Venous thromboembolism (VTE) in EuropeThe number of VTE events and associated morbidity and mortality
21 March 2007
Accepted after resubmission 25 July 2007
01 December 2017 (online)
Venous thromboembolism (VTE) is often asymptomatic, misdiagnosed, and unrecognized at death, and there is a lack of routine postmortem examinations. These factors are thought to result in marked underestimates ofVTE incidence. The objective of our study was to estimate the total burden of VTE within the European Union (EU) per annum. An epidemiological model was constructed to estimate the number of community- and hospital-acquired incidents and recurrent cases (attack rate) of nonfatal VTE and VTE-related deaths, as well as incident and prevalent cases of post-thrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (PH) occurring in the EU per annum. Individual models were developed for six EU countries. The models were populated with data from published literature and, where necessary, expert opinions. The findings were tested using probabilistic sensitivity analyses. The esti mated total number of symptomaticVTE events (range based on probabilistic sensitivity analysis) per annum within the six EU countries was 465,715 (404,664–538,189) cases of deep-vein thrombosis, 295,982 (242,450–360,363) cases of pulmonary embolism (PE), and 370,012 (300,193–483,108) VTE-related deaths. Of these deaths, an estimated 27,473 (7%) were diagnosed as being antemortem; 126,145 (34%) were sudden fatal PE, and 217,394 (59%) followed undiagnosed PE. Almost threequarters of all VTE-related deaths were from hospital-acquired VTE.VTE is a major health problem in the EU, with over one million VTE events or deaths per annum in the six countries examined. Given the availability of effective VTE prophylaxis, many of these events and deaths could have been prevented. These results have important implications for the allocation of healthcare resources.
- 1 Stein PD, Henry JW. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy.. Chest 1995; 108: 978-981.
- 2 Heit JA, Silverstein MD, Mohr DN. et al. Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study.. Arch Intern Med 1999; 159: 445-453.
- 3 Pineda LA, Hathwar VS, Grant BJ. Clinical suspicion of fatal pulmonary embolism.. Chest 2001; 120: 791-795.
- 4 Nicolaides AN, Breddin HK, Fareed J. et al. Prevention of venous thromboembolism. International Consensus Statement. Guidelines compiled in accordance with the scientific evidence.. Int Angiol 2001; 20: 1-37.
- 5 Nordstrom M, Lindblad B, Bergqvist D. et al. A prospective study of the incidence of deep-vein thrombosis within a defined urban population.. J Intern Med 1992; 232: 155-160.
- 6 Hull RD, Pineo GF, Stein PD. et al. Extended out-ofhospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: a systematic review.. Ann Intern Med 2001; 135: 858-869.
- 7 Mismetti P, Laporte S, Darmon JY. et al. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery.. Br J Surg 2001; 88: 913-930.
- 8 Douketis JD, Eikelboom JW, Quinlan DJ. et al. Short-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of prospective studies investigating symptomatic outcomes.. Arch Intern Med 2002; 162: 1465-1471.
- 9 Vaitkus PT, Leizorovicz A, Cohen AT. et al. Mortality rates and risk factors for asymptomatic deep vein thrombosis in medical patients.. Thromb Haemost 2005; 93: 76-79.
- 10 Prandoni P, Lensing AW, Cogo A. et al. The long-term clinical course of acute deep venous thrombosis.. Ann Intern Med 1996; 125: 1-7.
- 11 McColl MD, Ellison J, Greer IA. et al. Prevalence of the post-thrombotic syndrome in young women with previous venous thromboembolism.. Br J Haematol 2000; 108: 272-274.
- 12 Mohr DN, Silverstein MD, Heit JA. et al. The venous stasis syndrome after deep venous thrombosis or pulmonary embolism: a population-based study.. Mayo Clin Proc 2000; 75: 1249-1256.
- 13 Asbeutah AM, Riha AZ, Cameron JD. et al. Five-year outcome study of deep vein thrombosis in the lower limbs.. J Vasc Surg 2004; 40: 1184-1189.
- 14 Bova C, Rossi V, Ricchio R. et al. Incidence of post-thrombotic syndrome in patients with previous pulmonary embolism. A retrospective cohort study.. Thromb Haemost 2004; 92: 993-996.
- 15 Gabriel F, Labios M, Portoles O. et al. Incidence of post-thrombotic syndrome and its association with various risk factors in a cohort of Spanish patients after one year of follow-up following acute deep venous thrombosis.. Thromb Haemost 2004; 92: 328-336.
- 16 Roumen-Klappe EM, den Heijer M, Janssen MC. et al. The post-thrombotic syndrome: incidence and prognostic value of non-invasive venous examinations in a six-year follow-up study.. Thromb Haemost 2005; 94: 825-830.
- 17 Wille-Jorgensen P, Jorgensen LN, Crawford M. Asymptomatic postoperative deep vein thrombosis and the development of post-thrombotic syndrome. A systematic review and meta-analysis.. Thromb Haemost 2005; 93: 236-241.
- 18 Pengo V, Lensing AW, Prins MH. et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism.. N Engl J Med 2004; 350: 2257-2264.
- 19 Ribeiro A, Lindmarker P, Johnsson H. et al. Pulmonary embolism: one-year follow-up with echocardiography doppler and five-year survival analysis.. Circulation 1999; 99: 1325-1330.
- 20 Griffin J. Deep vein thrombosis and pulmonary embolism.. London: Office of Health Economics; 1996: 48-59.
