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Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
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Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
Women thrombosiscascais14
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Women thrombosiscascais14

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  • 1. Women Issues and Thrombosis Sabine Eichinger Dept. of Medicine I Medical University of Vienna/Austria
  • 2. Annual incidence of VTE 0,0 0,4 0,8 1,2 1,6 2,0 DVT PE + DVTall VTE Naess, J Thromb Haemost 2007 1.43 (95% CI 1.33–1.54) 0.93 (95% CI 0.85–1.02) 0.5 (95% CI 0.44–0.56) per1000persons
  • 3. Risk conditions / risk factors of VTE Advancing age Obesity Previous venous thromboembolism Surgery Trauma Active cancer Acute medical illnesses—eg, acute myocardial infarction, Heart failure, respiratory failure, infection Inflammatory bowel disease Antiphospholipid syndrome Dyslipoproteinaemia Nephrotic syndrome Paroxysmal nocturnal haemoglobinuria Myeloproliferative diseases Behçet’s syndrome Varicose veins Superficial vein thrombosis Congenital venous malformation Long-distance travel Prolonged bed rest Immobilisation Limb paresis Chronic care facility stay Pregnancy/puerperium Hormone contraceptives Hormone replacement therapy Heparin-induced thrombocytopenia Other drugs Chemotherapy Tamoxifen Thalidomide Antipsychotics Central venous catheter Vena cava filter Intravenous drug abuse Factor V Leiden Factor II G20210A Natural inhibitor deficiency High factor VIII, factor IX, or factor XI Lupus anticoagulant High thrombin activatable fibrinolysis inhibitor Hyperhomocysteinaemia Dysfibrinogenaemia or hyperfibrinogenaemia Plasminogen deficiency from Kyrle & Eichinger, Lancet 2005
  • 4. • Sex related differences in hemostasis Women issues and thrombosis
  • 5. Coagulation factors in women compared to men Sex-related differences Fibrinogen F VII, VIII, IX Lowe, Br J Haematol 1997
  • 6. Anticoagulant system Antithrombin Protein S Protein C (except older age) Sex-related differences Lowe, Br J Haematol 1997
  • 7. F1+2 TAT (D-Dimer) Coagulation activation Sex-related differences Lowe, Br J Haematol 1997
  • 8. • Sex related differences in hemostasis • Specific hormone-related issues – Pregnancy Women issues and thrombosis
  • 9. Pulmonary embolism is the most frequent cause of death during pregnancy or puerperium 1 of 500 women will have a venous thrombosis during pregnancy or puerperium
  • 10. Altered Rheology Pregnancy Vascular Injury Altered Hemostasis Prothrombotic State
  • 11. Coagulation factors Hemostasis during pregnancy Fibrinogen F VII, VIII, IX, X, XII vWF F V, XIII F XI
  • 12. Anticoagulant system Hemostasis during pregnancy Thrombomodulin TFPI Protein S APC-ratio Protein C Antithrombin
  • 13. Fibrinolytic system Hemostasis during pregnancy Plasminogen tPA PAI-1 PAI-2 TAFI
  • 14. F1+2 TAT FPA Soluble fibrin D-Dimer Plasmin-antiplasmin complexes Coagulation activation Increased fibrin generation Increased fibrinolysis Hemostasis during pregnancy
  • 15. 12 24 34 week of gestation 1000 3000 500 D-Dimer(ng/ml) * * * P<0.001 P<0.001 with LMWH (n = 66) w/o LMWH (n = 113) * p<0.001 Hoke & Eichinger, Thromb Haemost 2004 D-Dimer during pregnancy
  • 16. 36 year old woman • 1st pregnancy, 7th week of gestation after ovarian stimulation • Hormone therapy  progesteron • Regular consultancies at endocrinology clinic because of hypothyroidism • Palpitations since 3 days • Dyspnoe, acute • ER  suspicion of PE
  • 17. 36 year old woman • Otherwise healthy • No previous VTE • Father PE, FV Leiden heterozygous • Patient‘s thrombophilia screen normal • Heart rate 101/min • ECG: normal
  • 18. Approach to a patient with suspicion of VTE Clinic ImagingLab Diagnostic issues of VTE in pregnancy Not validated for pregnant women
