of the PREPIC2 trial led to a deceleration in prophylactic VCF insertion growth, the FDA alert had a bigger impact, leading to declining rates of prophylactic VCF use. Further investigations of prophylactic insertion of VCF in trauma, orthopedic, and neurosurgical patients are needed to determine whether current levels of use are justified.

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ArticleVenous thromboembolism: An overview

Highlights

Section snippets

What is venous thromboembolism?

DVT

PE

Prevalence

United States statistics

Predisposing factors

Venous stasis

Hypercoagulable states

Hypercoagulable state

Immobilization

Surgery and trauma

Pregnancy

Oral contraceptives and estrogen replacement

Malignancy

Conclusion

Chest

Chest

J Am Coll Cardiol

J Thromb Haemost

Lancet

Clin Radiol

Am J Med

Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis

J Am Med Assoc

Natural history of venous thromboembolism

Circulation

Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians

Ann Fam Med

Acute pulmonary embolism 1: Pathophysiology, clinical presentation, and diagnosis

Heart

Article
Venous thromboembolism: An overview