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| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Pulmonary embolism}}
{{Pulmonary embolism}}
{{PE editors}}
{{CMG}} {{ATI}}; {{AE}} {{Rim}}


==Overview==
==Overview==
The most common sources of pulmonary emboli are proximal leg [[deep venous thrombosis|deep venous thromboses]] (DVTs) or pelvic vein thromboses. Any risk factor for DVT also increases the risk of pulmonary embolism, therefore DVT and PE are considered to be a continuum termed [[venous thromboembolism]] ([[VTE]]). Approximately 15% of patients with a DVT will develop a pulmonary embolus.
The most common sources of pulmonary embolism (PE) are [[proximal]] leg [[deep venous thrombosis|deep venous thromboses]] ([[DVT]]s) or [[pelvic vein]] [[thromboses]]; therefore, any risk factor for [[DVT]] also increases the risk of PE.  Approximately 15% of patients with a [[DVT]] will develop a PE.  In these chapters on [[venous thromboembolism]] (VTE), the word risk factors refers to those epidemiologic and [[genetic]] variables that expose someone to a higher risk of developing [[venous thrombosis]].  The word triggers refer to those factors in the patients immediate history or environment that may have lead to the occurrence of the [[venous thrombosis]].  The risk factors for [[VTE]] are a constellation of predisposing conditions which stem from the three principles of [[Virchow's triad]]: stasis of the blood flow, damage to the vascular [[endothelial cell]]s, and [[hypercoagulability]]. Approximately 5 to 8% of the U.S. population has one of several [[genetic]] risk factors, also known as [[inherited]] [[thrombophilia]]s in which a [[genetic]] defect can be identified that increases the risk for [[thrombosis]].<ref>[http://www.cdc.gov/ncbddd/dvt/data.html CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein]</ref><ref name="pmid20331949">{{cite journal| author=Beckman MG, Hooper WC, Critchley SE, Ortel TL| title=Venous thromboembolism: a public health concern. | journal=Am J Prev Med | year= 2010 | volume= 38 | issue= 4 Suppl | pages= S495-501 | pmid=20331949 | doi=10.1016/j.amepre.2009.12.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20331949  }} </ref> The risk factors for VTE can be classified as temporary, modifiable and non-modifiable.  It is suggested that [[venous thrombosis]] also shares risk factors with [[arterial thrombosis]], such as [[obesity]], [[hypertension]], [[smoking]], and [[diabetes mellitus]].<ref name="pmid20620709">{{cite journal| author=Goldhaber SZ| title=Risk factors for venous thromboembolism. | journal=J Am Coll Cardiol | year= 2010 | volume= 56 | issue= 1 | pages= 1-7 | pmid=20620709 | doi=10.1016/j.jacc.2010.01.057 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620709  }} </ref>


==Risk Factors==
==Risk Factors==
The development of thrombosis is classically due to a group of causes referred to as [[Virchow's triad]]. Virchow's triad includes alterations in [[blood flow]], factors in the vessel wall, and factors affecting the properties of the [[blood]]. It is common for more than one risk factor to be present.


[[File:VTE Pathophysisology Virchow's triad.JPG|300x400px]]
Shown below is a list of predisposing factors for [[VTE]].<ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref> The risk factors are classified as moderate or weak depending on how strongly they predispose for a VTE.


'''Figure''': Virchow's triad encompasses three broad categories of factors that are thought to contribute to venous thrombosis.
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center |'''Moderate risk factors''' || style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center |'''Weak risk factors'''
|-
|  style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |❑ [[Chemotherapy]]<br>
❑ [[Chronic heart failure]]<br>
❑ [[Respiratory failure]]<br>
❑ [[Hormone replacement therapy]]<br>
❑ [[Cancer]]<br>
❑ [[Oral contraceptive pills]] <br>
❑ [[Stroke]] <br>
❑ [[Pregnancy]] <br>
❑ [[Postpartum]] <br>
❑ Prior history of [[VTE]] <br>
❑ [[Thrombophilia]] <br>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |❑ Advanced [[age]] <br>
❑ [[Laparoscopic surgery]] <br>
❑ Prepartum <br>
❑ [[Obesity]] <br>
❑ [[Varicose veins]]
|}


