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Navi BB, Zhang C, Miller B, Cushman M, Kasner SE, Elkind MSV, Tirschwell DL, Longstreth WT, Kronmal RA, Beyeler M, Elm J, Zweifler RM, Tarsia J, Cereda CW, Bianco G, Costamagna G, Michel P, Broderick JP, Gladstone DJ, Kamel H, Streib C. Apixaban vs Aspirin in Patients With Cancer and Cryptogenic Stroke: A Post Hoc Analysis of the ARCADIA Randomized Clinical Trial. JAMA Neurol 2024:2822378. [PMID: 39133474 PMCID: PMC11320331 DOI: 10.1001/jamaneurol.2024.2404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 06/06/2024] [Indexed: 08/13/2024]
Abstract
Importance Approximately 10% to 15% of ischemic strokes are associated with cancer; cancer-associated stroke, particularly when cryptogenic, is associated with high rates of recurrent stroke and major bleeding. Limited data exist on the safety and efficacy of different antithrombotic strategies in patients with cancer and cryptogenic stroke. Objective To compare apixaban vs aspirin for the prevention of adverse clinical outcomes in patients with history of cancer and cryptogenic stroke. Design, Setting, and Participants Post hoc analysis of data from 1015 patients with a recent cryptogenic stroke and biomarker evidence of atrial cardiopathy in the Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke (ARCADIA) trial, a multicenter, randomized, double-blind clinical trial conducted from 2018 to 2023 at 185 stroke centers in North America. Data analysis was performed from October 15, 2023, to May 23, 2024. Exposures Oral apixaban, 5 mg (or 2.5 mg if criteria met), twice daily vs oral aspirin, 81 mg, once daily. Subgroups of patients with and without cancer at baseline were examined. Main Outcomes and Measures The primary outcome for this post hoc analysis was a composite of major ischemic or major hemorrhagic events. Major ischemic events were recurrent ischemic stroke, myocardial infarction, systemic embolism, and symptomatic deep vein thrombosis or pulmonary embolism. Major hemorrhagic events included symptomatic intracranial hemorrhage and any major extracranial hemorrhage. Results Among 1015 participants (median [IQR] age, 68 [60-76] years; 551 [54.3%] female), 137 (13.5%) had a history of cancer. The median (IQR) follow-up was 1.5 (0.6-2.5) years for patients with history of cancer and 1.5 (0.6-3.0) years for those without history of cancer. Participants with history of cancer, compared with those without history of cancer, had a higher risk of major ischemic or major hemorrhagic events (hazard ratio [HR], 1.73; 95% CI, 1.10-2.71). Among those with history of cancer, 8 of 61 participants (13.1%) randomized to apixaban and 16 of 76 participants (21.1%) randomized to aspirin had a major ischemic or major hemorrhagic event; however, the risk was not significantly different between groups (HR, 0.61; 95% CI, 0.26-1.43). Comparing participants randomized to apixaban vs aspirin among those with cancer, events included recurrent stroke (5 [8.2%] vs 9 [11.8%]), major ischemic events (7 [11.5%] vs 14 [18.4%]), and major hemorrhagic events (1 [1.6%] vs 2 [2.6%]). Conclusions and Relevance Among participants in the ARCADIA trial with history of cancer, the risk of major ischemic and hemorrhagic events did not differ significantly with apixaban compared with aspirin. Trial Registration ClinicalTrials.gov Identifier: NCT03192215.
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Affiliation(s)
- Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Benjamin Miller
- Department of Neurology, University of Minnesota, Minneapolis
| | - Mary Cushman
- Division of Hematology and Oncology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Scott E. Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | | | - W. T. Longstreth
- Department of Neurology, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | | | - Morin Beyeler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jordan Elm
- Department of Biostatistics, Medical University of South Carolina, Charleston
| | | | - Joseph Tarsia
- Ochsner Neuroscience Institute, Ochsner Health, New Orleans, Louisiana
| | - Carlo W. Cereda
- Department of Neurology, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Giovanni Bianco
- Department of Neurology, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Gianluca Costamagna
- Stroke Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Neurology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Patrik Michel
- Department of Clinical Neurosciences, University of Lausanne, Lausanne, Switzerland
| | - Joseph P. Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David J. Gladstone
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, and Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
- Deputy Editor, JAMA Neurology
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Sawada J, Katayama T, Kikuchi-Takeguchi S, Kano K, Saito M, Mitsui N, Hiroshima S, Kinoshita M, Nakagawa N. Clinical features and prognostic factors of patients with cancer-associated stroke. Neurol Sci 2024; 45:2747-2757. [PMID: 38267601 DOI: 10.1007/s10072-024-07332-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Cerebrovascular diseases in cancer patients significantly aggravate their condition and prognosis; therefore, prompt and accurate diagnosis and treatment are important. The purpose of this study was to investigate patient demographics, laboratory data, brain magnetic resonance imaging (MRI) findings, and prognosis among patients with stroke and cancer, especially cancer-associated ischemic stroke (CAIS). METHODS We performed a retrospective, single-center study. We enrolled consecutive patients who had acute stroke and were admitted to our hospital between January 2011 and December 2021. We collected general demographic characteristics, cancer histopathological type, laboratory data, brain MRI findings, and prognosis data. RESULTS Among 2040 patients with acute stroke, a total of 160 patients (7.8%) had active cancer. The types of strokes were cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack in 124, 25, 5, and 6 patients, respectively. Among the patients with ischemic stroke, there were 69 cases of CAIS. Pancreas and adenocarcinoma were the most frequent types of primary tumor and histopathology. Patients with adenocarcinoma and those with cerebral infarctions in both bilateral anterior and posterior cerebral circulation areas showed higher D-dimer levels. Pancreatic cancer and high plasma D-dimer levels were associated with poor survival rate. CONCLUSION CAIS was seen more frequently in patients with pancreatic cancer and adenocarcinoma. Pancreatic cancer and high plasma D-dimer levels were potential factors of poor prognosis in patients with CAIS.
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Affiliation(s)
- Jun Sawada
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.
| | - Takayuki Katayama
- Department of Neurology, Asahikawa City Hospital, Asahikawa, Hokkaido, Japan
| | - Shiori Kikuchi-Takeguchi
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Kohei Kano
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Masato Saito
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Nobuyuki Mitsui
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Satoru Hiroshima
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Manabu Kinoshita
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Naoki Nakagawa
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
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Costamagna G, Navi BB, Beyeler M, Hottinger AF, Alberio L, Michel P. Ischemic Stroke in Cancer: Mechanisms, Biomarkers, and Implications for Treatment. Semin Thromb Hemost 2024; 50:342-359. [PMID: 37506734 DOI: 10.1055/s-0043-1771270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Ischemic stroke is an important cause of morbidity and mortality in cancer patients. The underlying mechanisms linking cancer and stroke are not completely understood. Long-standing and more recent evidence suggests that cancer-associated prothrombotic states, along with treatment-related vascular toxicity, such as with chemotherapy and immunotherapy, contribute to an increased risk of ischemic stroke in cancer patients. Novel biomarkers, including coagulation, platelet and endothelial markers, cell-free DNA, and extracellular vesicles are being investigated for their potential to improve risk stratification and patient selection for clinical trials and to help guide personalized antithrombotic strategies. Treatment of cancer-related stroke poses unique challenges, including the need to balance the risk of recurrent stroke and other thromboembolic events with that of bleeding associated with antithrombotic therapy. In addition, how and when to restart cancer treatment after stroke remains unclear. In this review, we summarize current knowledge on the mechanisms underlying ischemic stroke in cancer, propose an etiological classification system unique to cancer-related stroke to help guide patient characterization, provide an overview of promising biomarkers and their clinical utility, and discuss the current state of evidence-based management strategies for cancer-related stroke. Ultimately, a personalized approach to stroke prevention and treatment is required in cancer patients, considering both the underlying cancer biology and the individual patient's risk profile.
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Affiliation(s)
- Gianluca Costamagna
- Stroke Unit, Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas F Hottinger
- Services of Neurology and Oncology, Lundin Family Brain Tumor Research Center, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Hematology Central Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Arnold MJ. Thromboembolic Disease. Prim Care 2024; 51:65-82. [PMID: 38278574 DOI: 10.1016/j.pop.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Venous thromboembolism (VTE) encompasses deep vein thrombosis and pulmonary embolism, both of which can present on a spectrum from subtle symptoms to life- and limb-threatening emergencies. Some risk factors for VTE overlap cardiovascular risk factors and statin therapy can somewhat reduce the VTE risk. When presentations are not life-threatening, clinical prediction scores using the Well's criteria are best used to determine diagnostic testing. The mainstay of VTE treatment is anticoagulant therapy, although life- and limb-threatening presentations can also require thrombolytic therapy.
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Affiliation(s)
- Michael J Arnold
- Department of Family Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 40814, USA.
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Wang T, Liu X, Zhu Y, Zhang Y, Zhang Z, Huang G, Xu J. Antithrombotic strategy in cancer patients comorbid with acute coronary syndrome and atrial fibrillation. Front Cardiovasc Med 2023; 10:1325488. [PMID: 38162143 PMCID: PMC10756915 DOI: 10.3389/fcvm.2023.1325488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Abstract
It has been shown that patients with cancer have a longer expected life duration, benefiting from advanced medical therapy. Meanwhile, the risk of suffering from cardiovascular disease (CVD) has been increasing with ageing. A growing number of studies have elucidated the association between cancer and CVD. Cancer, atrial fibrillation (AF) and coronary artery disease share some common factors and interact with each other, such as obesity, aging, diabetes, and inflammation, but the potential specific mechanism is still unclear. In addition, cancer-specific and therapy-related factors may increase the risk of embolism and bleeding in patients with cancer than in general population. However, current available embolic and bleeding risk scores applied in patients with CVD may not be applicable for risk assessment in cancer patients, which would be difficult for clinicians to select an appropriate antithrombotic regimen and ensure the balance between bleeding and embolism. Moreover, different types of cancer have distinct risks, which may increase the complexity of antithrombotic therapy. In this review, we review the literature related to cancer, AF, and acute coronary syndrome, focusing on the epidemiological status, physiological mechanism, embolism and bleeding risks, and strategies of antithrombotic therapy.
