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Pantazi D, Alivertis D, Tselepis AD. Underlying Mechanisms of Thrombosis Associated with Cancer and Anticancer Therapies. Curr Treat Options Oncol 2024:10.1007/s11864-024-01210-7. [PMID: 38862694 DOI: 10.1007/s11864-024-01210-7] [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: 04/24/2024] [Indexed: 06/13/2024]
Abstract
OPINION STATEMENT Cancer-associated thrombosis (CAT) has been identified as the second most prevalent cause of death after cancer itself. Moreover, the risk of thrombotic events in cancer patients increases due to anticancer drugs, such as tyrosine kinase inhibitors (TKIs). Venous thromboembolism (VTE) as well as arterial thromboembolic (ATE) events are present in CAT. Although VTE occurs more frequently, ATE events are very significant and in some cases are more dangerous than VTE. Guidelines for preventing thrombosis refer mainly VTE as well as the contribution of ATE events. Several factors are involved in thrombosis related to cancer, but the whole pathomechanism of thrombosis is not clear and may differ between patients. The activation of the coagulation system and the interaction of cancer cells with other cells including platelets, endothelial cells, monocytes, and neutrophils are promoted by a hypercoagulable state caused by cancer. We present an update on the pathomechanisms of CAT and the effect of anticancer drugs, mainly targeted therapies with a focus on TKIs. Considering the risk of bleeding associated with anticoagulation in each cancer patient, the anticoagulation strategy may involve the use of FXIa inhibitors, direct oral anticoagulants, and low-molecular-weight heparin. Further research would be valuable in developing strategies for reducing CAT.
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Affiliation(s)
- Despoina Pantazi
- Laboratory of Biochemistry, Department of Chemistry/Atherothrombosis Research Centre, University of Ioannina, 451 10, Ioannina, Epirus, Greece.
| | - Dimitrios Alivertis
- Department of Biological Applications and Technology, University of Ioannina, 451 10, Ioannina, Epirus, Greece
| | - Alexandros D Tselepis
- Laboratory of Biochemistry, Department of Chemistry/Atherothrombosis Research Centre, University of Ioannina, 451 10, Ioannina, Epirus, Greece
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Mikail N, Chequer R, Imperiale A, Meisel A, Bengs S, Portmann A, Gimelli A, Buechel RR, Gebhard C, Rossi A. Tales from the future-nuclear cardio-oncology, from prediction to diagnosis and monitoring. Eur Heart J Cardiovasc Imaging 2023; 24:1129-1145. [PMID: 37467476 PMCID: PMC10501471 DOI: 10.1093/ehjci/jead168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023] Open
Abstract
Cancer and cardiovascular diseases (CVD) often share common risk factors, and patients with CVD who develop cancer are at high risk of experiencing major adverse cardiovascular events. Additionally, cancer treatment can induce short- and long-term adverse cardiovascular events. Given the improvement in oncological patients' prognosis, the burden in this vulnerable population is slowly shifting towards increased cardiovascular mortality. Consequently, the field of cardio-oncology is steadily expanding, prompting the need for new markers to stratify and monitor the cardiovascular risk in oncological patients before, during, and after the completion of treatment. Advanced non-invasive cardiac imaging has raised great interest in the early detection of CVD and cardiotoxicity in oncological patients. Nuclear medicine has long been a pivotal exam to robustly assess and monitor the cardiac function of patients undergoing potentially cardiotoxic chemotherapies. In addition, recent radiotracers have shown great interest in the early detection of cancer-treatment-related cardiotoxicity. In this review, we summarize the current and emerging nuclear cardiology tools that can help identify cardiotoxicity and assess the cardiovascular risk in patients undergoing cancer treatments and discuss the specific role of nuclear cardiology alongside other non-invasive imaging techniques.
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Affiliation(s)
- Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Renata Chequer
- Department of Nuclear Medicine, Bichat University Hospital, AP-HP, University Diderot, 75018 Paris, France
| | - Alessio Imperiale
- Nuclear Medicine, Institut de Cancérologie de Strasbourg Europe (ICANS), University Hospitals of Strasbourg, 67093 Strasbourg, France
- Molecular Imaging-DRHIM, IPHC, UMR 7178, CNRS/Unistra, 67093 Strasbourg, France
| | - Alexander Meisel
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Kantonsspital Glarus, Burgstrasse 99, 8750 Glarus, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Alessia Gimelli
- Imaging Department, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124 Pisa, Italy
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
- Department of Cardiology, University Hospital Inselspital Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
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3
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Kim MS, Byun SJ, Woo SJ, Park KH, Park SJ. A 12-year nationwide cohort study on the association between central retinal artery occlusion and cancer. Graefes Arch Clin Exp Ophthalmol 2023:10.1007/s00417-023-05984-8. [PMID: 36749440 DOI: 10.1007/s00417-023-05984-8] [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: 10/27/2022] [Revised: 01/05/2023] [Accepted: 01/26/2023] [Indexed: 02/08/2023] Open
Abstract
PURPOSE This study aims to investigate the association between incident central retinal artery occlusion (CRAO) and the subsequent development of cancer. METHODS We included incident CRAO patients from the 2002-2013 National Health Insurance Service database in South Korea. For the patient cohort, we included patients diagnosed with CRAO from the database, and excluded patients having CRAO or any cancer history during the first 2-year washout period (2002-2003). Then, we defined their 1:4 propensity-score matched non-CRAO subjects as controls, all of whom also had no history of cancer during the washout period. Time-varying covariate Cox regression models were conducted to determine the association of CRAO with cancer. Kaplan-Meier curves with log-rank test were also analyzed. RESULTS A total of 9712 patients with CRAO and 38,848 controls were included in the study. CRAO was associated with an increased risk of subsequent cancer (hazard ratio = 1.27; 95% confidence interval, 1.19-1.35). The incidence rate of overall cancer during the study period was 29.12 per 1000 person-years in the CRAO group and 22.77 per 1000 person-years in the control group. Incidence probability of overall cancer was significantly higher among CRAO patients than controls (P < 0.001, log-rank test). CONCLUSION The risk of cancer occurrence was increased in patients with CRAO. The results supported that CRAO could be attributed to one of the consequences of arterial thrombosis in cancer patients.
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Affiliation(s)
- Min Seok Kim
- Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Seong Jun Byun
- Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Se Joon Woo
- Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Kyu Hyung Park
- Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.,Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sang Jun Park
- Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.
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Screening for Coronary Artery Disease in Cancer Survivors: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2023; 5:22-38. [PMID: 36875910 PMCID: PMC9982229 DOI: 10.1016/j.jaccao.2022.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 02/24/2023] Open
Abstract
Coronary artery disease (CAD) is an important contributor to the cardiovascular burden in cancer survivors. This review identifies features that could help guide decisions about the benefit of screening to assess the risk or presence of subclinical CAD. Screening may be appropriate in selected survivors based on risk factors and inflammatory burden. In cancer survivors who have undergone genetic testing, polygenic risk scores and clonal hematopoiesis markers may become useful CAD risk prediction tools in the future. The type of cancer (especially breast, hematological, gastrointestinal, and genitourinary) and the nature of treatment (radiotherapy, platinum agents, fluorouracil, hormonal therapy, tyrosine kinase inhibitors, endothelial growth factor inhibitors, and immune checkpoint inhibitors) are also important in determining risk. Therapeutic implications of positive screening include lifestyle and atherosclerosis interventions, and in specific instances, revascularization may be indicated.
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Key Words
- ACS, acute coronary syndrome
- AYA, adolescent and young adult
- CAC, coronary artery calcium
- CAD, coronary artery disease
- CHIP, clonal hematopoiesis of indeterminate potential
- CMR, cardiac magnetic resonance
- CTA, computed tomography angiography
- CVD, cardiovascular disease
- IGF, insulin-like growth factor
- LDL, low-density lipoprotein
- PCE, pooled cohort equations
- PCI, percutaneous coronary intervention
- PRS, polygenic risk score
- ROS, reactive oxygen species
- TKI, tyrosine kinase inhibitor
- VEGF, vascular endothelial growth factor
- calcification
- coronary artery calcium
- coronary artery disease
- prevention
- risk factor
- risk prediction
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González Rodríguez P, Gisbert SMM, Chiriboga Granja JI, Medina MC, Palonés FJG. Anaplastic thyroid tumor as an embolic source of metastasis. J Vasc Surg Cases Innov Tech 2022; 8:386-389. [PMID: 35936021 PMCID: PMC9352510 DOI: 10.1016/j.jvscit.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/12/2022] [Indexed: 11/24/2022] Open
Abstract
Tumor-based arterial thromboembolism in patients with cancer is a poorly described concept that lacks evidence for surgical indications owing to its unusual occurrence. The study and understanding of this condition’s etiology is, however, essential because it could constitute the initial presentation or determine the prognosis of oncologic disease. In the present report, we have described the case of a 77-year-old female patient with multiple cerebral, splenic, and upper limb arterial embolic episodes. Embolectomy for acute upper limb ischemia revealed the histopathologic diagnosis of an anaplastic thyroid tumor.