Medical conditions included in the triad are:
The risk factors of VTE can be further classified into modifiable, non-modifiable and temporary.
* '''''Alterations in blood flow''''': Alterations in blood flow can be caused by some of the following conditions:
**[[Pregnancy]] which is a [[pro-coagulant]]
**[[Obesity]] which is also a [[pro-coagulant]]
**Being immobile for long periods of time. The immobilizations include:
***After a [[surgery]]
***[[Physical trauma|Injury]]
***[[Economy class syndrome|Long-distance air travel]]
* '''''Factors in the vessel wall''''':
** This is of limited direct relevance in VTE
* '''''Factors affecting the properties of the blood''''' (pro-coagulant state):
** [[Estrogen]]-containing [[hormonal contraception]]
** Genetic [[thrombophilias]] which include:
***[[Factor V Leiden]]
***[[Prothrombin]] mutation G20210A
***[[Protein C deficiency]]
***[[protein S deficiency]]
***[[Antithrombin]] deficiency
***[[Hyperhomocysteinemia]]
***[[Plasminogen]]/[[Fibrinolysis]] disorders
** Acquired thrombophilias which include:
***[[Antiphospholipid syndrome]]
***[[Nephrotic syndrome]]
***[[Paroxysmal nocturnal hemoglobinuria]]


'''Risk Factors Identified in the PIOPED Study'''<ref name="pmid8523135">{{cite journal| author=Worsley DF, Alavi A| title=Comprehensive analysis of the results of the PIOPED Study. Prospective Investigation of Pulmonary Embolism Diagnosis Study. | journal=J Nucl Med | year= 1995 | volume= 36 | issue= 12 | pages= 2380-7 | pmid=8523135 | doi= | pmc= | url= }} </ref>
===Modifiable Risk Factors===
Modifiable risk factors are reversible based upon lifestyle/behavior modification.
* [[Obesity]]: [[Obesity]] is defined as a [[body-mass index]] (BMI) above 30 kg/m2.<ref name="pmid20404252">{{cite journal| author=Holst AG, Jensen G, Prescott E| title=Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study. | journal=Circulation | year= 2010 | volume= 121 | issue= 17 | pages= 1896-903 | pmid=20404252 | doi=10.1161/CIRCULATIONAHA.109.921460 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20404252  }} </ref> <ref name="pmid21352080">{{cite journal| author=Vayá A, Martínez-Triguero ML, España F, Todolí JA, Bonet E, Corella D| title=The metabolic syndrome and its individual components: its association with venous thromboembolism in a Mediterranean population. | journal=Metab Syndr Relat Disord | year= 2011 | volume= 9 | issue= 3 | pages= 197-201 | pmid=21352080 | doi=10.1089/met.2010.0117 | pmc= | url= }} </ref> <ref name="pmid18695082">{{cite journal| author=Eichinger S, Hron G, Bialonczyk C, Hirschl M, Minar E, Wagner O et al.| title=Overweight, obesity, and the risk of recurrent venous thromboembolism. | journal=Arch Intern Med | year= 2008 | volume= 168 | issue= 15 | pages= 1678-83 | pmid=18695082 | doi=10.1001/archinte.168.15.1678 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18695082  }} </ref>


Independent risk factors identified in ''prospective investigation of pulmonary embolism diagnosis'' (PIOPED) include:
* [[Smoking]]:<ref name="pmid20404252">{{cite journal| author=Holst AG, Jensen G, Prescott E| title=Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study. | journal=Circulation | year= 2010 | volume= 121 | issue= 17 | pages= 1896-903 | pmid=20404252 | doi=10.1161/CIRCULATIONAHA.109.921460 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20404252  }} </ref> [[Smoking]] significantly increases the risk of [[DVT]], particularly among women who are taking [[oral contraceptive pills]] as well as among [[obese]] people.
* Immobilization, [[paresis]], or [[paralysis]]
 