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Affiliation(s)
- Tianbo Wang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Xiaohan Liu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yuxin Zhu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yue Zhang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Zhen Zhang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Gang Huang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Junbo Xu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
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Zhang Y, Yang Z, Almani MU, Soon-Shiong R, Liu B. Utilization and short-term outcomes of percutaneous left atrial appendage occlusion in patients with cancer. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:39. [PMID: 37924143 PMCID: PMC10625234 DOI: 10.1186/s40959-023-00192-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Percutaneous left atrial appendage occlusion (LAAO) has been rapidly evolving since FDA's approval in 2015 and has become more of a same-day-discharge procedure. Cancer patient with atrial fibrillation/flutter (AF) population can benefit from the procedure but the in-hospital outcomes and readmission data were rarely studied. OBJECTIVES We investigated the utilization, in-hospital and readmission outcomes in cancer patients with AF who underwent LAAO. METHODS Data were derived from the National Inpatient Sample and National Readmissions Database from 2016 to 2019. Patients with primary diagnosis of AF admitted for LAAO (ICD-10 code 02L73DK) were grouped by cancer as a secondary diagnosis. We assessed in-hospital mortality, length of stay, total hospital charges, and complications. Thirty-day readmission rates were compared. RESULTS LAAO was performed in 60,380 patients with AF and 3% were cancer patients. There were no differences in in-hospital mortality and total hospital charges; however, cancer patients tended to have longer hospital stay (1.59 ± 0.11 vs. 1.32 ± 0.02, p = 0.013). Among complications, cancer patients had higher rates in open or percutaneous pericardial drainage (adjusted odds ratio [aOR] 2.38; 95% confidence interval [CI] 1.19-4.76) and major bleeding events (aOR 7.07; 95% CI 1.82-27.38). There was no statistical significance of 30-day readmission rates between patients with and without cancer (10.0% vs. 9.1%, p = 0.34). The most common readmission reason in cancer patients was gastrointestinal bleeding. CONCLUSIONS LAAO is a promising procedure in cancer patients complicated by AF with contraindication to anticoagulation. Readmission rate is comparable between patients with and without cancer.
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Affiliation(s)
- Yaqi Zhang
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA.
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Zhuoran Yang
- Mount Sinai St Luke's and Mount Sinai West Hospital, New York, NY, USA
| | | | - Raquel Soon-Shiong
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Bolun Liu
- Mayo Clinic Health System, Mankato, MN, USA
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Balomenakis C, Papazoglou AS, Vlachopoulou D, Kartas A, Moysidis DV, Vouloagkas I, Tsagkaris C, Georgopoulos K, Samaras A, Karagiannidis E, Giannakoulas G. Risk of arterial thromboembolism, bleeding and mortality in atrial fibrillation patients with comorbid cancer: A systematic review and meta-analysis. Hellenic J Cardiol 2023; 74:65-73. [PMID: 37414144 DOI: 10.1016/j.hjc.2023.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/08/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023] Open
Abstract
AIMS Atrial fibrillation (AF) and cancer often co-exist. Each has been associated with an increased risk of morbidity and mortality. The aim of this meta-analysis was to synthesize available data regarding the incidence of arterial thromboembolism (TE), bleeding, and all-cause mortality in patients with AF with or without cancer. METHODS Literature search was conducted in PubMed, Ovid MEDLINE, WebOfScience, Scopus, CENTRAL, OpenGrey, and EThOS databases to identify studies that included patients with AF and accounted for cancer status with the incidence of TE (ischemic stroke, transient ischemic attack, or arterial thrombosis), major or clinically relevant non-major bleeding, and all-cause mortality. A random-effects meta-analysis was used. RESULTS Overall, 17 studies were included (3,149,547 patients). The risk of TE was similar in patients with AF with comorbid cancer compared with that in AF alone (pooled odds ratio [pOR] 0.97, 95% Confidence Interval [CI] 0.85-1.11, I2 = 87%). Major or clinically relevant non-major bleeding (pOR 1.65, 95% CI 1.35-2.02, I2 = 98%) and all-cause death (pOR 2.17, 95% CI 1.83-2.56, I2 = 98%) were significantly higher in patients with AF with cancer than in patients with AF only. The history of TE and hypertension and mean age were significant moderators of TE risk. CONCLUSION In patients with AF, the presence of cancer is associated with a similar risk of TE as well as an increased risk of bleeding and all-cause death compared with the absence of cancer.
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Affiliation(s)
- Charalampos Balomenakis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Andreas S Papazoglou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece; Athens Naval Hospital, Athens, Greece
| | - Dimitra Vlachopoulou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Ioannis Vouloagkas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Christos Tsagkaris
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Konstantinos Georgopoulos
- Faculty of Engineering, School of Electrical and Computer Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Samaras
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Efstratios Karagiannidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece.
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Wang TF, Carrier M. Revisiting important issues in cancer and atrial fibrillation. Res Pract Thromb Haemost 2023; 7:100156. [PMID: 37255852 PMCID: PMC10225913 DOI: 10.1016/j.rpth.2023.100156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 06/01/2023] Open
Affiliation(s)
- Tzu-Fei Wang
- Correspondence Tzu-Fei Wang, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 201A, Ottawa, ON K1H 8L6, Canada. @TzufeiWang
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Ganatra S, Abraham S, Kumar A, Parikh R, Patel R, Khadke S, Kumar A, Liu V, Diaz ANR, Neilan TG, Martin D, Hook B, Dani SS, Asnani A, Nohria A. Efficacy and safety of catheter ablation for atrial fibrillation in patients with history of cancer. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:19. [PMID: 37020260 PMCID: PMC10074889 DOI: 10.1186/s40959-023-00171-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/29/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Though the incidence of atrial fibrillation (AF) is increased in patients with cancer, the effectiveness of catheter ablation (CA) for AF in patients with cancer is not well studied. METHODS We conducted a retrospective cohort study of patients who underwent CA for AF. Patients with a history of cancer within 5-years prior to, or those with an exposure to anthracyclines and/or thoracic radiation at any time prior to the index ablation were compared to patients without a history of cancer who underwent AF ablation. The primary outcome was freedom from AF [with or without anti-arrhythmic drugs (AADs), or need for repeat CA at 12-months post-ablation]. Secondary endpoints included freedom from AF at 12 months post-ablation with AADs and without AADs. Safety endpoints included bleeding, pulmonary vein stenosis, stroke, and cardiac tamponade. Multivariable regression analysis was performed to identify independent risk predictors of the primary outcome. RESULTS Among 502 patients included in the study, 251 (50%) had a history of cancer. Freedom from AF at 12 months did not differ between patients with and without cancer (83.3% vs 72.5%, p 0.28). The need for repeat ablation was also similar between groups (20.7% vs 27.5%, p 0.29). Multivariable regression analysis did not identify a history of cancer or cancer-related therapy as independent predictors of recurrent AF after ablation. There was no difference in safety endpoints between groups. CONCLUSION CA is a safe and effective treatment for AF in patients with a history of cancer and those with exposure to potentially cardiotoxic therapy.
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Affiliation(s)
- Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, Burlington, MA, 01805, USA.
| | - Sonu Abraham
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, Burlington, MA, 01805, USA
| | - Ashish Kumar
- Department of Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Rohan Parikh
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, Burlington, MA, 01805, USA
| | - Rushin Patel
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, Burlington, MA, 01805, USA
| | - Sumanth Khadke
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, Burlington, MA, 01805, USA
| | - Amudha Kumar
- Cardio-Oncology Program, Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Victor Liu
- Cardio-Oncology Program, Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Andrea Nathalie Rosas Diaz
- Cardio-Oncology Program, Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC) and Cardio-Oncology Program, Massachusetts General Hospital, Boston, MA, USA
| | - David Martin
- Department of Cardiovascular Medicine, Electrophysiology Program, Brigham and Women's Hospital, Boston, MA, USA
| | - Bruce Hook
- Division of Cardiovascular Medicine, Department of Medicine, Electrophysiology Program, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Sourbha S Dani
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, Burlington, MA, 01805, USA
| | - Aarti Asnani
- Cardio-Oncology Program, Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Anju Nohria
- Cardio-Oncology Program, Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
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10
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Trinks-Roerdink EM, Geersing GJ, Hemels M, van Gelder IC, Klok FA, van Smeden M, Rutten FH, van Doorn S. External validation and updating of prediction models of bleeding risk in patients with cancer receiving anticoagulants. Open Heart 2023; 10:openhrt-2023-002273. [PMID: 37055175 PMCID: PMC10106080 DOI: 10.1136/openhrt-2023-002273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/27/2023] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVE Patients with cancer are at increased bleeding risk, and anticoagulants increase this risk even more. Yet, validated bleeding risk models for prediction of bleeding risk in patients with cancer are lacking. The aim of this study is to predict bleeding risk in anticoagulated patients with cancer. METHODS We performed a study using the routine healthcare database of the Julius General Practitioners' Network. Five bleeding risk models were selected for external validation. Patients with a new cancer episode during anticoagulant treatment or those initiating anticoagulation during active cancer were included. The outcome was the composite of major bleeding and clinically relevant non-major (CRNM) bleeding. Next, we internally validated an updated bleeding risk model accounting for the competing risk of death. RESULTS The validation cohort consisted of 1304 patients with cancer, mean age 74.0±10.9 years, 52.2% males. In total 215 (16.5%) patients developed a first major or CRNM bleeding during a mean follow-up of 1.5 years (incidence rate; 11.0 per 100 person-years (95% CI 9.6 to 12.5)). The c-statistics of all selected bleeding risk models were low, around 0.56. Internal validation of an updated model accounting for death as competing risk showed a slightly improved c-statistic of 0.61 (95% CI 0.54 to 0.70). On updating, only age and a history of bleeding appeared to contribute to the prediction of bleeding risk. CONCLUSIONS Existing bleeding risk models cannot accurately differentiate bleeding risk between patients. Future studies may use our updated model as a starting point for further development of bleeding risk models in patients with cancer.
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Affiliation(s)
- E M Trinks-Roerdink
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
| | - G J Geersing
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
| | - Mew Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - I C van Gelder
- Department of Cardiology, UMCG, Groningen, The Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Haemostasis, LUMC, Leiden, The Netherlands
| | - M van Smeden
- Department of Epidemiology & Health Economics, Julius Centre for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
| | - F H Rutten
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
| | - S van Doorn
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
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11
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Tsigkas G, Vakka A, Apostolos A, Bousoula E, Vythoulkas-Biotis N, Koufou EE, Vasilagkos G, Tsiafoutis I, Hamilos M, Aminian A, Davlouros P. Dual Antiplatelet Therapy and Cancer; Balancing between Ischemic and Bleeding Risk: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:jcdd10040135. [PMID: 37103014 PMCID: PMC10144375 DOI: 10.3390/jcdd10040135] [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: 01/21/2023] [Revised: 03/15/2023] [Accepted: 03/19/2023] [Indexed: 04/28/2023] Open
Abstract
Cardiovascular (CV) events in patients with cancer can be caused by concomitant CV risk factors, cancer itself, and anticancer therapy. Since malignancy can dysregulate the hemostatic system, predisposing cancer patients to both thrombosis and hemorrhage, the administration of dual antiplatelet therapy (DAPT) to patients with cancer who suffer from acute coronary syndrome (ACS) or undergo percutaneous coronary intervention (PCI) is a clinical challenge to cardiologists. Apart from PCI and ACS, other structural interventions, such as TAVR, PFO-ASD closure, and LAA occlusion, and non-cardiac diseases, such as PAD and CVAs, may require DAPT. The aim of the present review is to review the current literature on the optimal antiplatelet therapy and duration of DAPT for oncologic patients, in order to reduce both the ischemic and bleeding risk in this high-risk population.
