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Patel R, Singh A, Meng Z, Baldridge AS, Addison D, Akhter N. The risk vs. benefit calculus of anticoagulation in patients with ibrutinib-related atrial fibrillation. Leuk Lymphoma 2024; 65:168-174. [PMID: 37953609 PMCID: PMC10952122 DOI: 10.1080/10428194.2023.2278433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/29/2023] [Indexed: 11/14/2023]
Abstract
For ibrutinib-related atrial fibrillation (IRAF), guidelines for anticoagulation do not exist. We sought to describe stroke, bleeding, and anticoagulation rates among patients with IRAF. We performed a single-center retrospective review of 168 patients treated with ibrutinib followed from 2013 to 2022. Over a median follow-up of 6.4 years, 44 (26.0%) patients developed IRAF of which 38 (86.4%) had a CHA2DS2-VASc ≥2 and 7 (15.9%) had a HAS-BLED ≥3. Anticoagulation was initiated in 20 (45.5%) without a clear pattern in scores, risk factors, or cumulative dose, besides having another reason for anticoagulation. Few patients with IRAF developed non-hemorrhagic CVA (n = 3, 6.8%) or significant bleeding (n = 3, 6.8%). Among those with each adverse outcome, 2 in each group were anticoagulated and all were older than 65 years old. In conclusion, decisions for anticoagulation vary widely and patients who are elderly or with HTN may be most at risk for CVA or significant bleed.
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Affiliation(s)
- Ruchi Patel
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Arushi Singh
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Zhiying Meng
- Department of Medicine, Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Abigail S. Baldridge
- Department of Medicine, Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniel Addison
- Division of Cardiology, CardioOncology Program, The Ohio State University Medical Center, Columbus, OH
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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2
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Leiva O, Alam U, Bohart I, Yang EH. Interventional Cardio-Oncology: Unique Challenges and Considerations in a High-Risk Population. Curr Treat Options Oncol 2023:10.1007/s11864-023-01110-2. [PMID: 37296366 PMCID: PMC10356652 DOI: 10.1007/s11864-023-01110-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
OPINION STATEMENT Patients with cancer are at risk of developing cardiovascular disease (CVD) including atherosclerotic heart disease (AHD), valvular heart disease (VHD), and atrial fibrillation (AF). Advances in percutaneous catheter-based treatments, including percutaneous coronary intervention (PCI) for AHD, percutaneous valve replacement or repair for VHD, and ablation and left atrial appendage occlusion devices (LAAODs) for AF, have provided patients with CVD significant benefit in the recent decades. However, trials and registries investigating outcomes of these procedures often exclude patients with cancer. As a result, patients with cancer are less likely to undergo these therapies despite their benefits. Despite the inclusion of cancer patients in randomized clinical trial data, studies suggest that cancer patients derive similar benefits of percutaneous therapies for CVD compared with patients without cancer. Therefore, percutaneous interventions for CVD should not be withheld in patients with cancer, as they may still benefit from these procedures.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Usman Alam
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Isaac Bohart
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, UCLA Cardio-Oncology Program, University of California at Los Angeles, 100 Medical Plaza, Suite 630, Los Angeles, CA, 90095, USA.
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3
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Madnick DL, Fradley MG. Atrial Fibrillation and Cancer Patients: Mechanisms and Management. Curr Cardiol Rep 2022; 24:1517-1527. [PMID: 35976601 DOI: 10.1007/s11886-022-01769-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Cancer-related mortality has significantly declined over the past several decades as a result of improved screening, diagnostics, and therapeutics. Although cancer patients and survivors are living longer, there is increased risk of both short-term and long-term cardiovascular complications, including arrhythmia. In this review, we highlight the current evidence detailing the connections between atrial fibrillation and cancer, provide insight into the mechanisms driving this relationship, and share practical considerations for the management of atrial fibrillation in cancer patients and cancer survivors. RECENT FINDINGS Atrial fibrillation is an increasingly recognized condition among cancer patients, with epidemiological data showing increased incidence and worse outcomes in patients with cancer. Studies also describe a bidirectional relationship between cancer and atrial fibrillation, attributable in part to shared risk factors but also potentially due to shared biology. Cancer treatment-associated arrhythmia is an active area of investigation, with ongoing research to identify the mechanisms and pathophysiology behind this phenomenon. Furthermore, management of atrial fibrillation in patients with cancer presents unique challenges, particularly in management of anti-coagulation. Cancer patients have increased risk of developing atrial fibrillation due to the shared risk factors and biology of the two conditions. Moreover, various cancer therapeutics are known to be arrhythmogenic; however, mechanisms remain unclear. Further research is needed to better understand the pathophysiology of atrial fibrillation in cancer patient in order to establish prevention and treatment strategies specific to this population.