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New Insights on the Toxicity on Heart and Vessels of Breast Cancer Therapies. Med Sci (Basel) 2022; 10:medsci10020027. [PMID: 35736347 PMCID: PMC9229896 DOI: 10.3390/medsci10020027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular diseases are largely represented in patients with cancer and appear to be important side effects of cancer treatments, heavily affecting quality of life and leading to premature morbidity and death among cancer survivors. In particular, treatments for breast cancer have been shown to potentially play serious detrimental effects on cardiovascular health. This review aims to explore the available literature on breast cancer therapy-induced side effects on heart and vessels, illustrating the molecular mechanisms of cardiotoxicity known so far. Moreover, principles of cardiovascular risk assessment and management of cardiotoxicity in clinical practice will also be elucidated. Chemotherapy (anthracycline, taxanes, cyclophosphamide and 5-fluorouracil), hormonal therapy (estrogen receptor modulator and gonadotropin or luteinizing releasing hormone agonists) and targeted therapy (epidermal growth factor receptor 2 and Cyclin-dependent kinases 4 and 6 inhibitors) adverse events include arterial and pulmonary hypertension, supraventricular and ventricular arrhythmias, systolic and diastolic cardiac dysfunction and coronary artery diseases due to different and still not well-dissected molecular pathways. Therefore, cardiovascular prevention programs and treatment of cardiotoxicity appear to be crucial to improve morbidity and mortality of cancer survivors.
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Riedl JM, Schwarzenbacher E, Moik F, Horvath L, Gantschnigg A, Renneberg F, Posch F, Barth DA, Stotz M, Pichler M, Hatzl S, Fandler-Höfler S, Gressenberger P, Gary T, Jost PJ, Greil R, Ay C, Djanani A, Gerger A, Schlick K. Patterns of Thromboembolism in Patients with Advanced Pancreatic Cancer Undergoing First-Line Chemotherapy with FOLFIRINOX or Gemcitabine/nab-Paclitaxel. Thromb Haemost 2022; 122:633-645. [PMID: 34255340 DOI: 10.1055/a-1548-4847] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Recent advances in prophylactic anticoagulation and antineoplastic treatment for advanced pancreatic cancer (aPC) warrant an updated reassessment of thromboembolic risk in this population. This multicenter retrospective cohort study aims to comprehensively characterize incidence, risk factors, and outcomes of venous (VTE) and arterial thromboembolism (ATE) in homogenously treated patients with aPC. METHODS Four hundred and fifty-five patients with aPC undergoing palliative first-line chemotherapy (Gemcitabine/nab-Paclitaxel (GN) or FOLIRINOX) were included. Primary outcomes were objectively confirmed VTE and/or ATE. RESULTS Over a median follow-up of 26 months, 86 VTE (cumulative incidence: 20.0%; 95% confidence interval [CI]: 16.3-24.0) and 11 ATE events (cumulative incidence: 2.8%; 95% CI: 1.5-4.9) were observed. VTE diagnosis was associated with increased mortality (transition hazard ratio [THR]: 1.59 [95% CI: 1.21-2.09]) and increased risk of cancer progression (THR: 1.47 [95% CI: 1.08-2.01]), while the impact of ATE on mortality was numerically but not statistically significant (THR: 1.85 [95% CI: 0.87-3.94]). The strongest predictor of increased VTE risk was history of cancer-associated VTE (subdistribution hazard ratio [SHR]: 3.29 [95% CI: 2.09-5.18]), while the Khorana score (SHR: 0.78 [0.57-1.06]) failed to predict VTE risk. A history of cerebrovascular disease was associated with markedly increased ATE risk (SHR: 22.05 [95% CI: 6.83-71.22], p < 0.001), especially ischemic stroke. Risk of VTE/ATE did not significantly differ according to type of first-line chemotherapy. CONCLUSION Patients with aPC undergoing palliative first-line chemotherapy with FOLFIRINOX or GN face a high risk for VTE/ATE and its diagnosis is linked to worse clinical outcomes. VTE-risk prediction models have limited ability to sub-stratify thrombotic events in this high-risk scenario.
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Affiliation(s)
- Jakob M Riedl
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Esther Schwarzenbacher
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Moik
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Lena Horvath
- Department of Internal Medicine V: Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Felix Renneberg
- IIIrd Medical Department of Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectious Disease, Salzburg Cancer Research Institute, Paracelsus Medical University, Salzburg, Austria
| | - Florian Posch
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Dominik A Barth
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Stotz
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Pichler
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stefan Hatzl
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Paul Gressenberger
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Gary
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp J Jost
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Richard Greil
- IIIrd Medical Department of Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectious Disease, Salzburg Cancer Research Institute, Paracelsus Medical University, Salzburg, Austria
| | - Cihan Ay
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Angela Djanani
- Department of Internal Medicine I, Gastroenterology, Hepatology, Metabolism and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
| | - Armin Gerger
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Konstantin Schlick
- IIIrd Medical Department of Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectious Disease, Salzburg Cancer Research Institute, Paracelsus Medical University, Salzburg, Austria
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Gupta A, Marzook H, Ahmad F. Comorbidities and clinical complications associated with SARS-CoV-2 infection: an overview. Clin Exp Med 2022; 23:313-331. [PMID: 35362771 PMCID: PMC8972750 DOI: 10.1007/s10238-022-00821-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/12/2022] [Indexed: 01/08/2023]
Abstract
The novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causes major challenges to the healthcare system. SARS-CoV-2 infection leads to millions of deaths worldwide and the mortality rate is found to be greatly associated with pre-existing clinical conditions. The existing dataset strongly suggests that cardiometabolic diseases including hypertension, coronary artery disease, diabetes and obesity serve as strong comorbidities in coronavirus disease (COVID-19). Studies have also shown the poor outcome of COVID-19 in patients associated with angiotensin-converting enzyme-2 polymorphism, cancer chemotherapy, chronic kidney disease, thyroid disorder, or coagulation dysfunction. A severe complication of COVID-19 is mostly seen in people with compromised medical history. SARS-CoV-2 appears to attack the respiratory system causing pneumonia, acute respiratory distress syndrome, which lead to induction of severe systemic inflammation, multi-organ dysfunction, and death mostly in the patients who are associated with pre-existing comorbidity factors. In this article, we highlighted the key comorbidities and a variety of clinical complications associated with COVID-19 for a better understanding of the etiopathogenesis of COVID-19.
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Affiliation(s)
- Anamika Gupta
- Cardiovascular Research Group, Sharjah Institute for Medical Research, University of Sharjah, Sharjah, 27272, UAE
| | - Hezlin Marzook
- Cardiovascular Research Group, Sharjah Institute for Medical Research, University of Sharjah, Sharjah, 27272, UAE
| | - Firdos Ahmad
- Cardiovascular Research Group, Sharjah Institute for Medical Research, University of Sharjah, Sharjah, 27272, UAE. .,Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah, 27272, UAE.
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Panova-Noeva M, Falanga A. Editorial: Role of the Platelet Phenomenon in Cardiovascular Diseases and Cancer. Front Cardiovasc Med 2022; 9:859770. [PMID: 35402555 PMCID: PMC8984256 DOI: 10.3389/fcvm.2022.859770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Marina Panova-Noeva
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- *Correspondence: Marina Panova-Noeva
| | - Anna Falanga
- Department of Medicine and Surgery, University of Milan Bicocca, Monza, Italy
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
- Anna Falanga
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10
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Naschitz JE. Cancer-Associated Atherothrombosis: The Challenge. Int J Angiol 2021; 30:249-256. [PMID: 34853571 DOI: 10.1055/s-0041-1729920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The association between venous thrombosis and malignancy, having typical features of a paraneoplastic syndrome, has been established for a century. Currently, it is recognized that arterial thromboembolism (ATE) may also behave as a paraneoplastic syndrome. Recent matched cohort studies, systematic reviews, and observational studies concur in showing an increased incidence of acute coronary events, ischemic stroke, accelerated peripheral arterial disease, and in-stent thrombosis during the 6-month period before cancer diagnosis, peaking for 30 days immediately before cancer diagnosis. Cancer patients with ATE are at higher risk of in-hospital and long-term mortality as compared with noncancer patients. In the present review, we focus on the epidemiology, clinical variants and presentation, morbidity, mortality, primary and secondary prevention, and treatment of cancer-associated ATE. The awareness that cancer can be a risk factor for ATE and that cancer therapy can initiate cardiovascular complications make it mandatory to identify high-risk patients, modify preexistent cardiovascular risk factors, and adopt effective antithrombotic prophylaxis. For ATE prophylaxis, modifiable patient-related risk factors and oncology treatment-related factors are levers for intervention. Statins and platelet antiaggregants have been studied, but their efficacy for prevention of cancer-associated ATE remains to be demonstrated. Results of revascularization procedures for cancer-associated ATE are worse than for ATE in noncancer patients. It is important that a multidisciplinary approach is adopted for making informed decisions, by involving the vascular surgeon, interventional radiologist, oncologist, and palliative medicine, as well as the patients and their family.
