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Cohen AT, Wallenhorst C, Choudhuri S, Nassar A, Pollock KG, Martinez C. A Novel Risk Prediction Score for Clinically Significant Bleeding in Patients Anticoagulated for Venous Thromboembolism with Active Cancer. Thromb Haemost 2024; 124:324-336. [PMID: 37527782 DOI: 10.1055/a-2145-7238] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
BACKGROUND Cancer-associated venous thromboembolism (Ca-VTE) treatment with anticoagulation is associated with bleeding complications and there are limited data on risk factors. Current models do not provide accurate bleeding risk prediction. METHODS UK Clinical Practice Research Datalink data (2008-2020) were used to generate a cohort of patients with anticoagulant initiation for first Ca-VTE. Patients were observed up to 180 days for significant bleeding including major bleeding and clinically relevant nonmajor bleeding requiring hospitalization (CRNMB-H). A scoring scheme was developed from sub-distribution hazard ratios, and its discrimination (expressed by the C-statistic) estimated from cross-validation. RESULTS A total of 15,749 patients with Ca-VTE and anticoagulant treatment were included. In total, 537 significant bleeding events, 161 major bleeds, and 376 CRNMB-H were identified after adjudicated review in 4,914 person-years of observation. Incidence rates of 3.3 and 7.7 per 100 person-years were noted for major bleeding and CRNMB-H. Independent predictors of significant bleeding included cancer of the bladder, central nervous system, cervix, kidney, melanoma, prostate and upper gastrointestinal tract, metastases, minor surgery, minor trauma, and history of major bleeding or CRNMB (before or after the Ca-VTE diagnosis). Patients recognized as low, medium, and high risk (30.4, 56.8, and 1.7% of the population, respectively) had a 6-month significant bleeding incidence rate of 5.1, 19.0, and 56.5 per 100 person-years, respectively. Overall C-statistic for significant bleeding was 0.70 (95% confidence interval: 0.65-0.75), and 0.76 (0.68-0.84) and 0.67 (0.61-0.73) for major bleeding and for CRNMB-H, respectively. CONCLUSION This risk score may identify patients at risk of significant bleeding, while also helping to determine treatment duration.
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Affiliation(s)
- Alexander T Cohen
- Department of Haematology, Guy's and St Thomas' Hospitals, NHS Foundation Trust, King's College London, London, United Kingdom
| | | | | | - Ayman Nassar
- Bristol Myers Squibb Pharmaceuticals Ltd., Uxbridge, Middlesex, United Kingdom
| | - Kevin G Pollock
- Bristol Myers Squibb Pharmaceuticals Ltd., Uxbridge, Middlesex, United Kingdom
| | - Carlos Martinez
- Institute for Epidemiology, Statistics and Informatics GmbH, Frankfurt, Germany
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2
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Shaw JR, Li N, Abdulrehman J, Stella SF, St John M, Nixon J, Spyropoulos AC, Schulman S, Wang TF, Carrier M, Douketis JD. Periprocedural management of direct oral anticoagulants in patients with atrial fibrillation and active cancer. J Thromb Haemost 2024; 22:727-737. [PMID: 37949316 DOI: 10.1016/j.jtha.2023.10.028] [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: 09/22/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Cancer and atrial fibrillation (AF) are common concurrent disorders. Direct oral anticoagulants (DOACs) are prescribed to prevent stroke in patients with AF. Patients with cancer often undergo invasive procedures for diagnostic or therapeutic purposes, necessitating interruption of anticoagulation. There are limited data to guide best periprocedural anticoagulation management practices in the setting of active cancer. OBJECTIVES To describe patient characteristics, periprocedural management, and clinical outcomes in DOAC-treated patients with AF according to active cancer status. METHODS We conducted descriptive and comparative analyses using data from the PAUSE study. Multivariable logistic regression was used to determine whether active cancer status was an independent risk factor for bleeding outcomes. Covariates were selected a priori based on biological rationale and preexisting knowledge. RESULTS Patients with active cancer were older (P < .001), more likely to be thrombocytopenic (P = .026), have moderate renal dysfunction (P = .005), and more likely to receive low-dose DOAC therapy (P < .001). A greater proportion of patients with active cancer underwent a high-bleed-risk procedure (P < .001), with longer periprocedural DOAC-interruption intervals (P <.001) and lower preprocedural residual DOAC levels (P = .002). Active cancer was an independent predictor for surgical major bleeding (OR = 2.45; 95% CI, 1.08-5.14) after adjusting for study center, procedure category and bleed risk, thrombocytopenia, hypertension, and the use of a P2Y12 inhibitor. CONCLUSIONS Active cancer status is associated with an increased risk of surgical major bleeding among DOAC-treated patients with AF undergoing interruption of anticoagulation for elective invasive procedures.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Na Li
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Department of Computing and Software, McMaster University, Hamilton, ON, Canada
| | | | | | - Melanie St John
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Joanne Nixon
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, New York, USA. https://twitter.com/AlexSpyropoul
| | - Sam Schulman
- Department of Obstetrics and Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, ON, Canada. https://twitter.com/TzufeiWang
| | - Marc Carrier
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, ON, Canada. https://twitter.com/MarcCarrier1
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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3
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Ozawa M, Sone M, Sugawara S, Itou C, Kimura S, Arai Y, Kusumoto M. Necessity of Prophylactic Anticoagulation Therapy Following Inferior Vena Cava Stent Placement in Patients with Cancer. INTERVENTIONAL RADIOLOGY (HIGASHIMATSUYAMA-SHI (JAPAN) 2023; 8:70-74. [PMID: 37485490 PMCID: PMC10359174 DOI: 10.22575/interventionalradiology.2022-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/23/2023] [Indexed: 07/25/2023]
Abstract
Purpose Although percutaneous stent placement for malignant inferior vena cava syndrome is a highly feasible and effective treatment option, there is no clear evidence for the necessity of prophylactic anticoagulation therapy after inferior vena cava stent placement. This study retrospectively evaluated the necessity of prophylactic anticoagulation following inferior vena cava stent placement in patients with malignant inferior vena cava syndrome. Methods The data of 54 patients (28 men and 26 women; median age 61.2 years) with malignant inferior vena cava syndrome who received inferior vena cava stent placement between 2011 and 2021 were retrospectively reviewed. Prophylactic anticoagulation was administered to 15 of 54 patients (27.8%) following stent placement. Symptom recurrence rates at 1 and 2 months after stent placement were compared between patients with and without prophylactic anticoagulation using Gray relational analysis. The timeline of symptom recurrence, survival time, and adverse events were also evaluated. Results At 1 and 2 months, symptom recurrence rates were 48.6% and 71.4%, respectively, in patients with prophylactic anticoagulation and 28.3% and 37.0%, respectively, in patients without prophylactic anticoagulation. The overall median follow-up duration was 27 days and that of the patients with and without prophylactic anticoagulation was 37 and 25 days, respectively. The median survival times of patients with and without anticoagulation therapy were 69 and 30 days, respectively (p = 0.236). No procedure-related complications occurred. Conclusions There was no significant difference in the symptom recurrence rates after inferior vena cava stent placement with or without prophylactic anticoagulation in this study.