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Affiliation(s)
- David L Madnick
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael G Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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4
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Guha A, Jain A, Aggarwal A, Dey AK, Dani S, Ganatra S, Marchlinski FE, Addison D, Fradley MG. Length of stay and cost of care associated with admissions for atrial fibrillation among patients with cancer. BMC Cardiovasc Disord 2022; 22:272. [PMID: 35715747 PMCID: PMC9205123 DOI: 10.1186/s12872-022-02697-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 06/01/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The aim of this study is to assess the burden of AF-related hospitalizations inclusive of inflation-adjusted cost-of-care and length-of-stay (LOS) among cancer patients and the impact of direct current cardioversion (DCCV) on these outcomes. METHODS Using the National Inpatient Sample (NIS), patients hospitalized with either a primary or secondary diagnosis of AF and comorbid cancer were identified and both cost of hospitalization and LOS were evaluated for each group. Subgroup analyses were performed for specific cancer types (breast, lung, colon, prostate and lymphoma), and those receiving DCCV. RESULTS The prevalence of co-morbid AF was 8.2 million (16%) and 35.5 million (10%) among those with vs. those without cancer, respectively (odds ratio = 1.6, 95% confidence interval = 1.5-1.7; P < 0.001). Over time, both primary and prevalent AF admissions among those with comorbid cancer increased from 1.1% and 12.3% in 2003 to 1.5% and 21% in 2015, respectively. The total cost of hospitalization increased 94.4% among those with AF and comorbid cancer compared to 23.9% among those without cancer. Among the subgroup of patients with comorbid cancer and primary admission for AF undergoing DCCV, length of stay (2.7 vs. 2.2 days; P < 0.001, model 1) and cost of care ($7,093 vs. 6,152; P < 0.001) were both significantly higher. CONCLUSIONS AF related admissions are increasing for all populations especially amongst those patients with a comorbid diagnosis of cancer, including all cancer subtypes evaluated. Among those patients who underwent DCCV, cancer patients had longer length of stay and increased health care costs.
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Affiliation(s)
- Avirup Guha
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH USA
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH USA
| | - Anubhav Jain
- Department of Internal Medicine, Wayne State University School of Medicine, Ascension Providence Rochester Hospital, Rochester, MI USA
| | - Ankita Aggarwal
- Department of Internal Medicine, Wayne State University School of Medicine, Ascension Providence Rochester Hospital, Rochester, MI USA
| | - Amit K. Dey
- National Heart, Lung and Blood Institute, Bethesda, MD USA
| | - Sourbha Dani
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine Landsman Heart and Vascular Center, Lahey Hospital and Medical Center, Burlington, MA USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine Landsman Heart and Vascular Center, Lahey Hospital and Medical Center, Burlington, MA USA
| | - Francis E. Marchlinski
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH USA
- Cancer Control Program, Department of Medicine, Ohio State University Comprehensive Cancer Center, Columbus, OH USA
| | - Michael G. Fradley
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Cardio-Oncology Center of Excellence, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 USA
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Di W, Xu H, Xue T, Ling C. Advances in the Prediction and Risk Assessment of Lung Cancer-Associated Venous Thromboembolism. Cancer Manag Res 2021; 13:8317-8327. [PMID: 34764694 PMCID: PMC8575248 DOI: 10.2147/cmar.s328918] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022] Open
Abstract
According to the most recent data from the National Cancer Center, venous thromboembolism (VTE) has unsurprisingly become one of the most common complications in lung cancer. VTE not only interferes with the equilibrium of the clotting system but it also affects tumor progression and prognosis. For the identification of high-risk patients, many clinical risk assessment models have been developed and validated based on the risk factors found in previous studies. In this review, we will summarize advances in prediction and risk assessment of VTE, with a focus on early diagnosis and therapy, reduction of mortality, and the burden of medical costs in lung cancer patients.
