Predicting recurrence after unprovoked venous thromboembolism: prospective validation of the updated Vienna Prediction Model

Tritschler, Tobias; Méan, Marie; Limacher, Andreas; Rodondi, Nicolas; Aujesky, Drahomir

doi:10.1182/blood-2015-04-641225

Cited by 42 publications

(37 citation statements)

References 17 publications

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“…In the DULCIS management study, patients aged > 70 years had a four‐fold higher risk of recurrent VTE than younger patients. The Vienna prediction rule has been demonstrated to perform poorly when applied to an elderly population (> 65 years) . Our study further confirms and reinforces the low discriminative ability of prediction models in patients aged > 65 years.…”

Section: Discussionsupporting

confidence: 78%

External validation of the DASH prediction rule: a retrospective cohort study

Tosetto

Testa

Martinelli

et al. 2017

Journal of Thrombosis and Haemostasis

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Background The DASH prediction model has been proposed as a guide to identify patients at low risk of recurrence of venous thromboembolism (VTE), but has never been validated in an independent cohort. Aims To validate the calibration and discrimination of the DASH prediction model, and to evaluate the DASH score in a predefined patient subgroup aged > 65 years. Methods Patients with a proximal unprovoked deep vein thrombosis (DVT) or pulmonary embolism (PE) who received a full course of vitamin K antagonist or direct oral anticoagulant (> 3 months) and had D-dimer measured after treatment withdrawal were eligible. The DASH score was computed on the basis of the D-dimer level after therapy withdrawal and personal characteristics at the time of the event. Recurrent VTE events were symptomatic proximal or distal DVT/PE, and were analyzed with a time-dependent analysis. Observed 12-month and 24-month recurrence rates were compared with recurrence rates predicted by the DASH model. Results We analyzed a total of 827 patients, of whom 100 (12.1%) had an objectively documented recurrence. As compared with the original DASH cohort, there was a greater proportion of subjects with a 'low-risk' (≤ 1) DASH score (66.3% versus 51.6%, P < 0.001). The slope of the observed versus expected cumulative incidence at 2 years was 0.71 (95% confidence interval 0.51-1.45). The c-statistic was lower for subjects aged > 65 years (0.54) than for younger subjects (0.72). Conclusions These results confirm the validity of DASH prediction model, particularly in young subjects. The recurrence risk in elderly patients (> 65 years) was, however, > 5% even in those with the lowest DASH scores.

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Section: Discussionsupporting

confidence: 78%

External validation of the DASH prediction rule: a retrospective cohort study

Tosetto

Testa

Martinelli

et al. 2017

Journal of Thrombosis and Haemostasis

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“…Recurrence prediction using available prediction models in elderly patients could be especially important because of higher risk of bleeding related to prolonged anticoagulation. 27 Strengths of this study include the prospective investigation of PE with assessment of several fibrin clot variables. This study is unique in its exploration of whether the plasma fibrin clot phenotype may affect the PE recurrence risk estimation.…”

Section: Discussionmentioning

confidence: 99%

Prothrombotic Fibrin Clot Phenotype Is Associated With Recurrent Pulmonary Embolism After Discontinuation of Anticoagulant Therapy

Ząbczyk

Plens

Wójtowicz

et al. 2017

ATVB

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Objective-Pulmonary embolism (PE) is a life-threatening manifestation of venous thromboembolism with a high recurrence rate after anticoagulation cessation. Recently, we have reported that prothrombotic clot phenotype in venous thromboembolism patients is associated with an increased risk of recurrent deep-vein thrombosis. Approach and Results-We tested whether abnormal clot properties are predictive of recurrent PE. We investigated 156 consecutive white patients aged 18 to 65 years after the first-ever provoked or unprovoked PE (n=89), with or without deep-vein thrombosis. Plasma fibrin clot permeability (K s ), turbidity measurements, calibrated automated thrombography, and efficiency of fibrinolysis using clot lysis time, maximum D-dimer levels, and rate of increase in D-dimer levels were evaluated at ≥3 months of anticoagulant therapy, at least 4 weeks since the anticoagulation withdrawal. The primary end point was recurrent PE during a median follow-up of 50 months. Recurrent PE was diagnosed in 23 (14.7%; 5%/ yr) patients. Recurrent PE was associated with formation of denser fibrin networks reflected by lower K s (P=0.007) and impaired fibrinolysis, as evidenced by prolonged clot lysis time (P=0.012) and reduced maximum rate of increase in D-dimer levels in the lysis assay (P=0.004). Patients with recurrent PE had higher plasma D-dimer (P<0.001) and thrombin peak (P=0.007) compared with the remainder, whereas turbidity measurements and maximum D-dimer levels did not differ in the recurrence. Multivariate model showed that independent predictors of recurrent PE were female sex, unprovoked venous thromboembolism, higher plasma D-dimer, reduced K s , and reduced maximum rate of increase in D-dimer levels in the lysis assay (all P<0.05). Conclusions-Altered

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“…53 Recently, the accuracy of the updated VPM has been challenged by a relatively small multicenter cohort study including only elderly patients with unprovoked VTE. 54 In this study, the risk of recurrent VTE did not differ between low-and higher-risk patients at 12 months and the area under the receiver-operator characteristic (ROC) curve for predicting VTE recurrence was just 0.39. It should be remembered that the mean age in the derivation cohort of the VPM was significantly lower, suggesting that predicting relapses in elderly patients may prove difficult.…”

Section: Vpm Score (Vienna Prediction Model)mentioning

confidence: 59%

“…47 Caution should be exercised, however, because the VPM may underestimate recurrence rates. 53,54 The DASH model might provide different results in our patient, giving some support for therapy discontinuation (especially considering the bleeding history) if D-dimer levels were below 250 ng/mL, while strongly indicating therapy continuation for higher D-dimer levels, as for the HERDOO2 prediction model. We should also consider additional limitations.…”

Section: Use and Limitations Of Available Prediction Modelsmentioning

confidence: 86%

Scoring Systems for Estimating the Risk of Recurrent Venous Thromboembolism

Nichele

Tosetto

2017

Semin Thromb Hemost

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The risk of recurrence after suspension of anticoagulant treatment in patients with a first episode of unprovoked venous thromboembolism (VTE) is highly variable from patient to patient. Not all patients are candidates for life-long anticoagulant therapy, essentially because there remain concerns for such an option regarding hemorrhagic complications and clinical monitoring. Thus, the "treat all" approach may be inadequate for some patients at low risk of relapse. Proper assessment of the recurrence risk may be helpful to decide the optimal therapeutic strategy in such patients. In recent years, attempts have been made to develop and validate clinical prediction rules to estimate the absolute risk of VTE recurrence in individual patients. This article highlights the advantages and disadvantages of such options, presenting three different prediction rules that have been published so far.

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Predicting recurrence after unprovoked venous thromboembolism: prospective validation of the updated Vienna Prediction Model

Cited by 42 publications

References 17 publications

External validation of the DASH prediction rule: a retrospective cohort study

External validation of the DASH prediction rule: a retrospective cohort study

Prothrombotic Fibrin Clot Phenotype Is Associated With Recurrent Pulmonary Embolism After Discontinuation of Anticoagulant Therapy

Scoring Systems for Estimating the Risk of Recurrent Venous Thromboembolism

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