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Affiliation(s)
- Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Angeliki Vakka
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Anastasios Apostolos
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Eleni Bousoula
- Department of Cardiology, Tzaneio General Hospital, 185 36 Piraeus, Greece
| | | | | | - Georgios Vasilagkos
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Ioannis Tsiafoutis
- First Department of Cardiology, Red Cross Hospital, 115 26 Athens, Greece
| | - Michalis Hamilos
- Department of Cardiology, Heraklion University Hospital, 715 00 Heraklion, Crete, Greece
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, 6042 Charleroi, Belgium
| | - Periklis Davlouros
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
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12
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Bleeding and venous thromboembolism events in cancer patients taking direct oral anticoagulants vs. low molecular weight heparin. THROMBOSIS UPDATE 2022. [DOI: 10.1016/j.tru.2022.100129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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13
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Barbarawi M, Barbarawi O, Corcoran J, Obeidat K, Al-Abdouh A, Mhanna M, Al Kasasbeh M, Pickett CC. Efficacy and Safety of the Non-Vitamin K Antagonist Oral Anticoagulant Among patients with nonvalvular atrial fibrillation and Cancer: A Systematic Review and Network Meta-analysis. Curr Probl Cardiol 2022; 47:101346. [PMID: 35932849 DOI: 10.1016/j.cpcardiol.2022.101346] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/29/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Patients with cancer are at higher risk of atrial fibrillation (AF). Currently there are no definitive data on clinical outcomes for nonvitamin K antagonist oral anticoagulant (NOACs) and warfarin in cancer patients with AF. Therefore, we conducted a meta-analysis to evaluate the efficacy and safety of NOACs compared with warfarin. METHODS A search through Pubmed/MEDLINE, Embase, and Cochrane library was done from the databases inception to March 2022. Studies that compared NOACs to warfarin in the setting of AF and cancer were included. The primary outcomes were the incidence of major bleeding and ischemic stroke/systemic embolism (SE). Secondary outcomes were major adverse cardiovascular event (MACE), intracranial bleeding, and Major gastrointestinal bleeding. Risk ratios (RRs) with 95% confidence intervals (CI) were used to report the outcomes. RESULTS A total of 11 studies were included. We found that NOACs were associated with a lower incidence of major bleeding and combined ischemic stroke/SE in patients with AF and cancer compared with warfarin (RR 0.57; 95% CI 0.44-0.75, P < 0.0001 and RR 0.59; 95% CI 0.47-0.75, P < 0.0001, respectively). Also, there was lower incidence of Intracranial and major gastrointestinal bleeding in patients who received NOACs compared with warfarin (P < 0.0001). Network analyses revealed that apixaban and dabigatran were associated with reduction of major bleeding compared with warfarin. CONCLUSIONS Among patients who diagnosed with AF and cancer, NOACs were associated with lower incidence of major bleeding ischemic stroke/SE compared with warfarin. Furthermore, NOACs were associated with lower gastrointestinal and intracranial bleeding.
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Affiliation(s)
- Mahmoud Barbarawi
- Department of cardiology, University of Connecticut, Farmington, CT, USA.
| | - Owais Barbarawi
- Department of Internal Medicine, Islamic Hospital, Amman, Jordan
| | - Jason Corcoran
- Department of Medicine, Alabama College of Osteopathic Medicine, Dothan, Alabama, USA
| | - Khaldun Obeidat
- Departments of Medicine, Cook County Hospital, Chicago, IL, USA
| | - Ahmad Al-Abdouh
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Mahammed Mhanna
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Mariam Al Kasasbeh
- Department of Health Administration, Western Connecticut State University, CT, USA
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14
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Gonçalves-Teixeira P, Costa T, Fragoso I, Ferreira D, Brandão M, Leite-Moreira A, Sampaio F, Ribeiro J, Fontes-Carvalho R. Screening, Diagnosis and Management of Atrial Fibrillation in Cancer Patients: Current Evidence and Future Perspectives. Arq Bras Cardiol 2022; 119:328-341. [PMID: 35946695 PMCID: PMC9363048 DOI: 10.36660/abc.20201362] [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: 01/11/2021] [Accepted: 05/12/2021] [Indexed: 11/18/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population, carrying a high morbimortality burden, and this also holds true in cancer patients. The association between AF and cancer goes even further, with some studies suggesting that AF can be a marker of occult cancer. There is, however, a remarkable paucity of data concerning specific challenges of AF management in cancer patients. AF prompt recognition and management in this special population can lessen the arrhythmia-related morbidity and have an important prognostic benefit. This review will focus on current AF diagnosis and management challenges in cancer patients, with special emphasis on AF screening strategies and devices, and anticoagulation therapy with non-vitamin K antagonist oral anti-coagulants (NOACs) for thromboembolic prevention in these patients. Some insights concerning future perspectives for AF prevention, diagnosis, and treatment in this special population will also be addressed.
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Affiliation(s)
- Pedro Gonçalves-Teixeira
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal.,Departamento de Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto - Portugal.,Clínica Cardio-Oncológica, Centro Hospitalar Vila Nova de Gaia, Gaia - Portugal
| | - Telma Costa
- Clínica Cardio-Oncológica, Centro Hospitalar Vila Nova de Gaia, Gaia - Portugal.,Departamento de Oncologia, Centro Hospitalar Vila Nova de Gaia, Gaia - Portugal
| | - Isabel Fragoso
- Unidade de Atenção Primária à Saúde Aracetti, Arazede - Portugal
| | - Diogo Ferreira
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal.,Departamento de Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto - Portugal
| | - Mariana Brandão
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal
| | - Adelino Leite-Moreira
- Departamento de Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto - Portugal.,Departamento de Cirurgia Cardiotorácica, Hospital Universitário São João, Porto - Portugal.,Unidade de Pesquisa Cardiovascular (UnIC), Faculdade de Medicina, Universidade do Porto, Porto - Portugal
| | - Francisco Sampaio
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal.,Departamento de Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto - Portugal
| | - José Ribeiro
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal.,Clínica Cardio-Oncológica, Centro Hospitalar Vila Nova de Gaia, Gaia - Portugal
| | - Ricardo Fontes-Carvalho
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal.,Departamento de Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto - Portugal
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15
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Malavasi VL, Vitolo M, Proietti M, Diemberger I, Fauchier L, Marin F, Nabauer M, Potpara TS, Dan GA, Kalarus Z, Tavazzi L, Maggioni AP, Lane DA, Lip GYH, Boriani G. Impact of malignancy on outcomes in European patients with atrial fibrillation: A report from the ESC-EHRA EURObservational research programme in atrial fibrillation general long-term registry. Eur J Clin Invest 2022; 52:e13773. [PMID: 35305020 DOI: 10.1111/eci.13773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The management of patients with atrial fibrillation (AF) and malignancy is challenging given the paucity of evidence supporting their appropriate clinical management. PURPOSE To evaluate the outcomes of patients with active or prior malignancy in a contemporary cohort of European AF patients. METHODS Patients enrolled in the EURObservational Research Programme in AF General Long-Term Registry were categorized into 3 categories: No Malignancy (NoMal), Prior Malignancy (PriorMal) and Active Malignancy (ActiveMal). The primary outcomes were all-cause death and the composite outcome MACE. RESULTS A total of 10 383 patients were analysed. Of these, 9597 (92.4%) were NoMal patients, 577 (5.6%) PriorMal and 209 (2%) ActiveMal. Lack of any antithrombotic treatment was more prevalent in ActiveMal patients (12.4%) as compared to other groups (5.0% vs 6.3% for PriorMal and NoMal, p < .001). After a median follow-up of 730 days, there were 982 (9.5%) deaths and 950 (9.7%) MACE events. ActiveMal was independently associated with a higher risk for all-cause death (HR 2.90, 95% CI 2.23-3.76) and MACE (HR 1.54, 95% CI 1.03-2.31), as well as any haemorrhagic events and major bleeding (OR 2.42, 95% CI 1.49-3.91 and OR 4.18, 95% CI 2.49-7.01, respectively). Use of oral anticoagulants was not significantly associated with a higher risk for all-cause death or bleeding in ActiveMal patients. CONCLUSIONS In a large contemporary cohort of AF patients, active malignancy was independently associated with all-cause death, MACE and haemorrhagic events. Use of anticoagulants was not associated with a higher risk of all-cause death in patients with active malignancies.
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Affiliation(s)
- Vincenzo L Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | - Michael Nabauer
- Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Gheorghe-Andrei Dan
- 'Carol Davila' University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Zbigniew Kalarus
- Department of Cardiology, SMDZ in Zabrze, Medical University of Silesia, Katowice, Poland.,Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | | | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
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16
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Held N, Jung B, Baumann Kreuziger L. Management of cancer-associated thrombosis with thrombocytopenia: Impact of the ISTH guidance statement. Res Pract Thromb Haemost 2022; 6:e12726. [PMID: 35664532 PMCID: PMC9133434 DOI: 10.1002/rth2.12726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 11/09/2022] Open
Abstract
Background Optimal management of cancer-associated thrombosis (CAT) in patients with thrombocytopenia remains difficult given competing risks of recurrent thrombosis and increased bleeding. We determine the impact of the ISTH Scientific and Standardization Committee (SCC) guidance on CAT management and thrombocytopenia on platelet transfusion, bleeding, and recurrent thrombosis. Methods A retrospective review was performed of patients with CAT and thrombocytopenia who required anticoagulation for VTE for 11 months before and after implementation of the ISTH SCC guidance. Medical records were reviewed to identify the type of VTE event, number of platelet transfusions, incidence of bleeding, and VTE recurrence within pre- and postintervention time periods. Results A total of 41 and 80 cases were included in the preintervention and postintervention periods, respectively. The preintervention group showed a trend toward less acute VTE events (39% vs 55%; P = .05). The postintervention period had an increased per-patient platelet transfusion (median, 2.5 vs 4; P = .05). Nonmajor bleeding was increased in the postintervention group (2% vs 16%; P = 0.03) and included all six (8%) major hemorrhages (P = .09). There was numerically less recurrent thrombosis in the postintervention group (20% vs 8%; P = .07), which was not significantly different when accounting for acuity of VTE. Management adherence was strong, at 91%, in the postintervention group. Conclusion The ISTH guidance on management of cancer-associated thrombosis in patients with thrombocytopenia was successfully implemented in an academic medical center. There was no significant difference in bleeding or recurrent thrombosis outcomes after adjusting for acuity of VTE.