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Affiliation(s)
- Jochanan E Naschitz
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Comprehensive Geriatric Ward, Bait Balev Nesher, Nesher, Israel
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Liu F, Xu Z, Luo J, Yu P, Ma J, Yuan P, Zhu W. Effectiveness and Safety of DOACs vs. VKAs in AF Patients With Cancer: Evidence From Randomized Clinical Trials and Observational Studies. Front Cardiovasc Med 2021; 8:766377. [PMID: 34805320 PMCID: PMC8602680 DOI: 10.3389/fcvm.2021.766377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 10/13/2021] [Indexed: 01/05/2023] Open
Abstract
Background: The use of direct oral anticoagulants (DOACs) is recommended as the preferred treatment drug in patients with nonvalvular atrial fibrillation (AF). However, the effectiveness and safety of DOACs compared with vitamin K antagonists (VKAs) in patients with cancer and AF are still controversial. Therefore, we performed a meta-analysis regarding the effectiveness and safety of DOACs vs. VKAs in AF patients with cancer. Methods: A search of the Pubmed and EMBASE databases until August 2021 was performed. Adjusted risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using a random-effects model with an inverse variance method. Results: Thirteen studies were deemed to meet the criteria. For the effectiveness outcomes, the use of DOACs compared with VKAs use was significantly associated with decreased risks of stroke or systemic embolism (RR = 0.66, 95% CI: 0.54–0.80) and venous thromboembolism (RR = 0.40, 95% CI: 0.26–0.61), but not ischemic stroke (RR = 0.79, 95% CI: 0.56–1.11), myocardial infarction (RR = 0.78, 95% CI: 0.56–1.11), cardiovascular death (RR = 0.76, 95% CI: 0.53–1.09), and all-cause death (RR = 0.82, 95% CI: 0.43–1.56). For the safety outcomes, compared with VKAs use, the use of DOACs was associated with reduced risks of intracranial bleeding (RR = 0.60, 95% CI: 0.50–0.71) and gastrointestinal bleeding (RR = 0.87, 95% CI: 0.80–0.95). There were no significant differences in major bleeding (RR = 0.87, 95% CI: 0.74–1.04), major or nonmajor clinically relevant bleeding (RR = 0.87, 95% CI: 0.74–1.01), and any bleeding (RR = 0.88, 95% CI: 0.76–1.03). Conclusion: Compared with VKAs, DOACs appeared to have significant reductions in stroke or systemic embolism, venous thromboembolism, intracranial bleeding, and gastrointestinal bleeding, but comparable risks of ischemic stroke, myocardial infarction, cardiovascular death, all-cause death, major bleeding, major or nonmajor clinically relevant bleeding, and any bleeding in patients with AF and cancer.
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Affiliation(s)
- Fuwei Liu
- Department of Cardiology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - Zixuan Xu
- Department of Emergency, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jun Luo
- Department of Cardiology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - Peng Yu
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jianyong Ma
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Ping Yuan
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Franchini M, Tufano A, Casoria A, Coppola A. Arterial Thrombosis in Cancer Patients: An Update. Semin Thromb Hemost 2021; 47:942-949. [PMID: 34464985 DOI: 10.1055/s-0041-1733927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cancer is associated with an increased incidence of both venous thromboembolism (VTE) and arterial thrombosis (cardiovascular events and ischemic stroke). Cancer-associated arterial thrombotic events are less well studied than VTE, but increasingly recognized, particularly in specific malignancies and in association with specific anticancer therapies. The pathogenesis of arterial thrombotic events in cancer is complex and involves generation of tumor-associated procoagulant factors and a variety of alterations in platelet function as well as in the coagulation and fibrinolytic systems, and endothelial injury and dysfunction, that combine to produce hypercoagulability. The multifactorial interaction between this prothrombotic state, the individual cardiovascular risk, advanced age and presence of comorbidities, and the specific neoplasm characteristics and therapy, may induce the vascular events. Recent studies based on population databases and prospective or retrospective analyses with prolonged follow-up highlight that cancer patients experience an increased (approximately 1.5-2-fold) risk of both cerebrovascular and cardiovascular events compared with noncancer individuals, which peaks in the time period of the diagnosis of cancer but may persist for years. Beyond the type of cancer, the risk reflects the tumor burden, being higher in advanced stages and metastatic cancers. The occurrence of arterial thromboembolic events is also associated with increased overall mortality. We here present an update of the pathophysiology, risk factors, clinical evidence, and treatment considerations on cancer-associated arterial thrombosis, in the light of the need for specific multidisciplinary prevention and surveillance strategies in this setting, in the frame of cardio-oncology approaches.
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Affiliation(s)
- Massimo Franchini
- Department of Haematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Aniello Casoria
- Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Antonio Coppola
- Department of General and Specialist Medicine, Hub Center for Inherited Bleeding Disorders, University Hospital, Parma, Italy
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13
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Vrints CJM. Deep venous thrombosis and endothelial dysfunction in cancer: prevention and early initiated rehabilitation should be integral to a cardio-oncology programme. Eur J Prev Cardiol 2021; 29:1244-1247. [PMID: 34463767 DOI: 10.1093/eurjpc/zwab117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Christiaan J M Vrints
- Department of Cardiology, University of Antwerp & Antwerp University Hospital, Antwerp, Belgium
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14
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Kobayashi S, Koizume S, Takahashi T, Ueno M, Oishi R, Nagashima S, Sano Y, Fukushima T, Tezuka S, Morimoto M, Nakamura S, Narimatsu H, Ruf W, Miyagi Y. Tissue factor and its procoagulant activity on cancer-associated thromboembolism in pancreatic cancer. Cancer Sci 2021; 112:4679-4691. [PMID: 34382298 PMCID: PMC8586686 DOI: 10.1111/cas.15106] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/09/2021] [Accepted: 08/09/2021] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer frequently involves cancer-associated thromboembolism, which is strongly associated with poor prognosis. Tissue factor, a blood coagulation factor largely produced in cancer patients as a component of extracellular vesicles, plays a key role in the incidence of cancer-associated thromboembolism in patients with pancreatic cancer. However, no prospective studies have been published on the relationship between tissue factor and cancer-associated thromboembolism or patient clinical characteristics, including recent chemotherapy regimens. Thus, we aimed to address this in a Japanese cohort of 197 patients and 41 healthy volunteers. Plasma tissue factor levels were measured by ELISAs preevaluated by tissue factor specificity. Multivariable analysis was used to identify independent predictors of cancer-associated thromboembolism. We found that the cancer-associated thromboembolism rate in the patient cohort was 6.6% (4.6%, venous thromboembolism; 2.0%, arterial thromboembolism). Tissue factor levels of 100 pg/mL or higher at patient registration were predictive of cancer-associated thromboembolism, with positive and negative predictive values of 23.1% and 94.6%, respectively. Multivariable analysis showed that plasma tissue factor levels were an independent predictive factor for cancer-associated thromboembolism, with a risk ratio of 5.54 (95% confidence interval, 1.02-30.09). Unlike in healthy volunteers and patients without cancer-associated thromboembolism, tissue factor levels were highly correlated with extracellular vesicles' procoagulant activity in patients developing cancer-associated thromboembolism. Taken together, our data show that the tissue factor levels at patient registration were a predictive factor for cancer-associated thromboembolism in this cohort of patients with pancreatic cancer.
