Park SpringerPlus (2016)5:1777 DOI 10.1186/s40064-016-3475-8
Open Access
RESEARCH
Pulmonary embolism is more prevalent than deep vein thrombosis in cases of chronic obstructive pulmonary disease and interstitial lung diseases Sun Hyo Park*
Abstract Background: Chronic lung diseases may have an influence on pulmonary vessel walls as well as on pulmonary haemodynamics. However, there is limited data on the occurrence of pulmonary embolism (PE) and deep vein thrombosis (DVT) in patients with chronic lung diseases, which have the potential to contribute to the development of pulmonary vascular abnormalities. We aimed to explore the prevalence of PE and DVT in patients with COPD and ILD. Methods: We evaluated the venous thromboembolism prevalence associated with COPD and ILD using Korean Health Insurance Review and Assessment Service (HIRA) data from January 2011 to December 2011. This database (HIRA-NPS-2011-0001) was created using random sampling of outpatients; 1,375,842 sample cases were collected, and 670,258 (age ≥40) cases were evaluated. Patients with COPD, ILDs, or CTD were identified using the International Classification of Disease-10 diagnostic codes. Results: The PE prevalence rates per 100,000 persons for the study population with COPD, ILD, CTD, and the general population were 1185, 1746, 412, and 113, respectively, while the DVT prevalence for each group was 637, 582, 563, and 138, respectively. Conclusions: PE prevalence was significantly higher than that of DVT in patients with COPD or ILDs, while the prevalence of PE was lower than that for DVT in the general population or in patients with CTD. Keywords: Chronic obstructive pulmonary disease, Interstitial lung disease, Pulmonary embolism, Deep vein thrombosis, Prevalence Background The pathogenesis of pulmonary embolism (PE) explained by deep venous thrombosis (DVT), develops in the lower extremities where clots may dislodge and travel through the inferior vena cava eventually lodging in the pulmonary arteries (Elliott 1992). Small clots from the lower extremities may start to lyse immediately and may resolve without serious clinical deterioration. According to Virchow, venous thrombosis can be explained by blood stagnation (stasis), hypercoagulability, *Correspondence: [email protected] Department of Internal Medicine, Keimyung University Dongsan Medical Center, 56 Dalseong‑ro, Jung‑gu, Daegu 41931, Republic of Korea
and vascular endothelial damage (endothelial dysfunction) (Bagot and Arya 2008). Venous blood flow generation is partly contributed to by the contraction of the muscle. It is thought that the pulmonary artery is unlikely to experience vascular injury from external factors. However, chronic lung diseases such as chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD) may have an effect on the pulmonary circulation. In addition to airway and lung parenchymal abnormalities, COPD is also characterized by pulmonary vascular alterations, including medial wall thickening and muscularization of nonmuscularized arterioles (Magee et al. 1988; Wright et al. 1992). There have been studies that have focused on the vascular abnormalities experienced
© 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Park SpringerPlus (2016)5:1777
in ILDs, such as increased angiogenic chemokines, aberrant angiogenesis, and capillary endothelial abnormalities (Keane et al. 1997; Cosgrove et al. 2004; Renzoni et al. 2003; Sakao et al. 2006). Finally, the higher prevalence of pulmonary hypertension in patients with ILDs and COPD may contribute to increased vascular resistance of the pulmonary vascular beds as well as stagnation of blood flow (Chaouat et al. 2008; Behr and Ryu 2008). Therefore, we suspect that pulmonary vascular bed alterations may be involved in PE and lower extremity vein thrombosis epidemiology. We hypothesized that patients with chronic lung diseases involving pulmonary vascular beds would have a higher prevalence of PE rather than DVT. To test the hypothesis, we investigated the prevalence of PE and DVT with chronic lung diseases and connective tissue disorders (CTDs) and within the general population.
