Browsing by Subject "deep vein thrombosis"

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    Case description of stroke in a female patient with heterozygous MTHFR C677T mutation: Lessons learned in stroke prevention and the importance of continuity of care for women with multiple risk factors for thrombosis
    (2021-03) Bammann, Erin R.; d'Arnaud, Lindsey I.; Willhite, Sydney R.; Carroll, Jourdan G.; Goswami, Amartyadeb
    Case Description: A 58 year-old female with a history of antiphospholipid syndrome (APS) with multiple DVTs, spontaneous abortions, hypertension (HTN), hyperlipidemia (HLD), type 2 diabetes mellitus (T2DM), and tobacco use disorder presented to the hospital with dysarthria and headache for three days. Evaluation revealed a left MCA thrombotic CVA. Testing at the time of stroke was negative for antibodies associated with APS, but revealed heterozygous mutation of MTHFR C677T. Prior to this stroke, she had recently established care with a new primary care provider and cardiologist. She reported previously following with a hematologist who managed her APS with folic acid and vitamin D. She was prescribed no anticoagulation therapy and was taking 81 mg aspirin daily at the time of this event. Conclusions: There is mixed evidence regarding the patient’s diagnosis of APS as the underlying factor causing multiple DVTs. Nevertheless, the treatment for APS in the setting of multiple prior DVTs is anticoagulation, which was not part of the patient’s treatment plan prior to her stroke. A more detailed investigation of the patient’s medical history and re-evaluation of appropriate treatment when establishing care would have helped optimize her care and may have prevented her stroke. Clinical significance: Compared to men, women experience worse health outcomes after stroke, including increased mortality. When women are establishing care with new providers, this disruption in continuity of care presents an opportunity for re-evaluation of their risk factors and optimal primary prevention of stroke. This case illustrates how immediate investigation of a patient’s pre-existing diagnoses and treatment plan after a transition of care may help prevent poor health outcomes for women.
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    Routine Venous Thromboembolism Prophylaxis May Be Inadequate in the Hypercoagulable State of Severe Coronavirus Disease 2019
    (Wolters Kluwer, 2020-06-16) Maatman, Thomas K.; Jalali, Farid; Feizpour, Cyrus; Douglas, Anthony II; McGuire, Sean P.; Kinnaman, Gabriel; Hartwell, Jennifer L.; Maatman, Benjamin T.; Kreutz, Rolf P.; Kapoor, Rajat; Rahman, Omar; Zyromski, Nicholas J.; Meagher, Ashley D.; Medicine, School of Medicine
    Objectives: The aim of this study was to determine the frequency of venous thromboembolism in critically ill coronavirus disease 2019 patients and associate a degree of inflammatory marker elevation to venous thromboembolism development. Design: An observational study that identified patients with severe coronavirus disease 2019 between March 12, 2020, and March 31, 2020. Data reported are those available through May 6, 2020. Setting: A multicenter study including three Indianapolis area academic hospitals. Patients: Two-hundred forty consecutive patients with confirmed severe acute respiratory syndrome coronavirus 2 infection were admitted to one of three hospitals. One-hundred nine critically ill coronavirus disease 2019 patients admitted to the ICU were included in the analysis. Interventions: All patients received routine subcutaneous chemical venous thromboembolism prophylaxis. Measurements and Main Results: The primary outcome of this study was to determine the frequency of venous thromboembolism and the degree of inflammatory and coagulation marker elevation associated with venous thromboembolism development. Descriptive statistics outlined the frequency of venous thromboembolism at any time during severe coronavirus disease 2019. Clinical course and laboratory metrics were compared between patients that developed venous thromboembolism and patients that did not develop venous thromboembolism. Hypercoagulable thromboelastography was defined as two or more hypercoagulable parameters. Main Results: One-hundred nine patients developed severe coronavirus disease 2019 requiring ICU care. The mean (± sd) age was 61 ± 16 years and 57% were male. Seventy-five patients (69%) were discharged home, 7 patients (6%) remain in the hospital, and 27 patients (25%) died. Venous thromboembolism was diagnosed in 31 patients (28%) 8 ± 7 days after hospital admission, including two patients diagnosed with venous thromboembolism at presentation to the hospital. Elevated admission d-dimer and peak d-dimer were associated with venous thromboembolism development (p < 0.05). d-dimer greater than 2,600 ng/mL predicted venous thromboembolism with an area under the receiver operating characteristic curve of 0.760 (95% CI, 0.661–0.858; p < 0.0001), sensitivity of 89.7%, and specificity of 59.5%. Twelve patients (11%) had thromboelastography performed and 58% of these patients had a hypercoagulable study. The calculated coagulation index was hypercoagulable in 50% of patients with thromboelastography. Conclusions: These data show that coronavirus disease 2019 results in a hypercoagulable state. Routine chemical venous thromboembolism prophylaxis may be inadequate in preventing venous thromboembolism in severe coronavirus disease 2019.