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The Epidemiology of Venous Thromboembolism: Implications for Prevention and Management

Surgeon General's Workshop on Deep Vein Thrombosis

 

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 SLIDE 1: The Epidemiology of Venous Thromboembolism: Implications for Prevention and Management

John A. Heit, MD Professor of Medicine Director, Coagulation Laboratories & Coagulation Clinic Consultant, Cardiovascular Diseases and Hematology Research Mayo Clinic College of Medicine Rochester, MN

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 SLIDE 2:

Photograph demonstrating DVT.

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 SLIDE 3: Annual Incidence of VTE in Olmsted County, MN: 1966–1995

Age- and Sex-Adjusted Incidence per 100,000*

 Annual incidence/ 100,00095% CI
Overall126121.2, 130.8

Adjusted to the 1990 US white population.
Silverstein, et al. Arch Inter Med 1998; 158:585-93. Copyright © 1998, American Medical Association. All right reserved. Heit, et al. J Thromb Haemost 2005

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 SLIDE 4: Annual Incidence of VTE in Olmsted County, MN: 1966-1995 By Age and Gender

Line chart showing Annual Incidence of VTE in Olmsted County, MN: 1966-1995 By Age and Gender. Recent studies from several investigators now show that among a group of 100,000 persons observed for one year, about 120 will develop a first-lifetime venous thromboembolism. Said a different way, the incidence of venous thromboembolism is about 120 per 100,000 person-years.1,2,3 However, the incidence varies markedly depending on an individual's age and sex. For example, the incidence among persons that are 14 years of age or younger is less than 1 per 100,000 person-years. The incidence begins to increase dramatically around age 50, such for 85 year olds or older the incidence approaches 1000 per 100,000.1 The incidence is higher among women during childbearing years, while the incidence is higher among men after age 50.

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 SLIDE 5: VTE Incidence by Continent of Origin or Ethnicity

Continent of Origin or EthnicityIncidence (±SD) per 100,000
African-American*138 ± 6.5
White*103 ± 2.1
Hispanic*61 ± 2.8
Asian-American/Pacific Islander*29 ± 2.4
Native-American†33

*White RH, et al. Thromb Haemost 2005
†Hooper WC, et al. Thromb Res 2003.

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 SLIDE 6: Annual Number of Incident VTE in U.S.

  • White Americans 275,000*
  • African-Americans 29,000**

Using the age- and sex-adjusted 1991-1998 incidence, adjusted to year 2000 U.S. White* and African-American** populations, respectively.

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 SLIDE 7: Cumulative Recurrence of VTE

Line chart showing Cumulative Recurrence of VTE. About 30% of venous thromboembolism patients will develop a second episode within the next 10 years. The risk of recurrence is greatest within the first two years. However, the risk never falls to zero; compared to persons who have never suffered a deep vein thrombosis or pulmonary embolism, patients with one episode remain at higher risk for developing one or more additional venous thromboembolism events for the remainder of their lives.

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 SLIDE 8:

Photograph of DVT pathology

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 SLIDE 9: Survival after VTE

TimeDeep Vein Thrombosis AlonePulmonary Embolism
0 days97.076.5
7 days96.271.1
14 days95.768.7
30 days94.566.8
90 days91.962.8
1 year85.457.4

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 SLIDE 10:

EventCommunity-acquiredHospital-acquiredTotal
Non-fatal VTE      193,598            419,825         613,423    
DVT108,240268,125376,365
PE85,358151,700237,058
Fatal VTE      106,551                 189,819             296,370         
DVT64916092258
PE105,902188,210294,112
Grand Total300,149609,644 909,793

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 SLIDE 11: Total US 2002 VTE Events

Total VTE exceed:

  • total myocardial infarctions per year (n=865,000).*
  • total strokes per year (n=700,000).*

VTE-related deaths exceed:

  • myocardial infarction-related deaths per year (n=171,000; 2003).*
  • stroke-related deaths per year (n=158,000; 2003).*

*Data obtained from 2006 AHA “statistics” table

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 SLIDE 12: Annual Incidence of VTE by Event Type (PE vs. DVT)

Line chart showing Annual Incidence of VTE by Event Type (PE vs. DVT).

  • KEY POINT: Incidence rates for DVT and PE increase markedly with age.
  • The Olmstead County, Minn. 25-year population-based study demonstrated that there is a correlation between increasing age and the incidence of VTE.
  • PE, a potentially fatal complication of DVT, represents an increasing proportion of total VTE events with advancing age.

Results of this study emphasize the need for more effective and safe prophylactic therapy.

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 SLIDE 13:

Photograph of legs affected by DVT

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 SLIDE 14: Quality of Life after VTE Effect of Post-Thrombotic Syndrome

Two bar graphs showing Quality of Life after VTE Effect of Post-Thrombotic Syndrome.

Recall that blood in veins is flowing back to the heart. However, while in the standing position, gravity tends to "pull" the blood in the wrong direction. This tendency toward reversal of blood flow is prevented by venous valves located periodically throughout the course of the deep veins of the leg. A deep vein thrombosis may destroy one or more of these valves as well as cause persistent complete or partial obstruction of veins. The long-term consequence of this venous valvular dysfunction and/or venous outflow obstruction is a symptom complex of leg pain and swelling in the standing position. For those most severely affected, the skin at the inside ankle becomes thickened and darkened, and is prone to recurrent skin breakdown and painful ulcers that are difficult to heal. This symptom complex has been termed "venous stasis syndrome". About 12% of patients with venous stasis syndrome have had a previous deep vein thrombosis11, and about 30% of deep vein thrombosis will subsequently develop venous stasis syndrome (often called post thrombotic syndrome) within the next 10-20 years Almost 400,000 people suffer from post thrombotic syndrome in the US. Recent research shows that patients with postthrombotic syndrome have a significant reduction in quality of life that is of a similar magnitude to patients with chronic heart, lung or arthritic disease.

Our bodies have an internal ability of dissolve ("lyse") blood clots. Hence, for most patients with pulmonary embolism, the blood clot in the lungs lyses and blood flow is restored to normal. However, for unclear reasons, some pulmonary embolism patients fail to completely lyse these lung blood clots. This leads to another complication of venous thromboembolism, termed chronic thromboembolic pulmonary hypertension (CTEPH). These patients often are severely impaired due chronic shortness of breath and heart failure. Fortunately, this complication is relatively rare, with an incidence of about 6.5 per million person-years or about 1400 first lifetime cases of CTEPH each year.6,16 Nevertheless, over 4000 people are estimated to have CTEPH in the US.

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 SLIDE 15: Venous Thromboembolism Complications: Total US 2002 Incident & Prevalent Venous Stasis Syndrome and Chronic Thromboembolic Pulmonary Hypertension

EventCommunity-acquiredHospital-acquiredTotal
Complication
VSS†		93,613242,480395,673
CTEPH120721034135

*Events occurring with 90 days after hospitalization were categorized as hospital-acquired.
†Includes both incident and prevalent VSS (e.g., post thrombotic syndrome).

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 SLIDE 16: Trends in VTE Incidence

  • 1991-1997: 117.7 per 100,000 person-years
  • 1981-1990: 116.0 per 100,000 person-years

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 SLIDE 17: Epidemiology of VTE in the Community

Implications for Prevention of VTE

  • VTE is common, potentially lethal and often presents as sudden death.
  • VTE recurs frequently and causes long-term complications that reduce quality of life.
  • VTE incidence unchanged from 1980-1999.
  • As US average population age increases, number of VTE events and related deaths per year will increase.

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