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Affiliation(s)
- Wenjuan Di
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People's Republic of China
| | - Haotian Xu
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People's Republic of China
| | - Ting Xue
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People's Republic of China
| | - Chunhua Ling
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People's Republic of China
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Ibrutinib in patients with atrial fibrillation - the challenge of thromboembolic prophylaxis. ACTA ACUST UNITED AC 2021; 59:270-277. [PMID: 33913303 DOI: 10.2478/rjim-2021-0015] [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: 03/13/2021] [Indexed: 11/20/2022]
Abstract
Ibrutinib is a novel drug used in haematological malignancies. Its use is associated with an increased risk of atrial fibrillation (AF), which, in turn, exposes patients to embolic risk, including stroke. Reducing this risk requires anticoagulant therapy which is a matter of concern in the context of the increased bleeding risk of patients with haematological malignancies. In this context the presence of thrombocytopenia related to haematological disorder, ibrutinib-anticoagulants and ibrutinib-platelets interactions contribute to the amplification of the problem. The correct assessment of the thrombosis vs. haemorrhage balance represents a significant challenge for the clinician. In this paper we discuss practical issues related to anticoagulation in patients treated with ibrutinib and incident AF.
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7
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Rao VU, Reeves DJ, Chugh AR, O'Quinn R, Fradley MG, Raghavendra M, Dent S, Barac A, Lenihan D. Clinical Approach to Cardiovascular Toxicity of Oral Antineoplastic Agents: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:2693-2716. [PMID: 34045027 DOI: 10.1016/j.jacc.2021.04.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 12/14/2022]
Abstract
Precision medicine has ushered in a new era of targeted treatments for numerous malignancies, leading to improvements in overall survival. Unlike traditional chemotherapy, many molecular targeted antineoplastic agents are available in oral formulation, leading to enhanced patient convenience and a perception of reduced risk of adverse effects. Although oral antineoplastic agents are generally well-tolerated, cardiovascular toxicities are being reported with increasing frequency in part due to U.S. Food and Drug Administration and manufacturer recommended cardiac monitoring. Monitoring strategies have focused on left ventricular dysfunction, hypertension, and QT prolongation/arrhythmias. Given the rapid pace of development and availability of new oral antineoplastic agents, the purpose of this review is to provide clinicians with an up-to-date practical approach to monitoring and management of cardiovascular toxicities with the aim of improving overall outcomes for patients with cancer.
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Affiliation(s)
- Vijay U Rao
- Franciscan Cardio-Oncology Center, Indiana Heart Physicians, Franciscan Health, Indianapolis, Indiana, USA.
| | - David J Reeves
- Division of Oncology, Franciscan Health and Butler University College of Pharmacy and Health Sciences, Indianapolis, Indiana, USA
| | - Atul R Chugh
- Franciscan Cardio-Oncology Center, Indiana Heart Physicians, Franciscan Health, Indianapolis, Indiana, USA
| | - Rupal O'Quinn
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Meghana Raghavendra
- Franciscan Cardio-Oncology Center, Oncology and Hematology Specialists, Franciscan Health, Indianapolis, Indiana, USA
| | - Susan Dent
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Ana Barac
- Medstar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | - Daniel Lenihan
- Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, Missouri, USA
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8
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Russo AM. Anticoagulation in Cancer Patients With Atrial Fibrillation or Atrial Flutter: Are There Gaps in Care? JACC CardioOncol 2020; 2:755-757. [PMID: 34396291 PMCID: PMC8352248 DOI: 10.1016/j.jaccao.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Andrea M. Russo
- Department of Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
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9