**Travel of 4 hours or more in the past month would be considered an immobilization.
* Use of [[oral contraceptives]]<ref name="pmid17726684">{{cite journal| author=Pomp ER, Rosendaal FR, Doggen CJ| title=Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use. | journal=Am J Hematol | year= 2008 | volume= 83 | issue= 2 | pages= 97-102 | pmid=17726684 | doi=10.1002/ajh.21059 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17726684  }} </ref>
* Surgery within the last 3 months or having suffered a [[stroke]].
 
**These may have a connection to immobilization.
* [[Hyperhomocysteinemia]]:<ref name="pmid8592549">{{cite journal| author=den Heijer M, Koster T, Blom HJ, Bos GM, Briet E, Reitsma PH et al.| title=Hyperhomocysteinemia as a risk factor for deep-vein thrombosis. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 12 | pages= 759-62 | pmid=8592549 | doi=10.1056/NEJM199603213341203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8592549  }} </ref> [[Hyperhomocysteinemia]] can be reduced with [[vitamin B]] supplementation.
* History of [[venous thromboembolism]].
 
* Malignancies, especially [[lung cancer]].
===Non-Modifiable Risk Factors===
**Malignancies have been found in up to 17% of patients with an idiopathic [[deep vein thrombosis]] (DVT).
* Advanced age
* Current or past history of [[thrombophlebitis]].
* [[Trauma]] to the lower extremities or pelvis during the past 3 months.
* [[Smoking]]
* [[Central venous instrumentation]] within the past 3 months
* Prior pulmonary embolism
* [[Heart failure]]
* [[Heart failure]]
* [[Chronic obstructive pulmonary disease]]
* [[Thrombophilia]] or [[hypercoagulable state]]
** [[Factor V Leiden]]
** [[Prothrombin G20210A mutation]]
** [[Protein C deficiency]]
** [[Protein S deficiency]]
** [[Antithrombin deficiency]]
** [[Activated protein C resistance]]
** [[Antithrombin III deficiency]]
** [[Factor VIII]] [[mutation]]
** [[Antiphospholipid syndrome]]
** [[Heparin induced thrombocytopenia]]
** [[Nephrotic syndrome]]
** [[Paroxysmal nocturnal hemoglobinuria]]
* [[Polycythemia vera]]
 
===Temporary Risk Factors===
* [[Pregnancy]] and the peri-partum period
* Active [[cancer]]
* [[Central venous catheter]]