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Affiliation(s)
- Satoshi Kobayashi
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Kanagawa, Japan
| | - Shiro Koizume
- Molecular Pathology and Genetics Division, Kanagawa Cancer Center Research Institute, Kanagawa, Japan
| | - Tomoko Takahashi
- Molecular Pathology and Genetics Division, Kanagawa Cancer Center Research Institute, Kanagawa, Japan
| | - Makoto Ueno
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Kanagawa, Japan
| | - Ritsuko Oishi
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Kanagawa, Japan
| | - Shuhei Nagashima
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Kanagawa, Japan
| | - Yusuke Sano
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Kanagawa, Japan
| | - Taito Fukushima
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Kanagawa, Japan
| | - Shun Tezuka
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Kanagawa, Japan
| | - Manabu Morimoto
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Kanagawa, Japan
| | - Sho Nakamura
- Cancer Prevention and Control Division, Kanagawa Cancer Center Research Institute, Kanagawa, Japan
| | - Hiroto Narimatsu
- Cancer Prevention and Control Division, Kanagawa Cancer Center Research Institute, Kanagawa, Japan
| | - Wolfram Ruf
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Yohei Miyagi
- Molecular Pathology and Genetics Division, Kanagawa Cancer Center Research Institute, Kanagawa, Japan
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15
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Plasminogen activator inhibitor 1 and venous thrombosis in pancreatic cancer. Blood Adv 2021; 5:487-495. [PMID: 33496742 DOI: 10.1182/bloodadvances.2020003149] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/17/2020] [Indexed: 12/25/2022] Open
Abstract
Pancreatic cancer patients have a high risk of venous thromboembolism (VTE). Plasminogen activator inhibitor 1 (PAI-1) inhibits plasminogen activators and increases the risk of thrombosis. PAI-1 is expressed by pancreatic tumors and human pancreatic cell lines. However, to date, there are no studies analyzing the association of active PAI-1 and VTE in pancreatic cancer patients. We investigated the association of active PAI-1 in plasma and VTE in pancreatic cancer patients. In addition, we determined if the presence of human pancreatic tumors expressing PAI-1 impairs venous thrombus resolution in mice. Plasma levels of active PAI-1 in patients with pancreatic cancer and mice bearing human tumors were determined by enzyme-linked immunosorbent assay. We measured PAI-1 expression in 5 different human pancreatic cancer cell lines and found that PANC-1 cells expressed the highest level. PANC-1 tumors were grown in nude mice. Venous thrombosis was induced by complete ligation of the inferior vena cava (IVC). Levels of active PAI-1 were independently associated with increased risk of VTE in patients with pancreatic cancer (subdistribution hazard ratio per doubling of levels: 1.39 [95% confidence interval, 1.09-1.78], P = .007). Mice bearing PANC-1 tumors had increased levels of both active human and active mouse PAI-1 and decreased levels of plasmin activity. Importantly, mice bearing PANC-1 tumors exhibited impaired venous thrombus resolution 8 days after IVC stasis compared with nontumor controls. Our results suggest that PAI-1 contributes to VTE in pancreatic cancer.
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16
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The Pharmacological Approach to Oncologic Patients with Acute Coronary Syndrome. J Clin Med 2020; 9:jcm9123926. [PMID: 33287336 PMCID: PMC7761724 DOI: 10.3390/jcm9123926] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 11/26/2020] [Accepted: 11/28/2020] [Indexed: 01/03/2023] Open
Abstract
Among acute coronary syndrome (ACS) patients, 15% have concomitant cancer, especially in the first 6 months after their diagnosis, as well as in advanced metastatic stages. Lung, gastric, and pancreatic cancers are the most frequent malignancies associated with ACS. Chemotherapy and radiotherapy exert prothrombotic, vasospastic, and proinflammatory actions. The management of cancer patients with ACS is quite challenging: percutaneous revascularization is often underused, and antiplatelet and anticoagulant pharmacological therapy should be individually tailored to the thrombotic risk and to the bleeding complications. Sometimes oncological patients also show different degrees of thrombocytopenia, which further complicates the pharmacological strategies. The aim of this review is to summarize the current evidence regarding the treatment of ACS in cancer patients and to suggest the optimal management and therapy to reduce the risk of adverse coronary events after ACS in this high-risk population.
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17
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Faria AVS, Andrade SS, Peppelenbosch MP, Ferreira-Halder CV, Fuhler GM. Platelets in aging and cancer-"double-edged sword". Cancer Metastasis Rev 2020; 39:1205-1221. [PMID: 32869161 PMCID: PMC7458881 DOI: 10.1007/s10555-020-09926-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/12/2020] [Indexed: 02/06/2023]
Abstract
Platelets control hemostasis and play a key role in inflammation and immunity. However, platelet function may change during aging, and a role for these versatile cells in many age-related pathological processes is emerging. In addition to a well-known role in cardiovascular disease, platelet activity is now thought to contribute to cancer cell metastasis and tumor-associated venous thromboembolism (VTE) development. Worldwide, the great majority of all patients with cardiovascular disease and some with cancer receive anti-platelet therapy to reduce the risk of thrombosis. However, not only do thrombotic diseases remain a leading cause of morbidity and mortality, cancer, especially metastasis, is still the second cause of death worldwide. Understanding how platelets change during aging and how they may contribute to aging-related diseases such as cancer may contribute to steps taken along the road towards a "healthy aging" strategy. Here, we review the changes that occur in platelets during aging, and investigate how these versatile blood components contribute to cancer progression.
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Affiliation(s)
- Alessandra V S Faria
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, NL-3000 CA, Rotterdam, The Netherlands
- Department of Biochemistry and Tissue Biology, University of Campinas, UNICAMP, Campinas, SP, 13083-862, Brazil
| | | | - Maikel P Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, NL-3000 CA, Rotterdam, The Netherlands
| | - Carmen V Ferreira-Halder
- Department of Biochemistry and Tissue Biology, University of Campinas, UNICAMP, Campinas, SP, 13083-862, Brazil
| | - Gwenny M Fuhler
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, NL-3000 CA, Rotterdam, The Netherlands.
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18
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Characteristics, Management, and Outcomes of Acute Coronary Syndrome Patients with Cancer. J Clin Med 2020; 9:jcm9113642. [PMID: 33198355 PMCID: PMC7696544 DOI: 10.3390/jcm9113642] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023] Open
Abstract
Patients with cancer are at increased risk of cardiovascular disease, with a reported prevalence of acute coronary syndrome (ACS) ranging from 3% to 17%. The increased risk of ACS in these patients seems to be due to the complex interaction of shared cardiovascular risk factors, cancer type and stage, and chemotherapeutic and radiotherapy regimens. The management of ACS in patients with cancer is a clinical challenge, particularly due to cancer’s unique pathophysiology, which makes it difficult to balance thrombotic and bleeding risks in this specific patient population. In addition, patients with cancer have largely been excluded from ACS trials. Hence, an evidence-based treatment for ACS in this group of patients is unknown and only a limited proportion of them is treated with antiplatelets or invasive revascularization, despite initial reports suggesting their beneficial prognostic effects in cancer patients. Finally, cancer patients experiencing ACS are also at higher risk of in-hospital and long-term mortality as compared to non-cancer patients. In this review, we will provide an overview on the available evidence of the relationship between ACS and cancer, in terms of clinical manifestations, possible underlying mechanisms, and therapeutic and prognostic implications.
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19
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Mariani MV, Magnocavallo M, Straito M, Piro A, Severino P, Iannucci G, Chimenti C, Mancone M, Rocca DGD, Forleo GB, Fedele F, Lavalle C. Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and cancer a meta-analysis. J Thromb Thrombolysis 2020; 51:419-429. [PMID: 33044735 PMCID: PMC7886836 DOI: 10.1007/s11239-020-02304-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 02/07/2023]
Abstract
Background Direct oral anticoagulants (DOACs) are recommended as first-line anticoagulants in patients with atrial fibrillation (AF). However, in patients with cancer and AF the efficacy and safety of DOACs are not well established. Objective We performed a meta-analysis comparing available data regarding the efficacy and safety of DOACs vs vitamin K antagonists (VKAs) in cancer patients with non-valvular AF. Methods An online search of Pubmed and EMBASE libraries (from inception to May, 1 2020) was performed, in addition to manual screening. Nine studies were considered eligible for the meta-analysis involving 46,424 DOACs users and 182,797 VKA users. Results The use of DOACs was associated with reduced risks of systemic embolism or any stroke (RR 0.65; 95% CI 0.52–0.81; p 0.001), ischemic stroke (RR 0.84; 95% CI 0.74–0.95; p 0.007) and hemorrhagic stroke (RR 0.61; 95% CI 0.52–0.71; p 0.00001) as compared to VKA group. DOAC use was associated with significantly reduced risks of major bleeding (RR 0.68; 95% CI 0.50–0.92; p 0.01) and intracranial or gastrointestinal bleeding (RR 0.64; 95% CI 0.47–0.88; p 0.006). Compared to VKA, DOACs provided a non-statistically significant risk reduction of the outcomes major bleeding or non-major clinically relevant bleeding (RR 0.94; 95% CI 0.78–1.13; p 0.50) and any bleeding (RR 0.91; 95% CI 0.78–1.06; p 0.24). Conclusions In comparison to VKA, DOACs were associated with a significant reduction of the rates of thromboembolic events and major bleeding complications in patients with AF and cancer. Further studies are needed to confirm our results. Electronic supplementary material The online version of this article (10.1007/s11239-020-02304-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Michele Magnocavallo
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Martina Straito
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Paolo Severino
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Gino Iannucci
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristina Chimenti
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Massimo Mancone
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | | | | | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Abstract
Purpose of review The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), continues to spread with rising new cases and deaths. Patients with cancer represent a uniquely vulnerable population not only with higher susceptibility to COVID-19 but also at increased risk for its complications. This review focuses on the implications of COVID-19 in the cardiovascular health of patients with cancer. Recent findings Patients more susceptible to COVID-19 with increased severity of disease include those with cancer and cardiovascular comorbidities. In addition, the cardiovascular complications of COVID-19 including acute myocardial injury, thromboembolism, cardiomyopathy, myocarditis, and pericardial disease overlap with many of those encountered during cancer treatment. Summary Despite the absence of large studies of patients with both cancer and cardiovascular disease, the incidence of cardiovascular complications in cancer patients with COVID-19 is expected to be high. This has implications for cardiac monitoring, chemotherapy administration, and the diagnosis and treatment of cardiovascular disease during COVID-19.