Methods Study subjects
This is a retrospective cohort study based on data collected from the Korean Health Insurance Review and Assessment Service (HIRA) national database. HIRA is a government-affiliated organization that builds an accurate claims review and is a quality assessment system for the National Health Insurance (NHI). The NHI is the only public medical insurance system operated by the Ministry of Health and Welfare in Korea (Kim 2010a, b). We evaluated the prevalence of lung cancer associated with ILD and idiopathic pulmonary fibrosis (IPF) utilizing HIRA data from January 2011 to December 2011. The database (HIRA-NPS-2011-0001) was based on a stratified random sampling of outpatients from the whole population. However, data included both outpatients and inpatients health services utilization. However, data include both outpatients and inpatients health services utilization. The database (HIRA-NPS-2011-0001) was built with first medical claims of the patients during 2011 and followed up until December 2011. Extracting patients by stratification system were based on gender, age range, as well as diagnostic and prescription history. There were 1,375,842 sample cases and 670,258 of these (age ≥40) cases were evaluated. Patients with CTD, ILD, or COPD were identified based on the International Classification of Disease-10 (ICD-10) diagnostic codes. This study was approved by the institutional review board at Dongsan Hospital, Keimyung University School of Medicine. Consent was not obtained since the patient information was anonymized. Case identification
Cases were included in the study based upon diagnostic and treatment evidence of ILDs and IPF. Each case was included both the diagnostic and procedure codes were
Page 2 of 6
identified simultaneously. Diagnosis interstitial lung disease was based on doctor’s clinical judgment based on chest radiographic findings. These processes were performed automatically using a computer-based program. The ICD-10 diagnostic codes are used as a reference for the medical diagnosis of diseases and within the health insurance system. We used the J44 (ICD-10 code) for the obstructive pulmonary disease. The diagnosis of COPD was based on clinical findings and spirometry. The codes used for the identification of systemic CTDs were as follows: M05 for rheumatoid arthritis; M07 for psoriatic and enteropathic arthropathies; M30 for polyarteritis; M31 for other necrotizing vasculopathies; M32 for systemic lupus erythematosus; M33 for dermatopolymyositis; M34 for systemic sclerosis; M35 for other systemic involvement of connective tissue; and M45 for ankylosing spondylitis. The codes used for DVT included I80.2 (DVT, not otherwise specified [NOS]) and I80.3 (embolism or thrombosis of a lower extremity, NOS). The codes used for PE included I26 (pulmonary thromboembolism), I26.0 (PE with mention of acute cor pulmonale), and I26.9 (PE, NOS). The codes used for intra-abdominal thrombosis (IAT) included I81 (portal vein thrombosis), I82 (other venous embolism or thrombosis), I82.0 (Budd–Chiari syndrome), I82.2 (embolism or thrombosis of the vena cava), and I82.3 (embolism or thrombosis of the renal vein). The codes used for thrombosis, no specified site (TNSS) included I82.8 (embolism and thrombosis of other specified veins) and I82.9 [embolism of the vein, NOS, and thrombosis (vein), NOS]. Cases that were recorded as both DVT and PE we regarded as cases of PE. Venous thromboembolism was validated by simultaneous anticoagulation at the time of diagnosis. Analysis
We counted the number of patients diagnosed with ILD, CTD, or COPD in 2011 and calculated the prevalence rate. Ninety-five percent confidence intervals (CIs) were calculated using the normal approximation to the binomial distribution. A χ2 test was used to compare frequencies. P values
Open Access
RESEARCH
Pulmonary embolism is more prevalent than deep vein thrombosis in cases of chronic obstructive pulmonary disease and interstitial lung diseases Sun Hyo Park*
Abstract Background: Chronic lung diseases may have an influence on pulmonary vessel walls as well as on pulmonary haemodynamics. However, there is limited data on the occurrence of pulmonary embolism (PE) and deep vein thrombosis (DVT) in patients with chronic lung diseases, which have the potential to contribute to the development of pulmonary vascular abnormalities. We aimed to explore the prevalence of PE and DVT in patients with COPD and ILD. Methods: We evaluated the venous thromboembolism prevalence associated with COPD and ILD using Korean Health Insurance Review and Assessment Service (HIRA) data from January 2011 to December 2011. This database (HIRA-NPS-2011-0001) was created using random sampling of outpatients; 1,375,842 sample cases were collected, and 670,258 (age ≥40) cases were evaluated. Patients with COPD, ILDs, or CTD were identified using the International Classification of Disease-10 diagnostic codes. Results: The PE prevalence rates per 100,000 persons for the study population with COPD, ILD, CTD, and the general population were 1185, 1746, 412, and 113, respectively, while the DVT prevalence for each group was 637, 582, 563, and 138, respectively. Conclusions: PE prevalence was significantly higher than that of DVT in patients with COPD or ILDs, while the prevalence of PE was lower than that for DVT in the general population or in patients with CTD. Keywords: Chronic obstructive pulmonary disease, Interstitial lung disease, Pulmonary embolism, Deep vein thrombosis, Prevalence Background The pathogenesis of pulmonary embolism (PE) explained by deep venous thrombosis (DVT), develops in the lower extremities where clots may dislodge and travel through the inferior vena cava eventually lodging in the pulmonary arteries (Elliott 1992). Small clots from the lower extremities may start to lyse immediately and may resolve without serious clinical deterioration. According to Virchow, venous thrombosis can be explained by blood stagnation (stasis), hypercoagulability, *Correspondence: [email protected] Department of Internal Medicine, Keimyung University Dongsan Medical Center, 56 Dalseong‑ro, Jung‑gu, Daegu 41931, Republic of Korea
and vascular endothelial damage (endothelial dysfunction) (Bagot and Arya 2008). Venous blood flow generation is partly contributed to by the contraction of the muscle. It is thought that the pulmonary artery is unlikely to experience vascular injury from external factors. However, chronic lung diseases such as chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD) may have an effect on the pulmonary circulation. In addition to airway and lung parenchymal abnormalities, COPD is also characterized by pulmonary vascular alterations, including medial wall thickening and muscularization of nonmuscularized arterioles (Magee et al. 1988; Wright et al. 1992). There have been studies that have focused on the vascular abnormalities experienced
© 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Park SpringerPlus (2016)5:1777
in ILDs, such as increased angiogenic chemokines, aberrant angiogenesis, and capillary endothelial abnormalities (Keane et al. 1997; Cosgrove et al. 2004; Renzoni et al. 2003; Sakao et al. 2006). Finally, the higher prevalence of pulmonary hypertension in patients with ILDs and COPD may contribute to increased vascular resistance of the pulmonary vascular beds as well as stagnation of blood flow (Chaouat et al. 2008; Behr and Ryu 2008). Therefore, we suspect that pulmonary vascular bed alterations may be involved in PE and lower extremity vein thrombosis epidemiology. We hypothesized that patients with chronic lung diseases involving pulmonary vascular beds would have a higher prevalence of PE rather than DVT. To test the hypothesis, we investigated the prevalence of PE and DVT with chronic lung diseases and connective tissue disorders (CTDs) and within the general population.