  • 19. • Some signs and symptoms may be pregnancy related • Probability of VTE similarly high throughout pregnancy • In ~ 90% left leg affected • OR for VTE: ~ 4 during pregnancy, ~14 during puerperium, higher after cesarian section • Iliac vein thrombosis relatively frequent – groin pain, radiating to the back Clinical assessment - pretest probability Diagnostic issues of VTE in pregnancy
  • 20. • D-Dimer 0.74 µg/ml ( < 0.5 µg/ml) 36 year old woman
  • 21. Week of gestation Patients, n 95% CI <12 0 (0%) 0 - 60 13-28 12 (24%) 14 - 37 >28 41 (51%) 40 - 61 Chan W, Ann Intern Med 2007 Positive D-Dimer result in pregnant women
  • 22. • Cross-sectional study • 194 unselected pregnant women with suspected DVT • Intervention: – CUS, follow-up 3 months – Independent clinical assessment • 17 women (8.8%) had documented DVT Chan, Ann Intern Med 2009 Predicting DVT in pregnancy
  • 23. Chan, Ann Intern Med 2009 Potential predictive variables for DVT in pregnancy
  • 24. Chan, Ann Intern Med 2009 Pretest probability and performance of LEFt variables
  • 25. Approach to a woman with suspicion of VTE Imaging Diagnostic issues of VTE in pregnancy DVT compression ultrasound phlebography PE ventilation/perfusion scan computed tomography
  • 26. Compression ultrasound to exclude DVT Chan, CMAJ 2013
  • 27. • No evidence for safety of ruling out PE by V/Q scan or CT from prospective studies • Radiation – Teratogenesis – Carcinogenesis • Contrast media Diagnosis of PE – concerns during pregnancy Diagnostic issues of VTE in pregnancy
  • 28. Radiation dose to the fetus Radiation (mSv) Unilateral phlebography without shielding 3.14 Unilateral phlebography with shielding < 0.5 Perfusion scintigraphy (99mTc MAA, 200 MBq) 0.2-0.6 Perfusion scintigraphy (99mTc MAA, 40 MBq) 0.11-0.2 Ventilation sintigraphy (99mTc MAA, aerosol) 0.1-0.3 Ventilation scintigraphy (81m Kr, 600 MBq) 0.0001 Single-detector row helical CT 0.026 Multi-detector row helical CT 0.013 Natural radiation exposure 3.8/a Nijkeuter, J Thromb Haemost 2006
  • 29. • Teratogenesis no major concern after CT • Carcinogenesis: – V/Q scan: higher risk for fetus – CT: higher risk for mother • Contrast media: – Iodinated: seems safe, usual procedure – Gadolinium: contraindicated Diagnosis of PE - imaging techniques Diagnostic issues of VTE in pregnancy
  • 30. Suggested algorithm for exclusion of PE during pregnancy Clinical Suspicion CUS no DVT DVT treat Multi-slice CT (+shielding) / VQ scan (consider clinic, risks, D-Dimer) D-Dimer Diagnostic issues of VTE in pregnancy consider clinic, risks, D-Dimer
  • 31. 36 year old woman • Week 7  proximal deep vein thrombosis left leg • LMWH at therapeutic dose (weight adjusted) • Duration: throughout pregnancy until 6-8 wks after delivery • LMWH dose reduction before delivery • Outpatient care possible Treatment of VTE during pregnancy
  • 32. Bates, Chest 2012 Assisted reproduction • For women undergoing assisted reproduction, we recommend against the use of routine thrombosis prophylaxis (1B). • For women undergoing assisted reproduction who develop severe ovarian hyperstimulation syndrome, we suggest thrombosis prophylaxis (prophylactic LMWH) for 3 months postresolution of clinical ovarian hyperstimulation syndrome rather than no prophylaxis (2C) .
  • 33. Fetal loss Prevalent • 0.5 – 1% of couples (>3) • 3% of couples (>2) Recurrent miscarriage (revised nomenclature 2005) • 3 early (before 12 weeks of gestation) consecutive losses, or • 2 late (after 12 weeks of gestation) pregnancy losses Rai, Lancet 2006; Farquharson, Hum Reprod 2005
  • 34. Recurrent miscarriage ~ 50% explained • Chromosomal abnormalities in the fetus • Abnormal karyotype in the parents • Cervical incompetence • Endometrial infections • Endocrine disorders • Thrombophilia?