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21
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Argyriou A, Kafetzakis A, Saratzis A, Huasen B, Coscas R, Renard R, Bisdas T, Torsello G, Tsilimparis N, Calderbank T, Stavroulakis K. Revascularization Outcomes in Patients With Acute Limb Ischemia and Active Neoplastic Disease. J Endovasc Ther 2020; 28:100-106. [PMID: 32909530 DOI: 10.1177/1526602820954285] [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: 01/20/2023]
Abstract
PURPOSE To report the outcomes of surgical (ST), endovascular (ET), and hybrid (HT) treatment in cancer patients with acute limb ischemia (ALI). MATERIALS AND METHODS A multicenter retrospective registry collected 139 patients (mean age 72.3±12.4 years; 73 men) with ALI and active malignancy treated by ET (41, 29%), ST (70, 51%), or HT (28, 20%) in 7 European centers between July 2007 and February 2019. In 22 cases (16%) ALI was the first manifestation of the malignancy. Lung cancer was the most common diagnosis (38, 27%). The primary composite outcome was amputation-free survival (AFS). Overall survival, amputation-free time (AFT), and reintervention-free time (RFT) were also assessed. Cox regression analysis was applied to identify independent risk factors for the primary and secondary outcomes. Results are presented as the hazard ratio (HR) and 95% confidence intervals (CIs). RESULTS ET was associated with improved 12-month AFS compared with both ST (HR 2.27, 95% CI 1.20 to 4.28, p=0.002) and HT (HR 2.14, 95% CI 1.09 to 4.18, p=0.008). ST (HR 2.50, 95% CI 1.19 to 5.53, p=0.003) and HT (HR 3.10, 95% CI 1.45 to 6.65, p<0.001) were related to an increased risk for mortality compared with ET. At 12 months, the AFT was similar between the 3 groups (ET vs ST: HR 1.52, 95% CI 0.51 to 4.53, p=0.45 and ET vs HT: HR 1.21, 95% CI 0.36 to 4.11, p=0.73). The 12-month RFT also did not differ significantly between the 3 treatment options (ET vs ST: HR 1.10, 95% CI 0.49 to 2.46, p=0.79 and ET vs HT: HR 0.51, 95% CI 0.22 to 1.17, p=0.19). ST and/or HT increased the risk for the major amputation and/or death (HR 1.76, 95% CI 1.05 to 2.05, p=0.03), while Rutherford class I ischemia (HR 0.12, 95% CI 0.02 to 0.90, p=0.04) and previous vascular interventions on the index limb (HR 0.55, 95% CI 0.32 to 0.97, p=0.04) showed a protective effect. CONCLUSION In patients with ALI and active malignant disease, ET was associated with increased AFS and overall survival compared with both ST and HT, while the limb salvage and reintervention rates were comparable among the 3 groups.
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Affiliation(s)
- Angeliki Argyriou
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | | | | | - Bella Huasen
- Department of Interventional Radiology, Royal Preston Hospital NHS Foundation Trust, Preston, UK
| | - Raphaël Coscas
- Department of Vascular Surgery, Ambroise Paré Hospital, Boulogne-Billancourt, France.,UFR des sciences de la santé Simone Veil, Paris-Saclay University, Paris, France
| | - Regis Renard
- Department of Vascular Surgery, Ambroise Paré Hospital, Boulogne-Billancourt, France.,UFR des sciences de la santé Simone Veil, Paris-Saclay University, Paris, France
| | - Theodosios Bisdas
- Department of Vascular and Endovascular Surgery, Medical Center Athens, Greece
| | - Giovanni Torsello
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital Munich, Germany
| | - Tom Calderbank
- Department of Cardiovascular Science, University of Leicester, UK
| | - Konstantinos Stavroulakis
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany.,Department of Vascular Surgery, Ludwig-Maximilians-University Hospital Munich, Germany
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22
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Perrone F, Biagi A, Facchinetti F, Bozzetti F, Ramelli A, Vezzani A, Manca T, Gnetti L, Majori M, Alfieri V, Tiseo M. Systemic thromboembolism from a misdiagnosed non-bacterial thrombotic endocarditis in a patient with lung cancer: A case report. Oncol Lett 2020; 20:194. [PMID: 32952663 PMCID: PMC7479525 DOI: 10.3892/ol.2020.12056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 03/05/2020] [Indexed: 12/03/2022] Open
Abstract
Thromboembolic events are frequent in patients with cancer, commonly involving the venous and pulmonary circulation. The arterial system is rarely implicated in embolism and, when involved, a cardiogenic origin should always be excluded. In the present study, a case of a patient who developed multiple embolic events concomitantly with the diagnosis of locally-advanced non-small cell lung cancer with high expression levels of programmed death-ligand 1 (PD-L1) in >50% of tumor cells is reported. A cardiac defect interpreted as a patent foramen ovale required low molecular weight heparin administration. Despite the anti-coagulant therapy, before first-line anticancer treatment with pembrolizumab immunotherapy could be administered due to high PD-L1 expression levels, a new hospitalization was required due to the onset of novel ischemic manifestation. New transthoracic and transesophageal echocardiography revealed a previously misdiagnosed vegetation of the mitral valve that caused systemic embolization. The lack of any sign of infection led to the diagnosis of a non-bacterial thrombotic endocarditis (NBTE), whose embolic sprouting gave rise to the widespread ischemic events. No active anticancer treatment was feasible due to the rapid progression of the disease. NBTE can evolve quickly, eventually preventing any chance of treatment targeting the primary cause, which in the present study was lung cancer. If NBTE can be correctly diagnosed sooner then there may be the potential for anticancer therapy that does not worsen the hypercoagulability state, thus improving cancer-associated survival.
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Affiliation(s)
- Fabiana Perrone
- Medical Oncology Unit, University Hospital of Parma, I-43126 Parma, Italy
| | - Andrea Biagi
- Cardiology Department, University Hospital of Parma, I-43126 Parma, Italy
| | - Francesco Facchinetti
- Medical Oncology Unit, University Hospital of Parma, I-43126 Parma, Italy.,National Institute of Health and Medical Research, Gustave Roussy Cancer Campus, University of Paris-Saclay, 94800 Villejuif, France
| | | | - Andrea Ramelli
- Cardiac Surgery Intensive Care Unit, University of Parma, I-43126 Parma, Italy
| | - Antonella Vezzani
- Cardiac Surgery Intensive Care Unit, University of Parma, I-43126 Parma, Italy
| | - Tullio Manca
- Cardiac Surgery Intensive Care Unit, University of Parma, I-43126 Parma, Italy
| | - Letizia Gnetti
- Unit of Pathology, University of Parma, I-43126 Parma, Italy
| | - Maria Majori
- Unit of Pulmonology and Thoracic Endoscopy, University of Parma, I-43126 Parma, Italy
| | - Veronica Alfieri
- Unit of Respiratory Disease and Lung Function, University of Parma, I-43126 Parma, Italy
| | - Marcello Tiseo
- Medical Oncology Unit, University Hospital of Parma, I-43126 Parma, Italy.,Department of Medicine and Surgery, University of Parma, I-43126 Parma, Italy
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23
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Wu BC, Hu MH, Wang V. The resolution of carotid arterial thrombus by oral anticoagulation after IV thrombolysis for chemotherapy-induced stroke: A case report. Medicine (Baltimore) 2020; 99:e21922. [PMID: 32871929 PMCID: PMC7458174 DOI: 10.1097/md.0000000000021922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Cancer-related stroke has been regarded as an emerging subtype of ischemic event. Acute treatment for this subtype may include the antiplatelet agents, anticoagulants, or endovascular intervention. PATIENT CONCERNS A 63-year-old woman with sudden-onset right hemiparesis and conscious change was sent to our emergency department. The patient had underlying sigmoid adenocarcinoma and received chemotherapy FOLFIRI (FOL, folinic acid; F, fluorouracil; and IRI, irinotecan) with targeted therapy cetuximab following lower anterior resection since the diagnosis was made. DIAGNOSES Brain magnetic resonance angiography revealed a filling defect in left carotid bulb, and neurosonography showed a thick atherosclerotic plaque (size 4.9 mm) in the left internal carotid artery on day 5 after the onset of stroke. INTERVENTIONS During the first three hours after onset, administration of IV tissue plasminogen activator did not resolve the thrombus. Dabigatran (110 mg bid) started on day 7. OUTCOMES The atherosclerotic plaque dissolved on day 24. The patient recovered her muscle strength but still had nonfluent speech in mild extent. LESSONS Thrombolytic and anticoagulant medications in this patient suggested the thrombus formation with fibrin-rich content which may be attributable to both cancer and chemotherapy. Dabigatran, an oral anticoagulant, had a benefit for this subtype of ischemic stroke among patients with cancer.