Methods Study subjects
This is a retrospective cohort study based on data collected from the Korean Health Insurance Review and Assessment Service (HIRA) national database. HIRA is a government-affiliated organization that builds an accurate claims review and is a quality assessment system for the National Health Insurance (NHI). The NHI is the only public medical insurance system operated by the Ministry of Health and Welfare in Korea (Kim 2010a, b). We evaluated the prevalence of lung cancer associated with ILD and idiopathic pulmonary fibrosis (IPF) utilizing HIRA data from January 2011 to December 2011. The database (HIRA-NPS-2011-0001) was based on a stratified random sampling of outpatients from the whole population. However, data included both outpatients and inpatients health services utilization. However, data include both outpatients and inpatients health services utilization. The database (HIRA-NPS-2011-0001) was built with first medical claims of the patients during 2011 and followed up until December 2011. Extracting patients by stratification system were based on gender, age range, as well as diagnostic and prescription history. There were 1,375,842 sample cases and 670,258 of these (age ≥40) cases were evaluated. Patients with CTD, ILD, or COPD were identified based on the International Classification of Disease-10 (ICD-10) diagnostic codes. This study was approved by the institutional review board at Dongsan Hospital, Keimyung University School of Medicine. Consent was not obtained since the patient information was anonymized. Case identification
Cases were included in the study based upon diagnostic and treatment evidence of ILDs and IPF. Each case was included both the diagnostic and procedure codes were
Page 2 of 6
identified simultaneously. Diagnosis interstitial lung disease was based on doctor’s clinical judgment based on chest radiographic findings. These processes were performed automatically using a computer-based program. The ICD-10 diagnostic codes are used as a reference for the medical diagnosis of diseases and within the health insurance system. We used the J44 (ICD-10 code) for the obstructive pulmonary disease. The diagnosis of COPD was based on clinical findings and spirometry. The codes used for the identification of systemic CTDs were as follows: M05 for rheumatoid arthritis; M07 for psoriatic and enteropathic arthropathies; M30 for polyarteritis; M31 for other necrotizing vasculopathies; M32 for systemic lupus erythematosus; M33 for dermatopolymyositis; M34 for systemic sclerosis; M35 for other systemic involvement of connective tissue; and M45 for ankylosing spondylitis. The codes used for DVT included I80.2 (DVT, not otherwise specified [NOS]) and I80.3 (embolism or thrombosis of a lower extremity, NOS). The codes used for PE included I26 (pulmonary thromboembolism), I26.0 (PE with mention of acute cor pulmonale), and I26.9 (PE, NOS). The codes used for intra-abdominal thrombosis (IAT) included I81 (portal vein thrombosis), I82 (other venous embolism or thrombosis), I82.0 (Budd–Chiari syndrome), I82.2 (embolism or thrombosis of the vena cava), and I82.3 (embolism or thrombosis of the renal vein). The codes used for thrombosis, no specified site (TNSS) included I82.8 (embolism and thrombosis of other specified veins) and I82.9 [embolism of the vein, NOS, and thrombosis (vein), NOS]. Cases that were recorded as both DVT and PE we regarded as cases of PE. Venous thromboembolism was validated by simultaneous anticoagulation at the time of diagnosis. Analysis
We counted the number of patients diagnosed with ILD, CTD, or COPD in 2011 and calculated the prevalence rate. Ninety-five percent confidence intervals (CIs) were calculated using the normal approximation to the binomial distribution. A χ2 test was used to compare frequencies. P values