- 21 House of Commons Health Committee.. The prevention of venous thromboembolism in hospitalised patients. Second report of Session 2004-05. Available at: http://www.parliament.the-stationery-office.co.ukpa/cm200405/cmselect/cmhealth/99/99.pdf Accessed February 27, 2007.
- 22 Bergqvist D, Jendteg S, Johansen L. et al. Cost of long-term complications of deep venous thrombosis of the lower extremities: an analysis of a defined patient population in Sweden.. Ann Intern Med 1997; 126: 454-457.
- 23 Caprini JA, Botteman MF, Stephens JM. et al. Economic burden of long-term complications of deep vein thrombosis after total hip replacement surgery in the United States.. Value Health 2003; 6: 59-74.
- 24 Anderson Jr FA, Wheeler HB, Goldberg RJ. et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study.. Arch Intern Med 1991; 151: 933-938.
- 25 Silverstein MD, Heit JA, Mohr DN. et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study.. Arch Intern Med 1998; 158: 585-593.
- 26 Spencer FA, Emery C, Lessard D. et al. The Worcester Venous Thromboembolism study: a population-based study of the clinical epidemiology of venous thromboembolism.. J Gen Intern Med 2006; 21: 722-727.
- 27 Oger E. Incidence of venous thromboembolism: a community-based study in Western France. EPIGETBO Study Group. Groupe d’Etude de la Thrombose de Bretagne Occidentale.. Thromb Haemost 2000; 83: 657-660.
- 28 US Census Bureau.. International Data Base (IDB). Available at: http://www.census.gov/ipc/www/idbnew.html Accessed February 27, 2007.
- 29 Department of Health.. Hospital Episode Statistics (HES) data 2004–05. Available at: http://www.dh.gov.uk/PublicationsAndStatistics/Statistics/HospitalEpisodeStatistics/fs/en Accessed February 27, 2007.
- 30 Agence Technique de l’Information sur l’Hospitalisation.. Programme de médicalisation des systèmes d’information (PMSI) 2004. Available at: http://www.atih.sante.fr Accessed February 27, 2007.
- 31 Geerts WH, Pineo GF, Heit JA. et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.. Chest 2004; 126 (Suppl. 03) 338S-400S.
- 32 Geerts WH, Heit JA, Clagett GP. et al. Prevention of venous thromboembolism.. Chest 2001; 119 (Suppl. 01) 132S-175S.
- 33 Oster G, Tuden RL, Colditz GA. A cost-effectiveness analysis of prophylaxis against deep-vein thrombosis in major orthopedic surgery.. J Am Med Assoc 1987; 257: 203-208.
- 34 Heit JA, Mohr DN, Silverstein MD. et al. Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study.. Arch Intern Med 2000; 160: 761-768.
- 35 Piovella F, Anderson Jr FA. et al for the IMPROVE Investigators. Rates of clinically apparent venous thromboembolism and death resulting from pulmonary embolism among unselected hospitalized acutely ill medical patients versus rates predicted from clinical studies.. Blood (ASH Annual Meeting Abstracts) 2005; 106 Abstract 1620.
- 36 Cohen AT, Alikhan R. Prophylaxis of venous thromboembolism in medical patients.. Curr Opin Pulm Med 2001; 7: 332-337.
- 37 Dalen JE, Alpert JS. Natural history of pulmonary embolism.. Prog Cardiovasc Dis 1975; 17: 259-270.
- 38 Sullivan SD, Davidson BL, Kahn SR. et al. A cost-effectiveness analysis of fondaparinux sodium compared with enoxaparin sodium as prophylaxis against venous thromboembolism: use in patients undergoing major orthopaedic surgery.. Pharmacoeconomics 2004; 22: 605-620.
- 39 Kucher N, Koo S, Quiroz R. et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients.. N Engl J Med 2005; 352: 969-977.
- 40 Eurostat.. Eurostat statistics on health and safety 2001. Available at: al/page?_pageid=1996,45323734&_dad=portal&_ schema=PORTAL&screen=welcomeref& close=/health/public&language=en&product= EU_MASTER_health&root=EU_MASTER_health&scrollto=0" Accessed February 27, 2007.
- 41 Cohen AT, Edmondson RA, Phillips MJ. et al. The changing pattern of venous thromboembolic disease.. Haemostasis 1996; 26: 65-71.
- 42 Lindblad B, Sternby NH, Bergqvist D. Incidence of venous thromboembolism verified by necropsy over 30 years.. BMJ 1991; 302: 709-711.
- 43 Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis?. J R Soc Med 1989; 82: 203-205.
- 44 Arnold DM, Kahn SR, Shrier I. Missed opportunities for prevention of venous thromboembolism: an evaluation of the use of thromboprophylaxis guidelines.. Chest 2001; 120: 1964-1971.
- 45 Ageno W, Squizzato A, Ambrosini F. et al. Thrombosis prophylaxis in medical patients: a retrospective review of clinical practice patterns.. Haematologica 2002; 87: 746-750.
- 46 Rashid ST, Thursz MR, Razvi NA. et al. Venous thromboprophylaxis in UK medical inpatients.. J R Soc Med 2005; 98: 507-512.
- 47 Shojania KG, Duncan BW, McDonald KM. et al. Making health care safer: a critical analysis of patient safety practices.. Evidence report/technology assessment: number 43. Available at: http://www.ahrq.gov/clinic/ptsafety/ Accessed February 27, 2007.