  • 35. Thrombophilia and pregnancy complications Rey, Lancet 2003; Robertson, Br J Haematol 2006; Nelen, Fertil Steril 2000 Thrombophilia Sporadic miscarriage OR Recurrent miscarriage OR IU fetal death OR Lupus anticoagulant 3.0 7.8 2.4 Anticardiolipin antibodies 3.4 3.6 - 5.1 3.3 AT deficiency 1.5 0.9 7.6 (1.3 - 42.8) 20.1 (3.7 - 109.2) PC deficiency 1.4 1.6 3.1 PS deficiency heterogeneous data 14.7 (1.0 - 218.0) 7.4 (1.3 - 42.8) 20.1 (3.7 - 109.2) Factor V Leiden 1.7 2.0 2.1 - 3.3 Prothrombin 20210A 2.1 2.3 - 2.7 2.3 - 2.7 Homozygous/ combined defects 2.7 - - Hyperhomocysteinemia 6.3 2.7 - 4.2 1.0
  • 36. Clinical criteria • Thrombosis and/or • pregnancy complications: – >1 intrauterine fetal death (> 10th week); or – >3 consecutive miscarriages (< 10th week); or – >1 preterm delivery < 34th week because of eclampsia, severe preeclampsia, or placental insufficiency Laboratory criteria (2 exams, 12 weeks apart) • Lupusanticoagulants; or • Anticardiolipin-ab (IgG or IgM) medium or high titer (>40 GPL or MPL or >99th percentile); or • Anti-ß2 glycoprotein-I ab (IgG or IgM; > 99th percentile) Miyakis, J Thromb Haemost 2006 APLA-Syndrome
  • 37. Scenario 1: PLA +, previous miscarriage Phospholipidantibodies during pregnancy
  • 38. Relevance LAC ACA ß2GP-AK Recurrent pregnancy loss ++ + ? Late pregnancy loss ++ + ? Preeclampsia +/- +/- ? Placental abruption +/- +/- ? IUGR +/- +/- ? Opatrny, J Rheumatol 2006 Phospholipidantibodies during pregnancy
  • 39. Pregnancy complications and PLA: metaanalysis Early loss Late loss Preeclampsia IUGR LAC 2.97 (1.0-9.8) 2.4 (0.8-7.0) 1.5 (0.7-4.6) 6.9 (2.7-17.7) ACA 3.4 (1.3-8.7) 3.3 (1.6-6.7) 2.7 (1.7-4.5) NA Robertson, Br J Haematol 2005 Phospholipidantibodies during pregnancy
  • 40. Pregnancy complications and PLA Pregnancy loss HR (95% CI) UFH+ASS vs. ASS 0.46 (0.3-0.7) LMWH+ASS vs. ASS 0.78 (0.4-1.6) Ig vs. UFH/LMWH+ASS 2.51 (1.3-5.0) Empson, Cochrane Database of Systematic Reviews 2005
  • 41. Empson, Cochrane Database of Systematic Reviews 2005 Aspirin and pregnancy loss Phospholipidantibodies during pregnancy
  • 42. Empson, Cochrane Database of Systematic Reviews 2005 Heparin and pregnancy loss Phospholipidantibodies during pregnancy
  • 43. Mak, Rheumatology 2010 RR 1.3 (95% CI 1.04 - 1.6) Live births: metaanalysis Phospholipidantibodies during pregnancy
  • 44. Recommendations • For women who fulfill the laboratory criteria for PLA syndrome and meet the clinical PLA criteria based on a history of > 3 pregnancy losses, we recommend antepartum administration of prophylactic LMWH combined with low-dose aspirin, 75 to 100 mg/d, over no treatment (1B). Bates, ACCP Guidelines, Chest 2012Keeling, Br J Haematol 2012 Phospholipidantibodies during pregnancy
  • 45. ALIFE Study Kaandorp, N Eng J Med 2010
  • 46. SPIN Study Clark, Blood 2010 Enoxaparin 40 mg + ASA 75 mg Intensive surveillance > 2 consecutive pregnancy losses 147 147 Pregnancy loss 32 (22%) 29 (20%)OR 0.91 (95% CI 0.5-1.6)
  • 47. HAPPY Trial Martinelli, Blood 2012 N=63 N=65
  • 48. Recommendations • For women with recurrent early pregnancy loss (>3 miscarriages <10 weeks of gestation), we recommend screening for PLAs (1B). • For women with a history of pregnancy complications, we suggest not to screen for inherited thrombophilia (2C). • For women with APS and a history of preeclampsia or IUGR, low dose aspirin is recommended. • Given the absence of evidence that women with PLA syndrome and a single late pregnancy loss, preeclampsia, or fetal growth restriction benefit from the addition of UFH or LMWH to aspirin, we do not recommend for or against screening for PLAs in women with these pregnancy complications. Bates, ACCP Guidelines, Chest 2012Keeling, Br J Haematol 2012