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Affiliation(s)
- Bo-Chang Wu
- School of Medicine, College of Medicine, Fu-Jen Catholic University, New Taipei City
| | - Ming-Hung Hu
- Division of Hematology and Oncology, Department of Medicine, Taipei Municipal Wangfang Hospital
- Taipei Cancer Center, Taipei Medical University, Taipei
| | - Vinchi Wang
- School of Medicine, College of Medicine, Fu-Jen Catholic University, New Taipei City
- Department of Neurology, Cardinal Tien Hospital
- Medical Quality Management Center, Cardinal Tien Hospital, New Taipei City, Taiwan
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Sothornwit J, Temtanakitpaisan T, Aue-Aungkul A, Likitdee N, Kleebkaow P. Extragastrointestinal stromal tumor in the rectovaginal septum associated with acute arterial occlusion. Gynecol Oncol Rep 2020; 33:100609. [PMID: 32715074 PMCID: PMC7369603 DOI: 10.1016/j.gore.2020.100609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 02/07/2023] Open
Abstract
EGIST in rectovaginal septum with unusual presentation (excessive vaginal bleeding). EGIST was misdiagnosed by MRI as vaginal leiomyoma. The first report of untreated EGIST associated with acute arterial occlusion.
Extragastrointestinal stromal tumors (EGISTs) arise from atypical sites, such as the omentum, mesentery, retroperitoneal space, urinary bladder, or rectovaginal septum, and account for fewer than 10% of gastrointestinal stromal tumors (GISTs). Most EGISTs are asymptomatic at the time of diagnosis, due to the fact that they rarely cause symptoms until they grow to greater than 10 cm in diameter. Common presenting symptoms are a feeling of vaginal fullness and increased urinary frequency. Cases described in previous reports have been treated with surgery with or without targeted therapy. Here we report an unusual case of an EGIST at the rectovaginal septum presenting with excessive vaginal bleeding and acute arterial occlusion. This rectovaginal mass was successfully removed using the abdominoperineal approach and did not require targeted therapy.
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Affiliation(s)
- Jen Sothornwit
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Thailand
| | | | - Apiwat Aue-Aungkul
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Thailand
| | - Naratassapol Likitdee
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Thailand
| | - Pilaiwan Kleebkaow
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Thailand
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Abstract
There is increasing awareness that platelets play a significant role in creating a hypercoagulable environment that mediates tumor progression, beyond their classical hemostatic function. Platelets have heterogenic responses to agonists, and differential release and uptake of bioactive molecules may be manipulated via reciprocal cross-talk with cells of the tumor microenvironment. Platelets thus promote tumor progression by enhancing tumor growth, promoting the development of tumor-associated vasculature and encouraging invasion. In the metastatic process, platelets form the shield that protects tumor cells from high-velocity forces and immunosurveillance, while ensuring the establishment of the pre-metastatic niche. This review presents the complexity of these concepts, considering platelets as biomarkers for diagnosis, prognosis and potentially as therapeutic targets in cancer.
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Affiliation(s)
- Tanya N Augustine
- School of Anatomical Sciences, Faculty of the Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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26
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Abstract
Cardiogenic shock (CS) is increasingly recognized in patients with malignancies, while cancer is independently associated with worse prognosis in CS. A number of conditions may lead to CS in cancer, including acute coronary syndromes, cardiomyopathy, takotsubo syndrome, myocarditis, pulmonary embolism, tamponade, and cardiac herniation. In these conditions, CS may be related to cancer itself or to cancer therapy, including surgery, chemotherapy, or radiotherapy. Given the significantly improved overall survival of patients with malignancies, the early recognition and proper management of CS in cancer become increasingly important. In the present paper, we review the available evidence on CS in patients with malignancies and highlight issues related to its management.
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Zhang X, Zhang Y, Wang Y, Wu J, Chen H, Zhao M, Peng S. Modifying ICCA with Trp-Phe-Phe to Enhance in vivo Activity and Form Nano-Medicine. Int J Nanomedicine 2020; 15:465-481. [PMID: 32021191 PMCID: PMC6982437 DOI: 10.2147/ijn.s229856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/15/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND 1-(4-isopropylphenyl)-β-carboline-3-carboxylic acid (ICCA) was modified by Trp-Phe-Phe to form 1-(4-isopropylphenyl)-β-carboline-3-carbonyl-Trp-Phe-Phe (ICCA-WFF). PURPOSE The object of preparing ICCA-WFF was to enhance the in vivo efficacy of ICCA, to explore the possible targeting action, and to visualize the nano-feature. METHODS The advantages of ICCA-WFF over ICCA were demonstrated by a series of in vivo assays, such as anti-tumor assay, anti-arterial thrombosis assay, anti-venous thrombosis assay, P-selectin expression assay, and GPIIb/IIIa expression assay. The nano-features of ICCA-WFF were visualized by TEM, SEM and AFM images. The thrombus targeting and tumor-targeting actions were evidenced by FT-MS spectrum analysis. RESULTS The minimal effective dose of ICCA-WFF slowing tumor growth and inhibiting thrombosis was 10-fold lower than that of ICCA. ICCA-WFF, but not ICCA, formed nano-particles capable of safe delivery in blood circulation. In vivo ICCA-WFF, but not ICCA, can target thrombus and tumor. In thrombus and tumor, ICCA-WFF released Trp-Phe-Phe and/or ICCA. CONCLUSION Modifying ICCA with Trp-Phe-Phe successfully enhanced the anti-tumor activity, improved the anti-thrombotic action, formed nano-particles, targeted tumor tissue and thrombus, and provided an oligopeptide modification strategy for heterocyclic compounds.
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Affiliation(s)
- Xiaoyi Zhang
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
| | - Yixin Zhang
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
| | - Yaonan Wang
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
| | - Jianhui Wu
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
| | - Haiyan Chen
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
| | - Ming Zhao
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
- Beijing Laboratory of Biomedical Materials and Key Laboratory of Biomedical Materials of Natural Macromolecules, Department of Biomaterials, College of Materials Science and Engineering, Beijing University of Chemical Technology, Beijing100026, People’s Republic of China
| | - Shiqi Peng
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China, Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Capital Medical University, Beijing100069, People’s Republic of China
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Styczkiewicz K, Styczkiewicz M, Myćka M, Mędrek S, Kondraciuk T, Czerkies-Bieleń A, Wiśniewski A, Szmit S, Jankowski P. Clinical presentation and treatment of acute coronary syndrome as well as 1-year survival of patients hospitalized due to cancer: A 7-year experience of a nonacademic center. Medicine (Baltimore) 2020; 99:e18972. [PMID: 32000427 PMCID: PMC7004737 DOI: 10.1097/md.0000000000018972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The diagnosis of acute coronary syndrome (ACS) in patients with cancer constitutes a therapeutic challenge. We aimed to assess the clinical presentation and management of ACS as well as 1-year survival in patients hospitalized for cancer.This retrospective study included patients hospitalized between 2012 and 2018 in a nonacademic center. The inclusion criteria were diagnosis of active cancer and ACS recognized using standard criteria. Patients were assessed with respect to invasive or conservative ACS strategy. The primary endpoint was all-cause mortality, and the secondary endpoint was cardiovascular mortality during 1-year follow-up.We screened 25,165 patients, of whom 36 (0.14%) had ACS (mean [SD] age, 71.9 [9.8] years). The most common presentation was non-ST-segment elevation myocardial infarction (61% of patients). Coronary angiography was performed in 47% of patients, while 53% were treated conservatively. Overall, the primary endpoint occurred in 67% of patients and secondary endpoint in 28% during follow-up. The predictors of better outcome in a univariate analysis were invasive strategy, lack of metastases, aspirin use, and no cardiogenic shock. Invasive treatment and aspirin use remained significant predictors of better survival when adjusted for the presence of metastases (hazard ratio [HR] 0.37, confidence interval [CI] 0.15-0.92 and HR 0.39, CI 0.16-0.94, respectively) and ineligibility for cancer treatment (HR 0.37, CI 0.15-0.93 and HR 0.30, CI 0.12-0.73, respectively).The incidence of ACS in cancer patients is low but 1-year mortality rates are high. Guideline-recommended management was frequently underused. Our results suggest that invasive approach and aspirin use are associated with better survival regardless of cancer stage and eligibility for cancer treatment.
