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Herrmann J, López-Fernández T, Lyon AR. The year in cardiovascular medicine 2023: the top 10 papers in cardio-oncology. Eur Heart J 2024:ehae194. [PMID: 38591649 DOI: 10.1093/eurheartj/ehae194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/14/2024] [Accepted: 03/14/2024] [Indexed: 04/10/2024] Open
Affiliation(s)
- Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA
| | - Teresa López-Fernández
- Division of Cardiology, Cardiac Imaging and Cardio-Oncology Unit, La Paz University Hospital, IdiPAZ Research Institute, Paseo de la Castellana 261, 28046 Madrid, Spain
- Cardiology Department, Quiron Pozuelo University Hospital, Calle Diego de Velazquez 1, Pozuelo de Alarcón, 28223 Madrid, Spain
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Truong B, Hornsby L, Fox B, Chou C, Zheng J, Qian J. Benefit and risk of oral anticoagulant initiation strategies in patients with atrial fibrillation and cancer: a target trial emulation using the SEER-Medicare database. J Thromb Thrombolysis 2024; 57:638-649. [PMID: 38504063 PMCID: PMC11026243 DOI: 10.1007/s11239-024-02958-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/21/2024]
Abstract
Oral anticoagulants (OACs) are recommended for patients with atrial fibrillation (AFib) having CHA2DS2-VASc score ≥ 2. However, the benefits of OAC initiation in patients with AFib and cancer at different levels of CHA2DS2-VASc is unknown. We included patients with new AFib diagnosis and a record of cancer (breast, prostate, or lung) from the 2012-2019 Surveillance, Epidemiology, and End Results (SEER)-Medicare database (n = 39,915). Risks of stroke and bleeding were compared between 5 treatment strategies: (1) initiated OAC when CHA2DS2-VASc ≥ 1 (n = 6008), (2) CHA2DS2-VASc ≥ 2 (n = 8694), (3) CHA2DS2-VASc ≥ 4 (n = 20,286), (4) CHA2DS2-VASc ≥ 6 (n = 30,944), and (5) never initiated OAC (reference group, n = 33,907). Confounders were adjusted using inverse probability weighting through cloning-censoring-weighting approach. Weighted pooled logistic regressions were used to estimate treatment effect [hazard ratios (HRs) and 95% confidence interval (95% CIs)]. We found that only patients who initiated OACs at CHA2DS2-VASc ≥ 6 had lower risk of stroke compared without OAC initiation (HR 0.64, 95% CI 0.54-0.75). All 4 active treatment strategies had reduced risk of bleeding compared to non-initiators, with OAC initiation at CHA2DS2-VASc ≥ 6 being the most beneficial strategy (HR = 0.49, 95% CI 0.44-0.55). In patients with lung cancer or regional/metastatic cancer, OAC initiation at any CHA2DS2-VASc level increased risk of stroke and did not reduce risk of bleeding (except for Regimen 4). In conclusion, among cancer patients with new AFib diagnosis, OAC initiation at higher risk of stroke (CHA2DS2-VASc score ≥ 6) is more beneficial in preventing ischemic stroke and bleeding. Patients with advanced cancer or low life-expectancy may initiate OACs when CHA2DS2-VASc score ≥ 6.
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Affiliation(s)
- Bang Truong
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306d Walker Building, Auburn, AL, 36849, USA
| | - Lori Hornsby
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Brent Fox
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306d Walker Building, Auburn, AL, 36849, USA
| | - Chiahung Chou
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306d Walker Building, Auburn, AL, 36849, USA
| | - Jingyi Zheng
- Department of Mathematics and Statistics, Auburn University College of Sciences and Mathematics, Auburn, AL, USA
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306d Walker Building, Auburn, AL, 36849, USA.