'''Risk Factors from the Nurses' Health Study'''<ref name="pmid9039882">{{cite journal| author=Goldhaber SZ, Grodstein F, Stampfer MJ, Manson JE, Colditz GA, Speizer FE et al.| title=A prospective study of risk factors for pulmonary embolism in women. | journal=JAMA | year= 1997 | volume= 277 | issue= 8 | pages= 642-5 | pmid=9039882 | doi= | pmc= | url= }} </ref>
===Other Possible Risk Factors===
* [[Obesity]]: RR (relative risk) 2.9
Other possible factors associated with [[VTE]] include:
* [[Nutrition]] low in fish, fruits, and vegetables<ref name="pmid17179018">{{cite journal| author=Steffen LM, Folsom AR, Cushman M, Jacobs DR, Rosamond WD| title=Greater fish, fruit, and vegetable intakes are related to lower incidence of [[venous thromboembolism]]: the Longitudinal Investigation of Thromboembolism Etiology. | journal=Circulation | year= 2007 | volume= 115 | issue= 2 | pages= 188-95 | pmid=17179018 | doi=10.1161/CIRCULATIONAHA.106.641688 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17179018  }} </ref>
* [[Psychological stress]]<ref name="pmid18045241">{{cite journal| author=Rosengren A, Fredén M, Hansson PO, Wilhelmsen L, Wedel H, Eriksson H| title=Psychosocial factors and [[venous thromboembolism]]: a long-term follow-up study of Swedish men. | journal=J Thromb Haemost | year= 2008 | volume= 6 | issue= 4 | pages= 558-64 | pmid=18045241 | doi=10.1111/j.1538-7836.2007.02857.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18045241  }} </ref>
* [[Cardiovascular]] risk factors such as [[diabetes]] and [[hypercholesterolemia]]<ref name="pmid18086925">{{cite journal| author=Ageno W, Becattini C, Brighton T, Selby R, Kamphuisen PW| title=Cardiovascular risk factors and venous thromboembolism: a meta-analysis. | journal=Circulation | year= 2008 | volume= 117 | issue= 1 | pages= 93-102 | pmid=18086925 | doi=10.1161/CIRCULATIONAHA.107.709204 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18086925  }} </ref>
* [[Acute]] medical illness
* [[Drug abuse]] ([[intravenous]] drugs)<ref name="pmid11260066">{{cite journal| author=McColl MD, Tait RC, Greer IA, Walker ID| title=Injecting drug use is a risk factor for [[deep vein thrombosis]] in women in Glasgow. | journal=Br J Haematol | year= 2001 | volume= 112 | issue= 3 | pages= 641-3 | pmid=11260066 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11260066  }} </ref>
*[[Sickle cell disease]]<ref name="pmid23582935">{{cite journal| author=Naik RP, Streiff MB, Haywood C, Nelson JA, Lanzkron S| title=Venous thromboembolism in adults with sickle cell disease: a serious and under-recognized complication. | journal=Am J Med | year= 2013 | volume= 126 | issue= 5 | pages= 443-9 | pmid=23582935 | doi=10.1016/j.amjmed.2012.12.016 | pmc=PMC3627211 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23582935  }} </ref>
*[[Inflammatory bowel disease]]<ref name="pmid23629820">{{cite journal| author=Koutroumpakis EI, Tsiolakidou G, Koutroubakis IE| title=Risk of venous thromboembolism in patients with inflammatory bowel disease. | journal=Semin Thromb Hemost | year= 2013 | volume= 39 | issue= 5 | pages= 461-8 | pmid=23629820 | doi=10.1055/s-0033-1343886 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23629820  }} </ref>
*[[Antipsychotic drugs]]<ref name="pmid22731933">{{cite journal| author=Jönsson AK, Spigset O, Hägg S| title=Venous thromboembolism in recipients of antipsychotics: incidence, mechanisms and management. | journal=CNS Drugs | year= 2012 | volume= 26 | issue= 8 | pages= 649-62 | pmid=22731933 | doi=10.2165/11633920-000000000-00000 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22731933  }} </ref>
*[[Thrombocytosis]]<ref name="pmid22784217">{{cite journal| author=Ho KM, Yip CB, Duff O| title=Reactive thrombocytosis and risk of subsequent venous thromboembolism: a cohort study. | journal=J Thromb Haemost | year= 2012 | volume= 10 | issue= 9 | pages= 1768-74 | pmid=22784217 | doi=10.1111/j.1538-7836.2012.04846.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22784217  }} </ref>
*[[Varicose veins]]<ref name="pmid22915533">{{cite journal| author=Müller-Bühl U, Leutgeb R, Engeser P, Achankeng EN, Szecsenyi J, Laux G| title=Varicose veins are a risk factor for deep venous thrombosis in general practice patients. | journal=Vasa | year= 2012 | volume= 41 | issue= 5 | pages= 360-5 | pmid=22915533 | doi=10.1024/0301-1526/a000222 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22915533  }} </ref><ref name="pmid24112869">{{cite journal| author=Königsbrügge O, Lötsch F, Reitter EM, Brodowicz T, Zielinski C, Pabinger I et al.| title=Presence of varicose veins in cancer patients increases the risk for occurrence of venous thromboembolism. | journal=J Thromb Haemost | year= 2013 | volume= 11 | issue= 11 | pages= 1993-2000 | pmid=24112869 | doi=10.1111/jth.12408 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24112869  }} </ref>
 