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Hussain M, Misbah R, Donnellan E, Alkharabsheh S, Hou Y, Cheng F, Crookshanks M, Watson CJ, Toth AJ, Houghtaling P, Moudgil R, Budd GT, Tang WHW, Kwon DH, Jaber W, Griffin B, Kanj M, Collier P. Impact of timing of atrial fibrillation, CHA 2DS 2-VASc score and cancer therapeutics on mortality in oncology patients. Open Heart 2020; 7:e001412. [PMID: 33243931 PMCID: PMC7692982 DOI: 10.1136/openhrt-2020-001412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/23/2020] [Accepted: 11/09/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To investigate timing and age distribution of atrial fibrillation (AF) in selected oncology patients, and the impact of AF timing, CHA2DS2-VASc score and cancer therapeutics on mortality. METHODS This is a retrospective cohort study of oncology patients referred to the cardio-oncology service from 2011 to 2018 for echocardiographic cardiosurveillance and/or pre-existing cardiovascular risk factor/disease management. Rates of first AF diagnosis was assessed using a parametric multiphase hazard model (predictive modelling) and non-parametrically by Kaplan-Meier with transformations tested using a bootstrap methodology. RESULTS Among 6754 patients identified, 174 patients had their first AF diagnosis before cancer while 609 patients had their first diagnosis of AF after cancer. Most first AF diagnosis occurred at/early after cancer diagnosis. Increasing AF prevalence at time of cancer diagnosis was seen across older age groups ranges. Diagnosis of cancer at an older age and exposure to cardiotoxic treatment (anthracyclines, HER2-neu inhibitors, tyrosine kinase inhibitors including ibrutinib and radiation) were associated with an increased risk of AF.Modelling of the hazard function of AF identified a high left-skewed peak within 3 years after cancer diagnosis ('early phase'), followed by a gradual late slight rise 3 years after cancer diagnosis ('late phase'). AF diagnosis was only associated with death in the early phase (p<0.001), while CHA2DS2-VASc score was only associated with death in the late phase (p<0.001). CONCLUSIONS This study reports a nuanced/complex relationship between AF and cancer. First diagnosis of AF in patients with cancer was more common at/early after cancer diagnosis, especially in older patients and those exposed to cardiotoxic treatment. Pre-existing AF or a diagnosis of AF within 3 years after cancer diagnosis carried a negative prognosis. CHA2DS2-VASc score did not relate to mortality in those that developed AF within 3 years of cancer diagnosis.
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Affiliation(s)
- Muzna Hussain
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, County Antrim, UK
| | - Rabel Misbah
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Eoin Donnellan
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Saqer Alkharabsheh
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Yuan Hou
- Department of Genomic Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Feixiong Cheng
- Department of Genomic Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Crookshanks
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Chris J Watson
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, County Antrim, UK
| | - Andrew J Toth
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, United States
| | - Penny Houghtaling
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, United States
| | - Rohit Moudgil
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - G Thomas Budd
- Department of Solid Tumor Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Deborah H Kwon
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Wael Jaber
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Brian Griffin
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mohamad Kanj
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Patrick Collier
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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10
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Boriani G, Lee G, Parrini I, Lopez-Fernandez T, Lyon AR, Suter T, Van der Meer P, Cardinale D, Lancellotti P, Zamorano JL, Bax JJ, Asteggiano R. Anticoagulation in patients with atrial fibrillation and active cancer: an international survey on patient management. Eur J Prev Cardiol 2020; 28:611-621. [PMID: 33624005 DOI: 10.1093/eurjpc/zwaa054] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/20/2020] [Accepted: 08/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND In patients with active cancer and atrial fibrillation (AF) anticoagulation, thrombotic and bleeding risk still entail uncertainty. AIM We explored the results of an international survey examining the knowledge and behaviours of a large group of physicians. METHODS AND RESULTS A web-based survey was completed by 960 physicians (82.4% cardiologists, 75.5% from Europe). Among the currently available anticoagulants for stroke prevention in patients with active cancer, direct oral anticoagulants (DOACs) were preferred by 62.6%, with lower values for low molecular weight heparin (LMWH) (24.1%) and for warfarin (only 7.3%). About 46% of respondents considered that DOACs should be used in all types of cancers except in non-operable gastrointestinal cancers. The