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?

What is the role of direct oral anticoagulant (DOAC) agents in preventing venous thromboembolism (VTE) in patients who undergo hip or knee arthroplasties?

DOACs (eg, rivaroxaban, apixaban,and dabigatran) are increasingly considered for use after hip and knee arthroplasties due to their demonstrated efficacy against VTE prophylaxis and an acceptable safety profile. 

In a meta-analysis involving 16 trials in over 38,000 patients, when compared to enoxaparin, the risk of symptomatic VTE appeared to be significantly lower with rivaroxaban (relative risk 0.48, 95% C.I. 0.3-0.75), and similar with dabigatran and apixaban (1).

In the same study, compared to enoxaparin, the relative risk of clinically relevant bleeding was significantly higher with rivaroxaban (1.25, 95% C.I. 1.1-1.5), similar with dabigatran , but lower with apixaban (0.82, 95% C.I. 0.7-0.98) (1). The authors concluded that new anticoagulants did not differ significantly for efficacy and safety.

Of course, the decision to use a DOAC vs enoxaparin should be made on an individual basis taking into account a variety of factors,  such as patient preferences, cost, comorbidities, patient compliance with medications, etc…  

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 Reference

1.  Gomez-Outes, Suarez-Gea L, Vargas-Castrillon E.  Dabigatran, rivaroxaban, or apixaban versus enoxaparin for thromboprophylaxis after total hip or knee replacement: systematic review, meta-analysis, and indirect treatment. BMJ 2012;344:e3675. https://pubmed.ncbi.nlm.nih.gov/22700784/ 

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. 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!

What is the role of direct oral anticoagulant (DOAC) agents in preventing venous thromboembolism (VTE) in patients who undergo hip or knee arthroplasties?