== Risk Factors from the Nurse's Health Study==
The [[Nurse's Health Study]] (NHS) investigated the risk factors for [[PE]] among 112,822 female subjects.  The factors that are associated with increased [[PE]] in women are [[obesity]], [[smoking]], and [[hypertension]].  According to this study the [[relative risk]] (RR) and [[confidence interval]] (CI) for the occurrence of [[idiopathic]] [[VTE]] for each of the following factors are:<ref name="pmid9039882">{{cite journal| author=Goldhaber SZ, Grodstein F, Stampfer MJ, Manson JE, Colditz GA, Speizer FE et al.| title=A prospective study of risk factors for pulmonary embolism in women. | journal=JAMA | year= 1997 | volume= 277 | issue= 8 | pages= 642-5 | pmid=9039882 | doi= | pmc= | url= }} </ref>  
* [[Obesity]]: RR 2.9 (95% CI, 1.5-5.4)
* [[Smoking]]:
* [[Smoking]]:
**25 – 34 cigarettes per day (RR 1.9)
**25 – 34 cigarettes per day: RR 1.9 (95% CI, 0.9-3.7)  
**More than 35 cigarettes per day (RR 3.3)
**More than 35 cigarettes per day: RR 3.3 (95% CI, 1.7-6.5)
* [[Hypertension]]: RR 1.9
* [[Hypertension]]: RR 1.9 (95% CI, 1.2-2.8)
* [[Oral contraceptives]]: RR approximately 2 – 3
* [[Hypercholesterolemia]]: 1.1 (95% CI, 0.62-1.8)
* [[Hormone replacement therapy]]: RR approximately 2
* [[Diabetes]]: RR 0.7 (95% CI, 0.3-1.9)
In addition, [[surgery]], [[trauma]], [[cancer]] and immobilization are associated with provoked PE.


'''Risk Factors from the Physician's Health Study'''<ref name="pmid7877648">{{cite journal| author=Ridker PM, Hennekens CH, Lindpaintner K, Stampfer MJ, Eisenberg PR, Miletich JP| title=Mutation in the gene coding for coagulation factor V and the risk of myocardial infarction, stroke, and venous thrombosis in apparently healthy men. | journal=N Engl J Med | year= 1995 | volume= 332 | issue= 14 | pages= 912-7 | pmid=7877648 | doi=10.1056/NEJM199504063321403 | pmc= | url= }} </ref>
== Risk Factors from the Physician's Health Study==
* [[Anticardiolipin antibody]] level above the 95th percentile. <ref name="pmid1443986">{{cite journal| author=Ginsburg KS, Liang MH, Newcomer L, Goldhaber SZ, Schur PH, Hennekens CH et al.| title=Anticardiolipin antibodies and the risk for ischemic stroke and venous thrombosis. | journal=Ann Intern Med | year= 1992 | volume= 117 | issue= 12 | pages= 997-1002 | pmid=1443986 | doi= | pmc= | url= }} </ref>.
The following factors have been associated with elevated risk of [[VTE]] among subjects in the Physicians Health Study.  The [[relative risk]] for the occurrence of [[VTE]] among patients who have these factors compared to those who don't is provided below.
* [[Factor V Leiden]]
* [[Anticardiolipin antibody]] level above the 95th percentile (RR: 5.3; 95% CI, 1.55 to 18.3; P = 0.01)<ref name="pmid1443986">{{cite journal| author=Ginsburg KS, Liang MH, Newcomer L, Goldhaber SZ, Schur PH, Hennekens CH et al.| title=Anticardiolipin antibodies and the risk for ischemic stroke and venous thrombosis. | journal=Ann Intern Med | year= 1992 | volume= 117 | issue= 12 | pages= 997-1002 | pmid=1443986 | doi= | pmc= | url= }} </ref>
**RR 2.7, found in 40% of patients with idiopathic DVT.
* [[Factor V Leiden]] (RR: 2.7; 95% CI, 1.3 to 5.6; P = 0.008)<ref name="pmid7877648">{{cite journal| author=Ridker PM, Hennekens CH, Lindpaintner K, Stampfer MJ, Eisenberg PR, Miletich JP| title=Mutation in the gene coding for coagulation factor V and the risk of myocardial infarction, stroke, and venous thrombosis in apparently healthy men. | journal=N Engl J Med | year= 1995 | volume= 332 | issue= 14 | pages= 912-7 | pmid=7877648 | doi=10.1056/NEJM199504063321403 | pmc= | url= }} </ref>
* Use of oral contraceptives by a person with the Factor V mutation increases the risk of venous thromboembolism by about 35 times.
* Hyperhomocysteinemia increases the risk of a DVT by a factor of 3.
* Hyperhomocysteinemia in association with Factor V increases the risk of a DVT by 10 fold.
* [[Lupus anticoagulant]] was found in 8.5% of patients with idiopathic DVT.
 