lack of controlled studies on bleeding risk (33.5% of respondents) and the risk of drug interactions (31.5%) were perceived as problematic issues associated with use of anticoagulants in cancer. The decision on anticoagulation involved a cardiologist in 27.8% of cases, a cardiologist and an oncologist in 41.1%, and a team approach in 21.6%. The patient also was involved in decision-making, according to ∼60% of the respondents. For risk stratification, use of CHA2DS2-VASc and HAS-BLED scores was considered appropriate, although not specifically validated in cancer patients, by 66.7% and 56.4%, respectively. CONCLUSION This survey highlights that management of anticoagulation in patients with AF and active cancer is challenging, with substantial heterogeneity in therapeutic choices. Direct oral anticoagulants seems having an emerging role but still the use of LMWH remains substantial, despite the absence of long-term data on thromboprophylaxis in AF.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124 Modena, Italy
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, 57 Waterloo Road, London SE1 8WA, UK
| | - Iris Parrini
- Cardiology Division, Mauriziano Hospital, Via Magellano 1, 10128, Turin, Italy
| | - Teresa Lopez-Fernandez
- Division of Cardiology, Cardiac Imaging and Cardio-Oncology Unit, La Paz University Hospital, IdiPAZ Research Institute, CIBER CV, Calle de Pedro Rico, 6, 28029 Madrid, Spain
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton & Harefield NHS Foundation Trust and the National Heart & Lung Institute, Imperial College London, Sydney Street , Greater London, SW3 6NP, UK
| | - Thomas Suter
- Cardiology, University Hospital Inselspital, Freiburgstrasse 41G, 3010 Bern, Switzerland
| | - Peter Van der Meer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Daniela Cardinale
- Cardioncology Unit, European Institute of Oncology, I.R.C.C.S., Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Patrizio Lancellotti
- Department of Cardiology, CHU Sart Tilman, University of Liège Hospital, GIGA Cardiovascular Sciences, Avenue de L'Hòpital 1-11, 4000 Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Via Corriera, 1, 48033 Cotignola (Ravenna), and Anthea Hospital, Via Camillo Rosalba, 35/37, 70124 Bari, Italy
| | - Jose Luis Zamorano
- University Hospital Ramon y Cajal, CiberCV, Ctra. de Colmenar Viejo km. 9,100 28034 Madrid, Spain
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Riccardo Asteggiano
- School of Medicine, University of Insubria, Via Ravasi, 2, 21100 Varese, Italy.,LARC (Laboratorio Analisi e Ricerca Clinica), Corso Venezia, 10, 10155 Turin, Italy
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11
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Serrao A, Fiori L, Santoro C, De Luca ML, Ferretti A, De Luca G, Ligia S, Lapietra G, Mohamed S, Breccia M, Chistolini A. Direct oral anticoagulants in patients with hematologic malignancies. Hematol Oncol 2020; 38:589-596. [PMID: 32588912 DOI: 10.1002/hon.2770] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/08/2020] [Accepted: 06/12/2020] [Indexed: 01/19/2023]
Abstract
The anticoagulant treatment for patients with hematologic malignancies is low molecular weight heparin (LMWH), which is considered the safest in this particular patients setting. Although direct oral anticoagulants (DOACs) have proven their efficacy and safety in patients with cancer, their use can be challenging in patients with hematologic malignancies due to the peculiarity of these neoplasms: high thrombotic risk, possible onset of thrombocytopenia and concomitant anticancer therapies. The aim of our study was to evaluate the efficacy and safety of DOACs for venous thromboembolism or atrial fibrillation in patients with hematologic malignancies and plasmatic DOACs level during anticancer therapy and at time of bleeding or thrombotic complications. We evaluated patients with hematologic malignancies treated with DOACs for venous thromboembolism or atrial fibrillation-therapy was maintained until the platelet count was ≥50 × 109 /L. In case of concomitant anticancer treatment and haemorrhagic or thrombotic events, we checked DOACs plasma levels (trough and peak). The patients evaluated were 135: 104/135 were on anticancer therapy. We did not observe either thrombotic or major haemorrhagic adverse events. Minor bleedings occurred in 10 patients and clinical relevant non-major (CRNM) in two patients. There was a statistically significant correlation between bleedings and myelodysplastic syndrome. DOACs resulted effective and safe in patients with hematologic malignancies. DOACs plasma level can be helpful in suggesting an early dose adjustment to prevent haemorrhagic adverse event in patients on concomitant anticancer therapy. Larger prospective studies including hematologic patients are warranted to confirm the safety and efficacy of DOACs.
