Prognostic factors for VTE and bleeding in hospitalized medical patients: a systematic review and meta-analysis

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Darzi AJ1, Karam SG1, Charide R2, Ikobaltzeta IE1, Cushman M3, Gould MK4, Mbuagbaw L5, Spencer FA6, Spyropoulos AC7, Streiff MB8, Woller S9, Zakai NA3, Germini F10, Rigoni M11, Agarwal A12, Morsi RZ2, Iorio A10, Akl EA2, Schünemann HJ10
1Department of Health Research Methods, Evidence and Impact; Michael G. DeGroote Cochrane Canada and McMaster GRADE Centres; McMaster University, Hamilton, 2AUB GRADE Center, Clinical Research Institute; American University of Beirut, Beirut, 3Department of Medicine and Department of Pathology and Laboratory Medicine, Larner College of Medicine; University of Vermont, Burlington, 4Department of Research and Evaluation; Kaiser Permanente Southern California, Pasadena, 5Department of Health Research Methods, Evidence and Impact; Michael G. DeGroote Cochrane Canada and McMaster GRADE Centres; McMaster University and Biostatistics Unit, Father Sean O'Sullivan Research Centre; St Joseph's Healthcare; Hamilton, 6Department of Medicine, McMaster University; Hamilton, 7The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Northwell Health at Lenox Hill Hospital, Manhasset, 8Division of Hematology, Departments of Medicine and Pathology; The Johns Hopkins University School of Medicine, Baltimore, 9Department of Medicine, Intermountain Medical Center; University of Utah School of Medicine, Salt Lake City, 10Department of Health Research Methods, Evidence and Impact; Department of Medicine; Michael G. DeGroote Cochrane Canada and McMaster GRADE Centres; McMaster University, Hamilton, 11Healthcare Research and Innovation Program, Heath Technology Assessment Unit; Fondazione Bruno Kessler, Trento, 12Faculty of Medicine, University of Toronto, Toronto

Background: There may be many predictors of venous thromboembolism (VTE) and bleeding in hospitalized medical patients, but until now, systematic reviews and assessments of the certainty of the evidence have not been published.

Objectives: We conducted a systematic review to identify prognostic factors for VTE and bleeding in hospitalized medical patients

Methods: We searched Medline and EMBASE from inception through May 2018. We considered studies that identified potential prognostic factors for VTE and bleeding in hospitalized adult medical patients. Reviewers extracted data in duplicate and independently and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

Results: Of 69,410 citations, we included 17 studies in our analysis: 14 that reported on VTE and 3 that reported on bleeding. For VTE, moderate certainty evidence showed a probable association with older age, elevated CRP, D-dimer, fibrinogen levels, tachycardia, thrombocytosis, leukocytosis, fever, leg edema, lower Barthel Index score, immobility, paresis, previous history of VTE, thrombophilia, malignancy, critical illness and infections. For bleeding, moderate certainty evidence shows a probable association with older age, sex, anemia, obesity, low hemoglobin, gastroduodenal ulcers, rehospitalization, critical illness, thrombocytopenia, blood dyscrasias, hepatic disease, renal failure, antithrombotic medication and central venous catheter (CVC). Elevated CRP, a lower Barthel Index, history of malignancy and tachycardia are not included in most VTE risk assessment models (RAMs).

Conclusions: This study informs risk prediction in the management of hospitalized medical patients for VTE and bleeding; it also informs guidelines for VTE prevention and future research.