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Affiliation(s)
- Mizuki Ozawa
- Department of Diagnostic Radiology, National Cancer Center Hospital, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology, National Cancer Center Hospital, Japan
| | - Shunsuke Sugawara
- Department of Diagnostic Radiology, National Cancer Center Hospital, Japan
| | - Chihiro Itou
- Department of Diagnostic Radiology, National Cancer Center Hospital, Japan
| | - Shintaro Kimura
- Department of Diagnostic Radiology, National Cancer Center Hospital, Japan
| | - Yasuaki Arai
- Department of Diagnostic Radiology, National Cancer Center Hospital, Japan
| | - Masahiko Kusumoto
- Department of Diagnostic Radiology, National Cancer Center Hospital, Japan
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Verso M, Agnelli G, Munoz A, Connors JM, Sanchez O, Huisman M, Brenner B, Gussoni G, Cohen AT, Becattini C. Recurrent venous thromboembolism and major bleeding in patients with localised, locally advanced or metastatic cancer: an analysis of the Caravaggio study. Eur J Cancer 2022; 165:136-145. [DOI: 10.1016/j.ejca.2022.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/19/2022] [Accepted: 01/28/2022] [Indexed: 01/01/2023]
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Factors affecting the recurrence in patients with venous thromboembolism: A retrospective cohort study. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:384-390. [PMID: 34589258 PMCID: PMC8462109 DOI: 10.5606/tgkdc.dergisi.2021.20679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/13/2020] [Indexed: 11/29/2022]
Abstract
Background
The aim of the study was to evaluate the frequency of recurrence and the risk factors for recurrence in patients who were diagnosed with venous thromboembolism.
Methods
Between January 2005 and January 2015, a total of 412 venous thromboembolism patients (164 males, 248 females; mean age: 53.5±16.6 years; range: 19 to 95 years) were retrospectively analyzed. The demographics, underlying risk factors, comorbidities, imaging findings, and treatment data of the patients were recorded.
Results
At least one transient/permanent risk factor was found in 341 (82.7%) of the index events, and the other 71 (17.2%) were idiopathic. Recurrence developed in 76 (18.4%) of the patients. The duration of the treatment in the first event was significantly longer in recurrent cases (p=0.007). The recurrence rate in patients diagnosed with only deep vein thrombosis or patients diagnosed with pulmonary thromboembolism + deep vein thrombosis was significantly higher than the patients diagnosed with only pulmonary thromboembolism (24% vs. 14.2%, respectively; p=0.007). The rate of idiopathic venous thromboembolism was higher in recurrent cases than in non-recurrent cases (26.3% vs. 15.2%, respectively; p=0.028). At the end of the first year, the mean D-dimer levels were higher in recurrent cases (p=0.034). Hereditary risk factors were also higher in recurrent cases (39.5% vs. 19.3%, respectively; p=0.031). There was no significant correlation between recurrence and mortality.
Conclusion
The presence of deep vein thrombosis, idiopathic events, high D-dimer levels at the end of the first year and hereditary risk factors seem to be associated with recurrence.
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Dos Santos Fernandes CJC, Couturaud F. Moving forward for incidental pulmonary embolism in cancer patients. Eur Respir J 2021; 58:58/1/2004630. [PMID: 34215661 DOI: 10.1183/13993003.04630-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/11/2021] [Indexed: 11/05/2022]
Affiliation(s)
| | - Francis Couturaud
- Internal Medicine and Chest Diseases, Hopital de la Cavale Blanche, Brest, France
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7
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Nishimoto Y, Yamashita Y, Kim K, Morimoto T, Saga S, Amano H, Takase T, Hiramori S, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Yoshikawa Y, Shiomi H, Kato T, Makiyama T, Ono K, Sato Y, Kimura T. Risk Factors for Major Bleeding During Anticoagulation Therapy in Cancer-Associated Venous Thromboembolism - From the COMMAND VTE Registry. Circ J 2020; 84:2006-2014. [PMID: 33012736 DOI: 10.1253/circj.cj-20-0223] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients with cancer-associated venous thromboembolism (VTE) are at high risk for recurrent VTE and are recommended to receive prolonged anticoagulation therapy if they are at a low risk for bleeding. However, there are no established risk factors for bleeding during anticoagulation therapy.Methods and Results:The COMMAND VTE Registry is a multicenter retrospective registry enrolling 3,027 consecutive patients with acute symptomatic VTE among 29 Japanese centers. The present study population consisted of 592 cancer-associated VTE patients with anticoagulation therapy. We constructed a multivariable Cox proportional hazard model to estimate the hazard ratio (HR) and 95% confidence interval (CI) of the potential risk factors for major bleeding. During a median follow-up period of 199 days, major bleeding occurred in 72 patients. The cumulative incidence of major bleeding was 5.8% at 3 months, 13.8% at 1 year, 17.5% at 2 years, and 28.1% at 5 years. The most frequent major bleeding site was gastrointestinal tract (47%). Terminal cancer (adjusted HR, 4.17; 95% CI, 2.22-7.85, P<0.001), chronic kidney disease (adjusted HR, 1.89; 95% CI 1.06-3.37, P=0.031), and gastrointestinal cancer (adjusted HR, 1.78; 95% CI, 1.04-3.04, P=0.037) were independently associated with an increased risk of major bleeding. CONCLUSIONS Major bleeding events were common during anticoagulation therapy in real-world cancer-associated VTE patients. Terminal cancer, chronic kidney disease, and gastrointestinal cancer were the independent risk factors for major bleeding.
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Affiliation(s)
- Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | | | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital
| | | | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital
| | | | | | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital
| | | | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine
| | | | | | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Elbadawi A, Shnoda M, Mahmoud K, Elgendy IY. Efficacy and safety of direct oral anticoagulants vs. low molecular weight heparin for cancer-related venous thromboembolism: a meta-analysis of randomized trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:380-388. [PMID: 32556105 DOI: 10.1093/ehjcvp/pvaa067] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/26/2020] [Accepted: 06/11/2020] [Indexed: 11/14/2022]
Abstract
AIMS To examine the efficacy and safety of direct oral anticoagulants (DOACs) vs. low molecular weight heparin (LMWH) in patients with cancer-related venous thromboembolism (VTE). METHODS AND RESULTS An electronic search of the MEDLINE, SCOPUS, and Cochrane databases without language restrictions was performed through April 2020 for randomized controlled trials that compared the outcomes with DOACs vs. LMWH among patients with cancer-related VTE. Summary estimates were reported using random effects model. The main efficacy outcome was VTE recurrence, while the main safety outcome was major bleeding . The final analysis included four randomized trials with a total of 2907 patients. The weighted mean follow-up was 6.1 months. Compared with LMWH, DOACs were associated with lower incidence of VTE recurrence [5.7% vs. 9.1%, risk ratio (RR) 0.62; 95% confidence interval (CI) 0.44-0.87; P = 0.01], driven by lower incidence of deep venous thrombosis (RR 0.60, 95% CI 0.39-0.93; P = 0.02). There was no difference in the incidence of major bleeding between DOACs and LMWH (4.8% vs. 3.6%, RR 1.33; 95% CI 0.84-2.11; P = 0.23). The incidence of all-cause mortality was similar (RR 0.99; 95% CI 0.84-1.16; P = 0.91). Subgroup analysis suggested no differences according to the type of DOAC regarding recurrent VTE or major bleeding (Pinteraction = 0.53 and Pinteraction = 0.11, respectively). CONCLUSION Among patients with cancer-related VTE, DOACs were associated with lower incidence of VTE recurrence and no difference in the incidence of major bleeding compared with LMWH. Future studies examining the subset of cancer patients who drive the most benefit are encouraged.
