Kevin Kunzmann

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Findings from a new study suggest placement of an inferior vena cava (IVC) filter was linked to significant decreases in mortality and pulmonary embolism risk among cancer patients with 


A population-based cohort analysis conducted by a team of Texas-based investigators, results indicated IVC filter placement could help mitigate the increased risk of fatal pulmonary embolism in patients with cancer.

Investigators, led by Samyuktha Balabhadra, MD, of the Department of Radiology at the University of Texas Health McGovern School of Medicine, sought to understand the appropriate use of IVC filters in patients with cancer by evaluating associations between the devices and pulmonary embolism development among cancer patients with DVT.

“This knowledge gap in IVC filter utility and outcomes is even more pronounced for patients with cancer because very few studies have investigated this patient population, to our knowledge,” they wrote. “Defining the appropriate use of IVC filters in patients with cancer remains a substantially unmet clinical need.”

Their assessment included administrative data on 88,585 patients from state inpatient databases for California and Florida, ranging in years from 2005-2014.

Balabhadra and colleagues identified patients with cancer and acute lower extremity DVT through diagnostic and procedure codes. The team evaluated subsequent hospital visits among eligible patients for the placement of an IVC filter, new embolism development, new DVT development, and in-hospital mortality.

Pulmonary embolism-free survival was measured from initial DVT diagnosis date until the development of pulmonary embolism. In the event that a patient received a pulmonary embolism diagnosis at the same time as their initial DVT diagnosis, they were considered to not have developed a new pulmonary embolism.

Median patient age was 71 years old, with half (50.8%) being male. Patients were analyzed across 534,623 inpatient encounters, with a median follow-up time of 479 days.

Of the cohort, 33,740 patients (38.1%) underwent IVC filter placement—most (80.4%) occurring within 30 days of initial DVT diagnosis. Patients with comorbid risk factors including upper gastrointestinal bleeding, intracranial hemorrhage, and coagulopathy were at 32%, 21%, and 9% greater odds of receiving a filter, respectively.

A new pulmonary embolism developed in 5.1% of IVC filter-recipient patients after their initial DVT diagnosis.

Investigators observed a 31% improvement in pulmonary embolism-free survival among these patients than those who did not receive an IVC filter—even after propensity score matching and competing risk analysis (HR, 0.69; 95% CI, 0.64-0.75; 

 <.001).

IVC filter placement additionally reduced pulmonary embolism development risk among patients with very high-risk, high-risk, and low-risk malignant neoplasms.

Despite previous analyses, investigators did not observe an association between IVC filter placement and increased new DVT development risk, with account for patient anticoagulation use and imbalanced risk factors.

That said, Balabhadra and colleagues stressed the potential risk of IVC filter placement, as per communications from the US Food and Drug Administration (FDA) in 2014 and 2010 on their link to device migration, penetration, and embolization.

“The most common complication associated with IVC filters, however, is an increased incidence of DVT,” investigators wrote. “As the devices themselves represent foreign material within a blood vessel, they are to some extent thrombogenic and can lead to thrombus formation and propagation.”

Nonetheless, the team concluded that, when accounting for death as a competing risk and comorbidities by propensity score matching, IVC filter placement in cancer patients with DVT was linked to significantly reduced new pulmonary embolism.

“These data suggest that IVC filter use in patients with cancer is of potential benefit in appropriately selected patients, and that further investigations into the appropriate use of these devices is warranted,” they wrote.

The study, “

Association of Inferior Vena Cava Filter Placement With Rates of Pulmonary Embolism in Patients With Cancer and Acute Lower Extremity Deep Venous Thrombosis

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New research suggests IVC filter placement could attenuate the risk of pulmonary embolism in patients with cancer-related DVT. 

IVC Filter Could Cut Pulmonary Embolism Risk in Cancer-Related DVT

How ACE2 Reduction Associated with Aging Affects COVID-19 Severity,

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A new perspective from a team of Maryland-based cardiovascular clinicians sheds insight on an often forgotten facet of the inherent COVID-19 risk carried by patients with cardiovascular history: the decline in angiotensin-converting enzyme 2 (ACE2) expression associated with aging, and the response of care most common in such patients.

In an essay published Friday morning, a trio of investigators-Majd AlGhatrif, MD, MA; Oscar Cingolani, MD; and Edward G. Lakatta, MD; of Johns Hopkins School of Medicine, the National Institute on Aging and National Institutes of Health-called for the urgent expansion of renin-angiotensin system (RAS)-based intervention assessment as part of the need for clinical understanding as to how lung complications are driving novel coronavirus (COVID-19) mortality worldwide.

As the team noted, ACE2 is not only prevalent in the pathogenesis of COVID-19, but is part of RAS signaling. Though data is scarce on the topic, it is known now that ACE2 is both targeted by SARS-CoV-2 in its entrances to cells and a critical player in anti-inflammation during RAS signaling-converting angiotensin II to angiotensin 1-7.

The age-associated decrease of ACE2 expression, which investigators have observed in the lungs of rats, is in line with “a constellation of major proinflammatory changes perpetrated by an age-associated increase in RAS signaling throughout the body,” the team wrote.

Such proinflammatory profiles are featured in patients with hypertension and diabetes-a pair of diseases highly common in older patients.