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Cheong MA, Leader A. Cancer and arterial thrombosis: therapeutic options. Res Pract Thromb Haemost 2024; 8:102393. [PMID: 38660456 PMCID: PMC11039399 DOI: 10.1016/j.rpth.2024.102393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
A State of the Art lecture titled "Cancer and Arterial Thrombosis: Therapeutic Options" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. This State of the Art review delves into the complex relationship between cancer and arterial thromboembolism (ATE), encompassing acute coronary syndrome, ischemic strokes, and peripheral arterial disease. The burden of cancer-associated ATE is not well defined, but studies indicate elevated risks, particularly in the 6 months after a cancer diagnosis. Incidence varies among cancer subtypes, with lung cancer displaying the highest rates. Additionally, the pathophysiology of cancer-associated ATE involves a multifaceted interplay of cancer-induced hypercoagulopathy, cancer therapy-related thrombosis, and personal risk factor contributors. ATEs are clinically heterogeneous and in the context of cancer have particular mechanistic differences compared with ATE patients without cancer. This requires modifications in approach and tailored management considerations. Specific etiologies contributing to ATE, such as coronary vasospasm and non-bacterial-thrombotic endocarditis, need to be considered. The diagnosis of cancer alone usually does not contraindicate patients to standard guideline-based therapies for the management of ATE, although nuances in treatment may need to be considered in light of the underlying cancer. Atrial fibrillation in cancer patients further complicates the thrombotic landscape. Cancer patients with atrial fibrillation are at a higher risk of ATE, necessitating careful consideration of anticoagulation therapy as clinical benefits and bleeding risks need to be weighed. ATE may also be a presenting sign of underlying malignancy, which requires increased awareness and focused clinical evaluation for cancer in selected cases. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- May Anne Cheong
- Department of Haematology, Singapore General Hospital, Singapore
| | - Avi Leader
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Drozdinsky G, Arad N, Spectre G, Livneh N, Poran I, Raanani P, Falanga A, Ten Cate H, Gafter-Gvili A, Leader A. Anticoagulation in cancer patients with atrial fibrillation and grade 3-4 thrombocytopenia. Thromb Res 2024; 235:92-97. [PMID: 38308884 DOI: 10.1016/j.thromres.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/03/2024] [Accepted: 01/17/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Atrial fibrillation or flutter (AF) is prevalent in cancer patients. Many of these patients have an indication for anticoagulation (AC) but are also at risk for developing chemotherapy-induced thrombocytopenia. There are scarce data regarding management of AC and risk of bleeding and thrombosis in cancer patients with AF and thrombocytopenia. AIM To assess anticoagulation management and incidence of bleeding and arterial thromboembolism (ATE) in cancer patients with AF and grade 3-4 thrombocytopenia (platelets <50 × 109/L). METHODS A retrospective cohort study included adults with active cancer, grade 3-4 thrombocytopenia and AF with CHA2DS2-VASc score ≥ 1. Patients were stratified according to AC discontinuation (No-AC) or continuation (Continue-AC) when platelets dropped below 50 × 109/L and followed for 30 days. The study outcomes were ATE (ischemic stroke, transient ischemic attack or systemic emboli) and major bleeding. Cox proportional hazards model was used to calculate hazard ratios (HR) with death as a competing risk (Fine and Gray model). RESULTS The cohort included 131 patients; 90 in the No-AC group and 41 in the Continue-AC group. Patient characteristics were balanced between the groups. The 30-day cumulative incidence of ATE was 2 % [95 % CI 0.4 %-7 %] in the No-AC group and 2 % [0.2 %-11 %] in the Continue-AC group (HR 0.92 [95 % CI 0.09-9.88]). The 30-day cumulative incidence of major bleeding was 7.8 % [95 % CI 3.40 %-14.52 %] and 2.44 % [95 % CI 0.18 %-11.22 %] in the No-AC and Continue-AC groups, respectively (HR 3.29 [95 % CI 0.42-26.04]). CONCLUSIONS The high rate of bleeding and low rate of ATE in thrombocytopenic cancer patients with AF suggests that holding AC during time-limited periods may be a reasonable approach.
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Affiliation(s)
- Genady Drozdinsky
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Arad
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Spectre
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Nir Livneh
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Otolaryngology Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - Itamar Poran
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Anna Falanga
- University of Milano-Bicocca, Department of Medicine, Milan, Italy; Immunohematology and Transfusion Medicine Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Hugo Ten Cate
- Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Center for Thrombosis and Hemostasis, Gutenberg University Medical Center, Mainz, Germany
| | - Anat Gafter-Gvili
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; Department of Medicine A, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; Hematology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, US; Weill Cornell Medical College, New York, NY, USA.