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Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Mina Shnoda
- Department of Medicine, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Karim Mahmoud
- Department of Medicine, Floyd Medical Center, Rome, GA, USA
| | - Islam Y Elgendy
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College-Qatar, Education City, PO Box 24144, Doha, Qatar
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Sabatino J, De Rosa S, Polimeni A, Sorrentino S, Indolfi C. Direct Oral Anticoagulants in Patients With Active Cancer: A Systematic Review and Meta-Analysis. JACC: CARDIOONCOLOGY 2020; 2:428-440. [PMID: 34396250 PMCID: PMC8352218 DOI: 10.1016/j.jaccao.2020.06.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 01/08/2023]
Abstract
Background Many patients with cancer have a hypercoagulable state and an increased risk of developing venous thromboembolism (VTE), arterial occlusion, and pulmonary emboli. Patients with cancer may also have an increased risk of bleeding with anticoagulant treatment. Recent trials have reported that direct oral anticoagulants (DOACs) are noninferior to the low-molecular-weight heparin, dalteparin, in preventing VTE, but have a higher bleeding rate. Objectives This study compared the efficacy and risks of DOACs versus dalteparin in patients with cancer-related VTEs across all randomized controlled trials (RCTs). Methods This study performed a systematic analysis of RCTs published in PubMed, SCOPUS, and Google Scholar from September 1, 2007 through March 31, 2020 that reported clinical outcomes of treatment with DOACs versus dalteparin in patients with cancer with acute VTE. Two investigators independently performed study selection and data extraction. Extracted data were recorded and exported to statistical software for all analyses (OpenMetaAnalyst). Results This study included 4 randomized trials (N = 2,907). Compared with DOACs, dalteparin was associated with higher VTE recurrence (risk ratio [RR]: 1.55; 95% confidence interval [CI]: 1.19 to 2.03; p = 0.001), whereas clinically relevant nonmajor bleeding (CRNMB) was significantly less frequent with dalteparin than that with DOACs (RR: 0.68; 95% CI: 0.54 to 0.86; p = 0.001). The risk of CRNMB was largely observed with patients with gastrointestinal malignancies. No significant differences were observed in major bleeding (RR: 0.74; 95% CI: 0.52 to 1.06; p = 0.11). Conclusions DOACs were noninferior to dalteparin in preventing VTE recurrence in patients with cancer without a significantly increased risk of major bleeding. However, DOACs were associated with higher rates of CRNMB compared with dalteparin, primarily in patients with gastrointestinal malignancies.
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Key Words
- CI, confidence interval
- CRNMB, clinically relevant nonmajor bleeding
- DOAC, direct oral anticoagulant
- DOACs
- DVT, deep vein thrombosis
- GI, gastrointestinal
- LMWH, low-molecular-weight heparin
- PE, pulmonary embolism
- RCT, randomized controlled trial
- RR, risk ratio
- VKA, vitamin K antagonist
- VTE, venous thromboembolism
- cancer
- direct oral anticoagulants
- hypercoagulable state
- venous thromboembolism
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Affiliation(s)
- Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
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Nishimoto Y, Yamashita Y, Morimoto T, Saga S, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Yoshikawa Y, Shiomi H, Kato T, Makiyama T, Ono K, Sato Y, Kimura T. Predictive ability of modified Ottawa score for recurrence in patients with cancer-associated venous thromboembolism: From the COMMAND VTE Registry. Thromb Res 2020; 191:66-75. [DOI: 10.1016/j.thromres.2020.04.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/18/2020] [Accepted: 04/29/2020] [Indexed: 12/21/2022]
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Sorigue M, Cañamero E, Siguenza P, Nomdedeu M, López-Núñez JJ. Recent developments and persisting challenges in the prevention and treatment of venous thromboembolism in patients with hematological malignancies. Leuk Lymphoma 2020; 61:1277-1291. [DOI: 10.1080/10428194.2020.1713321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Marc Sorigue
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Eloi Cañamero
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Patricia Siguenza
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Meritxell Nomdedeu
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Juan J. López-Núñez
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
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12
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Fuentes HE, McBane RD, Wysokinski WE, Tafur AJ, Loprinzi CL, Murad MH, Riaz IB. Direct Oral Factor Xa Inhibitors for the Treatment of Acute Cancer-Associated Venous Thromboembolism: A Systematic Review and Network Meta-analysis. Mayo Clin Proc 2019; 94:2444-2454. [PMID: 31685262 DOI: 10.1016/j.mayocp.2019.05.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/01/2019] [Accepted: 05/13/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To explore the efficacy and safety of direct oral factor Xa inhibitors in the treatment of cancer-associated acute venous thromboembolism (VTE). PATIENTS AND METHODS MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), and Embase databases were searched for trials comparing direct oral anticoagulants (DOACs) to dalteparin for the management of cancer-associated acute VTE. Databases were searched from inception to September 19, 2018. A network meta-analysis using both frequentist and Bayesian methods was performed to analyze VTE recurrence and major and clinically relevant nonmajor bleeding. RESULTS We identified 3 randomized controlled trials, at low risk of bias, that enrolled 1739 patients with cancer-associated VTE. Direct comparison revealed a lower rate of VTE recurrence in DOAC compared with dalteparin groups (odds ratio [OR], 0.48; 95% CI, 0.24-0.96; I2=46%). Indirect comparison suggested that apixaban had greater reduction in VTE recurrence compared with dalteparin (OR, 0.10; 95% CI, 0.01-0.82) but not rivaroxaban or edoxaban. Apixaban also had the highest probability of being ranked most effective. By direct comparisons, there was an increased likelihood of major bleeding in the DOAC group compared with dalteparin (OR, 1.70; 95% CI, 1.04-2.78). Clinically relevant nonmajor bleeding did not differ. Indirect estimates were imprecise. Subgroup analyses in gastrointestinal cancers suggested that dalteparin may have the lowest risk of bleeding, whereas estimates in urothelial cancer were imprecise. CONCLUSION Direct oral anticoagulants appear to lower the risk of VTE recurrence compared with dalteparin while increasing major bleeding. Apixaban may be associated with the lowest risk of VTE recurrence compared with the other DOACs.