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Affiliation(s)
- Katarzyna Styczkiewicz
- Department of Cardiology, Specialist Hospital in Brzozów, Subcarpathian Oncological Center, Brzozów
| | - Marek Styczkiewicz
- Department of Cardiology, Specialist Hospital in Brzozów, Subcarpathian Oncological Center, Brzozów
| | - Monika Myćka
- Department of Cardiology, Specialist Hospital in Brzozów, Subcarpathian Oncological Center, Brzozów
| | - Sabina Mędrek
- Department of Cardiology, Specialist Hospital in Brzozów, Subcarpathian Oncological Center, Brzozów
| | - Tomasz Kondraciuk
- Department of Cardiology, Specialist Hospital in Brzozów, Subcarpathian Oncological Center, Brzozów
| | - Anna Czerkies-Bieleń
- Department of Cardiology, Specialist Hospital in Brzozów, Subcarpathian Oncological Center, Brzozów
| | - Andrzej Wiśniewski
- Subcarpathian Center for Cardiovascular Intervention, G.V.M. Carint, Sanok
| | - Sebastian Szmit
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, Otwock
| | - Piotr Jankowski
- 1st Department of Cardiology, Interventional Electrocardiology and Hypertension, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
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Lenihan DJ, Fradley MG, Dent S, Brezden-Masley C, Carver J, Filho RK, Neilan TG, Blaes A, Melloni C, Herrmann J, Armenian S, Thavendiranathan P, Armstrong GT, Ky B, Hajjar L. Proceedings From the Global Cardio-Oncology Summit: The Top 10 Priorities to Actualize for CardioOncology. JACC CardioOncol 2019; 1:256-272. [PMID: 34396188 PMCID: PMC8352295 DOI: 10.1016/j.jaccao.2019.11.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/04/2019] [Indexed: 12/27/2022] Open
Abstract
The discipline of cardio-oncology has expanded at a remarkable pace. Recent developments and challenges to clinicians who practice cardio-oncology were presented at the Global Cardio-Oncology Summit on October 3 to 4, 2019, in São Paulo, Brazil. Here, we present the top 10 priorities for our field that were discussed at the meeting, and also detail a potential path forward to address these challenges. Defining robust predictors of cardiotoxicity, clarifying the role of cardioprotection, managing and preventing thromboembolism, improving hematopoietic stem cell transplant outcomes, personalizing cardiac interventions, building the cardio-oncology community, detecting and treating cardiovascular events associated with immunotherapy, understanding tyrosine kinase inhibitor cardiotoxicity, and enhancing survivorship care are all priorities for the field. The path forward requires a commitment to research, education, and excellence in clinical care to improve our patients' lives.
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Key Words
- CV, cardiovascular
- CVD, cardiovascular disease
- DOAC, direct oral anticoagulant
- GCOS, Global Cardio-Oncology Summit
- GLS, global longitudinal strain
- HCT, hematopoietic cell transplantation
- ICI, immune checkpoint inhibitor
- LVEF, left ventricular ejection fraction
- PD-1, programmed cell death 1 or its ligand
- PD-L1, programmed cell death ligand 1
- TKI, tyrosine kinase inhibitor
- VTE, venous thromboembolism
- anthracycline
- antiangiogenic therapy
- bone marrow transplantation
- breast cancer
- cancer survivorship
- immunotherapy
- thrombosis
- tyrosine kinase inhibitor
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Affiliation(s)
- Daniel J. Lenihan
- Cardio-Oncology Center of Excellence, Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Michael G. Fradley
- Cardio-Oncology Program, Moffitt Cancer Center, University of South Florida, Tampa, Florida, USA
| | - Susan Dent
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Joseph Carver
- Cardio-Oncology Center of Excellence at the Abramson Cancer Center, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roberto Kalil Filho
- Cardio-Oncology Program, Department of Cardiopneumology, Cancer Institute and Heart Institute, University of São Paulo, Brazil
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Blaes
- Division of Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Saro Armenian
- City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Paaladinesh Thavendiranathan
- Division of Cardiology, Peter Munk Cardiac Centre, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, University of Toronto, Toronto, Canada
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Bonnie Ky
- Cardio-Oncology Center of Excellence at the Abramson Cancer Center, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ludhmila Hajjar
- Cardio-Oncology Program, Department of Cardiopneumology, Cancer Institute and Heart Institute, University of São Paulo, Brazil
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30
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Yu J, Li A, Laureano M, Crowther M. Frequency of arterial thromboembolism in populations with malignancies: A systematic review. Thromb Res 2019; 184:16-23. [PMID: 31678748 DOI: 10.1016/j.thromres.2019.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/16/2019] [Accepted: 10/02/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Populations with cancer have been documented to have a greater risk of developing venous thromboembolism. The frequency of arterial thromboembolism (ATE) in cancer patients is unclear; while evidence examining this question has grown, it has yet to be systematically summarized. This study aims to systematically review the frequency of ATE in patients with cancer. METHODS A search of MEDLINE, Embase, CENTRAL, and Web of Science from inception to 28 January, 2019 was conducted. Two independent reviewers screened for eligible studies. Studies comparing the frequency of ATE between populations with cancer and controls were included while studies examining the frequency of ATE in the context of cancer therapies (e.g., chemotherapy, radiotherapy) were excluded. Data corresponding to the follow-up times closest to diagnosis and 1-year follow-up were extracted. Results Twelve retrospective cohort studies involving 1,260,237 patients were included. Ten studies concluded increased ATE risk in populations with malignancies. At the time point closest to diagnosis, patients with bladder, breast, colorectal, gastric, lung, non-Hodgkin lymphoma, and pancreatic cancers were at an increased risk. This risk diminished around 1 year after diagnosis except in patients with lung or pancreatic cancers. High heterogeneity within and between studies precluded meta-analysis. CONCLUSIONS Patients with cancer appear to have an increased risk of developing ATE, with the highest risk immediately after diagnosis and in patients with lung and pancreatic cancers. Better information on the attribu01 risk will require prospective studies that record comprehensive patient characteristics and interventions.
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Affiliation(s)
- James Yu
- McMaster University, Faculty of Health Sciences, Hamilton, ON, Canada.
| | - Allen Li
- McMaster University, Faculty of Health Sciences, Hamilton, ON, Canada.
| | - Marissa Laureano
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Mark Crowther
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada.
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31
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De Stefano V. Arterial thrombosis and cancer: the neglected side of the coin of Trousseau syndrome. Haematologica 2019; 103:1419-1421. [PMID: 30171017 DOI: 10.3324/haematol.2018.197814] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Valerio De Stefano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Istituto di Ematologia, Università Cattolica, Roma, Italia
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32
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Abstract
Chemotherapy-associated myocardial toxicity is increasingly recognized with the expanding armamentarium of novel chemotherapeutic agents. The onset of cardiotoxicity during cancer therapy represents a major concern and often involves clinical uncertainties and complex therapeutic decisions, reflecting a compromise between potential benefits and harm. Furthermore, the improved cancer survival has led to cardiovascular complications becoming clinically relevant, potentially contributing to premature morbidity and mortality among cancer survivors. Specific higher-risk populations of cancer patients can benefit from prevention and screening measures during the course of cancer therapies. The pathobiology of chemotherapy-induced myocardial dysfunction is complex, and the individual patient risk for heart failure entails a multifactorial interaction between the selected chemotherapeutic regimen, traditional cardiovascular risk factors, and individual susceptibility. Treatment with several specific chemotherapeutic agents, including anthracyclines, proteasome inhibitors, epidermal growth factor receptor inhibitors, vascular endothelial growth factor inhibitors, and immune checkpoint inhibitors imparts increased risk for cardiotoxicity that results from specific therapy-related mechanisms. We review the pathophysiology, risk factors, and imaging considerations as well as patient surveillance, prevention, and treatment approaches to mitigate cardiotoxicity prior, during, and after chemotherapy. The complexity of decision-making in these patients requires viable discussion and partnership between cardiologists and oncologists aiming together to eradicate cancer while preventing cardiotoxic sequelae.
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Affiliation(s)
- Oren Caspi
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Doron Aronson
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- To whom correspondence should be addressed. E-mail:
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33
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Mosarla RC, Vaduganathan M, Qamar A, Moslehi J, Piazza G, Giugliano RP. Anticoagulation Strategies in Patients With Cancer: JACC Review Topic of the Week. J Am Coll Cardiol 2019; 73:1336-1349. [PMID: 30898209 PMCID: PMC7957366 DOI: 10.1016/j.jacc.2019.01.017] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 02/08/2023]
Abstract
Patients with active cancer are at an increased risk of arterial and venous thromboembolism (VTE) and bleeding events. Historically, in patients with cancer, low molecular weight heparins have been preferred for treatment of VTE, whereas warfarin has been the standard anticoagulant for stroke prevention in patients with atrial fibrillation (AF). More recently, direct oral anticoagulants (DOACs) have been demonstrated to reduce the risk of venous and arterial thromboembolism in large randomized clinical trials of patients with VTE and AF, respectively, thus providing an attractive oral dosing option that does not require routine laboratory monitoring. In this review, we summarize available clinical trial data and guideline recommendations, and outline a practical approach to anticoagulation management of VTE and AF in cancer.
