Sex differences in temporal trends in main and secondary pulmonary embolism diagnosis and case fatality rates: 2003-2019.

AIMS: There is controversy regarding the incidence and outcomes of pulmonary embolism (PE) according to sex. Our aim was to address sex differences in temporal trends in main and secondary hospital PE diagnoses, management and case fatality rates (CFR). METHODS AND RESULTS: Retrospective analysis of Spain´s National Healthcare System hospital database, years 2003-2019, for patients ≥18 years with main or secondary PE diagnosis. Trends by sex in hospital diagnosis, use of procedures, and CFRs were analysed by joinpoint and Poisson regression models. Of 339 469 PE diagnoses, 52% were in women. Sixty-five percent were main diagnosis, 35.2% secondary. Total annual diagnoses and frequentation rates increased similarly in men and women: average annual percent change (AAPC): 2.0% (95% CI, 1.3-2.6; P < 0.005). Secondary PEs were more common in men (37.8% vs. 32.9%, P < 0.001). Men showed greater comorbidity than women (Charlson index 2.22 ± 0.01 vs. 1.74 ± 0.01, P < 0.001), particularly cancer in the secondary diagnosis group (40.9% vs. 31.6%, P < 0.001). CFRs for PE as main diagnosis were comparable and decreased in parallel in men (from 13.8% in 2003 to 7.3% in 2019) and women (from 13.1% in 2003 to 6.9% in 2019). However, for PE as secondary diagnosis, CFRs remained higher (P < 0.001) in men (from 42.5% in 2003 to 26.2% in 2019) than women (from 34.4% in 2003 to 22.8% in 2019). CONCLUSION: PE hospital diagnosis increased significantly between 2003 and 2019 in men and women for both main and secondary diagnosis. Although in-hospital CFR decreased one third still remains very high, especially in men with secondary PE diagnosis.

Arterial and venous involvement in Behçet's syndrome: a narrative review.

Behçet syndrome (BS) is a unique type of vasculitis that affects veins and arteries of all sizes, leading to recurrent vascular events, mostly venous thrombosis. The prevalence of venous thromboembolism in BS patients ranges between 15 and 40%. Thrombosis is usually an early manifestation leading to diagnosis of BS in up to 40% of patients. BS is per se a model of inflammation-induced thrombosis. The primary autoimmune response activates lymphocytes that in turn produce a cytokine cascade that activates neutrophils, which modify the secondary structure of fibrinogen making it less susceptible to plasmin-induced lysis. This leads to endothelial dysfunction, platelet activation and overexpression of tissue factor leading to inflammatory thrombi, usually attached to the wall. The pathogenesis of thrombosis is especially relevant to direct the specific treatment, that is based on immunosuppression rather than anticoagulation. Superficial vein thrombosis (SVT) and deep vein thrombosis (DVT) are the most common form of thrombosis in BS, but thrombosis in atypical sites (cava vein, suprahepatic veins, intracardiac thrombus) and arterial involvement can also occur. We assessed the latest update of the European League Against Rheumatism recommendations for the management of BS. Vascular Behçet treatment is usually based of immunosuppressants, and the role of anticoagulation remains controversial. The use of interventional and surgical procedures should be carefully evaluated, due to the risk of triggering a vascular pathergy phenomenon.

Circadian rhythms in thrombosis and atherothrombotic events.

Biological circadian rhythms in living organisms are regulated by molecular clocks. Several of these clocks are present in blood vessels, peripheral tissues, and immune cells. There is strong evidence linking dysregulation of circadian rhythms to the development of cardiovascular disease. Dysregulation of circadian rhythms is believed to activate inflammatory processes at specific times of day, leading to an increased risk of thrombosis and atherosclerosis progression. Research into circadian clock genes and molecular networks has the potential to identify therapeutic targets to reduce cardiovascular risk. In this review, we summarize the evidence linking circadian rhythms to thrombosis and atherothrombotic events and discuss potential therapeutic implications.

Update on extended treatment for venous thromboembolism.

The importance of assessing the probability of venous thromboembolism recurrence, a condition that includes deep vein thrombosis and pulmonary embolism, lies in the fact that it is the most important factor in deciding the duration of anticoagulant treatment. Risk of recurrence depends mostly on the presence of a risk factor for developing venous thromboembolism, with patients with unprovoked events being at the higher risk of recurrence. The risk of recurrence needs to be balanced with the risk of bleeding and the potential severity of these thrombotic and hemorrhagic events. In patients with an unprovoked venous thromboembolism who complete treatment for the acute (first 10 days) and post-acute phase of the disease (from day 10 to 3-6 months), the decision has to be made regarding prolonged antithrombotic therapy to prevent recurrences. The main goal of extended treatment is preventing recurrences with a safety profile in terms of bleeding risk. Many therapeutic options are now available for these patients, including antiplatelet therapy with aspirin or direct oral anticoagulants. Moreover, apixaban and rivaroxaban at prophylactic doses have demonstrated efficacy in preventing recurrences with a low risk of bleeding. Key messages Extending treatment (longer than 3-6 months) is challenging in patients with venous thromboembolism (VTE) and depend on the risk of venous thromboembolism recurrence, the bleeding risk and patient and physician preferences. Anticoagulation treatment should be stopped in patients with provoked VTE and in those with unprovoked VTE and a high bleeding risk after an initial period of 3-6 months. There are some therapeutic alternatives (including Aspirin and low dose of some NOACs) to reduce venous thromboembolism recurrence risk in patients with unprovoked VTE and a low bleeding risk for extended treatment of VTE (after an initial period of 3-6 months).