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Pernod G, Cohen A, Mismetti P, Sanchez O, Mahé I. Cancer-related arterial thromboembolic events. Arch Cardiovasc Dis 2024; 117:101-113. [PMID: 38057257 DOI: 10.1016/j.acvd.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/08/2023]
Abstract
Cancer is associated with a hypercoagulable state and is a well-known independent risk factor for venous thromboembolism, whereas the association between cancer and arterial thromboembolism is less well established. Arterial thromboembolism, primarily defined as myocardial infarction or stroke is significantly more frequent in patients with cancer, independently of vascular risk factors and associated with a three-fold increase in the risk of mortality. Patients with brain cancer, lung cancer, colorectal cancer and pancreatic cancer have the highest relative risk of developing arterial thromboembolism. Antithrombotic treatments should be used with caution due to the increased risk of haemorrhage, as specified in current practice guidelines.
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Affiliation(s)
- Gilles Pernod
- Service de Médecine Vasculaire, Université Grenoble-Alpes, Grenoble, France; F-CRIN INNOVTE network, Saint-Etienne, France.
| | - Ariel Cohen
- Service de cardiologie, hôpital Saint-Antoine, hôpital Tenon, Assistance publique-Hôpitaux de Paris, Sorbonne université, Paris, France; Unité INSERM UMRS 1166 Unité de recherche sur les maladies cardiovasculaires et métaboliques, Institut Hospitalo-Universitaire, Institut de Cardiométabolisme et Nutrition (ICAN), 75013, Sorbonne Université, Paris, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Olivier Sanchez
- Service de pneumologie et de soins intensifs, AP-HP, hôpital européen Georges-Pompidou, Paris, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Isabelle Mahé
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; F-CRIN INNOVTE network, Saint-Etienne, France
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De Luca L, Camilli M, Canale ML, Mistrulli R, Andreoli F, Giacalone G, Turazza FM, Gabrielli D, Bisceglia I. Current Data and Future Perspectives on Patients with Atrial Fibrillation and Cancer. Cancers (Basel) 2023; 15:5357. [PMID: 38001617 PMCID: PMC10670853 DOI: 10.3390/cancers15225357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Atrial fibrillation (AF) is an increasingly recognized comorbidity in patients with cancer. Indeed, cancer patients have a significantly higher incidence of AF than that observed in the general population. A reciprocal relationship between these two diseases has been observed, as much as some assume AF to be a marker for occult cancer screening, especially in older adults. The pathophysiological mechanisms are many and varied, including the underlying pro-inflammatory state, specific treatments (chemo- and radiotherapy), and surgery. The therapeutic management of patients with cancer and AF involves the same rhythm and frequency control strategies as the general population; however, the numerous interactions with chemotherapeutics, which lead to a significant increase in side effects, as well as the extreme fragility of the patient, should be considered. Anticoagulant therapy is also a complex challenge to address, as bleeding and stroke risk scores have not been fully assessed in this subpopulation. Furthermore, in large studies establishing the efficacy of direct oral anticoagulants (DOACs), cancer patients have been underrepresented. In this review, we elaborate on the mechanisms linking AF to cancer patients with a particular focus on the therapeutic challenges in this population.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy; (D.G.); (I.B.)
| | - Massimiliano Camilli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy;
| | - Maria Laura Canale
- Division of Cardiology, Azienda USL Toscana Nord-Ovest, Versilia Hospital, 55041 Lido di Camaiore, Italy;
| | - Raffaella Mistrulli
- Clinical and Molecular Medicine Department, Sapienza University of Rome, 00185 Roma, Italy; (R.M.); (F.A.); (G.G.)
| | - Federico Andreoli
- Clinical and Molecular Medicine Department, Sapienza University of Rome, 00185 Roma, Italy; (R.M.); (F.A.); (G.G.)
| | - Guido Giacalone
- Clinical and Molecular Medicine Department, Sapienza University of Rome, 00185 Roma, Italy; (R.M.); (F.A.); (G.G.)
| | - Fabio Maria Turazza
- Cardiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy;
| | - Domenico Gabrielli
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy; (D.G.); (I.B.)
| | - Irma Bisceglia
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy; (D.G.); (I.B.)
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Wang TF, Carrier M. Revisiting important issues in cancer and atrial fibrillation. Res Pract Thromb Haemost 2023; 7:100156. [PMID: 37255852 PMCID: PMC10225913 DOI: 10.1016/j.rpth.2023.100156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 06/01/2023] Open
Affiliation(s)
- Tzu-Fei Wang
- Correspondence Tzu-Fei Wang, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 201A, Ottawa, ON K1H 8L6, Canada. @TzufeiWang
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