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Affiliation(s)
- Alessandra Serrao
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
| | - Luciano Fiori
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
| | - Cristina Santoro
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
| | - Maria L De Luca
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
| | - Antonietta Ferretti
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
| | - Giulia De Luca
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
| | - Silvio Ligia
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
| | - Gianfranco Lapietra
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
| | - Sara Mohamed
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
| | - Massimo Breccia
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
| | - Antonio Chistolini
- Hematology, Departement of Translational and Precision Medicine, "Sapienza", University of Rome, Rome, Italy
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12
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Sequeira AR, Bhandari A, Kilpatrick B, Fradley MG, Mohanty BD. Managing thromboembolic risk from atrial fibrillation in patients with cancer: a role for nonpharmacologic approaches. Future Cardiol 2020; 16:687-693. [PMID: 32643392 DOI: 10.2217/fca-2020-0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Atrial fibrillation (AF) in the setting of malignancy poses a unique challenge given the confluent pathologies and risks of current treatments. Oral anticoagulation is recommended to reduce the risk of systemic thromboembolism in high-risk individuals with AF. The 'Watchman' device for left atrial appendage closure has shown comparable efficacy compared with anticoagulation with warfarin; however, patients with cancer were not included in trials testing Watchman safety and efficacy. We present the current treatment approaches for the management of AF in patients with malignancy. We review contemporary guidelines and propose a novel clinical decision tree by which physicians can consider left atrial appendage closure in cancer patients, and at last, suggest future investigation that might further clarify the clinical benefit of this approach.
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Affiliation(s)
| | - Ajay Bhandari
- Internal Medicine, University of South Florida, FL 33606, USA
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13
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Pineda-Gayoso R, Alomar M, Lee DH, Fradley MG. Cardiovascular Toxicities of Bruton’s Tyrosine Kinase Inhibitors. Curr Treat Options Oncol 2020; 21:67. [DOI: 10.1007/s11864-020-00764-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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14
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15
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Alomar M, Fradley MG. Electrophysiology Translational Considerations in Cardio-Oncology: QT and Beyond. J Cardiovasc Transl Res 2019; 13:390-401. [DOI: 10.1007/s12265-019-09924-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/04/2019] [Indexed: 12/14/2022]
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16
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Li J, Wan N, Wen J, Cheng G, He L, Cheng L. Quantitative detection and evaluation of thrombus formation based on electrical impedance spectroscopy. Biosens Bioelectron 2019; 141:111437. [PMID: 31279177 DOI: 10.1016/j.bios.2019.111437] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/06/2019] [Accepted: 06/12/2019] [Indexed: 01/13/2023]
Abstract
Thrombus formation is quantitatively measured and evaluated by the electrical impedance spectroscopy method in this study, which confirms the possibility for the application of a promising non-invasive thrombus detection method. The impedance parameter Z*(t) of blood from the electrical impedance spectroscopy is utilized to elaborate the impedance performance of blood during thrombus formation process. Experimental results indicate that the impedance Z*(t) of blood has regular variations under the formation of thrombus, which could be divided into three stages. Modified Hanai equation is proposed to quantitatively expound the three stages of impedance Z*(t) variation. The amount of fibrin and thrombus clot is founded to be accounted for the impedance variation of blood, which confirms the feasibility and theoretical basis of the non-invasive and on-line thrombus bio-detection technology for patients with serious cardiovascular disease.
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Affiliation(s)
- Jianping Li
- Institute of Precision Machinery and Smart Structure, College of Engineering, Zhejiang Normal University, Jinhua, 321004, Zhejiang Province, China
| | - Nen Wan
- Institute of Precision Machinery and Smart Structure, College of Engineering, Zhejiang Normal University, Jinhua, 321004, Zhejiang Province, China.
| | - Jianming Wen
- Institute of Precision Machinery and Smart Structure, College of Engineering, Zhejiang Normal University, Jinhua, 321004, Zhejiang Province, China
| | - Guangming Cheng
- Institute of Precision Machinery and Smart Structure, College of Engineering, Zhejiang Normal University, Jinhua, 321004, Zhejiang Province, China
| | - Lidong He
- Institute of Precision Machinery and Smart Structure, College of Engineering, Zhejiang Normal University, Jinhua, 321004, Zhejiang Province, China
| | - Li Cheng
- Institute of Precision Machinery and Smart Structure, College of Engineering, Zhejiang Normal University, Jinhua, 321004, Zhejiang Province, China
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