  • 49. Tender loving care 195 couples with recurrent (3 or more) miscarriage 85 without explanation Dedicated antenatal care, psychological support: live birth rate 86% No specific antenatal care: live birth rate 33 % Stray-Pedersen, Am J Obstet Gynecol 1984
  • 50. Scenario 2: PLA +, previous VTE Phospholipidantibodies during pregnancy
  • 51. Vitamin K antagonists and pregnancy  Warfarin-embryopathy - 6th to 9th (12th) gestational week - Dose dependent - Prevalence 5 – 7% - Bone and cartilage malformation - CNS-defects (opticus atrophy, microcephaly, mental retardation), Pathomechanism unclear
  • 52. • Conception during warfarin  stop when pregnancy is confirmed • LMWH at therapeutic dose (weight adjusted) • Last therapeutic dose 24 before planned delivery • Post partum switch to oral anticoagulant Scenario 2: PLA +, previous VTE Phospholipidantibodies during pregnancy
  • 53. • Sex related differences in hemostasis • Specific hormone-related issues – Pregnancy – Hormone use • Oral contraceptives • Hormone replacement therapy Women issues and thrombosis
  • 54. Coagulation factors during oral contraceptives Fibrinogen F II, VII, VIII, X Lowe, Br J Haematol 1997; Middeldorp, Thromb Haemost 2000 Hormone contraceptives F V
  • 55. Anticoagulant system APC-ratio Protein S Hormone contraceptives Lowe, Br J Haematol 1997; Rosing, Lancet 1999; Tans, Thromb Haemost 2000 Antithrombin Protein C
  • 56. Estimated annual incidence of venous thrombosis OC – Vandenbroucke, Lancet 1994 all > 70 yrs OC + 1/100 1/10 000 3-4/10 000
  • 57. Thrombosis Risk According to Duration of OC Use Van Hylckama Vlieg, BMJ 2009 Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis Study (MEGA)
  • 58. Risk of venous thrombosis Van Hylckama Vlieg, BMJ 2009 Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis Study (MEGA)
  • 59. Thrombosis risk according to oestrogen dose Van Hylckama Vlieg, BMJ 2009 Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis Study (MEGA)
  • 60. Risks with use of combined contraceptives van Hylckama Vlieg, J Thromb Haemost 2011 MEGA case-control study OR (95% CI) Danish national cohort study RR (95% CI) Combined oral contraceptives Estrogen 30 µg + noresthisterone Estrogen 30 µg + levonorgestrel Estrogen 37.5 µg + lynestrenol Estrogen 30 µg + norgestimate Estrogen 30 µg + desogestrel Estrogen 30 µg + gestodene Estrogen 30 µg + drospirenone Estrogen 35 µg + cyproterone acetate IUD (Mirena ) 3.9 (1.4-10.6) 3.6 (2.9-4.6) 5.6 (3.0-10.2) 5.9 (1.7-21.0) 7.3 (5.3-10.0) 5.6 (3.7-8.4) 6.3 (2.9-13.7) 6.8 (4.7-10.0) 0.3 (0.1-1.1) 2.02 (1.75-2.34) 3.55 (3.30-3.83) 4.00 (3.26-4.91) 0.89 (0.64-1.26)
  • 61. Risks with use of progestin-only contraceptives Mantha, Br Med Journal 2012 Oral preparations
  • 62. Risks with use of progestin-only contraceptives Mantha, Br Med Journal 2012 Injectables
  • 63. Hormone contraceptives and thrombotic risk • Female hormone intake increases the thrombotic risk • Combined oral contraceptives: – risk related to dose of estrogen and type of progestogen – safest option levonorgestrel combined with a low dose of estrogen • Progestogen-only contraception: – Limited data – Oral preparations considered as generally safe – No increased risk with IUD-Mirena
  • 64. Estimated annual incidence of venous thrombosis OC – FVL – Vandenbroucke, Lancet 1994 all > 70 yrs OC + OC + FVL + FVL + 1/100 0.8/10 000 3/10 000 5.7/10 000 28.5/10 000
  • 65. Family history and the risk of a first VTE Family history Odds Ratio (95% CI) negative 1.0 (ref.) All Any relative >1 relative 2.5 (1.9 - 3.2) 4.2 (2.4 - 7.4) Genetic factors* Any relative >1 relative 2.7 (1.7 - 4.4) 4.9 (1.8 - 13.4) Bezemer, Arch Intern Med 2009 * Low AT/PS/PC, FVL, FII 20210A
  • 66. Hormone contraception Recommendations to a woman without VTE First degree relative + VTE • Not tested  consider alternative contraception • Tested and positive  consider alternative contraception • Tested but negative  consider alternative contraception