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Affiliation(s)
- Nicole Held
- Division of Hematology/Oncology, Department of MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
| | | | - Lisa Baumann Kreuziger
- Division of Hematology/Oncology, Department of MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
- Versiti Blood Research InstituteMilwaukeeWisconsinUSA
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17
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Nakajima S, Kawano H, Yamashiro K, Tanaka R, Kameda T, Kurita N, Hira K, Miyamoto N, Ueno Y, Watanabe M, Hirano T, Fujimoto S, Urabe T, Hattori N. Post-Treatment Plasma D-Dimer Levels Are Associated With Short-Term Outcomes in Patients With Cancer-Associated Stroke. Front Neurol 2022; 13:868137. [PMID: 35444612 PMCID: PMC9015657 DOI: 10.3389/fneur.2022.868137] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/17/2022] [Indexed: 12/21/2022] Open
Abstract
Background and Objective Hypercoagulability is associated with increased risks of ischemic stroke and subsequent mortality in patients with active cancer. This study investigated the relationships between plasma D-dimer levels after stroke treatment and short-term outcomes in patients with cancer-associated stroke. Methods This retrospective, observational, multicenter study analyzed consecutive patients with cancer-associated ischemic stroke. Hypercoagulability was assessed by plasma D-dimer levels before and after stroke treatment. Short-term outcomes were assessed in terms of poor outcomes (a modified Rankin Scale score >3), cumulative rates of recurrent ischemic stroke, and mortality at 30 days after admission. Results Of 282 patients, 135 (47.9%) showed poor outcomes. Recurrent ischemic stroke was observed in 28 patients (9.9%), and the cumulative mortality rate was 12.4%. Multivariate analysis showed that post-treatment plasma D-dimer levels ≥10 μg/ml were independently associated with both poor outcomes (adjusted odds ratio [OR], 9.61; 95% confidence interval [CI], 3.60–25.70; P < 0.001) and mortality (adjusted OR, 9.38; 95% CI, 3.32–26.44; P < 0.001). Pre-treatment plasma D-dimer levels ≥10 μg/ml were not associated with these outcomes. Patients who received heparin had higher pre-treatment plasma D-dimer levels than those treated with other anticoagulants. Heparin produced a significant reduction in D-dimer levels from pre- to post-treatment without increasing the incidence of hemorrhagic events. Conclusion A high plasma D-dimer level after stroke treatment was associated with poor short-term outcomes in patients with cancer-associated stroke. Using anticoagulants to reduce D-dimer levels may improve short-term outcomes in these patients.
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Affiliation(s)
- Sho Nakajima
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Hiroyuki Kawano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Kazuo Yamashiro
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Ryota Tanaka
- Division of Neurology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Tomoaki Kameda
- Department of Neurology, Shin-Oyama City Hospital, Tochigi, Japan
| | - Naohide Kurita
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Kenichiro Hira
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Nobukazu Miyamoto
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuji Ueno
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Masao Watanabe
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
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18
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Stefan A, Petkovic M, König A, Koch J, Hagemann F, Wuerstlein R, Harbeck N, Mahner S, Kaltofen T. Increased risk for thromboembolic events from combination of a gynecologic malignancy with severe acute respiratory syndrome coronavirus 2 infection: a case report. J Med Case Rep 2022; 16:119. [PMID: 35313981 PMCID: PMC8937821 DOI: 10.1186/s13256-022-03340-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 02/19/2022] [Indexed: 01/08/2023] Open
Abstract
PURPOSE During the severe acute respiratory syndrome coronavirus 2 pandemic, several patient groups are at particular risk. Mortality is higher among cancer patients and may be increased further by thromboembolic events, which are more common in coronavirus 2019 patients according to recent publications. We discuss the association of gynecologic malignancies, Severe acute respiratory syndrome coronavirus 2, and thromboembolism by reporting a case study and summarizing available literature. CASE REPORT A 71-year-old Caucasian patient with ovarian cancer receiving first-line chemotherapy was diagnosed with deep vein thrombosis and pulmonary embolism. Routine screening revealed infection with severe acute respiratory syndrome coronavirus 2 in absence of specific symptoms. After uneventful recovery, oncologic treatment could be continued a few weeks later. METHODS We performed a systematic review of the literature on PubMed following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The search included articles ahead of print, published between 1 December 2019 and 1 June 2020. Cross-searches were conducted on all relevant articles. RESULTS We identified five articles meeting the defined criteria, including two retrospective studies, a review, a position paper, as well as a letter to the editor. CONCLUSION Cancer patients infected with severe acute respiratory syndrome coronavirus 2 have a relatively poor outcome, which may partially be due to a higher rate of thromboembolic events. Thromboprophylaxis is recommended, and scoring systems are helpful in early detection. In cancer patients with severe acute respiratory syndrome coronavirus 2, individual risk for thromboembolic events should be taken into account when considering interruption versus continuation of antitumoral therapy. However, further data and studies are required.
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Affiliation(s)
- Alexandra Stefan
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany.
| | - Marija Petkovic
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Alexander König
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Julian Koch
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Friederike Hagemann
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Rachel Wuerstlein
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Nadia Harbeck
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Sven Mahner
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Till Kaltofen
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
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19
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Ozkan E, Mondal A, Douglass M, Hopkins SP, Garren M, Devine R, Pandey R, Manuel J, Singha P, Warnock J, Handa H. Bioinspired ultra-low fouling coatings on medical devices to prevent device-associated infections and thrombosis. J Colloid Interface Sci 2022; 608:1015-1024. [PMID: 34785450 PMCID: PMC8665144 DOI: 10.1016/j.jcis.2021.09.183] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 01/12/2023]
Abstract
Addressing thrombosis and biofouling of indwelling medical devices within healthcare institutions is an ongoing problem. In this work, two types of ultra-low fouling surfaces (i.e., superhydrophobic and lubricant-infused slippery surfaces) were fabricated to enhance the biocompatibility of commercial medical grade silicone rubber (SR) tubes that are widely used in clinical care. The superhydrophobic (SH) coatings on the tubing substrates were successfully created by dip-coating in superhydrophobic paints consisting of polydimethylsiloxane (PDMS), perfluorosilane-coated hydrophobic zinc oxide (ZnO) and copper (Cu) nanoparticles (NPs) in tetrahydrofuran (THF). The SH surfaces were converted to lubricant-infused slippery (LIS) surfaces through the infusion of silicone oil. The anti-biofouling properties of the coatings were investigated by adsorption of platelets, whole blood coagulation, and biofilm formation in vitro. The results revealed that the LIS tubes possess superior resistance to clot formation and platelet adhesion than uncoated and SH tubes. In addition, bacterial adhesion was investigated over 7 days in a drip-flow bioreactor, where the SH-ZnO-Cu tube and its slippery counterpart significantly reduced bacterial adhesion and biofilm formation of Escherichia coli relative to control tubes (>5 log10 and >3 log10 reduction, respectively). The coatings also demonstrated good compatibility with fibroblast cells. Therefore, the proposed coatings may find potential applications in high-efficiency on-demand prevention of biofilm and thrombosis formation on medical devices to improve their biocompatibility and reduce the risk of complications from medical devices.
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Affiliation(s)
- Ekrem Ozkan
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States
| | - Arnab Mondal
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States
| | - Megan Douglass
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States
| | - Sean P Hopkins
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States
| | - Mark Garren
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States
| | - Ryan Devine
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States
| | - Rashmi Pandey
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States
| | - James Manuel
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States
| | - Priyadarshini Singha
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States
| | - James Warnock
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States
| | - Hitesh Handa
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA 30602, United States.
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20
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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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21
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Deitelzweig S, Keshishian AV, Zhang Y, Kang A, Dhamane AD, Luo X, Klem C, Ferri M, Jiang J, Yuce H, Lip GY. Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients With Active Cancer. JACC: CARDIOONCOLOGY 2021; 3:411-424. [PMID: 34604802 PMCID: PMC8463723 DOI: 10.1016/j.jaccao.2021.06.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 06/13/2021] [Indexed: 01/01/2023]
Abstract
Background Patients with cancer are more likely to develop nonvalvular atrial fibrillation (NVAF). Currently there are no definitive clinical trials or treatment guidelines for NVAF patients with concurrent cancer. Objectives This subgroup analysis of the ARISTOPHANES study compared the risk of stroke/systemic embolism (stroke/SE) and major bleeding (MB) among NVAF patients with active cancer who were prescribed non–vitamin K antagonist oral anticoagulants (NOACs) or warfarin. Methods A retrospective observational study was conducted in NVAF patients with active cancer who newly initiated apixaban, dabigatran, rivaroxaban, or warfarin from January 1, 2013, through September 30, 2015, with the use of Medicare and 4 U.S. commercial claims databases. Cox models were used to estimate the risk of stroke/SE and MB in the pooled propensity score–matched cohorts. Results A total of 40,271 patients were included, with main cancer types of prostate (29%), female breast (17%), genitourinary (14%), and lung (13%). Compared with warfarin, apixaban was associated with a lower risk of stroke/SE (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.45-0.78) and MB (HR: 0.58; 95% CI: 0.50-0.68); dabigatran and rivaroxaban had similar risks of stroke/SE (dabigatran: HR: 0.88 [95% CI: 0.54-1.41]; rivaroxaban: HR: 0.82 [95% CI: 0.62-1.08]) and MB (dabigatran: HR: 0.76 [95% CI: 0.57-1.01]; rivaroxaban: HR: 0.95 [95% CI: 0.85-1.06]). Risks of stroke/SE and MB varied among NOAC-NOAC comparisons, while consistent treatment effects were seen for all treatment comparisons across key cancer types. Conclusions Among this cohort of NVAF patients with active cancer, the risk of stroke/SE and MB varied among oral anticoagulants and were consistent across cancer types.
