Consequently, the difference between observed survival after deep vein thrombosis or pulmonary embolism and expected survival is uncertain. Finally, 2 studies have reported independent predictors of survival after venous thromboembolism, but both were limited in the number of covariates that could be tested because of sample size constraints. To address these limitations, we identified the inception cohort of Olmsted County, Minnesota, residents with deep vein thrombosis or pulmonary embolism first diagnosed during the year period, through , and performed a population-based follow-up study to estimate short-term and long-term survival, to compare observed survival with age- and sex-adjusted expected survival, and to determine independent predictors of short-term and long-term survival after incident venous thromboembolism.
Using the data resources of the Rochester Epidemiology Project, 16 we identified the inception cohort of Olmsted County, Minnesota, residents with a first lifetime deep vein thrombosis or pulmonary embolism during the year period, through A master list of residents with deep vein thrombosis, pulmonary embolism, or similar diagnoses, or who had any diagnostic test or procedure that could be used in the diagnosis of deep vein thrombosis or pulmonary embolism was constructed by searching all available computer databases, logbooks, and other records of local health care providers.
All subjects were followed forward in time through their linked medical records in the community retrospective cohort study until death, the most recent clinical contact, or July 19, For each subject, all inpatient and outpatient medical records of any local health care provider were searched for vital status at last clinical contact.
For deceased patients, all death certificates were reviewed regardless of location at death. Each episode of deep vein thrombosis or pulmonary embolism was categorized into the highest possible of 3 levels of diagnostic certainty "definite," "probable," or "possible" according to previously defined criteria. A pulmonary embolism was categorized as "definite" when confirmed by pulmonary angiography, computed tomographic scan, magnetic resonance imaging, or pathologic examination of thrombus removed at surgery or autopsy; as "probable" if testing for the definite level of diagnostic certainty was either not performed or indeterminate and a perfusion or ventilation-perfusion lung scan was interpreted as high probability for pulmonary embolism; and as "possible" if confirmatory tests were either not done or were indeterminate and 1 the medical record indicated that a physician made a diagnosis of pulmonary embolism, 2 signs and symptoms consistent with pulmonary embolism were present, and 3 the patient received a course of anticoagulation therapy with heparin, warfarin, or a similar agent or a surgical procedure for pulmonary embolism such as an inferior vena cava filter.
A short period of anticoagulation therapy while awaiting completion of diagnostic evaluation for either suspected deep vein thrombosis or pulmonary embolism was insufficient grounds for inclusion. An episode of venous thromboembolism consisting of both deep vein thrombosis and pulmonary embolism was categorized into the highest level of diagnostic certainty present for either manifestation.
Because pulmonary embolism is a complication of deep vein thrombosis, results are presented as deep vein thrombosis alone or pulmonary embolism with or without deep vein thrombosis.
During the course of the study, routine diagnostic testing for acute pulmonary embolism among patients with deep vein thrombosis was not performed unless there was additional clinical evidence of pulmonary embolism.
Venous thromboembolism events first identified during the patient's lifetime and meeting our diagnostic criteria, as well as autopsy-confirmed events, which had been objectively verified by an invasive or noninvasive test on the date of death, were classified as "antemortem-discovered. Nemetz, MD, unpublished data, Mayo Clinic pathologists performed all autopsy examinations and completed the death certificates of persons dying within Olmsted County during the study period. Postmortem-discovered pulmonary embolism events were classified as a "cause of death" only if the pathologist labeled it as such in the autopsy report, or if the death certificate listed pulmonary embolism as an immediate or underlying cause of death, or included pulmonary embolism on part 1 of the death certificate.
Postmortem-discovered pulmonary embolism events were classified as a "contributory cause of death" if pulmonary embolism was listed as a contributing cause or other significant condition on part 2 of the death certificate.
Pulmonary embolism events first identified on postmortem examination but not specifically labeled as a "cause of death" in the autopsy report or listed on the death certificate were categorized as "noncausal for death.
A large number of baseline characteristics were tested as predictors of survival after the initial episode of venous thromboembolism. Data on these characteristics were collected by review of all medical records inpatient and outpatient in the community for each subject. Active malignancy, chemotherapy, all surgery variables, anesthesia, trauma, hormone therapy, oral contraceptive therapy, and tamoxifen therapy were recorded as present only if documented within the 3 months prior to the venous thromboembolic event.
Congestive heart failure, serious neurologic disease, chronic lung disease, chronic liver disease, chronic renal disease, myeloproliferative diseases, and inflammatory bowel disease were recorded as present if documented any time prior to the incident venous thromboembolic event. Body mass index calculations were based on the most recent height and weight measurements prior to the incident event.
