Acute Pulmonary Embolism in Women: Focus on Estrogen Therapy as a Predisposing Factor
-
Hassan Aghajani
,
Mahboobeh Aghajani
,
Saeed Ghodsi
,
Yaser Jenab
,
Azita Hajhossein Talasaz
,
Amine Ghram
,
Saeed Tofighi
Abstract
Acute pulmonary embolism (APE) is a potentially fatal disorder. The literature shows that estrogen therapy is correlated with an increase in mortality and morbidity. Accordingly, the purpose of the present study was to investigate the prevalence and prognostic significance of the recent history of estrogen therapy in women with APE. This study was conducted on female patients admitted to our hospital between January 2008 and January 2016. A total of 276 patients (mean age=62.66±08 y) with confirmed APE were divided into groups with and without recent estrogen therapy. The relationships between estrogen and clinical findings, risk factors, imaging findings, and in-hospital mortality were analyzed. Among the 276 women with APE at presentation, 37 (13.4%) patients had a recent history of estrogen therapy. The estrogen group had a lower frequency of hypertension (21.6% vs49.8%; P< .001), immobilization of at least 3 days (16.2% vs 33.5%; P= .035), and pleural effusion (0% vs16.7%; P= .007) than the group without recent estrogen use. Among the 276 patients, the rate of 1 year’s mortality was 15.8% for the group without recent estrogen therapy. No death occurred in the estrogen group. Older age, tachycardia, tachypnea, malignancy, and lack of obesity were the predictors of 1 year’s mortality. Among the patients with APE in our study, 13.4% had a history of recent estrogen therapy. No death occurred during the 1-year follow-up of these patients.
1. McDaid A, Logette E, Buchillier V, et al. Risk prediction of developing venous thrombosis in combined oral contraceptive users. Garcia de Frutos P, ed. PLOS ONE. 2017;12(7):e0182041. doi:10.1371/journal.pone.0182041.
2. Jenab Y, Lotfi-Tokaldany M, Alemzadeh-Ansari M-J, et al. Correlates of Syncope in Patients With Acute Pulmonary Thromboembolism. Clinical and Applied Thrombosis/Hemostasis. 2015;21(8):772-776. doi:10.1177/1076029614540037.
3. Lehnert P, Møller CH, Carlsen J, Grande P, Steinbrüchel DA. Surgical treatment of acute pulmonary embolism—a 12-year retrospective analysis. Scandinavian Cardiovascular Journal. 2012;46(3):172-176. doi:10.3109/14017431.2011.642811.
4. Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosis. Lancet (London, England). 2012;379(9828):1835-1846. doi:10.1016/S0140-6736(11)61904-1.
5. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in Nonorthopedic Surgical Patients. Chest. 2012;141(2):e227S-e277S. doi:10.1378/chest.11-2297.
6. Marušič AP, Locatelli I, Mrhar A, et al. Influence of Prescribed Blood Products on the Incidence of Deep Vein Thrombosis and Pulmonary Embolism in Surgical Patients. Clinical and Applied Thrombosis/Hemostasis. 2017;23(8):938-942. doi:10.1177/1076029616689301.
7. Likis F. Contraceptive applications of estrogen. Journal of Midwifery & Women’s Health. 2002;47(3):139-156. doi:10.1016/S1526-9523(02)00234-9.
8. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of combined oral contraceptives and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2015;350(may26 13):h2135-h2135. doi:10.1136/bmj.h2135.
9. Cushman M, Kuller LH, Prentice R, et al. Estrogen Plus Progestin and Risk of Venous Thrombosis. JAMA. 2004;292(13):1573. doi:10.1001/jama.292.13.1573.
10. Marjoribanks J, Farquhar C, Roberts H, Lethaby A, Lee J. Long-term hormone therapy for perimenopausal and postmenopausal women. In: Farquhar C, ed. Cochrane Database of Systematic Reviews. Vol 1. Chichester, UK: John Wiley & Sons, Ltd; 2017:CD004143. doi:10.1002/14651858.CD004143.pub5.
11. Seyyedi S, Jenab Y, Tokaldany ML, Shirani S, Sadeghian S, Jalali A. Syncope paradox in the outcome of patients with pulmonary thromboembolism: short-term and midterm outcome. The Clinical Respiratory Journal. 2016;10(1):90-97. doi:10.1111/crj.12183.