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Affiliation(s)
- Harry E Fuentes
- Division of Hematology and Medical Oncology, Mayo Clinic, Rochester, MN
| | | | | | - Alfonso J Tafur
- Cardiovascular Medicine Division, NorthShore University HealthSystem, Evanston, IL
| | | | | | - Irbaz Bin Riaz
- Division of Hematology and Medical Oncology, Mayo Clinic, Rochester, MN
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Sakamoto J, Yamashita Y, Morimoto T, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Saga S, Nishimoto Y, Sasa T, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Yoshikawa Y, Shiomi H, Kato T, Makiyama T, Ono K, Tamura T, Nakagawa Y, Kimura T. Cancer-Associated Venous Thromboembolism in the Real World ― From the COMMAND VTE Registry ―. Circ J 2019; 83:2271-2281. [DOI: 10.1253/circj.cj-19-0515] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Toru Takase
- Department of Cardiology, Kindai University Hospital
| | | | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital
| | | | | | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kindai University Faculty of Medicine
| | | | | | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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14
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Elmoamly S, Mattar M, Yacoub MF, Afif A. Can Biomarkers of Coagulation, Platelet Activation, and Inflammation Predict Venous Thromboembolism in Patients with Haematological Malignancies? Acta Haematol 2019; 141:245-253. [PMID: 30965330 DOI: 10.1159/000496914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 01/15/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The incidence of venous thromboembolism (VTE) in haematological malignancies varies according to the type and grade of the disease and clinical variables, and there is a need to develop a tool to predict the occurrence of VTE in cancer patients at diagnosis to tailor prophylactic anticoagulation use during treatment. OBJECTIVE To study the incidence of VTE in haematological malignancies and clarify whether vascular and inflammatory biomarkers could be used as predictors of VTE in those patients. METHODS This was a prospective observational cohort study. Hypercoagulability and inflammatory biomarkers were assayed in a group of 171 patients with haematological malignancies at diagnosis. These markers included (1) coagulation and fibrinolysis activation markers (D-dimer, fibrinogen, antithrombin, plasminogen activator inhibitor 1), (2) endothelial and platelet activation markers (von Willebrand factor and soluble P-selectin), and (3) inflammatory markers (tumour necrosis factor αand interleukin 6). The end point was mortality or symptomatic VTE. RESULTS/CONCLUSION The incidence of symptomatic VTE was 7%. None of the tested biomarkers showed statistical significance as predictors for the occurrence of VTE in haematological malignancies. However, there were statistically significant associations between the occurrence of VTE and central venous access device insertion, the prothrombin time, and the erythrocyte sedimentation rate. An ESR above 106.5 mm/h is associated with increased VTE occurrence.
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Affiliation(s)
- Shereef Elmoamly
- Department of Internal Medicine and Clinical Haematology, Faculty of Medicine, Cairo University, Cairo, Egypt,
| | - Mervat Mattar
- Department of Internal Medicine and Clinical Haematology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maha F Yacoub
- Department of Internal Medicine and Clinical Haematology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Afif
- Department of Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
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15
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Khorana AA, McCrae KR, Milentijevic D, Fortier J, Nelson WW, Laliberté F, Crivera C, Lefebvre P, Schein J. Duration of anticoagulant therapy and VTE recurrence in patients with cancer. Support Care Cancer 2019; 27:3833-3840. [PMID: 30734088 PMCID: PMC6726708 DOI: 10.1007/s00520-019-4661-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/16/2019] [Indexed: 12/26/2022]
Abstract
Purpose Anticoagulant therapy for at least 3–6 months is currently recommended for treatment of venous thromboembolism (VTE) in patients with cancer, but the optimal duration of treatment is unknown. This study examines the association between the duration of anticoagulation treatment and VTE recurrence in cancer patients. Methods The Humana claims database was used to identify newly diagnosed cancer patients who had their first VTE diagnosis between January 1, 2013, and May 31, 2015, and initiated injectable or oral anticoagulant therapy. Follow-up was calculated from the index treatment initiation to the end of eligibility or end of data (June 2015). VTE recurrence was defined as a hospitalization with a primary diagnosis of VTE. Cox proportional hazards models were used to evaluate the risk of VTE recurrence by duration of therapy in patients who discontinued therapy. Results The study included 1158 patients. Compared to patients treated for 0 to 3 months, VTE recurrences were significantly lower among patients treated for 3 to 6, or over 6 months. After adjustment for baseline characteristics, patients treated for 3 to 6 months (HR [95%CI], 0.53; 0.37–0.76) and more than 6 months (HR [95%CI], 0.48; 0.34–0.68) were still significantly less likely to have VTE recurrences compared to patients treated for 0 to 3 months (both p < 0.01). Findings were similar using a VTE event definition that included outpatient visits. Conclusions Among newly diagnosed cancer patients with VTE, anticoagulant therapy lasting more than 3 months was associated with a lower risk of VTE recurrence. Electronic supplementary material The online version of this article (10.1007/s00520-019-4661-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic and Case Comprehensive Cancer Center, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Keith R McCrae
- Hematology and Medical Oncology, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Dejan Milentijevic
- Janssen Scientific Affairs, LLC, 1000 U.S. Route 202 South, Raritan, NJ, 08869, USA
| | - Jonathan Fortier
- Groupe d'analyse, Ltée, 1190, avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montréal, QC, H3B 0G7, Canada
| | - Winnie W Nelson
- Janssen Scientific Affairs, LLC, 1000 U.S. Route 202 South, Raritan, NJ, 08869, USA
| | - François Laliberté
- Groupe d'analyse, Ltée, 1190, avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montréal, QC, H3B 0G7, Canada.
| | - Concetta Crivera
- Janssen Scientific Affairs, LLC, 1000 U.S. Route 202 South, Raritan, NJ, 08869, USA
| | - Patrick Lefebvre
- Groupe d'analyse, Ltée, 1190, avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montréal, QC, H3B 0G7, Canada
| | - Jeff Schein
- Janssen Scientific Affairs, LLC, 1000 U.S. Route 202 South, Raritan, NJ, 08869, USA
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Scotté F, Leroy P, Chastenet M, Aumont L, Benatar V, Elalamy I. Treatment and Prevention of Cancer-Associated Thrombosis in Frail Patients: Tailored Management. Cancers (Basel) 2019; 11:cancers11010048. [PMID: 30621020 PMCID: PMC6356758 DOI: 10.3390/cancers11010048] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 12/22/2018] [Accepted: 12/28/2018] [Indexed: 01/11/2023] Open
Abstract
Advanced age is one of the major determinants of frailty in patients with cancer-associated thrombosis. However, multiple other factors contribute to frailty in these patients. The identification of frailty in patients with cancer-associated thrombosis is critical as it influences the complexity of the anticoagulant treatment in this population at high risk of venous thromboembolism and bleeding. Factors that contribute to frailty in patients with cancer-associated thrombosis include age, type of cancer, comorbidities such as chronic kidney disease, poly-pharmacotherapy, treatment compliance, cognitive impairment, anemia, thrombocytopenia, mobility, nutritional status, Eastern Cooperative Oncology Group grade, risk of falls, and reduced life expectancy. In the absence of specific clinical studies current anticoagulant treatment guidelines for the management are not fully applicable to frail patients with cancer. The anticoagulant treatment should therefore benefit from a tailored approach based on an algorithm that takes into account the specificities of the malignant disease.
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Affiliation(s)
- Florian Scotté
- Department of Medical Oncology and Supportive Care. Hôpital Foch, 92150 Suresnes, France.
| | - Pauline Leroy
- Department of Medical Oncology and Supportive Care. Hôpital Foch, 92150 Suresnes, France.
| | - Mathilde Chastenet
- Department of Medical Oncology and Supportive Care. Hôpital Foch, 92150 Suresnes, France.
| | - Laure Aumont
- Department of Medical Oncology and Supportive Care. Hôpital Foch, 92150 Suresnes, France.
| | - Vidal Benatar
- Heathics Clinical Consultants. 111 rue des Tennerolles, 92210 Saint-Cloud, France.
| | - Ismaïl Elalamy
- Department of Hematology, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Sorbonne Université, INSERM UMR S938, 75012 Paris, France.
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Saksena D, Mishra YK, Muralidharan S, Kanhere V, Srivastava P, Srivastava CP. Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario. Indian J Thorac Cardiovasc Surg 2019; 35:3-44. [PMID: 33061064 PMCID: PMC7525528 DOI: 10.1007/s12055-019-00789-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation. METHODS A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings. RESULTS The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately. CONCLUSIONS Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.