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Affiliation(s)
- Ramya C Mosarla
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts. https://twitter.com/mvaduganathan
| | - Arman Qamar
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. https://twitter.com/AqamarMD
| | - Javid Moslehi
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory Piazza
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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34
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Chu G, Versteeg HH, Verschoor AJ, Trines SA, Hemels MEW, Ay C, Huisman MV, Klok FA. Atrial fibrillation and cancer - An unexplored field in cardiovascular oncology. Blood Rev 2019; 35:59-67. [PMID: 30928168 DOI: 10.1016/j.blre.2019.03.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 03/15/2019] [Accepted: 03/22/2019] [Indexed: 12/28/2022]
Abstract
An increasing body of evidence suggests an association between cancer and atrial fibrillation (AF). The exact magnitude and underlying mechanism of this association are however unclear. Cancer-related inflammation, anti-cancer treatment and other cancer-related comorbidities are proposed to affect atrial remodelling, increasing the susceptibility of cancer patients for developing AF. Moreover, cancer is assumed to modify the risk of thromboembolisms and bleeding. A thorough and adequate understanding of these risks is however lacking, as current literature is scarce and show ambiguous results in AF patients. The standardized risk-models that normally aid the clinician in the decision of initiating anticoagulant therapy do not take the presence of malignancy into account. Other factors that complicate risk assessment in AF patients with cancer include drug-drug interactions and other cancer-related comorbidities such as renal impairment. In this review, we highlight the available literature regarding epidemiological association, risk assessment and anticoagulation therapy in AF patients with cancer.
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Affiliation(s)
- Gordon Chu
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, the Netherlands.
| | - Henri H Versteeg
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, the Netherlands
| | - Arie J Verschoor
- Department of Medical Oncology, Leiden University Medical Centre, the Netherlands
| | - Serge A Trines
- Department of Cardiology, Heart-Lung Centre, Leiden University Medical Centre, the Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Menno V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, the Netherlands
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35
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Becatti M, Emmi G, Bettiol A, Silvestri E, Di Scala G, Taddei N, Prisco D, Fiorillo C. Behçet's syndrome as a tool to dissect the mechanisms of thrombo-inflammation: clinical and pathogenetic aspects. Clin Exp Immunol 2018; 195:322-333. [PMID: 30472725 DOI: 10.1111/cei.13243] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2018] [Indexed: 01/01/2023] Open
Abstract
Behçet's syndrome (BS) is a complex disease with different organ involvement. The vascular one is the most intriguing, considering the existence of a specific group of patients suffering from recurrent vascular events involving the venous and, more rarely, the arterial vessels. Several clinical clues suggest the inflammatory nature of thrombosis in BS, especially of the venous involvement, thus BS is considered a model of inflammation-induced thrombosis. Unique among other inflammatory conditions, venous involvement (together with the arterial one) is currently treated with immunosuppressants, rather than with anti-coagulants. Although many in-vitro studies have suggested the different roles of the multiple players involved in clot formation, in-vivo models are crucial to study this process in a physiological context. At present, no clear mechanisms describing the pathophysiology of thrombo-inflammation in BS exist. Recently, we focused our attention on BS patients as a human in-vivo model of inflammation-induced thrombosis to investigate a new mechanism of clot formation. Indeed, fibrinogen displays a critical role not only in inflammatory processes, but also in clot formation, both in the fibrin network and in platelet aggregation. Reactive oxygen species (ROS)-derived modifications represent the main post-translational fibrinogen alterations responsible for structural and functional changes. Recent data have revealed that neutrophils (pivotal in the pathogenetic mechanisms leading to BS damage) promote fibrinogen oxidation and thrombus formation in BS. Altogether, these new findings may help understand the pathogenetic bases of inflammation-induced thrombosis and, more importantly, may suggest potential targets for innovative therapeutic approaches.
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Affiliation(s)
- M Becatti
- Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Firenze, Italy
| | - G Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Italy
| | - A Bettiol
- Department of Experimental and Clinical Medicine, University of Firenze, Italy.,Department of Neurosciences, Psychology, Pharmacology and Child Health (NEUROFARBA), University of Firenze, Italy
| | - E Silvestri
- Department of Experimental and Clinical Medicine, University of Firenze, Italy
| | - G Di Scala
- Department of Experimental and Clinical Medicine, University of Firenze, Italy
| | - N Taddei
- Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Firenze, Italy
| | - D Prisco
- Department of Experimental and Clinical Medicine, University of Firenze, Italy
| | - C Fiorillo
- Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Firenze, Italy
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36
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Abstract
Cancer patients have a pro-thrombotic state attributed to the ability of cancer cells to activate the coagulation system and interact with hemostatic cells, thus tilting the balance between pro- and anticoagulants. Mechanisms underlying the coagulation system activation involve tumor cells, endothelial cells, platelets, and white blood cells. Anti-cancer therapies, including anti-angiogenic drugs, significantly increase the risk of thrombosis during treatment. Along with the role of coagulation proteins in the hemostatic system, these proteins also serve as growth factors to the tumor. Heparanase is a pro-angiogenic and pro-metastatic protein. Our previous studies have demonstrated that it enhances tissue factor (TF) activity and is present at high levels in tumor cells and patients' blood. Strategies to attenuate heparanase effects by heparin mimetics or peptides interrupting the TF-heparanase interaction are good candidates to attenuate tumor growth and thrombotic manifestations.
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Affiliation(s)
- Yona Nadir
- Thrombosis and Hemostasis Unit, Department of Hematology, Rambam Health Care Campus, Haifa, Israel
| | - Benjamin Brenner
- Thrombosis and Hemostasis Unit, Department of Hematology, Rambam Health Care Campus, Haifa, Israel
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Brenner B, Bikdeli B, Tzoran I, Madridano O, López-Reyes R, Suriñach JM, Blanco-Molina Á, Tufano A, Núñez JJL, Trujillo-Santos J, Monreal M. Arterial Ischemic Events Are a Major Complication in Cancer Patients with Venous Thromboembolism. Am J Med 2018; 131:1095-1103. [PMID: 29807000 DOI: 10.1016/j.amjmed.2018.04.037] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/15/2018] [Accepted: 04/21/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Venous thromboembolism is common in patients with malignancies, affecting up to 10% of this patient population. The association between arterial ischemic events and venous thromboembolism also has been established. However, the influence of arterial ischemic events on outcomes in cancer patients with venous thromboembolism has not been fully determined. METHODS The current study analyzed clinical characteristics, time course, risk factors, incidence and severity of venous thromboembolism recurrences, arterial ischemic events and major bleeding in 5717 patients with active cancer and venous thromboembolism recruited into RIETE (multi-center prospective registry of patients with objectively confirmed venous thromboembolism). RESULTS During the anticoagulation course (median 7.3 months), 499 (8.7%) patients developed venous thromboembolism recurrences, 63 (1.1%) developed arterial events, and 346 (6.1%) suffered from major bleeding. Overall, major bleeding and arterial events appeared earlier (median 35 and 36 days, respectively) than venous thromboembolism recurrences (median 97 days). Thirty-day mortality rates after each event were: 20% after recurrent pulmonary embolism, 13% after recurrent deep vein thrombosis, 41% after major bleeding, 40% after myocardial infarction, 64% after ischemic stroke, and 83% after lower limb amputation. Bleeding was the leading cause of death (67 fatal bleeds), whereas cumulative mortality due to arterial ischemic events (n = 27) was similar to that related to pulmonary embolism recurrences (n = 26). CONCLUSIONS In this study, arterial ischemic events and major bleeding appeared early after venous thromboembolism in patients with active cancer and were among frequent causes of their deaths. The risk and severity of arterial events need to be considered in this clinical setting.
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Affiliation(s)
- Benjamin Brenner
- Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center/ New York-Presbyterian Hospital, New York, NY; Center for Outcomes Research & Evaluation (CORE), Yale University School of Medicine, New Haven, Conn; Cardiovascular Research Foundation (CRF), New York, NY
| | - Inna Tzoran
- Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Olga Madridano
- Department of Internal Medicine, Hospital Universitario Infanta Sofía, Madrid, Spain
| | - Raquel López-Reyes
- Department of Pneumonology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - José María Suriñach
- Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | | | - Antonella Tufano
- Regional Reference Centre for Coagulation Disorders, Department of Clinical Medicine and Surgery, Federico II, University Hospital, Naples, Italy
| | - Juan José López Núñez
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Murcia, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
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