12. (US) O of the SG, National Heart L and BI (US). SECTION I: Deep Vein Thrombosis and Pulmonary Embolism as Major Public Health Problems. 2008. https://www.ncbi.nlm.nih.gov/books/NBK44181/. Accessed October 26, 2017.
13. De Stefano V, Rossi E, Leone G. Inherited Thrombophilia, Pregnancy, and Oral Contraceptive Use: Clinical Implications. Seminars in Vascular Medicine. 2003;03(1):047-060. doi:10.1055/s-2003-38332.
14. Mac Gillavry MR, Prins MH. Oral Contraceptives and Inherited Thrombophilia: A Gene-Environment Interaction with a Risk of Venous Thrombosis? Seminars in Thrombosis and Hemostasis. 2003;29(2):219-226. doi:10.1055/s-2003-38838.
15. Shiraev TP, Omari A, Rushworth RL. Trends in pulmonary embolism morbidity and mortality in Australia. Thrombosis Research. 2013;132(1):19-25. doi:10.1016/j.thromres.2013.04.032.
16. Polo Friz H, Molteni M, Del Sorbo D, et al. Mortality at 30 and 90 days in elderly patients with pulmonary embolism: a retrospective cohort study. Internal and Emergency Medicine. 2015;10(4):431-436. doi:10.1007/s11739-014-1179-z.
17. Ageno W, Agnelli G, Imberti D, et al. Prevalence of risk factors for venous thromboembolism in the Italian population: results of a cross-sectional study from the Master Registry. Internal and Emergency Medicine. 2013;8(7):575-580. doi:10.1007/s11739-011-0644-1.
18. Keller K, Beule J, Coldewey M, Dippold W, Balzer JO. Heart rate in pulmonary embolism. Internal and Emergency Medicine. 2015;10(6):663-669. doi:10.1007/s11739-015-1198-4.
19. Strauß R, Ewig S, Richter K, König T, Heller G, Bauer TT. The prognostic significance of respiratory rate in patients with pneumonia: a retrospective analysis of data from 705,928 hospitalized patients in Germany from 2010-2012. Deutsches Arzteblatt international. 2014;111(29-30):503-8, i-v. doi:10.3238/arztebl.2014.0503.
20. Aujesky D, Roy P-M, Le Manach CP, et al. Validation of a model to predict adverse outcomes in patients with pulmonary embolism. European Heart Journal. 2006;27(4):476-481. doi:10.1093/eurheartj/ehi588.
21. Stein PD, Beemath A, Olson RE. Obesity as a risk factor in venous thromboembolism. The American Journal of Medicine. 2005;118(9):978-980. doi:10.1016/j.amjmed.2005.03.012.
22. Yang G, De Staercke C, Hooper WC. The effects of obesity on venous thromboembolism: A review. Open journal of preventive medicine. 2012;2(4):499-509. doi:10.4236/ojpm.2012.24069.
23. Goldhaber SZ. Risk Factors for Venous Thromboembolism. Journal of the American College of Cardiology. 2010;56(1):1-7. doi:10.1016/j.jacc.2010.01.057.
24. Goldhaber SZ, Visani L, De Rosa M, al. et, Jorfeldt L, Just H. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet (London, England). 1999;353(9162):1386-1389. doi:10.1016/S0140-6736(98)07534-5.
25. Gosselin M V, Rubin GD, Leung AN, Huang J, Rizk NW. Unsuspected pulmonary embolism: prospective detection on routine helical CT scans. Radiology. 1998;208(1):209-215. doi:10.1148/radiology.208.1.9646815.
26. Douma RA, Kok MGM, Verberne LM, Kamphuisen PW, Büller HR. Incidental venous thromboembolism in cancer patients: prevalence and consequence. Thrombosis Research. 2010;125(6):e306-e309. doi:10.1016/j.thromres.2010.02.010.
27. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and Validation of a Prognostic Model for Pulmonary Embolism. American Journal of Respiratory and Critical Care Medicine. 2005;172(8):1041-1046. doi:10.1164/rccm.200506-862OC.
28. Grifoni S, Olivotto I, Cecchini P, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000;101(24):2817-2822. http://www.ncbi.nlm.nih.gov/pubmed/10859287. Accessed May 13, 2016.