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Key Words
- AF, atrial fibrillation
- GI, gastrointestinal
- GU, genitourinary
- ICH, intracranial hemorrhage
- MB, major bleeding
- NOAC, non–vitamin K antagonist oral anticoagulant
- NVAF, nonvalvular atrial fibrillation
- PSM, propensity score matching
- SE, systemic embolism
- VTE, venous thromboembolism
- active cancer
- anticoagulants
- bleeding
- nonvalvular atrial fibrillation
- stroke
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, Louisiana, USA
- University of Queensland School of Medicine—Ochsner Clinical School, New Orleans, Louisiana, USA
- Address for correspondence: Dr Steven Deitelzweig, Ochsner Health 1514 Jefferson Highway, 11th floor, Hospital Medicine, New Orleans, Louisiana 70121, USA. @statinmedresearch
| | - Allison V. Keshishian
- STATinMED Research, Ann Arbor, Michigan, USA
- New York City College of Technology, City University of New York, New York, New York, USA
| | - Yan Zhang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Amiee Kang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Amol D. Dhamane
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | | | - Christian Klem
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Mauricio Ferri
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Jenny Jiang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, New York, USA
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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22
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Santoro C, Capone V, Canonico ME, Gargiulo G, Esposito R, Sanna GD, Parodi G, Esposito G. Single, Dual, and Triple Antithrombotic Therapy in Cancer Patients with Coronary Artery Disease: Searching for Evidence and Personalized Approaches. Semin Thromb Hemost 2021; 47:950-961. [PMID: 34261150 DOI: 10.1055/s-0041-1726298] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Improvement in life expectancy of patients suffering from oncohematologic disorders has turned cancer from an acute into a chronic condition, making the management of comorbidities problematic, especially when it comes to both acute and chronic cardiovascular diseases. Treatment-related adverse events and drug-drug interactions often influence the therapeutic approach of patients with active malignancies and cardiovascular disease. Furthermore, tumor cells and platelets maintain a complex crosstalk that on one hand enhances tumor dissemination and on the other hand induces hemostasis abnormalities. Hence, clinicians should move carefully in the intricate land mines established by patients with active cancer under antithrombotic therapy. To date, there is no consensus on the antithrombotic treatment of patients with cardiovascular diseases and concomitant malignancies. The aim of this review is to collect the available scientific evidence, including the latest clinical trials and guidelines, in order to provide guidance on the management of antithrombotic treatment (both antiplatelet and anticoagulant therapy) in cancer patients with either pre-existent or new-onset coronary artery disease. Randomized-controlled trials on antithrombotic treatment in oncologic populations, which by far have thus far been excluded, have to be promoted to supply recommendations in the oncohematologic setting.
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Affiliation(s)
- Ciro Santoro
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Valentina Capone
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Mario Enrico Canonico
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy.,Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Roberta Esposito
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | | | - Guido Parodi
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
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23
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Atterman A, Friberg L, Asplund K, Engdahl J. Atrial Fibrillation, Oral Anticoagulants, and Concomitant Active Cancer: Benefits and Risks. TH OPEN 2021; 5:e176-e182. [PMID: 34104856 PMCID: PMC8169314 DOI: 10.1055/s-0041-1728670] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 02/11/2021] [Indexed: 01/02/2023] Open
Abstract
Aim To determine to what extent active cancer influences the benefit-risk relationship among patients with atrial fibrillation receiving oral anticoagulants for stroke prevention. Methods In this cohort study of all patients with atrial fibrillation in the Swedish Patient register during 2006 to 2017, 8,228 patients with active cancer and 323,394 without cancer were followed up to 1 year after initiation of oral anticoagulants. Cox regression models, adjusting for confounders and the competing risk of death, were used to assess risk of cerebrovascular and bleeding events. Results Among patients treated with oral anticoagulants, the risk for cerebrovascular events did not differ between cancer patients and noncancer patients (subhazard ratio [sHR]: 1.12, 95% confidence interval [CI]: 0.98-1.29). Cancer patients had a higher risk for bleedings (sHR: 1.69, CI: 1.56-1.82), but not for fatal bleedings (sHR: 1.17, CI: 0.80-1.70). Use of nonvitamin K oral anticoagulants was associated with lower risk of both cerebrovascular events and bleedings compared with warfarin. Conclusion Patients with atrial fibrillation and active cancer appear to have similar net cerebrovascular benefit of oral anticoagulant treatment to patients without cancer, despite an increased risk of nonfatal bleedings. Use of nonvitamin K oral anticoagulants was associated with lower risk of all studied outcomes.
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Affiliation(s)
- Adriano Atterman
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Leif Friberg
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Kjell Asplund
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Johan Engdahl
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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24
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Valeriani E, Di Nisio M, Riva N, Caiano LM, Porreca E, Bang SM, Beyer-Westendorf J, Sartori MT, Barillari G, Santoro R, Kamphuisen PW, Alatri A, Malato A, Vidili G, Oh D, Schulman S, Ageno W. Clinical history of cancer-associated splanchnic vein thrombosis. J Thromb Haemost 2021; 19:983-991. [PMID: 33306241 DOI: 10.1111/jth.15214] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cancer represents a risk factor for splanchnic vein thrombosis (SVT) and usual site venous thromboembolism (VTE). OBJECTIVES To compare characteristics and outcomes of patients with cancer-associated SVT and usual site VTE. PATIENTS/METHODS Patients with solid cancer and SVT were enrolled in an international, prospective registry between May 2008 and January 2012. The comparison cohort included (1:1 ratio) patients with solid cancer and usual site VTE treated at two thrombosis centers who had a minimum of 12 months follow-up at December 2019 or experienced one of the outcomes within 12 months follow-up. Recurrent VTE, major bleeding, and all-cause mortality were evaluated at 12-month follow-up. RESULTS A total of 264 patients (132 in each cohort) were enrolled. Patients with SVT were less likely to have metastatic disease (36.1% vs 72.5%) or receive cancer therapy at thrombosis diagnosis (29.6% vs 64.9%). The most frequent cancer types were hepatobiliary and pancreatic in the SVT cohort and gastrointestinal in the usual site VTE cohort. Fewer patients with SVT received anticoagulation (68.9% vs 99.2%), and treatment duration was shorter (6.0 vs 11.0 months). The cumulative incidence of major bleeding (2.3% vs 4.7%) was nonsignificantly lower in the SVT cohort, whereas recurrent thrombosis (4.7% vs 5.5%) and all-cause mortality (41.7% vs 39.4%) were comparable between the two cohorts. CONCLUSIONS The risk of recurrent thrombosis and bleeding appears to be similar in cancer patients with SVT and cancer patients with usual site VTE, despite some differences in baseline characteristics and anticoagulant treatment. Further prospective studies are warranted to confirm these findings.
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Affiliation(s)
- Emanuele Valeriani
- Department of Medical, Oral and Biotechnological Sciences "G. d'Annunzio" University, Chieti, Italy
- Department of Diagnostic and Therapeutic Medicine, Campus-Bio Medico University, Rome, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti-Pescara, Italy
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Lucia Maria Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences "G. d'Annunzio" University, Chieti, Italy
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University, Seoul, South Korea
| | - Jan Beyer-Westendorf
- Division of Hematology and Hemostaseology, Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | | | - Giovanni Barillari
- Department of Internal Medicine, Ospedale S. Maria della Misericordia, Udine, Italy
| | - Rita Santoro
- Haemophilia Center, Azienda Ospedaliera Pugliese- Ciaccio, Catanzaro, Italy
| | - Pieter W Kamphuisen
- Department of Vascular Medicine, University of Groningen, Groningen, The Netherlands
| | - Adriano Alatri
- Hemostasis and Thrombosis Center, A.O. Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Alessandra Malato
- Department of Hematology, Policlinico Universitario di Palermo, Palermo, Italy
| | - Gianpaolo Vidili
- Department of Clinical Medicine, University Hospital of Sassari, Sassari, Italy
| | - Doyeun Oh
- Department of Internal Medicine, Pochon CHA University, Seoul, Korea
| | - Sam Schulman
- Department of Medicine, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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25
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Steffel J, Ruff CT, Yin O, Braunwald E, Park JG, Murphy SA, Connolly S, Antman EM, Giugliano RP. Randomized, Double-Blind Comparison of Half-Dose Versus Full-Dose Edoxaban in 14,014 Patients With Atrial Fibrillation. J Am Coll Cardiol 2021; 77:1197-1207. [PMID: 33663737 DOI: 10.1016/j.jacc.2020.12.053] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND In the ENGAGE AF-TIMI 48 (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis In Myocardial Infarction 48) trial, the lower dose edoxaban regimen (LDER) and the higher dose edoxaban regimen (HDER) were noninferior to well-managed warfarin for stroke prevention in atrial fibrillation. OBJECTIVES The objective of the present analysis of the ENGAGE AF TIMI-48 trial was to comprehensively compare the net clinical outcome (NCO) of LDER (30 mg once daily, dose reduced to 15 mg in selective patients) versus HDER (60 mg once daily, dose reduced to 30 mg in selective patients). METHODS This study performed a pre-specified analysis of the ENGAGE AF-TIMI 48 trial, comparing patients on LDER versus HDER. RESULTS The pre-defined primary NCO (stroke/systemic embolism [SEE], major bleeding, death) was less frequent with LDER (7.26% vs. 8.01%; hazard ratio: 0.90; 95% confidence interval: 0.84 to 0.98; p = 0.014). The secondary (disabling stroke, life-threatening bleeding, or all-cause mortality) and tertiary pre-defined NCOs (stroke, SEE, life-threatening bleeding, or all-cause mortality) were similar between the 2 dosing regimens. Patients randomized to LDER versus HDER had a significantly higher risk of stroke/SEE (2.04% vs. 1.56%; hazard ratio: 1.31; 95% confidence interval: 1.12 to 1.52; p < 0.001). Conversely, major bleeding, intracranial hemorrhage, major gastrointestinal bleeding, and life-threatening bleeding occurred significantly less frequently with LDER compared with those of HDER. These findings were supported by multiple pharmacokinetic findings. CONCLUSIONS In the ENGAGE AF-TIMI 48 trial, the primary NCO was reduced with LDER versus HDER, whereas the secondary and tertiary NCOs were similar between the 2 dosing regimens. These results may aid physicians in evidence-based individualization of edoxaban dosing. However, the approved HDER remains the standard therapy among the available edoxaban dosing regimens for stroke prevention in atrial fibrillation. (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis In Myocardial Infarction 48 [ENGAGE AF-TIMI 48]; NCT00781391).
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland. https://twitter.com/SteffelJ
| | - Christian T Ruff
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ophelia Yin
- Daiichi-Sankyo, Inc., Basking Ridge, New Jersey, USA
| | - Eugene Braunwald
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeong-Gun Park
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sabina A Murphy
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stuart Connolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Elliott M Antman
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert P Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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26
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Navi BB, Kasner SE, Elkind MSV, Cushman M, Bang OY, DeAngelis LM. Cancer and Embolic Stroke of Undetermined Source. Stroke 2021; 52:1121-1130. [PMID: 33504187 DOI: 10.1161/strokeaha.120.032002] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
One-quarter to one-third of ischemic strokes have no established mechanism after standard diagnostic evaluation and are classified as embolic stroke of undetermined source (ESUS). Failure of randomized trials to demonstrate a benefit of direct oral anticoagulants over aspirin for the treatment of ESUS as a single homogeneous entity has led to renewed interest by stroke experts to divide ESUS into subgroups. Emerging data suggest that active cancer, which is present in 5% to 10% of patients with ESUS, is a distinct and important subgroup of ESUS with unique clinical characteristics, underlying pathophysiologies, and treatment and prognostic considerations. Furthermore, the prevalence of cancer-related ESUS is expected to increase as patients with cancer, even those with distant metastases, survive longer due to improvements in cancer treatments. In this topical review, we examine the epidemiological link between ESUS and cancer, the clinical features and potential mechanistic underpinnings of ESUS with cancer (with a focus on novel biomarkers and their relationship to recurrent stroke and other thromboembolic events), and the potential treatment strategies for cancer-related ESUS. We include a critical appraisal of existing data and ongoing or planned clinical trials of different antithrombotic approaches. As cancer-related ESUS is a dynamic disease with variable course, we recommend close collaboration between neurologists and oncologists to develop individualized management plans.