'''Other risk factors include:'''
*[[Acute medical illness]]
*Drug abuse (intravenous [IV] drugs)
*[[Hemolytic anemias]]
*[[Homocystinuria]]
*[[Hypercoagulable states]], which can be caused by hereditary factors.
*[[Hyperlipidemias]]
*[[Inflammatory bowel disease]]
*[[Phenothiazines]]
*[[Pregnancy]]
*[[Thrombocytosis]]
*[[Varicose veins]]
*[[Venography]]
*[[Venous pacemakers]]
*[[Venous stasis]]
*[[Warfarin]] (first few days of therapy)


==References==
==References==
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Latest revision as of 23:53, 29 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

The most common sources of pulmonary embolism (PE) are proximal leg deep venous thromboses (DVTs) or pelvic vein thromboses; therefore, any risk factor for DVT also increases the risk of PE. Approximately 15% of patients with a DVT will develop a PE. In these chapters on venous thromboembolism (VTE), the word risk factors refers to those epidemiologic and genetic variables that expose someone to a higher risk of developing venous thrombosis. The word triggers refer to those factors in the patients immediate history or environment that may have lead to the occurrence of the venous thrombosis. The risk factors for VTE are a constellation of predisposing conditions which stem from the three principles of Virchow's triad: stasis of the blood flow, damage to the vascular endothelial cells, and hypercoagulability. Approximately 5 to 8% of the U.S. population has one of several genetic risk factors, also known as inherited thrombophilias in which a genetic defect can be identified that increases the risk for thrombosis.[1][2] The risk factors for VTE can be classified as temporary, modifiable and non-modifiable. It is suggested that venous thrombosis also shares risk factors with arterial thrombosis, such as obesity, hypertension, smoking, and diabetes mellitus.[3]

Risk Factors

Shown below is a list of predisposing factors for VTE.[4][5] The risk factors are classified as moderate or weak depending on how strongly they predispose for a VTE.

Moderate risk factors Weak risk factors
❑ Chemotherapy

❑ Chronic heart failure
❑ Respiratory failure
❑ Hormone replacement therapy
❑ Cancer
❑ Oral contraceptive pills
❑ Stroke
❑ Pregnancy
❑ Postpartum
❑ Prior history of VTE
❑ Thrombophilia

❑ Advanced age

❑ Laparoscopic surgery
❑ Prepartum
❑ Obesity
❑ Varicose veins

The risk factors of VTE can be further classified into modifiable, non-modifiable and temporary.

Modifiable Risk Factors

Modifiable risk factors are reversible based upon lifestyle/behavior modification.