29. Spencer FA, Goldberg RJ, Lessard D, et al. Factors Associated With Adverse Outcomes in Outpatients Presenting With Pulmonary Embolism: The Worcester Venous Thromboembolism Study. Circulation: Cardiovascular Quality and Outcomes. 2010;3(4):390-394. doi:10.1161/CIRCOUTCOMES.110.937441.
30. Laporte S, Mismetti P, Decousus H, et al. Clinical Predictors for Fatal Pulmonary Embolism in 15 520 Patients With Venous Thromboembolism: Findings From the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) Registry. Circulation. 2008;117(13):1711-1716. doi:10.1161/CIRCULATIONAHA.107.726232.
31. Carson JL, Kelley MA, Duff A, et al. The Clinical Course of Pulmonary Embolism. New England Journal of Medicine. 1992;326(19):1240-1245. doi:10.1056/NEJM199205073261902.
32. Bova C, Pesavento R, Marchiori A, et al. Risk stratification and outcomes in hemodynamically stable patients with acute pulmonary embolism: a prospective, multicentre, cohort study with three months of follow-up. Journal of thrombosis and haemostasis : JTH. 2009;7(6):938-944. doi:10.1111/j.1538-7836.2009.03345.x.
33. Cai B, Bedayat A, George E, et al. Malignancy and Acute Pulmonary Embolism. Journal of Thoracic Imaging. 2013;28(3):196-201. doi:10.1097/RTI.0b013e3182870bf9.
34. Sood R, Faubion SS, Kuhle CL, Thielen JM, Shuster LT. Prescribing menopausal hormone therapy: an evidence-based approach. International journal of women’s health. 2014;6:47-57. doi:10.2147/IJWH.S38342.
35. Sassarini J, Lumsden MA. Oestrogen replacement in postmenopausal women. Age and Ageing. 2015;44(4):551-558. doi:10.1093/ageing/afv069.
36. NAUFFAL D, BALLESTER M, REYES RL, et al. Influence of recent immobilization and recent surgery on mortality in patients with pulmonary embolism. Journal of Thrombosis and Haemostasis. 2012;10(9):1752-1760. doi:10.1111/j.1538-7836.2012.04829.x.
37. Postmenopausal Estrogen Therapy: Route of Administration and Risk of Venous Thromboembolism. Obstet Gynecol. 2013;(121):887–90. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Gynecologic-Practice/co556.pdf?dmc=1&ts=20171027T1330229370. Accessed October 27, 2017.
38. Wu O. Postmenopausal hormone replacement therapy and venous thromboembolism. Gender medicine. 2005;2 Suppl A:S18-27. http://www.ncbi.nlm.nih.gov/pubmed/16551553. Accessed October 10, 2017.
39. Trenor CC, Chung RJ, Michelson AD, et al. Hormonal contraception and thrombotic risk: a multidisciplinary approach. Pediatrics. 2011;127(2):347-357. doi:10.1542/peds.2010-2221.
2. Jenab Y, Lotfi-Tokaldany M, Alemzadeh-Ansari M-J, et al. Correlates of Syncope in Patients With Acute Pulmonary Thromboembolism. Clinical and Applied Thrombosis/Hemostasis. 2015;21(8):772-776. doi:10.1177/1076029614540037.
3. Lehnert P, Møller CH, Carlsen J, Grande P, Steinbrüchel DA. Surgical treatment of acute pulmonary embolism—a 12-year retrospective analysis. Scandinavian Cardiovascular Journal. 2012;46(3):172-176. doi:10.3109/14017431.2011.642811.
4. Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosis. Lancet (London, England). 2012;379(9828):1835-1846. doi:10.1016/S0140-6736(11)61904-1.
5. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in Nonorthopedic Surgical Patients. Chest. 2012;141(2):e227S-e277S. doi:10.1378/chest.11-2297.
6. Marušič AP, Locatelli I, Mrhar A, et al. Influence of Prescribed Blood Products on the Incidence of Deep Vein Thrombosis and Pulmonary Embolism in Surgical Patients. Clinical and Applied Thrombosis/Hemostasis. 2017;23(8):938-942. doi:10.1177/1076029616689301.
7. Likis F. Contraceptive applications of estrogen. Journal of Midwifery & Women’s Health. 2002;47(3):139-156. doi:10.1016/S1526-9523(02)00234-9.
8. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of combined oral contraceptives and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2015;350(may26 13):h2135-h2135. doi:10.1136/bmj.h2135.
