Epidemiology of Venous Thromboembolism in the East. Heng Joo NG Department of Haematology Singapore General Hospital Singapore

Transcription

1 Epidemiology of Venous Thromboembolism in the East Heng Joo NG Department of Haematology Singapore General Hospital Singapore

2 Early Literature Tinckler LF Br Med J 1964;1:502

3 Propagating a notion.. Hwang WS. Singapor Med J. 1968;9: cases of pulmonary embolism in 36,176 autopsies (0.08 %)

4 40 years on Asians VTE : Myth or fact?

5 MeSH terms venous thrombosis, pulmonary embolism, Asia, Asian continental ancestry group 436 citations, 63 papers meeting criteria

6 Epidemiologic Studies of VTE in Asians Population-based Post-mortem Selected high-risk groups Hospitalized patients

7 Population-based studies - Caucasians Year Study Site Study Type Annual DVT incidence Annual PE incidence 1991 Worcester, USA Retrospective, 379,953 residents 48 per 100,000 population 23 per 100,000 population 1998 Minnesota, USA 2000 Western France Retrospective, 103,670 residents Restrospective, 342,000 residents 2008 Europe Systematic review estimates 48 per 100,000 population 124 per 100,000 population 148 per 100,000 population 69 per 100,000 population 60 per 100,000 population 95 per 100,000 population

8 Population-based studies - Asians Br J Surg Apr;91(4): Retrospective study of 2,082,245 admissions Incidence of DVT 17.1 per 100,000 population Incidence of PE 3.9 per 100,000 population

9 Ann Acad Med Singapore 2009;38:470-7 Assuming that 42.5% of the 2006 Singapore population was served by NHG, the estimated population-based incidence of VTE and PE is 57 and 15 per 100,000, respectively.

10 Population-based studies Comparison between Asians and Caucasians in Western Population Incidence of Idiopathic DVT and secondary VTE among ethnic groups in California White, R. H. et. al. Ann Intern Med 1998;128:

11 Race VTE incidence (per 100,000 population) African Americans 141 Caucasians 104 Hispanics 55 Asians/Pacific Islanders 21 Keenan CR and White RH. Curr Opin Pulm Med. 2007

12 Keenan CR and White RH. Curr Opin Pulm Med. 2007

13 Am J Cardiol Jun 1;85(11):

14 Pulmonary thromboembolism in Asians/Pacific Islanders in the United States: analysis of data from the National Hospital Discharge Survey and the United States Bureau of the Census. Stein PD, Kayali F, Olson RE, Milford CE. Am J Med Apr 1;116(7):

15 Population studies summarised Reported VTE incidence highest in European studies Comparisons between ethnic groups within population studies in the West show lower rates of symptomatic VTE among Asians Limited published population-based studies in Asia reported incidence of symptomatic VTE appears lower than reported Western incidence but is not insignificant

16 Post mortem studies

17 Pulmonary embolism is not uncommon results and implications of a five year study of 116 necropsies Lau G. Ann Acad Med Singapore. 1995;24: ,044 coroner s autopsies in Singapore Prevalence of 1.05%

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19 Clinicopathological pattern of pulmonary thromboembolism in Chinese autopsy patients: comparison with Caucasian series. Chau KY, Yuen ST, Wong MP. Pathology Aug;29(3): Significant pulmonary thromboembolism 4.7% Most were asymptomatic DVT more common in calf veins

20 Overall incidence in adult medical patients %

21 Post-mortem studies summarised Comparative incidence of autopsyconfirmed deaths due to PE appears comparable between Asians and Caucasians in more recent studies Post-mortem incidence may vary considerably, depending on the patient pool and practices of the study site

22 Selected high-risk patient groups studies in Singapore and Malaysia Year Author Screening Method Population N Incidence 1989 Mitra Venography Proximal femur % fractures 1993 Kum CK Various Colorectal % (symptomatic) malignancies 1996 Dhillon KS Venography THR, TKR, femur % (20% proximal DVT) fractures 2000 Ruban Duplex scan TKR % (63.4% of total were distal DVT) 2004 Lim WW Doppler US Orthopaedic fractures % (at 5-7 POD, proximal DVT) 2006 De Silva Doppler US Acute stroke NA 30% (at 1 week) 45% (at 1 month) 2007 Tan SS Doppler US Acute stroke % (at 1 week) 4.8% (at 1 month

23 VTE Epidemiology Studies in Hong Kong Year Author Screening Population N Incidence Method 1979 Mok CK Venography Proximal femur fractures % 2002 Liu HS Various Hospitalised patients NA 16.6 per 100, Chan LY Various Gynaecologic surgery % (90 % distal) 2003 Ko PS Doppler THR and TKR % at 1 week Ultrasound 2004 Cheuk BL Various Public healthcare database NA DVT 17.1 per 100,000 PE 3.9 per 100, Chan LY Doppler LSCS patients 93 O% at 3-7 days Ultrasound 2006 Leung V Doppler Ultrasound Hospitalised medical patients, with clinical symptoms or raised d- dimers %

24 Deep vein thrombosis after total knee arthroplasty. Wang CJ et al Selected At-risk Groups Orthopaedic Surgery J Formos Med Assoc Nov;99(11): Overall incidence of DVT 63.6% (95.6% distal DVT)

25 Selected high-risk Groups Orthopaedic Surgery J Thromb Haemost 2005; 3:

26 J Thromb Haemost 2005; 3:

27 J Thromb Haemost 2005; 3:

28 J Thromb Haemost 2005; 3:

29 Adjudicated symptomatic VTE or sudden death at 1 month 1.5% J Thromb Haemost 2005; 3:

30 Br J Anaesth Jun;78(6):660-5 Symptomatic VTE in placebo group - 1.2% Total VTE in placebo group 37.3% Study method venography 43% proximal

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32 DVT detected in 45% of patients between days of ischemic stroke by Doppler ultrasound

33 Selected high-risk population summarised When subjected to a major provoking factor, the incidence of VTE in Asians and Caucasians are similar Asians tend to have more distal DVTs than proximal DVTs

34 Epidemiologic studies in hospitalised patients

35 VTE Trends among hospitalized patients in Singapore Study period Total admissions 48, , ,217 Acute DVT Acute DVT rate per 10,000 admissions (%) 7.9 (0.079%) 15.8 (0.158%) 45.3 (0.453%) 1. Kueh YK et al Ann Acad Med Singapore Lee LH et al Ann Acad Med Singapore Ng HJ and Lee LH Thromb Haemost 2008

36 VTE Trends among hospitalized patients in Singapore Discipline DVT rates (per 100 admissions) p-value Orthopaedic < Medicine <0.001 Other surgical disciplines Gynaecology Obstetrics

37 VTE Trends among hospitalized patients in Singapore DVT per 10,000 admissions

38 Hospitalized patient incidence in Singapore summarized Increasing incidence of VTE cases among hospitalized patients Marked increase in VTE rates likely accounted for by changes in clinicians attitudes towards VTE and possibly changes in disease patterns VTE burden among hospitalised patients is substantial

39 VTE in the East Conclusions, Future Research Questions In the general population, why are Asians less likely to clot? Why are clots in Asians more confined to distal rather than proximal veins? Can Asians be better risk stratified to guide prophylaxis strategies? What are the reasons for the increase in VTE incidence among hospitalised patients over the years?

40 Thank you