Is my patient with varicose veins at higher risk of venous thromboembolism?

Although varicose veins are common and usually not associated with serious health complications, increasing scientific evidence suggests that they are associated with increased risk of subsequent incident deep venous thrombosis (DVT) and pulmonary embolism (PE). 1-3

A 2018 retrospective cohort study involving patients with the diagnosis of varicose veins and controls (>200,000 subjects each) based on claims data from Taiwan found a higher incidence rate of DVT among cases (hazard ratio [HR] 5.3, 95%C.I. 5.1-5.6). Increased risk of DVT with varicose veins was reported in all age groups but decreased with increasing age.  The HR was higher within the first year of the diagnosis of varicose veins. 1

In the same study, the incidence of PE was higher among participants with varicose veins (HR 1.7 95% C.I. 1.5-1.9).  Again, the association did not significantly differ by age.1  Other smaller studies have found similar association between DVT and varicose veins. 2,3

Although these studies at best demonstrate an association (not necessarily a cause and effect relationship) between varicose veins and venous thromboembolism, several possible explanations have been posited. Animal studies have demonstrated higher concentrations of macrophages, monocytes, neutrophils, lymphocytes, and matrix metalloproteinases in venous valves exposed to high pressure for prolonged periods.  The resultant inflammatory state in patients with varicose veins may in turn promote a prothrombotic state contributing to venous thromboembolism. 1,4

Bonus Pearl: Did you know that nearly 1 of 4  adults in the United States have been reported to have varicose veins?

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References

  1. Chang SL, Huang YL, Lee MC, et al. Association of varicose veins with incident venous thromboembolism and peripheral artery disease. JAMA 208;319:807-817. https://jamanetwork.com/journals/jama/fullarticle/2673551
  2. Muller-Buhl U, Leutgeb R, et al. Varicose veins are a risk factor for deep venous thrombosis in general practice patients. Vasa 2012;41:360-65. https://pubmed.ncbi.nlm.nih.gov/22915533/
  3. Engbers MJ, Karasu A, Blom JW, et al. Clinical features of venous insufficiency and the risk of venous thrombosis in older people. Br J Haematol 2015;171:417-23. https://pubmed.ncbi.nlm.nih.gov/26221838/
  4. Riva N, Donadini MP, Ageno W. Epidemiology and pathophysiology of venous thromboembolism: similarities with atherothrombosis and the role of inflammation. Thromb Haemost 2015;113:1176-1183. https://pubmed.ncbi.nlm.nih.gov/25472800/

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers, Mass General Hospital, Harvard Medical School or its affiliated institutions. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Is my patient with varicose veins at higher risk of venous thromboembolism?

How effective are the mRNA Covid-19 vaccines in reducing the risk of hospitalization among adults 65 years of age or older?

The mRNA vaccines by Pfizer and Moderna seem very effective in not only reducing risk of symptomatic Covid-19 but also risk of hospitalization among adults 65 years of age or older.   A CDC study published on April 28, 2021, showed a vaccine efficacy of 94% among fully immunized and 64% among partially immunized adults ≥ 65 years of age  with approximately one-half of subjects  ≥75 years old.1

This study was carried out in 24 hospitals in 14 states in the U.S. during January 1, 2021-March 26, 2021, and involved 417 patients: 187 case-patients with Covid-19 and 230 controls with negative SARS-CoV-2 PCR test.  Among patients with Covid-19, 10% were partially immunized (vs 27% among controls) and 0.5% were fully immunized (vs. 8% among controls). 1

An Israeli study in a nationwide mass vaccination setting involving persons (28% ≥ 60 y) receiving Pfizer mRNA vaccine similarly found a vaccine efficacy of 74% for hospitalization for partially immunized and 87% for fully immunized persons.2

The high effectiveness of mRNA vaccines against more severe Covid-19 requiring hospitalization is great news, of course, as advanced age is by far the greatest risk factor for death from Covid-19, independent of underlying comorbidities.3   

Bonus Pearl: Did you know that prior to the availability of effective Covid-19 vaccination, adults over 65 years of age represented 80% of hospitalizations and had a 23-fold greater risk of death than those under 65?3

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References

  1. Tenforde MW, Olson SM, Self WH, et al. Effectiveness of Pfizer-BioNTech and Moderna vaccines against COVID-19 among hospitalized adults aged ≥65 years-United States, January-March 2021. https://www.cdc.gov/mmwr/volumes/70/wr/mm7018e1.htm?s_cid=mm7018e1_w
  2. Dagan N, Barda N, Kepten E, et al. BNT162b2mRNA Covid-19 vaccine in a nationwide mass vaccination setting. N Engl J Med 2021;384:1412-1423. https://www.nejm.org/doi/10.1056/NEJMoa2101765
  3. Mueller AL, McNamara MS, Sinclair DA. Why does COVID-19 disproportionately affect older people. Aging (Albany NY) 2020;12:9959-9981. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288963/

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers, Mass General Hospital, Harvard Medical School or its affiliated institutions. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

How effective are the mRNA Covid-19 vaccines in reducing the risk of hospitalization among adults 65 years of age or older?