9. Cushman M, Kuller LH, Prentice R, et al. Estrogen Plus Progestin and Risk of Venous Thrombosis. JAMA. 2004;292(13):1573. doi:10.1001/jama.292.13.1573.
10. Marjoribanks J, Farquhar C, Roberts H, Lethaby A, Lee J. Long-term hormone therapy for perimenopausal and postmenopausal women. In: Farquhar C, ed. Cochrane Database of Systematic Reviews. Vol 1. Chichester, UK: John Wiley & Sons, Ltd; 2017:CD004143. doi:10.1002/14651858.CD004143.pub5.
11. Seyyedi S, Jenab Y, Tokaldany ML, Shirani S, Sadeghian S, Jalali A. Syncope paradox in the outcome of patients with pulmonary thromboembolism: short-term and midterm outcome. The Clinical Respiratory Journal. 2016;10(1):90-97. doi:10.1111/crj.12183.
12. (US) O of the SG, National Heart L and BI (US). SECTION I: Deep Vein Thrombosis and Pulmonary Embolism as Major Public Health Problems. 2008. https://www.ncbi.nlm.nih.gov/books/NBK44181/. Accessed October 26, 2017.
13. De Stefano V, Rossi E, Leone G. Inherited Thrombophilia, Pregnancy, and Oral Contraceptive Use: Clinical Implications. Seminars in Vascular Medicine. 2003;03(1):047-060. doi:10.1055/s-2003-38332.
14. Mac Gillavry MR, Prins MH. Oral Contraceptives and Inherited Thrombophilia: A Gene-Environment Interaction with a Risk of Venous Thrombosis? Seminars in Thrombosis and Hemostasis. 2003;29(2):219-226. doi:10.1055/s-2003-38838.
15. Shiraev TP, Omari A, Rushworth RL. Trends in pulmonary embolism morbidity and mortality in Australia. Thrombosis Research. 2013;132(1):19-25. doi:10.1016/j.thromres.2013.04.032.
16. Polo Friz H, Molteni M, Del Sorbo D, et al. Mortality at 30 and 90 days in elderly patients with pulmonary embolism: a retrospective cohort study. Internal and Emergency Medicine. 2015;10(4):431-436. doi:10.1007/s11739-014-1179-z.
17. Ageno W, Agnelli G, Imberti D, et al. Prevalence of risk factors for venous thromboembolism in the Italian population: results of a cross-sectional study from the Master Registry. Internal and Emergency Medicine. 2013;8(7):575-580. doi:10.1007/s11739-011-0644-1.
18. Keller K, Beule J, Coldewey M, Dippold W, Balzer JO. Heart rate in pulmonary embolism. Internal and Emergency Medicine. 2015;10(6):663-669. doi:10.1007/s11739-015-1198-4.
19. Strauß R, Ewig S, Richter K, König T, Heller G, Bauer TT. The prognostic significance of respiratory rate in patients with pneumonia: a retrospective analysis of data from 705,928 hospitalized patients in Germany from 2010-2012. Deutsches Arzteblatt international. 2014;111(29-30):503-8, i-v. doi:10.3238/arztebl.2014.0503.
20. Aujesky D, Roy P-M, Le Manach CP, et al. Validation of a model to predict adverse outcomes in patients with pulmonary embolism. European Heart Journal. 2006;27(4):476-481. doi:10.1093/eurheartj/ehi588.
21. Stein PD, Beemath A, Olson RE. Obesity as a risk factor in venous thromboembolism. The American Journal of Medicine. 2005;118(9):978-980. doi:10.1016/j.amjmed.2005.03.012.
22. Yang G, De Staercke C, Hooper WC. The effects of obesity on venous thromboembolism: A review. Open journal of preventive medicine. 2012;2(4):499-509. doi:10.4236/ojpm.2012.24069.
23. Goldhaber SZ. Risk Factors for Venous Thromboembolism. Journal of the American College of Cardiology. 2010;56(1):1-7. doi:10.1016/j.jacc.2010.01.057.
24. Goldhaber SZ, Visani L, De Rosa M, al. et, Jorfeldt L, Just H. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet (London, England). 1999;353(9162):1386-1389. doi:10.1016/S0140-6736(98)07534-5.