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Affiliation(s)
- Babak B Navi
- Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY (B.B.N.).,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY (B.B.N., L.M.D.)
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY (M.S.V.E.)
| | - Mary Cushman
- Division of Hematology and Oncology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington (M.C.)
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.)
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY (B.B.N., L.M.D.)
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27
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Song X, Liu Z, Zeng R, Shao J, Liu B, Zheng Y, Liu C, Ye W. Treatment of venous thromboembolism in cancer patients: a systematic review and meta-analysis on the efficacy and safety of different direct oral anticoagulants (DOACs). ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:162. [PMID: 33569464 PMCID: PMC7867886 DOI: 10.21037/atm-20-8156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background To evaluate the efficacy and safety of different direct oral anticoagulants (DOACs) compared with low molecular weight heparins (LMWHs) in the treatment of venous thromboembolism (VTE) in cancer patients. Methods Literature was searched in databases including Cochrane Library, EMBASE (Ovid), and MEDLINE (PubMed). Eligible studies were included, and data were collected independently by 2 reviewers. We conducted a systematic review of the efficacy and safety of DOACs in the treatment of VTE in cancer patients. The odds ratios (ORs) of different DOACs compared with LMWHs for VTE, deep vein thrombosis (DVT), pulmonary embolism (PE) recurrence, major bleeding, and clinically relevant non-major bleeding (CRNMB), were calculated in meta-analyses and subgroup analyses. Results A total of 18 articles were eligible for analyses, including 4 randomized controlled trials (RCTs) and 14 retrospective studies. Both RCTs and retrospective studies confirmed that DOACs decreased the risk of VTE recurrence [RCTs: OR, 0.60; 95% confidence interval (CI), 0.45–0.80; retrospective studies: OR, 0.73; 95% CI, 0.59–0.90] and DVT recurrence (RCTs: OR, 0.54; 95% CI, 0.36–0.80; retrospective studies: OR, 0.20; 95% CI, 0.06–0.63), but not PE recurrence or fatal PE in cancer patients. Subgroup analyses revealed an important role of rivaroxaban in decreasing recurrent VTE. Meanwhile, major bleeding events were not increased in the DOAC group, but the risks of CRNMBs were significantly elevated. Subgroup analyses confirmed the role of rivaroxaban in increasing the risk of major bleeding events and CRNMBs. Conclusions Compared with LMWHs, DOACs (especially rivaroxaban) significantly reduce the risk of VTE and DVT, but not PE recurrence, in patients with cancer. Although DOACs did not increase the major bleeding events in pooled analysis, rivaroxaban showed an elevated risk of this adverse effect in subgroup analysis. In addition, the risk of CRNMB events was increased after the application of DOACs including rivaroxaban.
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Affiliation(s)
- Xiaojun Song
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Zhili Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Rong Zeng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Jiang Shao
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Bao Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Changwei Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Wei Ye
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
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28
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Rutjes AW, Porreca E, Candeloro M, Valeriani E, Di Nisio M. Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy. Cochrane Database Syst Rev 2020; 12:CD008500. [PMID: 33337539 PMCID: PMC8829903 DOI: 10.1002/14651858.cd008500.pub5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) often complicates the clinical course of cancer. The risk is further increased by chemotherapy, but the trade-off between safety and efficacy of primary thromboprophylaxis in cancer patients treated with chemotherapy is uncertain. This is the third update of a review first published in February 2012. OBJECTIVES To assess the efficacy and safety of primary thromboprophylaxis for VTE in ambulatory cancer patients receiving chemotherapy compared with placebo or no thromboprophylaxis, or an active control intervention. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 3 August 2020. We also searched the reference lists of identified studies and contacted content experts and trialists for relevant references. SELECTION CRITERIA Randomised controlled trials comparing any oral or parenteral anticoagulant or mechanical intervention to no thromboprophylaxis or placebo, or comparing two different anticoagulants. DATA COLLECTION AND ANALYSIS We extracted data on risk of bias, participant characteristics, interventions, and outcomes including symptomatic VTE and major bleeding as the primary effectiveness and safety outcomes, respectively. We applied GRADE to assess the certainty of evidence. MAIN RESULTS We identified six additional randomised controlled trials (3326 participants) for this update, bringing the included study total to 32 (15,678 participants), all evaluating pharmacological interventions and performed mainly in people with locally advanced or metastatic cancer. The certainty of the evidence ranged from high to very low across the different outcomes and comparisons. The main limiting factors were imprecision and risk of bias. Thromboprophylaxis with direct oral anticoagulants (direct factor Xa inhibitors apixaban and rivaroxaban) may decrease the incidence of symptomatic VTE (risk ratio (RR) 0.43, 95% confidence interval (CI) 0.18 to 1.06; 3 studies, 1526 participants; low-certainty evidence); and probably increases the risk of major bleeding compared with placebo (RR 1.74, 95% CI 0.82 to 3.68; 3 studies, 1494 participants; moderate-certainty evidence). When compared with no thromboprophylaxis, low-molecular-weight heparin (LMWH) reduced the incidence of symptomatic VTE (RR 0.62, 95% CI 0.46 to 0.83; 11 studies, 3931 participants; high-certainty evidence); and probably increased the risk of major bleeding events (RR 1.63, 95% CI 1.12 to 2.35; 15 studies, 7282 participants; moderate-certainty evidence). In participants with multiple myeloma, LMWH resulted in lower symptomatic VTE compared with the vitamin K antagonist warfarin (RR 0.33, 95% CI 0.14 to 0.83; 1 study, 439 participants; high-certainty evidence), while LMWH probably lowers symptomatic VTE more than aspirin (RR 0.51, 95% CI 0.22 to 1.17; 2 studies, 781 participants; moderate-certainty evidence). Major bleeding was observed in none of the participants with multiple myeloma treated with LMWH or warfarin and in less than 1% of those treated with aspirin. Only one study evaluated unfractionated heparin against no thromboprophylaxis, but did not report on VTE or major bleeding. When compared with placebo or no thromboprophylaxis, warfarin may importantly reduce symptomatic VTE (RR 0.15, 95% CI 0.02 to 1.20; 1 study, 311 participants; low-certainty evidence) and may result in a large increase in major bleeding (RR 3.82, 95% CI 0.97 to 15.04; 4 studies, 994 participants; low-certainty evidence). One study evaluated antithrombin versus no antithrombin in children. This study did not report on symptomatic VTE but did report any VTE (symptomatic and incidental VTE). The effect of antithrombin on any VTE and major bleeding is uncertain (any VTE: RR 0.84, 95% CI 0.41 to 1.73; major bleeding: RR 0.78, 95% CI 0.03 to 18.57; 1 study, 85 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS In ambulatory cancer patients, primary thromboprophylaxis with direct factor Xa inhibitors may reduce the incidence of symptomatic VTE (low-certainty evidence) and probably increases the risk of major bleeding (moderate-certainty evidence) when compared with placebo. LMWH decreases the incidence of symptomatic VTE (high-certainty evidence), but increases the risk of major bleeding (moderate-certainty evidence) when compared with placebo or no thromboprophylaxis. Evidence for the use of thromboprophylaxis with anticoagulants other than direct factor Xa inhibitors and LMWH is limited. More studies are warranted to evaluate the efficacy and safety of primary prophylaxis in specific types of chemotherapeutic agents and types of cancer, such as gastrointestinal or genitourinary cancer.
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Affiliation(s)
- Anne Ws Rutjes
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Matteo Candeloro
- Internal Medicine Unit, "University G. D'Annunzio" Foundation, Chieti, Italy
| | - Emanuele Valeriani
- Internal Medicine Unit, "University G. D'Annunzio" Foundation, Chieti, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti Scalo, Italy
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
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Páramo JA. Prediction and treatment of bleeding in patients under anticoagulant treatment. Med Clin (Barc) 2020; 156:20-25. [PMID: 33218693 DOI: 10.1016/j.medcli.2020.06.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/17/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
Major bleeding is a common complication of anticoagulant treatment. Risk assessment tools are relevant in the management of patients with atrial fibrillation and venous thromboembolism. The combination of clinical, biological and genetic markers is incorporated to build predictive scores to help in the decision process about intensity and duration of treatment. The optimal management of bleeding involves the application of predictive scores in combination with anticoagulant reversal strategies.
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Affiliation(s)
- José A Páramo
- Servicio de Hematología, Clínica Universidad de Navarra, IdiSNA, CIBERCV, Pamplona, Navarra, España.
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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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31
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Sorigue M, Miljkovic MD. Atrial Fibrillation and Stroke Risk in Patients With Cancer: A Primer for Oncologists. J Oncol Pract 2020; 15:641-650. [PMID: 31825754 DOI: 10.1200/jop.18.00592] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Cancer and atrial fibrillation (AF) are common conditions, but for patients affected with both, there is a lack of data about management of anticoagulation and cerebrovascular outcomes. In the first section of this review, we summarize the most relevant studies on stroke risk and management of AF in patients with active cancer, attempting to answer questions of whether to anticoagulate, whom to anticoagulate, and what agents to use. In the second section of the review, we suggest a decision algorithm on the basis of the available evidence and provide practical recommendations for each of the anticoagulant options. In the third section, we discuss the limitations of the available evidence. On the basis of low-quality evidence, we find that patients with cancer and AF have a risk of stroke similar to that of the general population but a substantially higher risk of bleeding regardless of the anticoagulant agent used; this makes anticoagulation-related decisions complex and evidence from the general population not immediately applicable. In general, we suggest stopping anticoagulation in patients with high risk of bleeding and in those with a moderate bleeding risk without a high thromboembolic risk and recommend anticoagulation as in the general population for patients at a low risk for bleeding. However, regardless of initial therapy, we recommend reassessing whether anticoagulation should be given at each point in the clinical course of the disease. High-quality evidence to guide anticoagulation for AF in patients with cancer is needed.