Non-Modifiable Risk Factors

Temporary Risk Factors

Other Possible Risk Factors

Other possible factors associated with VTE include:

Risk Factors from the Nurse's Health Study

The Nurse's Health Study (NHS) investigated the risk factors for PE among 112,822 female subjects. The factors that are associated with increased PE in women are obesity, smoking, and hypertension. According to this study the relative risk (RR) and confidence interval (CI) for the occurrence of idiopathic VTE for each of the following factors are:[21]

  • Obesity: RR 2.9 (95% CI, 1.5-5.4)
  • Smoking:
    • 25 – 34 cigarettes per day: RR 1.9 (95% CI, 0.9-3.7)
    • More than 35 cigarettes per day: RR 3.3 (95% CI, 1.7-6.5)
  • Hypertension: RR 1.9 (95% CI, 1.2-2.8)
  • Hypercholesterolemia: 1.1 (95% CI, 0.62-1.8)
  • Diabetes: RR 0.7 (95% CI, 0.3-1.9)

In addition, surgery, trauma, cancer and immobilization are associated with provoked PE.

Risk Factors from the Physician's Health Study

The following factors have been associated with elevated risk of VTE among subjects in the Physicians Health Study. The relative risk for the occurrence of VTE among patients who have these factors compared to those who don't is provided below.

