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Semin Thromb Hemost 2019; 45(08): 793-801
DOI: 10.1055/s-0039-1697682
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Venous Thromboembolism in Patients with Liver Cirrhosis: Findings from the RIETE (Registro Informatizado de la Enfermedad TromboEmbolica) Registry

Behnood Bikdeli
1   Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
2   Center for Outcomes Research & Evaluation, Yale School of Medicine, New Haven, Connecticut
3   Cardiovascular Research Foundation, New York, New York
,
David Jiménez
4   Department of Respiratory, Hospital Ramón y Cajal, Madrid, Spain
5   Department of Medicine, Universidad de Alcalá (IRYCIS), Madrid, Spain
,
Guadalupe Garcia-Tsao
6   Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
,
Raquel Barba
7   Department of Internal Medicine, Fundación Hospital Alcorcón, Madrid, Spain
,
Carme Font
8   Department of Medical Oncology, Hospital Clínic, Barcelona, Spain
,
María del Carmen Díaz-Pedroche
9   Department of Internal Medicine, Hospital Universitario de Octubre, Madrid, Spain
,
Lucia Mazzolai
10   Department of Angiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
,
Derek Henry Wallace Little
11   Department of Medicine, McMaster University, Hamilton, Ontario, Canada
,
Antonella Tufano
12   Regional Reference Centre for Coagulation Disorders, Department of Clinical Medicine and Surgery, Federico II, University Hospital, Naples, Italy
,
Alfonso J. Tafur
13   Department of Medicine, Vascular Medicine, NorthShore University HealthSystem, University of Chicago, Chicago, Illinois
,
Deborah Siegal
11   Department of Medicine, McMaster University, Hamilton, Ontario, Canada
,
Gregory Y.H. Lip
14   Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
15   Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
,
Manuel Monreal
16   Department of Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
17   Department of Medicine, Universidad Católica de Murcia, Murcia, Spain
,
for the RIETE Investigators› Institutsangaben
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Publikationsdatum:
15. Oktober 2019 (online)

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Abstract

Patients with cirrhosis are not only at an increased risk of bleeding but also at risk of venous thromboembolism (VTE). We sought to determine the clinical characteristics, management, and outcomes after VTE in patients with cirrhosis. We used the data from RIETE (Registro Informatizado de la Enfermedad TromboEmbolica), an international registry of patients with VTE, to compare the outcomes in patients with and without cirrhosis. Main outcomes included all-cause mortality, pulmonary embolism (PE)-related mortality, recurrent VTE, and bleeding. Among 43,611 patients with acute VTE, 187 (0.4%) had cirrhosis. Of these, 184 (98.4%) received anticoagulation for a median of 109 days (interquartile range [IQR]: 43–201 days), most commonly with enoxaparin (median dose: 1.77 [IQR: 1.38–2.00] mg/kg/day). Compared with patients without cirrhosis, those with cirrhosis had a higher rate of all-cause mortality (10.7 vs. 3.4%; odds ratio [OR]: 3.41; 95% confidence interval [CI]: 2.03–5.46) and fatal bleeding (2.1 vs. 0.2%; OR: 13.94; 95% CI: 3.65–37.90) but similar rates of fatal PE (0.5 vs. 0.5%; OR: 1.17; 95% CI: 0.03–6.70). Patients with cirrhosis had a higher rate of all-cause mortality per 100 patient-years of follow-up (58.9 vs. 16.0; hazard ratio [HR]: 3.70; 95% CI: 2.69–4.91). One-year hazard ratio of clinically relevant bleeding (HR: 2.86; 95% CI: 1.91–4.27), fatal bleeding (HR: 8.51; 95% CI: 3.5–20.7), or recurrent VTE (HR: 2.08; 95% CI: 1.00–4.36) was higher in patients with cirrhosis. Cirrhosis is a challenging comorbidity in patients with VTE. Most patients were treated with anticoagulation and had an elevated risk of recurrence, similar risk of fatal PE, and a very high risk of bleeding including fatal bleeds.

Keywords

venous thromboembolism - cirrhosis - bleeding

Disclosures

We express our gratitude to Sanofi Spain for supporting this registry with an unrestricted educational grant. We also express our gratitude to Bayer Pharma AG for supporting this registry. Bayer Pharma AG's support was limited to the part of RIETE outside Spain, which accounts for a 25.24% of the total patients included in the RIETE registry. Dr. Bikdeli reports that he serves as a consulting expert (on behalf of the plaintiff) for litigation related to a specific IVC filter. The content of this paper is not directly related to that litigation. Dr. Bikdeli was supported by the National Heart, Lung, and Blood Institute, National Institutes of Health (NHLBI/NIH), through grant number T32 HL007854. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.


* A full list of the RIETE investigators is given in the Appendix.


Supplementary Material