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Sobieraj DM, Baker WL, Smith E, Sasiela K, Trexler SE, Kim O, Coleman CI. Anticoagulation for the Treatment of Cancer-Associated Thrombosis: A Systematic Review and Network Meta-Analysis of Randomized Trials. Clin Appl Thromb Hemost 2018; 24:182S-187S. [PMID: 30244595 PMCID: PMC6714836 DOI: 10.1177/1076029618800792] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
To perform a systematic review and network meta-analysis evaluating the efficacy and safety of low-molecular-weight heparins (LMWHs), vitamin K antagonists (VKAs), and direct-acting oral anticoagulants (DOACs) for the treatment of cancer-associated thrombosis (CAT). We searched MEDLINE, Cochrane Central Register of Controlled Trials, and conference abstracts through March 2018. Randomized controlled trials (RCTs) enrolling adults with CAT comparing 2 or more full-dose anticoagulants (LMWH, VKA, and DOAC) and evaluating recurrent venous thromboembolism (VTE), major bleeding, and/or all-cause mortality were included. Reviewers identified studies, extracted data, and assessed the quality of the evidence in duplicate. A frequentist network meta-analysis, which uses direct and indirect evidence to simultaneously compare multiple interventions, was performed using a random-effects approach. Results are reported as pooled relative risks (RRs) with 95% confidence intervals (CIs). We included 13 RCTs (n = 6292): 7 compared LMWHs with VKAs, 4 compared DOACs with VKAs, and 2 compared DOACs with LMWHs. The risk of recurrent VTE was significantly reduced by 28% and 54% with a DOAC compared to an LMWH and a VKA, respectively. Low-molecular-weight heparins significantly reduced the risk of recurrent VTE by 36% versus VKAs. The risk of major bleeding was 14% higher with DOACs compared to LMWHs and 15% and 25% lower with DOACs and LMWHs versus VKAs, although 95% CIs included unity for each. The risk of all-cause mortality appeared similar for all 3 comparisons (RR = 1.0 for each comparison). Direct-acting oral anticoagulants appeared superior in reducing recurrent VTE in patients with CAT compared to LMWH and VKAs, but an increased risk of major bleeding versus LMWH cannot be ruled out.
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Affiliation(s)
- Diana M. Sobieraj
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - William L. Baker
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
| | | | - Katarzyna Sasiela
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Stephanie E. Trexler
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Oliver Kim
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Craig I. Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
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Peippo MH, Kurki S, Lassila R, Carpén OM. Real-world features associated with cancer-related venous thromboembolic events. ESMO Open 2018; 3:e000363. [PMID: 30094068 PMCID: PMC6069925 DOI: 10.1136/esmoopen-2018-000363] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/30/2018] [Accepted: 06/02/2018] [Indexed: 11/26/2022] Open
Abstract
Background The incidence of venous thromboembolism (VTE) is 1–2/1000 individuals. Patients with cancer, especially during chemotherapy, are at enhanced risk, but real-world data on factors associated with VTE events are still scarce. Aim The aim of this retrospective study was to survey the incidence of VTE based on a large hospital database, and to identify comorbidities and features associated with VTE events. We focused on cancer-related VTE events and on factors indicating increased VTE risk during chemotherapy. Methods The cohort included patients treated at Turku University Hospital during years 2005–2013. Health information was derived and analysed from multiple electronic databases. The diagnoses of VTE and all comorbidities, including type of cancer, were based on International Classification of Diseases 10th Revision coding. For further analysis, we focused on 16 common types of cancers treated with chemotherapy. Age, gender, surgery, radiotherapy, distant metastasis, available laboratory values and platinum-based chemotherapy were evaluated for VTE group, and associations were estimated by Cox regression analyses. Results The entire database contained information from 495 089 patients, of whom 5452 (1.1%) had a VTE diagnosis. Among individuals with VTE, 1437 (26.4%) had diagnosis of coronary heart disease and 1467 (26.9%) had cancer diagnosis. Among 7778 patients with cancer treated with chemotherapy, 282 (3.6%) had a VTE, platinum-based chemotherapy being a major risk factor (HR 1.77, 95% CI 1.40 to 2.24, p<0.001). In multivariate analysis, elevated blood neutrophil counts (>3.25×109 cells/L, HR 1.96, 95% CI 1.33 to 2.89, p<0.001) and plasma creatinine (>62.5 μmol/L; HR 1.60, 95% CI 1.21 to 2.13, p=0.001) values were independent indicators of increased VTE risk during chemotherapy. Conclusions Longitudinal electronic health record analysis provides a powerful tool to gather meaningful real-world information to study clinical associations, like comorbidities, and to identify markers associated with VTE. The combination of various clinical and laboratory variables could be used for VTE risk evaluation and targeted prevention.
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Affiliation(s)
- Maija Helena Peippo
- Institute of Biomedicine, Research Center for Cancer, Infections and Immunity, University of Turku, Turku, Finland
| | - Samu Kurki
- Auria Biobank, University of Turku and Turku University Hospital, Turku, Finland
| | - Riitta Lassila
- Unit of Coagulation Disorders, Department of Hematology and Comprehensive Cancer Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Mikael Carpén
- Genome Scale Biology Research Program and Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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McBane Ii R, Loprinzi CL, Ashrani A, Perez-Botero J, Leon Ferre RA, Henkin S, Lenz CJ, Le-Rademacher JG, Wysokinski WE. Apixaban and dalteparin in active malignancy associated venous thromboembolism. The ADAM VTE Trial. Thromb Haemost 2017; 117:1952-1961. [PMID: 28837207 DOI: 10.1160/th17-03-0193] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 06/24/2017] [Indexed: 12/13/2022]
Abstract
Currently, low molecular weight heparin (LMWH) is the guideline endorsed treatment of patients with cancer associated venous thromboembolism (VTE). While apixaban is approved for the treatment of acute VTE, there are limited data supporting its use in cancer patients. The rationale and design of this investigator initiated Phase IV, multicenter, randomized, open label, superiority trial assessing the safety of apixaban versus dalteparin for cancer associated VTE is provided (ADAM-VTE; NCT02585713). The main aim of the ADAM-VTE trial is to test the hypothesis that apixaban is associated with a significantly lower rate of major bleeding compared to dalteparin in the treatment of cancer patients with acute VTE. The primary safety outcome is rate of major bleeding. Secondary efficacy objective is to assess the rates of recurrent VTE or arterial thromboembolism. Cancer patients with acute VTE (n=300) are randomized to receive apixaban (10 mg twice daily for 7 days followed by 5 mg twice daily thereafter) or dalteparin (200 IU/Kg daily for 30 days followed by 150 IU/kg daily thereafter) for 6 months. Stratification factors used for randomization include cancer stage and cancer specific risk of venous thromboembolism using the Khorana score. Participating centers are chosen from the Academic and Community Cancer Research United (ACCRU) consortium comprised of 90 oncology practices in the United States and Canada. Based on the hypothesis to be tested, we anticipate that these trial results will provide evidence supporting apixaban as an effective treatment of cancer associated VTE at lower rates of major bleeding compared to LMWH.