Body mass index could not be calculated in 82 cases because of missing weight or height or both. Smoking status was based on tobacco use in the 3 months prior to the incident event. Due to the relatively high autopsy rate during the study period, a substantial number of incident cases of venous thromboembolism were first identified at autopsy and the time interval from onset to death could not be determined.
For purposes of analysis, these cases were grouped with those whose death was known to have occurred within 7 days of the diagnosis of venous thromboembolism. Consequently, most of the venous thromboembolism cases categorized as dying within 7 days of onset were postmortem-discovered events. Therefore, we performed 2 analyses: an analysis of those who died within 7 days of the incident event including postmortem-discovered events short-term survival and an analysis of those who survived at least 7 days after the incident event long-term survival.
Evaluation of baseline characteristics as predictors of short- or long-term survival was performed using logistic regression models no subjects were lost to follow-up within the first 7 days and Cox proportional hazards models, respectively. The selection of variables to be included in all final models was validated using bootstrap methods.
For the Cox model, the proportional hazards assumption was assessed for all variables. When the proportional hazards assumption failed, lack of proportionality was accounted for in the modeling. For the calculation of expected survival, the Minnesota white population was used to develop a hypothetical cohort of individuals of identical age, sex, and follow-up period as our study group.
Because of incomplete information regarding smoking status, the smoking variable was assessed as a potential predictor of survival only after determining the otherwise final model.
Similarly, because pregnancy, postpartum state, oral contraceptive use, and tamoxifen therapy pertained only to women, these variables also were assessed only after determining the otherwise final model. After screening potential cases, Olmsted County residents were identified who had a confirmed first lifetime diagnosis of deep vein thrombosis or pulmonary embolism between January 1, , and December 31, The mean age at onset was The patients were followed up for a total of 14, person-years after the event date 6.
The median duration of follow-up was 7. However, After excluding autopsy-discovered cases, the median duration of follow-up was 7. The overall 1-day survival after venous thromboembolism was Overall 7-day survival was If those postmortem-discovered pulmonary embolism events that were categorized as not causal for death are excluded, The Kaplan-Meier estimated probabilities of survival at later dates after onset of venous thromboembolism are shown in Table 1. This was true for patients with deep vein thrombosis alone as well as for patients with pulmonary embolism with or without deep vein thrombosis.
For patients who survived for a full year after venous thromboembolism, subsequent survival was still worse than expected, overall at 8 years, Five hundred fifty-eight patients were categorized as dying within 7 days of their incident venous thromboembolism event and none of the remaining patients were lost to follow-up within the first 7 days.
Although all autopsy-discovered cases of deep vein thrombosis were included, the type of venous thromboembolism event deep vein thrombosis alone vs pulmonary embolism with or without deep vein thrombosis was not assessed in the final modeling process because of potential bias favoring autopsy detection of pulmonary embolism over lower extremity deep vein thrombosis.
However, since Many patient characteristics were interrelated as predictors of short-term survival, as shown in the multivariate logistic model Table 3. Independent predictors of reduced short-term survival were increasing age, male sex, earlier event year, lower BMI, confinement to a hospital or nursing home at the onset of venous thromboembolism, and a history of congestive heart failure, chronic lung disease, neurologic disease, or malignancy.
Short-term survival decreased with advancing age, but the rate of decrease varied by patient location at the onset of venous thromboembolism.
Confinement to a hospital or nursing home at the time of venous thromboembolism onset was associated with worse survival over all ages. Short-term survival also was decreased among venous thromboembolism patients with malignancy, but the rate of decrease varied by concurrent chemotherapy and sex. Minus Related Pages. Pulmonary embolism PE : Blood clot that has traveled from a deep vein to a lung.
PE is a leading cause of death in a woman during pregnancy or just after having a baby. Sudden death — 1 of 4 people who have a PE die without warning. Blood clots are a leading cause of death in people with cancer after the cancer itself. Things to Know Blood clots can happen to anyone. They are often preventable. Women who take hormones, whether birth control pills or estrogen therapy, are also at an increased risk, as are pregnant women and women in the six weeks after childbirth.
People who have to spend an extended amount of time in bed, most often because of hospitalization and recovery from an illness or surgery, have a heightened risk, too. Treatment involves medications that thin your blood and slow its ability to clot.
If a pulmonary embolism is life-threatening, your doctor can administer a thrombolytic, an agent that will dissolve the clot quickly. Because thrombolytics can cause you to bleed, they're used only when your life is in danger. Silverstein adds that the most worrisome complication of PE is death. If you have repeated clots, over time they can damage your lungs, and that can lead to chronic heart disease.
Other factors that could further increase your risk:. Age is also a risk factor. Because the signs — if any — will be subtle, err on the side of caution.
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