The increase of ACE2 in such patients with ACE inhibitors and angiotensin receptor blockers (ARBs) presents a paradox to investigators: how can ACE2 reduction in older, cardiovascular-risk patients put them at greater risk of COVID-19 severe symptoms when ACE2 is the gateway for the disease into cells?

The team pointed to data procured from the severe acute respiratory syndrome (SARS) epidemic of 2003, which most prominently affected persons in their 30s and 40s-despite these younger patients reporting lower disease severity and risk of mortality versus older people with pre-existing conditions.

“Similarly, in the COVID-19 pandemic, it is plausible that greater expression of ACE2 leads to higher predisposition to incur the disease,” they wrote.

Preliminary epidemiologic data from South Korea-the country with the greatest rate of population-wide testing for the disease-shows that younger adults are reporting the greatest rate of infection, despite perceived higher ACE2 levels. COVID-19 severity, however, has been observed in older patient populations, such as that of Italy’s.

“Hence, compared with young individuals, older persons with (cardiovascular disease) who already have reduced ACE2 levels will be expected to be more predisposed to exaggerated inflammation with further reduction in ACE2 expression in the context of COVID-19, manifesting with greater disease severity,” they explained.

The team hypothesized that SARS-CoV-2 binding to ACE2 creates an acutely exaggerated proinflammatory background, thereby predisposing older adults with hypertension and diabetes treated with ACE inhibitors and ARBs to correct ACE2 levels at a greater risk of disease severity and mortality.

This belief, they wrote, aligns with evidence of angiotensin II antagonists benefitting sepsis-associated acute lung injury.

Going forward, the team advised that clinicians continue treating patients with ACE inhibitors and ARB and pursue clinical investigations that consider RAS interventions for COVID-19 severity reduction.

The Dilemma of Coronavirus Disease 2019, Aging, and Cardiovascular Disease

Why Older Patients Are More At Risk for COVID-19 : A Decline In ACE2 Expression

US Adult E-Cigarette Use Climbing, Despite Cardiology Health Concerns

Electronic cigarette use has grown to approximately 1 in every 20 US adults, according to new findings presented virtually at the American College of Cardiology (ACC) 2020 Scientific Sessions this week.

An assessment of 930,000 surveyed US adults, conducted by Mahmoud Al Rifai, MD, MPH, cardiology fellow at Baylor College of Medicine and colleagues, showed that approximately 29,000 people identified as current e-cigarette users.

Investigators used data from the annual, large-scale phone survey Behavioral Risk Factor Surveillance System (BRFSS)-a four-decade data collection program designed to represent the characteristics and demographics of the US adult population.

Current e-cigarette use was defined as participants indicating they used e-cigarettes daily or on some days. Al Rifai and colleagues compared the 2018 findings-the most recently available data-to those reported in 2016.

When looking at e-cigarette and vaping use among subpopulations, investigators noted particularly greater rates among women (4.3% vs 3.3%), former smokers (7.9% vs 5.2%), and adults aged 45-54 years old (5.2% vs 3.9%).

Current use among people who use smokeless tobacco products nearly doubled in the observed 3 years (16.2% vs 9.2%).

The surveyed population rate from 2018 translated to about 10.8 million total US adults, investigators noted-an increase of a half-percentage point from 2016 results (4.8% vs 4.3%).

Though a three-year jump of just 0.5% may not sound significant, Al Rifai noted it does indicate a great amount of new e-cigarette users relative to the overall US population.

“Based on our findings, I think the trend is only going to go upward, but we don’t know yet what the long-term health effects are,” he said in a statement.

Al Rifai’s belief that such national tends reflect the increased marketing and advertisement of e-cigarette and vaping product makers to young adult audiences is evidenced by findings from earlier this year showing market-leading JUUL products constitute about two-thirds of the increasing annual e-cigarette dollar sales.

A pair of smaller-scale studies being presented virtually by ACC 2020 show potential association between vaping and heart disease. One-a blood sample-based assessment of non-smokers, smokers, and e-cigarette users-showed both e-cigarette and smoke tobacco users are significantly more affected by oxidative stress associated with heart artery plaque buildup than non-smokers.

Holly Middlekauff, MD, UCLA cardiologist and senior study author, said the findings show not only that circulating immune cells report greater oxidative stress in smokers and e-cigarette users, but that there are also more chronic inflammatory cells present.

“Our study suggests there is a continuum of harm, with non-users having the least amount of oxidative stress, electronic cigarette users showing an intermediate level and chronic tobacco smokers having the largest amount of oxidative stress,” Middlekauf noted in a statement.

Al Rifai called on a sense of urgency in conducting further research into the prevalence of vaping and its long-term implication on individual and public health metrics. As he noted, it’s been too soon to tell what that harm may be.

“Because e-cigarettes have only been around for about a decade, many large cohort studies have only just recently started incorporating e-cigarette information into their questionnaires,” he said. “Yet, the cumulative effects of e-cigarettes may take years to develop, especially in the context of cardiovascular disease.”

The study, "Trends in Prevalence of E-Cigarette Use Among U.S. Adults. Behavioral Risk Factor Surveillance System, 2016 And 2017," was presented at ACC 2020.

Author | Kevin Kunzmann

Articles

IVC Filter Could Cut Pulmonary Embolism Risk in Cancer-Related DVT

Why Older Patients Are More At Risk for COVID-19 : A Decline In ACE2 Expression

US Adult E-Cigarette Use Climbing, Despite Cardiology Health Concerns