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Affiliation(s)
- Robert McBane Ii
- Robert D. McBane II, MD, Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, USA, Tel.: +1 507 266 3964, Fax: +1 507 266 1617, E-mail:
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Elalamy I, Mahé I, Ageno W, Meyer G. Long-term treatment of cancer-associated thrombosis: the choice of the optimal anticoagulant. J Thromb Haemost 2017; 15:848-857. [PMID: 28222250 DOI: 10.1111/jth.13659] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Indexed: 01/20/2023]
Abstract
Patients with cancer-associated thrombosis (CAT) carry a higher risk of recurrence, bleeding and mortality as compared with non-cancer patients. The specific profiles of cancer patients, combining frequent co-morbidities, the use of anti-tumoral therapies and the cancer progression itself, represent a major therapeutic challenge for choosing a long-term anticoagulant treatment. This review discusses the practical basis of making a choice between the available drugs for a long-term antithrombotic strategy, linked to their pharmacology, mechanism of action, evidence of clinical benefits, and advantages and limitations in such a complex clinical context. In patients with cancer, low-molecular-weight heparins (LMWHs) are the preferred option for the secondary prevention of venous thromboembolism according to current guidelines, because their efficacy is significantly superior to vitamin K antagonists (VKAs). Even though LMWHs are effective and safe in cancer patients, they require daily subcutaneous injections, which may be problematic for a long-term therapy that may exceed 6 months' duration. Compared with VKAs, non-vitamin-K antagonist oral anticoagulants or direct oral anticoagulants (DOACs) are more target specific and do not require laboratory monitoring, whereas the oral route of administration makes them potentially attractive alternatives to LMWH. In randomized controlled trials in the general population DOACs have been shown to be non-inferior to VKAs in terms of efficacy with a lower rate of clinically relevant or major bleeding. However, given the limited number of cancer patients enrolled in these studies (with poorly defined active cancer), available trials are inconclusive regarding the usefulness of DOACs in the cancer setting. Ongoing head-to-head comparisons vs. LMWH in patients with CAT may allow an informed choice to be made regarding the DOAC option.
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Affiliation(s)
- I Elalamy
- Biological Hematology Department, Hôpital TENON APHP Hôpitaux Universitaires de l'Est Parisien, INSERM UMRS 938 Université Pierre et Marie Curie, Paris 6, Paris, France
| | - I Mahé
- Internal Medicine Department, Hôpital Louis Mourier, APHP, Colombes, France
- Université Paris-Diderot Paris 7, EA 7334, Sorbonne Paris Cité, Paris, France
| | - W Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - G Meyer
- Respiratory and Intensive Care, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Université Paris Descartes Paris 5, Sorbonne Paris Cité, Paris, France
- INSERM UMRS 970, CIC 1418, Paris, France
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Ageno W, Turpie AGG. Spotlight on real-world evidence for the treatment of DVT: XALIA. Thromb Haemost 2016; 116:S41-S49. [PMID: 27623684 DOI: 10.1160/th16-06-0488] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/10/2016] [Indexed: 01/08/2023]
Abstract
Venous thromboembolism (VTE), comprising both deep-vein thrombosis (DVT) and pulmonary embolism (PE), is a serious and common cardiovascular disease associated with the risk of chronic complications, recurrent VTE events and even death. The treatment landscape has, in recent years, seen a paradigm shift from the use of traditional anticoagulants (low-molecular-weight heparin [LMWH] overlapping with and followed by a vitamin K antagonist [VKA]) to non-VKA oral anticoagulants (NOACs). This class of agents, encompassing direct factor Xa inhibitors and direct thrombin inhibitors have shown non-inferior efficacy and better safety to standard of care in randomised controlled trials (RCTs). The direct, oral factor Xa inhibitor rivaroxaban was the first to be approved for treatment of acute DVT and PE and secondary prevention of recurrent VTE events based on data from EINSTEIN DVT and EINSTEIN PE, respectively. Real-world evidence now helps to further support data from RCTs, and also bridges the gap for physicians regarding any areas of clinical uncertainty that may not be addressed by RCTs. XA inhibition with rivaroxaban for Long-term and Initial Anticoagulation in venous thromboembolism (XALIA) was the first large, prospective, observational, real-world study that has investigated the safety and effectiveness profile of rivaroxaban in patients with DVT and PE associated with DVT in routine clinical practice. This article will present the key clinical outcomes from this important global non-interventional study, and will discuss remaining questions to be addressed in Phase IV studies.
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Affiliation(s)
- Walter Ageno
- Walter Ageno, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy, Tel.: +39 0339 8623760, E-mail:
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Benefit and risk of primary thromboprophylaxis in ambulatory patients with advanced pancreatic cancer receiving chemotherapy. Blood Coagul Fibrinolysis 2016; 27:270-4. [DOI: 10.1097/mbc.0000000000000413] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149:315-352. [PMID: 26867832 DOI: 10.1016/j.chest.2015.11.026] [Citation(s) in RCA: 3245] [Impact Index Per Article: 405.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We update recommendations on 12 topics that were in the 9th edition of these guidelines, and address 3 new topics. METHODS We generate strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence. RESULTS For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C). For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B). For DVT, we suggest not using compression stockings routinely to prevent PTS (Grade 2B). For subsegmental pulmonary embolism and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C), and anticoagulation over clinical surveillance with a high risk (Grade 2C). We suggest thrombolytic therapy for pulmonary embolism with hypotension (Grade 2B), and systemic therapy over catheter-directed thrombolysis (Grade 2C). For recurrent VTE on a non-LMWH anticoagulant, we suggest LMWH (Grade 2C); for recurrent VTE on LMWH, we suggest increasing the LMWH dose (Grade 2C). CONCLUSIONS Of 54 recommendations included in the 30 statements, 20 were strong and none was based on high-quality evidence, highlighting the need for further research.
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Valade S, Lemiale V, Roux A, Schnell D, Mariotte E, Reuter D, Canet E, Schlemmer B, Azoulay E. Life-threatening complications and outcomes in patients with malignancies and severe pulmonary embolism. Thromb Res 2015; 135:610-5. [PMID: 25618264 DOI: 10.1016/j.thromres.2015.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 01/07/2015] [Accepted: 01/08/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Data are scarce about ICU patients with malignancy and severe pulmonary embolism. Here, our main objective was to identify risk factors for life-threatening complications, organ failures, and death in ICU patients with severe pulmonary embolism, with special attention to the impact of malignancy. We also described the clinical features of PE in patients with and without malignancies. METHODS Data from consecutive adults admitted to our ICU in 2002-2011 with severe pulmonary embolism were collected retrospectively. Multivariate analysis was performed to look for factors associated with death, organ failures, or life-threatening complications (major bleeding, recurrent PE, and cardiac arrest). RESULTS Of 119 included patients (42 [35%] with bilateral pulmonary embolism), 41 had solid malignancies, 27 hematological malignancies, and 51 no malignancies. The most common symptoms were syncope (40%) and hemoptysis (18%) in patients with solid and hematological malignancies, respectively. Life-threatening complications occurred in 23 (19%) patients; risk factors were obesity (OR, 13.22; 1.93-90.70), disseminated intravascular coagulation/ischemic hepatitis (OR, 27.06; 5.14-142.46), fluid load ≥1000 mL/24 h (OR, 6.42; 1.60-25.76), and solid malignancy (OR, 5.45; 1.15-25.89). Inhospital mortality was 27/119 (23%) and respiratory or circulatory failure developed in 36 (30%) patients. Risk factors for these adverse outcomes were older age (OR, 1.04/year; 1.01-1.07), higher oxygen flow rate (OR, 1.28/L; 1.13-1.45); and renal failure (OR, 8.08; 2.50-26.11); whereas chest pain was protective (OR, 0.13; 0.04-0.48). CONCLUSION In this study, solid malignancy was a risk factor for life-threatening complications but not for death.
