Pulmonary embolism risk factors
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Editor(s)-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. Any risk factor for DVT also increases the risk of pulmonary embolism, and 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. In these chapters on 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. 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.[1]
Risk Factors
Shown below is a list of predisposing factors to VTE.[2][3] 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 |
❑ Advanced age ❑ Laparoscopic surgery |
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.
- Smoking:[4] Smoking significantly increases the risk of DVT, particularly among women who are taking oral contraceptive pills as well as among obese people.
- Use of oral contraceptives[7]
- Hyperhomocysteinemia:[8] Hyperhomocysteinemia can be reduced with vitamin B supplementation.
Non-Modifiable Risk Factors
- Advanced age
- Heart failure
- 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
Other Possible Risk Factors
Other possible factors associated with VTE include:
- Nutrition low in fish[9]
- Psychological stress[9]
- Cardiovascular risk factors such as diabetes and hypercholesterolemia[9]
- Acute medical illness
- Drug abuse (intravenous [IV] drugs)
- Hemolytic anemias
- Dyslipidemia
- Inflammatory bowel disease
- Phenothiazines
- Thrombocytosis
- Varicose veins
- Venography
- Warfarin (first few days of therapy)
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:[10]
- 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[11]
- Anticardiolipin antibody level above the 95th percentile. [12].
- Factor V Leiden
- RR 2.7, found in 40% of patients with idiopathic DVT.
- 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 about 10 times.
- Lupus anticoagulant was found in 8.5% of patients with idiopathic DVT.
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 4.0 4.1 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 9.0 9.1 9.2 Konofal E, Lecendreux M, Cortese S (2010). "Sleep and ADHD". Sleep Med. 11 (7): 652–8. doi:10.1016/j.sleep.2010.02.012. PMID 20620109.
- ↑ 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.
- ↑ 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.
- ↑ 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.