  • 67. Hormone replacement therapy • Estrogen (to relief symptoms) – oral, transdermal, intravaginal – daily ± Progestogen (for endometrial protection) – oral, transdermal, IUD – cyclic or daily • Tibolone – oral synthetic steroid; estrogenic, androgenic, and progestogenic actions
  • 68. = FVIII, AT, PC, PS, F1+2, TAT  Fibrinogen, FVII, FIX Menopause Effect on hemostatic parameters Lowe, Br J Haematol 1997
  • 69. Effect on hemostatic parameters Hormone replacement therapy Teede, ATVB 2000
  • 70. Risk of thrombotic events: meta-analysis Sare, Eur Heart J 2008 Subjects / Events OR (95% CI) P-value VTE 42 381 / 547 2.05 (1.44–2.92) <0.0001 Cerebrovascular Disease 43 549 / 1034 1.24 (1.09–1.41) 0.001 Coronary Heart Disease 43 159 / 1636 1.00 (0.90–1.11) 0.97 Hormone replacement therapy
  • 71. Risk of VTE according to dose HRT exposure Rate ratio (95% CI) Oral estrogen Low dose High dose Very high dose 1.52 (1.44–1.61) 1.19 (1.04–1.35) 1.55 (1.45–1.65) 1.84 (1.63–2.09) Hormone replacement therapy Renoux, J Thromb Haemost 2010
  • 72. Risk of VTE according to dose HRT exposure Rate ratio (95% CI) Oral estrogen Low dose High dose Very high dose 1.52 (1.44–1.61) 1.19 (1.04–1.35) 1.55 (1.45–1.65) 1.84 (1.63–2.09) Patch Low dose High dose 1.00 (0.89–1.12) 0.99 (0.87–1.12) 1.05 (0.81–1.36) Hormone replacement therapy Renoux, J Thromb Haemost 2010
  • 73. Cases / Controls OR (95% CI) Non-users 93 / 261 1.0 (ref.) Oral estrogen 32 / 27 3.5 (1.8–6.8) Transdermal estrogen 30 / 93 0.9 (0.5–1.6) Scarabin, Lancet 2003 Hormone replacement therapy Risk of VTE during estrogen replacement
  • 74. HR (95% CI) Non-users 1.0 (ref.) Micronized progesterone 0.9 (0.6-1.5) Pregnane derivatives 1.3 (0.9-2.0) Norpregnane derivatives 1.8 (1.2 -2.7) Nortestosterone 1.4 (0.7–2.4) Hormone replacement therapy Risk of VTE: effect of progestogens Canonico, Arterioscler Thromb Vasc Biol 2010
  • 75. Hormone replacement therapy • Female hormone intake increases the risk of VTE • Risk related to dose and type of estrogen and route of administration • Increased by additional progestogens • Related to type of progestogen • Risk benefit ratio must be assessed in each woman
  • 76. 0 1 2 3 4 5 6 7 p<0.0001 Men Women 10 20 30 40 Men vs. Women Years after anticoagulation Probabilityofrecurrence% Kyrle, N Engl J Med 2004 50 Risk of recurrent VTE
  • 77. Risk of recurrence Years after Discontinuation of Anticoagulation CumulativeProbabilityofRecurrence(%) n = 145 n = 272 no combined contraceptive use combined contraceptive use p < 0.001 *FV Leiden,, age and site of index VTE Eischer, J Thromb Haemost 2014
  • 78. events/patients (n/n) RR* (95% CI) Estrogen - 49/297 1 Estrogen + 22/333 0.4 (0.2-0.8) CC - 27/145 1 CC + 14/272 0.4 (0.2-0.8) HRT - 39/203 1 HRT + 8/57 0.7 (0.3-1.5) * adjusted for age, site of VTE and F V Leiden Risk of recurrence Eischer, J Thromb Haemost 2014
  • 79. Female hormone intake Study Intervention Recurrence/ 100 pt. years 95% CI Christiansen JAMA 2005 OC continued OC discontinued 2.8% 1.3% 1.6 – 5.0 0.8 – 2.1 Høibraaten Thromb Hamost 2000 HRT Placebo 8.5% 1.1% 2.6 – 14.4 0 – 3.2 Risk of recurrent VTE
  • 80. Risk of recurrence: route of administration Olié, Menopause 2011 Hormone replacement therapy Cases / Controls OR (95% CI) Non-users 93 / 261 1.0 (ref.) Oral estrogen 32 / 27 6.4 (1.5 – 27.3) Transdermal estrogen 30 / 93 1.0 (0.4 – 2.4)
  • 81. Risk of recurrent VTE in men and women • The risk of recurrent VTE is significantly lower in women than in men. • No specific predictor of recurrence with the exception of high FVIII was found in men. • In women several distinct risk factors of recurrence could be identified: high D-Dimer, high FVIII, high FIX, FII G20210A, overweight, high hematocrit
  • 82. The difference between men and women - a conundrum!

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