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Affiliation(s)
- S Valade
- ICU, Saint Louis Teaching Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France.
| | - V Lemiale
- ICU, Saint Louis Teaching Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - A Roux
- Respiratory care unit, European Georges Pompidou Hospital, 20 rue Leblanc, 75015 Paris, France
| | - D Schnell
- ICU, Saint Louis Teaching Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - E Mariotte
- ICU, Saint Louis Teaching Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - D Reuter
- ICU, Saint Louis Teaching Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - E Canet
- ICU, Saint Louis Teaching Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - B Schlemmer
- ICU, Saint Louis Teaching Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - E Azoulay
- ICU, Saint Louis Teaching Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
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Kopolovic I, Lee AYY, Wu C. Management and outcomes of cancer-associated venous thromboembolism in patients with concomitant thrombocytopenia: a retrospective cohort study. Ann Hematol 2014; 94:329-36. [DOI: 10.1007/s00277-014-2198-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 08/22/2014] [Indexed: 11/30/2022]
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Abstract
Approximately 6 million Americans are treated with chronic anticoagulation. Of these, 10% of patients will require temporary anticoagulation interruption for an invasive procedure each year. Anticoagulation management during this period requires a formal strategy in order to limit both bleeding and thromboembolic complications. This article will give health care providers a stepwise approach to this process. The first step is to determine whether warfarin discontinuation is necessary for the planned procedure. For procedures requiring warfarin discontinuation, the second step is to determine the appropriate timing. The third step is to identify the patient-specific thromboembolic risk in order to determine which patients require bridging therapy with parenteral anticoagulants. The fourth step is both the most complicated and most critical step in this management strategy. This decision-making step involves choosing the appropriate anticoagulant regimen, dose, and timing of reinitiation that is best tailored to a specific patient, as well as determining procedural variables, in order to limit bleeding and thrombotic complications.
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Affiliation(s)
- Alfonso Tafur
- Department of Medicine (AT), Cardiovascular Section, Vascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Connolly GC, Menapace L, Safadjou S, Francis CW, Khorana AA. Prevalence and Clinical Significance of Incidental and Clinically Suspected Venous Thromboembolism in Lung Cancer Patients. Clin Lung Cancer 2013; 14:713-8. [DOI: 10.1016/j.cllc.2013.06.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 05/17/2013] [Accepted: 06/18/2013] [Indexed: 11/16/2022]
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Connolly GC, Francis CW. Cancer-associated thrombosis. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:684-691. [PMID: 24319253 DOI: 10.1182/asheducation-2013.1.684] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Cancer-associated thrombosis accounts for almost one-fifth of all cases of venous thromboembolism (VTE) and is a leading cause of death, morbidity, delays in care, and increased costs. Our understanding of risk factors for cancer-associated thrombosis has expanded in recent years, and investigators have begun to use biomarkers and clinical prediction models to identify those cancer patients at greatest risk for VTE. The Khorana Risk Model, which is based on easily obtained biomarkers and clinical factors, has now been validated in several studies. Recent clinical trials of prophylaxis and treatment of VTE in cancer patients are reviewed here. In addition, consensus guidelines and expert opinion regarding management of VTE in specific challenging situations are presented.
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Affiliation(s)
- Gregory C Connolly
- 1James P. Wilmot Cancer Center and Department of Medicine, University of Rochester, Rochester, NY
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Three-month mortality rate and clinical predictors in patients with venous thromboembolism and cancer. Findings from the RIETE registry. Thromb Res 2013; 131:24-30. [DOI: 10.1016/j.thromres.2012.10.007] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 09/14/2012] [Accepted: 10/17/2012] [Indexed: 12/21/2022]
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Tafur AJ, Wysokinski WE, McBane RD, Wolny E, Sutkowska E, Litin SC, Daniels PR, Slusser JP, Hodge DO, Heit JA. Cancer effect on periprocedural thromboembolism and bleeding in anticoagulated patients. Ann Oncol 2012; 23:1998-2005. [PMID: 22473596 DOI: 10.1093/annonc/mds058] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Patients with active cancer are often on chronic anticoagulation and frequently require interruption of this treatment for invasive procedures. The impact of cancer on periprocedural thromboembolism (TE) and major bleeding is not known. PATIENTS AND METHODS Two thousand one hundred and eighty-two consecutive patients referred for periprocedural anticoagulation (2484 procedures) using a standardized protocol were followed forward in time to estimate the 3-month incidence of TE, major bleeding and survival stratified by anticoagulation indication. For each indication, we tested active cancer and bridging heparin therapy as potential predictors of TE and major bleeding. RESULTS Compared with patients without cancer, active cancer patients (n=493) had more venous thromboembolism (VTE) complications (1.2% versus 0.2%; P=0.001), major bleeding (3.4% versus 1.7%; P=0.02) and reduced survival (95% versus 99%; P<0.001). Among active cancer patients, only those chronically anticoagulated for VTE had higher rates of periprocedural VTE (2% versus 0.16%; P=0.002) and major bleeding (3.7% versus 0.6%; P<0.001). Bridging with heparin increased the rate of major bleeding in cancer patients (5% versus 1%; P=0.03) without impacting the VTE rate (0.7% versus 1.4%, P=0.50). CONCLUSIONS Cancer patients anticoagulated for VTE experience higher rates of periprocedural VTE and major bleeding. Periprocedural anticoagulation for these patients requires particular attention to reduce these complications.
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Affiliation(s)
- A J Tafur
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester
| | - W E Wysokinski
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester.
| | - R D McBane
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester
| | - E Wolny
- Department of Radiotherapy, Memorial Regional Hospital, Zielona Gora
| | - E Sutkowska
- Division of Rehabilitation, Department of Orthopedic Surgery, University Medical School of Wroclaw, Wroclaw, Poland
| | - S C Litin
- General Internal Medicine, Department of Internal Medicine
| | - P R Daniels
- General Internal Medicine, Department of Internal Medicine
| | - J P Slusser
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - D O Hodge
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - J A Heit
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester
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Saccullo G, Malato A, Raso S, Santoro M, Zammit V, Casuccio A, Siragusa S. Cancer patients requiring interruption of long-term warfarin because of surgery or chemotherapy induced thrombocytopenia: the use of fixed sub-therapeutic doses of low-molecular weight heparin. Am J Hematol 2012; 87:388-91. [PMID: 22374861 DOI: 10.1002/ajh.23122] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 01/01/2012] [Accepted: 01/10/2012] [Indexed: 11/09/2022]
Abstract
No data are available regarding the management of cancer patients requiring interruption of long-term vitamin-K antagonist (VKA) therapy. For this purpose, we tested the efficacy and safety of fixed doses of low-molecular weight heparin (LMWH) in substitution of VKA because of invasive procedures or chemotherapy-induced thrombocytopenia. In cancer patients on VKA, therapy was discontinued 5 ± 1 days before surgery or chemotherapy. Heparin was given at prophylactic dosage in patients at low risk and at fixed subtherapeutic doses (3,800 or 4,000 UI anti-FXa, b.i.d.) in those at high-risk for thrombosis. LMWH was reinitiated 12 hr after surgery and VKA the day after. In patients receiving chemotherapy, LMWH was reinitiated 12/24 hr after obtaining a stable platelet count ≥ 30,000 mmc(3) and VKA after a stable platelet count ≥ 50,000 mmc(3) . Thromboembolism and major bleeding events were recorded from the time of VKA suspension to 30 ± 2 days postprocedure or until the next chemotherapy. Overall, 156 patients (56.4% at low risk and 43.5% at high risk for thrombosis) were enrolled; 34.6% underwent major surgery, 40.4% nonmajor surgery, and 25% chemotherapy. Thrombotic events occurred in five patients [3.2%, 95% confidence interval (CI): 1.41-7.27], four belonging to the high-risk and one to the low-risk group. Major bleeding occurred in five patients (3.2%, 95 CI: 1.41-7.27), all belonging to the high-risk group (three during major surgery and two during chemotherapy). In conclusion, LMWH given at fixed subtherapeutic is a feasible and relatively safe approach for bridging therapy in cancer patients on long-term VKA.