25. Gosselin M V, Rubin GD, Leung AN, Huang J, Rizk NW. Unsuspected pulmonary embolism: prospective detection on routine helical CT scans. Radiology. 1998;208(1):209-215. doi:10.1148/radiology.208.1.9646815.
26. Douma RA, Kok MGM, Verberne LM, Kamphuisen PW, Büller HR. Incidental venous thromboembolism in cancer patients: prevalence and consequence. Thrombosis Research. 2010;125(6):e306-e309. doi:10.1016/j.thromres.2010.02.010.
27. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and Validation of a Prognostic Model for Pulmonary Embolism. American Journal of Respiratory and Critical Care Medicine. 2005;172(8):1041-1046. doi:10.1164/rccm.200506-862OC.
28. Grifoni S, Olivotto I, Cecchini P, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000;101(24):2817-2822. http://www.ncbi.nlm.nih.gov/pubmed/10859287. Accessed May 13, 2016.
29. Spencer FA, Goldberg RJ, Lessard D, et al. Factors Associated With Adverse Outcomes in Outpatients Presenting With Pulmonary Embolism: The Worcester Venous Thromboembolism Study. Circulation: Cardiovascular Quality and Outcomes. 2010;3(4):390-394. doi:10.1161/CIRCOUTCOMES.110.937441.
30. Laporte S, Mismetti P, Decousus H, et al. Clinical Predictors for Fatal Pulmonary Embolism in 15 520 Patients With Venous Thromboembolism: Findings From the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) Registry. Circulation. 2008;117(13):1711-1716. doi:10.1161/CIRCULATIONAHA.107.726232.
31. Carson JL, Kelley MA, Duff A, et al. The Clinical Course of Pulmonary Embolism. New England Journal of Medicine. 1992;326(19):1240-1245. doi:10.1056/NEJM199205073261902.
32. Bova C, Pesavento R, Marchiori A, et al. Risk stratification and outcomes in hemodynamically stable patients with acute pulmonary embolism: a prospective, multicentre, cohort study with three months of follow-up. Journal of thrombosis and haemostasis : JTH. 2009;7(6):938-944. doi:10.1111/j.1538-7836.2009.03345.x.
33. Cai B, Bedayat A, George E, et al. Malignancy and Acute Pulmonary Embolism. Journal of Thoracic Imaging. 2013;28(3):196-201. doi:10.1097/RTI.0b013e3182870bf9.
34. Sood R, Faubion SS, Kuhle CL, Thielen JM, Shuster LT. Prescribing menopausal hormone therapy: an evidence-based approach. International journal of women’s health. 2014;6:47-57. doi:10.2147/IJWH.S38342.
35. Sassarini J, Lumsden MA. Oestrogen replacement in postmenopausal women. Age and Ageing. 2015;44(4):551-558. doi:10.1093/ageing/afv069.
36. NAUFFAL D, BALLESTER M, REYES RL, et al. Influence of recent immobilization and recent surgery on mortality in patients with pulmonary embolism. Journal of Thrombosis and Haemostasis. 2012;10(9):1752-1760. doi:10.1111/j.1538-7836.2012.04829.x.
37. Postmenopausal Estrogen Therapy: Route of Administration and Risk of Venous Thromboembolism. Obstet Gynecol. 2013;(121):887–90. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Gynecologic-Practice/co556.pdf?dmc=1&ts=20171027T1330229370. Accessed October 27, 2017.
38. Wu O. Postmenopausal hormone replacement therapy and venous thromboembolism. Gender medicine. 2005;2 Suppl A:S18-27. http://www.ncbi.nlm.nih.gov/pubmed/16551553. Accessed October 10, 2017.
39. Trenor CC, Chung RJ, Michelson AD, et al. Hormonal contraception and thrombotic risk: a multidisciplinary approach. Pediatrics. 2011;127(2):347-357. doi:10.1542/peds.2010-2221.
| Files | ||
| Issue | Vol 59, No 6 (2021) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/acta.v59i6.6894 | |
| Keywords | ||
| Pulmonary embolism Estrogen Mortality Thromboembolism Deep vein thrombosis | ||
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How to Cite
1.
Aghajani H, Aghajani M, Ghodsi S, Jenab Y, Hajhossein Talasaz A, Ghram A, Tofighi S. Acute Pulmonary Embolism in Women: Focus on Estrogen Therapy as a Predisposing Factor. Acta Med Iran. 2021;59(6):357-363.