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Affiliation(s)
- Marc Sorigue
- ICO-Hospital Germans Trias i Pujol.IJC, UAB, Badalona, Spain
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32
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Hilkens NA, Li L, Rothwell PM, Algra A, Greving JP. Refining prediction of major bleeding on antiplatelet treatment after transient ischaemic attack or ischaemic stroke. Eur Stroke J 2020; 5:130-137. [PMID: 32637646 PMCID: PMC7309362 DOI: 10.1177/2396987319898064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/03/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction Bleeding is the main safety concern of treatment with antiplatelet drugs. We aimed to refine prediction of major bleeding on antiplatelet treatment after a transient ischaemic attack (TIA) or stroke by assessing the added value of new predictors to the existing S2TOP-BLEED score. Patients and methods We used Cox regression analysis to study the association between candidate predictors and major bleeding among 2072 patients with a transient ischaemic attack or ischaemic stroke included in a population-based study (Oxford Vascular Study – OXVASC). An updated model was proposed and validated in 1094 patients with a myocardial infarction included in OXVASC. Models were compared with c-statistics, calibration plots, and net reclassification improvement. Results Independent predictors for major bleeding on top of S2TOP-BLEED variables were peptic ulcer (hazard ratio (HR): 1.72; 1.04–2.86), cancer (HR: 2.40; 1.57–3.68), anaemia (HR: 1.55; 0.99–2.44) and renal failure (HR: 2.20; 1.57–4.28). Addition of those variables improved discrimination from 0.69 (0.64–0.73) to 0.73 (0.69–0.78) in the TIA/stroke cohort (p = 0.01). Performance improved particularly for upper gastro-intestinal bleeds (0.70; 0.64–0.75 to 0.77; 0.72–0.82). Net reclassification improved over the entire range of the score (net reclassification improvement: 0.56; 0.36–0.76). In the validation cohort, discriminatory performance improved from 0.68 (0.62–0.74) to 0.70 (0.64–0.76). Discussion and Conclusion Peptic ulcer, cancer, anaemia and renal failure improve predictive performance of the S2TOP-BLEED score for major bleeding after stroke. Future external validation studies will be required to confirm the value of the STOP-BLEED+ score in transient ischaemic attack/stroke patients.
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Affiliation(s)
- Nina A Hilkens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Linxin Li
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Peter M Rothwell
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Ale Algra
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
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Spyropoulos AC, Lipardi C, Xu J, Lu W, Suh E, Yuan Z, Levitan B, Sugarmann C, De Sanctis Y, Spiro TE, Barnathan ES, Raskob GE. Improved Benefit Risk Profile of Rivaroxaban in a Subpopulation of the MAGELLAN Study. Clin Appl Thromb Hemost 2020; 25:1076029619886022. [PMID: 31746218 PMCID: PMC7019408 DOI: 10.1177/1076029619886022] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Acutely ill medical patients are at risk of venous thromboembolism (VTE) and VTE-related
mortality during hospitalization and posthospital discharge, but widespread adoption of
extended thromboprophylaxis has not occurred. We analyzed a subpopulation within the
MAGELLAN study of extended thromboprophylaxis with rivaroxaban to reevaluate the benefit
risk profile. We identified 5 risk factors for major and fatal bleeding after a clinical
analysis of the MAGELLAN study and analyzed efficacy and safety with these patients
excluded (n = 1551). Risk factors included: active cancer, dual antiplatelet therapy at
baseline, bronchiectasis/pulmonary cavitation, gastroduodenal ulcer, or bleeding within 3
months before randomization. We evaluated efficacy, safety, and benefit risk using
clinically comparable endpoints in the subpopulation. At day 10, rivaroxaban was
noninferior to enoxaparin (relative risk [RR] = 0.82, 95% confidence interval [CI] =
0.58-1.15) and at day 35 rivaroxaban was significantly better than enoxaparin/placebo (RR
= 0.68, 95% CI = 0.53-0.88) in reducing VTE and VTE-related death. Major bleeding was
reduced at day 10 (RR = 2.18, 95% CI = 1.07-4.44 vs 1.19, 95% CI = 0.54-2.65) and at day
35 (2.87, 95% CI = 1.60-5.15 vs 1.48, 95% CI = 0.77-2.84) for MAGELLAN versus this
subpopulation, respectively. The benefit risk profile was favorable in this subpopulation
treated for 35 days, with the number needed to treat ranging from 55 to 481 and number
needed to harm from 455 to 1067 for all pairwise evaluations. Five exclusionary criteria
defined a subpopulation of acutely ill medical patients with a positive benefit risk
profile for in-hospital and extended thromboprophylaxis with rivaroxaban.
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Affiliation(s)
- Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,The Feinstein Institute for Medical Research, Manhasset, NY, USA.,Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill Hospital, NY, USA
| | | | - Jianfeng Xu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Wentao Lu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Eunyoung Suh
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Zhong Yuan
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | | | | | - Yoriko De Sanctis
- Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, NJ, USA
| | - Theodore E Spiro
- Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, NJ, USA
| | | | - Gary E Raskob
- College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Majmudar K, Golemi I, Tafur AJ, Toro JD, Visonà A, Falgá C, Sahuquillo JC, Lorente MA, Tufano A, Weinberg I, Di Micco P, Monreal M. Outcomes after venous thromboembolism in patients with gastric cancer: Analysis of the RIETE Registry. Vasc Med 2020; 25:210-217. [PMID: 32000631 DOI: 10.1177/1358863x19893432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastric cancer is the fifth most common malignancy worldwide. Venous thromboembolism is an independent predictor of death among patients with gastric cancer. We aimed to describe the factors associated with mortality, thrombosis recurrence, and bleeding complications in patients with gastric cancer who develop venous thromboembolism. We included 612 patients with gastric cancer and venous thromboembolism in the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry from 2001 to 2018. We used Cox proportional hazard ratios and a Fine-Gray model to define factors associated with outcomes. The overall mortality at 6 months was 44.4%. Factors associated with increased 6-month mortality included immobility (HR 1.8, 95% CI 1.3-2.4; p < 0.001), anemia (HR 1.4, 95% CI 1.1-1.8; p < 0.02), and leukocytosis (HR 1.8, 95% CI 1.4-2.3; p < 0.001). Recurrent thrombosis occurred in 6.5% of patients and major bleeding complications in 8.5% of the cohort. Male sex was the main factor associated with thrombosis recurrence (HR 2.1, 95% CI 1.1-4.0; p < 0.02) and hemoglobin below 10 g/dL (HR 1.6, 95% CI 1.05-2.50; p = 0.03) the main factor associated with bleeding. In conclusion, patients with gastric cancer who develop venous thrombosis have a very high likelihood of death. Low hemoglobin in this population is associated with poor outcomes.
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Affiliation(s)
- Kaushal Majmudar
- Department of Medicine, Division of Internal Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Iva Golemi
- Department of Medicine, Division of Internal Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Alfonso J Tafur
- Department of Medicine, Division of Vascular Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Jorge Del Toro
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adriana Visonà
- Department of Vascular Medicine, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
| | - Conxita Falgá
- Department of Internal Medicine, Hospital de Mataró, Barcelona, Spain
| | | | | | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Regional Reference Centre for Coagulation Disorders, Federico II University Hospital, Naples, Italy
| | - Ido Weinberg
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pierpaolo Di Micco
- Department of Medicine, UOC Medicina, Fatebenefratelli Hospital of Napoli, Italy
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Universidad Autónoma de Barcelona, Barcelona, Spain
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Sorigue M, Cañamero E, Siguenza P, Nomdedeu M, López-Núñez JJ. Recent developments and persisting challenges in the prevention and treatment of venous thromboembolism in patients with hematological malignancies. Leuk Lymphoma 2020; 61:1277-1291. [DOI: 10.1080/10428194.2020.1713321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Marc Sorigue
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Eloi Cañamero
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Patricia Siguenza
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Meritxell Nomdedeu
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Juan J. López-Núñez
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
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Yamaguchi I, Kanematsu Y, Shimada K, Korai M, Miyamoto T, Shikata E, Yamaguchi T, Yamamoto N, Yamamoto Y, Kitazato K, Okayama Y, Takagi Y. Active Cancer and Elevated D-Dimer Are Risk Factors for In-Hospital Ischemic Stroke. Cerebrovasc Dis Extra 2019; 9:129-138. [DOI: 10.1159/000504163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/16/2019] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background and Purpose:</i></b> Little attention has been paid to the pathogenesis of in-hospital stroke, despite poor outcomes and a longer time from stroke onset to treatment. We studied the pathophysiology and biomarkers for detecting patients who progress to in-hospital ischemic stroke (IHS). <b><i>Methods:</i></b> Seventy-nine patients with IHS were sequentially recruited in the period 2011–2017. Their characteristics, care, and outcomes were compared with 933 patients who had an out-of-hospital ischemic stroke (OHS) using a prospectively collected database of the Tokushima University Stroke Registry. <b><i>Results:</i></b> Active cancer and coronary artery disease were more prevalent in patients with IHS than in those with OHS (53.2 and 27.8% vs. 2.0 and 10.9%, respectively; <i>p</i> < 0.001), the median onset-to-evaluation time was longer (300 vs. 240 min; <i>p</i> = 0.015), and the undetermined etiology was significantly higher (36.7 vs. 2.4%; <i>p</i> < 0.001). Although there was no significant difference in stroke severity at onset between the groups, patients with IHS had higher modified Rankin Scale (mRS) scores (3–6) at discharge (67.1 vs. 50.3%; <i>p</i> = 0.004) and rates of death during hospitalization (16.5 vs. 2.9%; <i>p</i> < 0.001). D-dimer (5.8 vs. 0.8 µg/mL; <i>p</i> < 0.001) and fibrinogen (532 vs. 430 mg/dL; <i>p</i> = 0.014) plasma levels at the time of onset were significantly higher in patients with IHS after propensity score matching. Multivariate logistic regression analysis revealed that active cancer (odds ratio [OR] 2.30; 95% confidence interval [CI] 1.26–4.20), prestroke mRS scores 3–5 (OR 6.78; 95% CI 3.96–11.61), female sex (OR 1.57; 95% CI 1.19–2.08), and age ≥75 years (OR 2.36; 95% CI 1.80–3.08) were associated with poor outcomes. <b><i>Conclusions:</i></b> Patients with IHS had poorer outcomes than those with OHS because of a higher prevalence of active cancer and functional dependence before stroke onset. Elevated plasma levels of D-dimer and fibrinogen, especially with active cancer, can help identify patients who are at a higher risk of progression to IHS.