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Affiliation(s)
- Giorgia Saccullo
- Cattedra ed U.O. di Ematologia con trapianto, Dipartimento di Medicina Interna e specialistica (DIMIS), Azienda Ospedaliera Universitaria Policlinico P. Giaccone, Università di Palermo, Italy
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Palareti G. Recurrent venous thromboembolism: what is the risk and how to prevent it. SCIENTIFICA 2012; 2012:391734. [PMID: 24278687 PMCID: PMC3820456 DOI: 10.6064/2012/391734] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 09/10/2012] [Indexed: 05/07/2023]
Abstract
Venous thromboembolism (VTE) that includes deep vein thrombosis and/or pulmonary embolism is a frequent, severe, and potentially lethal disease. After a first episode, VTE has a strong tendency to recur. While VTE is an acute disease, it may have variable outcomes in early and late phases after initial presentation. Furthermore, the incidence of late, clinically important consequences (postthrombotic syndrome and/or chronic thromboembolic pulmonary hypertension) increases in case of recurrent events. The aims of the present review are (i) to analyze the incidence and risk factors for recurrence of VTE (either those related to the type of first thrombotic event or to the patients), the risks associated with occurrence of recurrent events, and the problems linked to the diagnosis, not always easy, of recurrent events; (ii) to discuss whether or not it is possible to predict the individual risk of recurrence after a first event, by stratifying patients at high or low risk of recurrence, and how this can influence their treatment; (iii) to comment what the current guidelines and guidance suggest/recommend about anticoagulant treatment after a first VTE event and, finally, to propose practical indications on how to manage individual patients affected by VTE.
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Affiliation(s)
- Gualtiero Palareti
- Department of Angiology and Blood Coagulation, Via Albertoni 15, 40138 Bologna (BO), Italy
- *Gualtiero Palareti:
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Smith HO, Delic L. Postoperative Surveillance and Perioperative Prophylaxis. Gynecol Oncol 2011. [DOI: 10.1002/9781118003435.ch6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
Abstract
The risk of venous thromboembolism (VTE) is increased in cancer patients. To improve prediction of VTE in cancer patients, we performed a prospective and observational cohort study of patients with newly diagnosed cancer or progression of disease after remission. A previously developed risk scoring model for prediction of VTE that included clinical (tumor entity and body mass index) and laboratory (hemoglobin level and thrombocyte and leukocyte count) parameters was expanded by incorporating 2 biomarkers, soluble P-selectin, and D-Dimer. Of 819 patients 61 (7.4%) experienced VTE during a median follow-up of 656 days. The cumulative VTE probability in the original risk model after 6 months was 17.7% in patients with the highest risk score (≥ 3, n = 93), 9.6% in those with score 2 (n = 221), 3.8% in those with score 1 (n = 229), and 1.5% in those with score 0 (n = 276). In the expanded risk model, the cumulative VTE probability after 6 months in patients with the highest score (≥ 5, n = 30) was 35.0% and 10.3% in those with an intermediate score (score 3, n = 130) as opposed to only 1.0% in patients with score 0 (n = 200); the hazard ratio of patients with the highest compared with those with the lowest score was 25.9 (8.0-84.6). Clinical and standard laboratory parameters with addition of biomarkers enable prediction of VTE and allow identification of cancer patients at high or low risk of VTE.
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Connolly GC, Khorana AA, Kuderer NM, Culakova E, Francis CW, Lyman GH. Leukocytosis, thrombosis and early mortality in cancer patients initiating chemotherapy. Thromb Res 2010; 126:113-8. [PMID: 20684071 DOI: 10.1016/j.thromres.2010.05.012] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Leukocytosis has been associated with thrombosis and mortality in cancer patients. We explored the association of leukocytosis with venous thromboembolism (VTE) and early mortality in cancer patients initiating chemotherapy. METHODS Data from a prospective, multicenter observational study of treatment-related complications in 4,405 ambulatory cancer patients initiating chemotherapy was used for this analysis. The association of leukocytosis, VTE and mortality during the course of chemotherapy was evaluated in univariate and multivariate analysis. RESULTS Ninety-three patients (2.1%) developed VTE and 134 (3%) died over a median follow up of 75 days (range 0-384). Of 4391 patients with available baseline white blood cell (WBC) count, 561 (12.8%) had elevated pretreatment leukocyte counts, defined as WBC > 11 x 10(9) cells/L. VTE occurred in 25 of 561 patients (4.5%) with baseline leukocytosis compared to 68 of 3830 (1.8%) with WBC <or= 11 x 10(9) cells/L (P < 0.0001). Baseline leukocytosis was associated with VTE by multivariate analysis as well (HR 2.1, 95% confidence interval 1.3-3.4, p = 0.003). Forty one patients (7.3%) with leukocytosis died compared to 92 (2.4%) with WBC <or= 11 x 10(9) cells/L (P < 0.0001). Baseline leukocytosis was associated with early mortality by multivariate analysis as well (HR 2.2, 95% confidence interval 1.5-3.3, p < 0.0001). Mortality was greatest in patients with both leukocytosis and VTE. In multivariate analysis several factors were predictive of leukocytosis. CONCLUSIONS Elevated WBC, particularly neutrophils, is strongly associated with increased risk of VTE and mortality in cancer patients receiving systemic chemotherapy. Further studies are needed to elicit the mechanisms involved.
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Affiliation(s)
- Gregory C Connolly
- James P. Wilmot Cancer Center, Department of Medicine, University of Rochester, Rochester, NY, USA
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Putti MC, Randi ML. Thrombotic complications in children with haematologic malignacies. Thromb Res 2010; 125 Suppl 2:S151-4. [DOI: 10.1016/s0049-3848(10)70034-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kovac Z, Kovac M, Mitic G, Antonijevic N. The oncology treatment of patients who use oral anticoagulants is connected with high risk of bleeding complications. J Thromb Thrombolysis 2010; 30:210-4. [DOI: 10.1007/s11239-010-0438-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Monreal M, Trujillo-Santos J. Lessons from VTE registries: the RIETE experience. Best Pract Res Clin Haematol 2009; 22:25-33. [DOI: 10.1016/j.beha.2008.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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