References

  1. ↑ CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein
  2. ↑ Beckman MG, Hooper WC, Critchley SE, Ortel TL (2010). "Venous thromboembolism: a public health concern". Am J Prev Med. 38 (4 Suppl): S495–501. doi:10.1016/j.amepre.2009.12.017. PMID 20331949.
  3. ↑ Goldhaber SZ (2010). "Risk factors for venous thromboembolism". J Am Coll Cardiol. 56 (1): 1–7. doi:10.1016/j.jacc.2010.01.057. PMID 20620709.
  4. ↑ Anderson FA, Spencer FA (2003). "Risk factors for venous thromboembolism". Circulation. 107 (23 Suppl 1): I9–16. doi:10.1161/01.CIR.0000078469.07362.E6. PMID 12814980.
  5. ↑ Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
  6. ↑ 6.0 6.1 Holst AG, Jensen G, Prescott E (2010). "Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study". Circulation. 121 (17): 1896–903. doi:10.1161/CIRCULATIONAHA.109.921460. PMID 20404252.
  7. ↑ Vayá A, Martínez-Triguero ML, España F, Todolí JA, Bonet E, Corella D (2011). "The metabolic syndrome and its individual components: its association with venous thromboembolism in a Mediterranean population". Metab Syndr Relat Disord. 9 (3): 197–201. doi:10.1089/met.2010.0117. PMID 21352080.
  8. ↑ Eichinger S, Hron G, Bialonczyk C, Hirschl M, Minar E, Wagner O; et al. (2008). "Overweight, obesity, and the risk of recurrent venous thromboembolism". Arch Intern Med. 168 (15): 1678–83. doi:10.1001/archinte.168.15.1678. PMID 18695082.
  9. ↑ Pomp ER, Rosendaal FR, Doggen CJ (2008). "Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use". Am J Hematol. 83 (2): 97–102. doi:10.1002/ajh.21059. PMID 17726684.
  10. ↑ den Heijer M, Koster T, Blom HJ, Bos GM, Briet E, Reitsma PH; et al. (1996). "Hyperhomocysteinemia as a risk factor for deep-vein thrombosis". N Engl J Med. 334 (12): 759–62. doi:10.1056/NEJM199603213341203. PMID 8592549.
  11. ↑ Steffen LM, Folsom AR, Cushman M, Jacobs DR, Rosamond WD (2007). "Greater fish, fruit, and vegetable intakes are related to lower incidence of [[venous thromboembolism]]: the Longitudinal Investigation of Thromboembolism Etiology". Circulation. 115 (2): 188–95. doi:10.1161/CIRCULATIONAHA.106.641688. PMID 17179018. URL–wikilink conflict (help)
  12. ↑ Rosengren A, Fredén M, Hansson PO, Wilhelmsen L, Wedel H, Eriksson H (2008). "Psychosocial factors and [[venous thromboembolism]]: a long-term follow-up study of Swedish men". J Thromb Haemost. 6 (4): 558–64. doi:10.1111/j.1538-7836.2007.02857.x. PMID 18045241. URL–wikilink conflict (help)
  13. ↑ Ageno W, Becattini C, Brighton T, Selby R, Kamphuisen PW (2008). "Cardiovascular risk factors and venous thromboembolism: a meta-analysis". Circulation. 117 (1): 93–102. doi:10.1161/CIRCULATIONAHA.107.709204. PMID 18086925.
  14. ↑ McColl MD, Tait RC, Greer IA, Walker ID (2001). "Injecting drug use is a risk factor for [[deep vein thrombosis]] in women in Glasgow". Br J Haematol. 112 (3): 641–3. PMID 11260066. URL–wikilink conflict (help)
  15. ↑ Naik RP, Streiff MB, Haywood C, Nelson JA, Lanzkron S (2013). "Venous thromboembolism in adults with sickle cell disease: a serious and under-recognized complication". Am J Med. 126 (5): 443–9. doi:10.1016/j.amjmed.2012.12.016. PMC 3627211. PMID 23582935.
  16. ↑ Koutroumpakis EI, Tsiolakidou G, Koutroubakis IE (2013). "Risk of venous thromboembolism in patients with inflammatory bowel disease". Semin Thromb Hemost. 39 (5): 461–8. doi:10.1055/s-0033-1343886. PMID 23629820.
  17. ↑ Jönsson AK, Spigset O, Hägg S (2012). "Venous thromboembolism in recipients of antipsychotics: incidence, mechanisms and management". CNS Drugs. 26 (8): 649–62. doi:10.2165/11633920-000000000-00000. PMID 22731933.
  18. ↑ Ho KM, Yip CB, Duff O (2012). "Reactive thrombocytosis and risk of subsequent venous thromboembolism: a cohort study". J Thromb Haemost. 10 (9): 1768–74. doi:10.1111/j.1538-7836.2012.04846.x. PMID 22784217.
  19. ↑ Müller-Bühl U, Leutgeb R, Engeser P, Achankeng EN, Szecsenyi J, Laux G (2012). "Varicose veins are a risk factor for deep venous thrombosis in general practice patients". Vasa. 41 (5): 360–5. doi:10.1024/0301-1526/a000222. PMID 22915533.
  20. ↑ Königsbrügge O, Lötsch F, Reitter EM, Brodowicz T, Zielinski C, Pabinger I; et al. (2013). "Presence of varicose veins in cancer patients increases the risk for occurrence of venous thromboembolism". J Thromb Haemost. 11 (11): 1993–2000. doi:10.1111/jth.12408. PMID 24112869.
  21. ↑ Goldhaber SZ, Grodstein F, Stampfer MJ, Manson JE, Colditz GA, Speizer FE; et al. (1997). "A prospective study of risk factors for pulmonary embolism in women". JAMA. 277 (8): 642–5. PMID 9039882.
  22. ↑ Ginsburg KS, Liang MH, Newcomer L, Goldhaber SZ, Schur PH, Hennekens CH; et al. (1992). "Anticardiolipin antibodies and the risk for ischemic stroke and venous thrombosis". Ann Intern Med. 117 (12): 997–1002. PMID 1443986.
  23. ↑ Ridker PM, Hennekens CH, Lindpaintner K, Stampfer MJ, Eisenberg PR, Miletich JP (1995). "Mutation in the gene coding for coagulation factor V and the risk of myocardial infarction, stroke, and venous thrombosis in apparently healthy men". N Engl J Med. 332 (14): 912–7. doi:10.1056/NEJM199504063321403. PMID 7877648.

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