Pulmonary embolism risk factors

| Resident
Survival
Guide

|
|
|

Pulmonary Embolism Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Pulmonary Embolism from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

Natural History, Complications and Prognosis

Diagnosis

Diagnostic criteria

Assessment of Clinical Probability and Risk Scores

Pulmonary Embolism Assessment of Probability of Subsequent VTE and Risk Scores

History and Symptoms

Physical Examination

Laboratory Findings

Arterial Blood Gas Analysis

D-dimer

Biomarkers

Electrocardiogram

Chest X Ray

Ventilation/Perfusion Scan

Echocardiography

Compression Ultrasonography

MRI

Treatment

Treatment approach

Medical Therapy

IVC Filter

Pulmonary Embolectomy

Pulmonary Thromboendarterectomy

Discharge Care and Long Term Treatment

Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Follow-Up

Support group

Special Scenario

Pregnancy

Cancer

Trials

Landmark Trials

Case Studies

Case #1

Pulmonary embolism risk factors On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Pulmonary embolism risk factors

CDC on Pulmonary embolism risk factors

Pulmonary embolism risk factors in the news

Blogs on Pulmonary embolism risk factors

Directions to Hospitals Treating Pulmonary embolism risk factors

Risk calculators and risk factors for Pulmonary embolism risk factors

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

[edit | edit source]

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

[edit | edit source]

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

[edit | edit source]

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

* Obesity: Obesity is defined as a body-mass index (BMI) above 30 kg/m2.[6] [7] [8]

* Smoking:[6] 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[9]

* Hyperhomocysteinemia:[10] Hyperhomocysteinemia can be reduced with vitamin B supplementation.

### Non-Modifiable Risk Factors

[edit | edit source]

* 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

[edit | edit source]

* Pregnancy and the peri-partum period
* Active cancer
* Central venous catheter

### Other Possible Risk Factors

[edit | edit source]

Other possible factors associated with VTE include:

* Nutrition low in fish, fruits, and vegetables[11]
* Psychological stress[12]
* Cardiovascular risk factors such as diabetes and hypercholesterolemia[13]
* Acute medical illness
* Drug abuse (intravenous drugs)[14]
* Sickle cell disease[15]
* Inflammatory bowel disease[16]
* Antipsychotic drugs[17]
* Thrombocytosis[18]
* Varicose veins[19][20]

## Risk Factors from the Nurse's Health Study

[edit | edit source]

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

[edit | edit source]

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.

* Anticardiolipin antibody level above the 95th percentile (RR: 5.3; 95% CI, 1.55 to 18.3; P = 0.01)[22]
* Factor V Leiden (RR: 2.7; 95% CI, 1.3 to 5.6; P = 0.008)[23]

## References

[edit | edit source]

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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
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)CS1 maint: Multiple names: authors list (link)
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)CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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)CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link) CS1 maint: PMC format (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)

Template:WH Template:WS