Photo Credit: ALIOUI Mohammed Elamine

Managing acute VTE risks in thrombocytopenia is challenging for clinicians, given the substantial gap in guidelines addressing the decision-making process.

Managing acute venous thromboembolism (VTE) in patients with thrombocytopenia is challenging for clinicians given the substantial gap in guidelines addressing the decision-making process in this patient population.

New research from Ramón Lecumberri, MD, PhD, and colleagues provided important insights that challenge and expand upon the existing paradigms of VTE management. They reported their findings in the American Journal of Hematology.

Using data from the RIETE registry to investigate the impact of baseline thrombocytopenia on early VTE-related outcomes, depending on the initial presentation as pulmonary embolism (PE) or isolated lower-limb deep vein thrombosis (DVT), the researchers conducted a comprehensive analysis of 90,418 patients with VTE. The study included adult patients who were diagnosed with symptomatic DVT in the lower limbs or PE, confirmed by objective imaging tests.

Thrombocytopenia was categorized as severe (<50,000/μL; n=303) or moderate (50,000-99,999/μL; n=1882). The primary outcome was fatal PE within 15 days of diagnosis. Secondary outcomes included VTE recurrence, major bleeding, and all-cause mortality.

Among the 52,703 patients with PE, those with severe thrombocytopenia had a cumulative incidence rate of fatal PE of 5.5% within the first 15 days after diagnosis, compared with 4.5% in patients with moderate thrombocytopenia and 1.1% in those with normal platelet counts. The researchers observed a similar pattern in major bleeding events, with a cumulative incidence of 4.5%, 3.6%, and 1.4% in each subgroup. In the 37,715 patients with isolated DVT, the cumulative incidences of fatal PE were 0%, 0.2%, and 0.05%.

Multivariable analysis confirmed a consistent increase in the risk of fatal PE, major bleeding, and recurrent VTE. The findings showed a five-fold increase in the risk for fatal PE in severe thrombocytopenia (aHR, 4.89; 95% CI, 2.55-9.39), while moderate thrombocytopenia increased the risk for fatal PE by nearly four-fold (HR, 3.80; 95% CI, 2.74–5.27). Additionally, initial presentation with PE significantly worsened prognosis compared with isolated DVT.

“The heightened risk of early fatal PE, major bleeding, and recurrent VTE in patients with baseline thrombocytopenia, especially in those presenting with acute PE, emphasizes the need for a nuanced approach to their care,” the authors said. “Moderate thrombocytopenia is not substantially safer than severe thrombocytopenia, inviting a paradigm shift in treatment strategies, ensuring that all thrombocytopenic patients receive the vigilant care necessary to mitigate the risks of adverse outcomes.”