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D’Souza M, Smedegaard L, Madelaire C, Bang C, Nielsen D, Torp-Pedersen C, Gislason G, Schou M, Fosbøl E. Atrial fibrillation and anticoagulation in patients with breast cancer. SCAND CARDIOVASC J 2019; 53:247-254. [DOI: 10.1080/14017431.2019.1638517] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Maria D’Souza
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Gentofte, Denmark
| | - Laerke Smedegaard
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Gentofte, Denmark
| | - Christian Madelaire
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Gentofte, Denmark
| | - Casper Bang
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Denmark
- Department of Research, The Danish Heart Foundation, Copenhagen, Denmark
| | - Dorte Nielsen
- Department of Clinical Oncology, Copenhagen University Hospital Herlev-Gentofte, Herlev, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Gentofte, Denmark
- Department of Epidemiology, University of Aalborg, Aalborg, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Gentofte, Denmark
- Department of Research, The Danish Heart Foundation, Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Herlev, Denmark
| | - Emil Fosbøl
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Denmark
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Farge D, Frere C. Recent advances in the treatment and prevention of venous thromboembolism in cancer patients: role of the direct oral anticoagulants and their unique challenges. F1000Res 2019; 8. [PMID: 31297188 PMCID: PMC6600867 DOI: 10.12688/f1000research.18673.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2019] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer and is associated with poor prognosis. Low-molecular-weight heparins (LMWHs) are the standard of care for the treatment of cancer-associated thrombosis. Primary VTE prophylaxis with LMWH is recommended after cancer surgery and in hospitalized patients with reduced mobility. However, owing to wide variations in VTE and bleeding risk, based on disease stage, anti-cancer treatments, and individual patient characteristics, routine primary prophylaxis is not recommended in ambulatory cancer patients undergoing chemotherapy. Efforts are under way to validate risk assessment models that will help identify those patients in whom the benefits of primary prophylaxis will outweigh the risks. In recent months, long-awaited dedicated clinical trials assessing the direct oral anticoagulants (DOACs) in patients with cancer have reported promising results. In comparison with the LMWHs, the DOACs were reported to be non-inferior to prevent VTE recurrence. However, there was an increased risk of bleeding, particularly in gastrointestinal cancers. Safe and optimal treatment with the DOACs in the patient with cancer will require vigilant patient selection based on patient characteristics, co-morbidities, and the potential for drug-drug interactions.
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Affiliation(s)
- Dominique Farge
- Université de Paris, IRSL, Paris, France.,Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, Paris, France.,McGill University, Montral, QC, Canada
| | - Corinne Frere
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France.,Assistance Publique Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Haematology, Paris, France
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Lee JH, Oh YM, Lee SD, Lee JS. Rivaroxaban versus Low-Molecular-Weight Heparin for Venous Thromboembolism in Gastrointestinal and Pancreatobiliary Cancer. J Korean Med Sci 2019; 34:e160. [PMID: 31144482 PMCID: PMC6543062 DOI: 10.3346/jkms.2019.34.e160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/09/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Low-molecular-weight heparin (LMWH) is the standard treatment for venous thromboembolism (VTE) in patients with active cancer. However, use of factor Xa inhibitors, such as rivaroxaban, is increasing on the basis of limited clinical evidence. The present single-center study compared the incidence of bleeding and other treatment outcomes in gastrointestinal and pancreatobiliary cancer (GI tract cancer) patients administered rivaroxaban or LMWH for the treatment of VTE. METHODS Retrospective data from 281 GI tract cancer patients who were treated for VTE with rivaroxaban (n = 78) or LMWH (n = 203) between 1 January 2012 and 31 December 2016, were analyzed. Primary end-point was the incidence of major and clinically relevant bleeding. Secondary outcomes included the incidence of recurrent VTE and mortality. RESULTS Clinically relevant bleeding occurred in 19 patients (24.4%) in the rivaroxaban group and 31 (15.3%) in the LMWH group (P = 0.074). No inter-group difference was observed for rate of VTE recurrence (3.8% with rivaroxaban vs. 3.9% with LMWH; P > 0.999) or incidence of major bleeding (5.1% with rivaroxaban vs. 8.9% with LMWH; P = 0.296). Multivariate Cox proportional hazards analysis for age, cancer type, metastasis, history of chemotherapy or recent surgery, and Eastern Cooperative Oncology Group performance status revealed a 1.904-fold higher risk of bleeding with rivaroxaban than LMWH (1.031-3.516; P = 0.040). No significant inter-group difference was found in terms of hazard ratio for all-cause mortality. CONCLUSION Compared to LMWH, rivaroxaban was associated with a higher incidence of clinically relevant bleeding in GI tract cancer patients presenting with VTE.
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Affiliation(s)
- Jang Ho Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Do Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Center for Pulmonary Hypertension and Venous Thrombosis, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Center for Pulmonary Hypertension and Venous Thrombosis, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Sorigue M, Sarrate E, Miljkovic M. Anticoagulation for atrial fibrillation in patients with active cancer. Int J Cardiol 2019; 280:98. [DOI: 10.1016/j.ijcard.2018.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/27/2018] [Accepted: 11/02/2018] [Indexed: 11/24/2022]
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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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Zwicker JI, Schlechter BL, Stopa JD, Liebman HA, Aggarwal A, Puligandla M, Caughey T, Bauer KA, Kuemmerle N, Wong E, Wun T, McLaughlin M, Hidalgo M, Neuberg D, Furie B, Flaumenhaft R. Targeting protein disulfide isomerase with the flavonoid isoquercetin to improve hypercoagulability in advanced cancer. JCI Insight 2019; 4:125851. [PMID: 30652973 PMCID: PMC6478409 DOI: 10.1172/jci.insight.125851] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/14/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Protein disulfide isomerase (PDI) is a thiol isomerase secreted by vascular cells that is required for thrombus formation. Quercetin flavonoids inhibit PDI activity and block platelet accumulation and fibrin generation at the site of a vascular injury in mouse models, but the clinical effect of targeting extracellular PDI in humans has not been studied. METHODS We conducted a multicenter phase II trial of sequential dosing cohorts to evaluate the efficacy of targeting PDI with isoquercetin to reduce hypercoagulability in cancer patients at high risk for thrombosis. Patients received isoquercetin at 500 mg (cohort A, n = 28) or 1000 mg (cohort B, n = 29) daily for 56 days, with laboratory assays performed at baseline and the end of the study, along with bilateral lower extremity compression ultrasound. The primary efficacy endpoint was a reduction in D-dimer, and the primary clinical endpoint included pulmonary embolism or proximal deep vein thrombosis. RESULTS The administration of 1000 mg isoquercetin decreased D-dimer plasma concentrations by a median of -21.9% (P = 0.0002). There were no primary VTE events or major hemorrhages observed in either cohort. Isoquercetin increased PDI inhibitory activity in plasma (37.0% in cohort A, n = 25, P < 0.001; 73.3% in cohort B, n = 22, P < 0.001, respectively). Corroborating the antithrombotic efficacy, we also observed a significant decrease in platelet-dependent thrombin generation (cohort A median decrease -31.1%, P = 0.007; cohort B median decrease -57.2%, P = 0.004) and circulating soluble P selectin at the 1000 mg isoquercetin dose (median decrease -57.9%, P < 0.0001). CONCLUSIONS Isoquercetin targets extracellular PDI and improves markers of coagulation in advanced cancer patients. TRIAL REGISTRATION Clinicaltrials.gov NCT02195232. FUNDING Quercegen Pharmaceuticals; National Heart, Lung, and Blood Institute (NHLBI; U54HL112302, R35HL135775, and T32HL007917); and NHLBI Consortium Linking Oncology and Thrombosis (U01HL143365).
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Affiliation(s)
- Jeffrey I. Zwicker
- Division of Hemostasis and Thrombosis and
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin L. Schlechter
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Howard A. Liebman
- Jane Anne Nohl Division of Hematology, University of Southern California, Los Angeles, California, USA
| | | | - Maneka Puligandla
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Kenneth A. Bauer
- Division of Hemostasis and Thrombosis and
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy Kuemmerle
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - Ellice Wong
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ted Wun
- Division of Hematology Oncology, University of California Davis School of Medicine, VA Northern California Health Care System, Sacramento, California, USA
| | | | - Manuel Hidalgo
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Donna Neuberg
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Abstract
PURPOSE OF REVIEW Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients, and its management is often associated with complications including risk of recurrent VTE and bleeding. Here, we review the current data on pitfalls during anticoagulation in cancer patients and measures necessary to avoid them. RECENT FINDINGS Although low-molecular-weight heparin monotherapy has been the standard of treatment for several years, emerging data for direct oral anticoagulants (DOACs) are leading to new paradigms in treatment. Reports of recent randomized trials suggest a lower risk of recurrent thrombosis but higher risk of bleeding, particularly in gastrointestinal cancer patients, with DOACs. Careful patient selection and individualization of therapy based on risk of bleeding as well as recurrent VTE are keys. Problems like bleeding, recurrence, thrombocytopenia, drug-drug interactions, renal impairment, nausea-vomiting along with concerns about adherence arise during anticoagulation in cancer patients. However, with adequate pre-treatment assessment, correct anticoagulant selection and proper monitoring during anticoagulation, these issues can be addressed safely and effectively.
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Affiliation(s)
- Harsh K Patel
- Kansas City VA Medical Center, 4801 Linwood Blvd, Kansas City, MO, 64128, USA
| | - Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic, 10201 Carnegie Ave./CA60, Cleveland, OH, 44195, USA.
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Malavasi VL, Fantecchi E, Gianolio L, Pesce F, Longo G, Marietta M, Cascinu S, Lip GYH, Boriani G. Atrial fibrillation in patients with active malignancy and use of anticoagulants: Under-prescription but no adverse impact on all-cause mortality. Eur J Intern Med 2019; 59:27-33. [PMID: 30385084 DOI: 10.1016/j.ejim.2018.10.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 08/13/2018] [Accepted: 10/16/2018] [Indexed: 02/07/2023]
Abstract
Prescription of anticoagulants (ACs) in patients with cancer and atrial fibrillation (AF) is challenging and the impact on survival is not defined. In this study data prospectively collected in Oncology Units were retrospectively evaluated. Among 4664 patients admitted for malignancy, 394 patients (8.4%) had documented AF (mean age of 74 ± 9) and AC was prescribed to 155 patients (40%). Neither the type of cancer, the stage of the disease (metastatic or not) nor the ongoing treatments were significantly associated with prescription of AC, which was independently associated with BMI (OR 1.10; CI 95% 1.03-1.17; p = .003), valvular heart disease (OR 3.76; CI95% 1.59-8.87; p = .002), and previous venous thromboembolism (OR 6.67; 95%CI 2.67-16.70; p < .001). During a median follow-up of 212 days, survival from all-cause death was 37%, 28% and 18% at 6 months, 1 and 2 years, respectively. Only variables related to neoplastic disease or to patient clinical complexity were independently associated with mortality. A CHA2DS2VASc ≥ 4 was significantly associated with mortality (HR 1.33; 95%CI 1.06-1.67; p = .013). Treatment with ACs was not significantly related to mortality, neither in the whole cohort of patients, nor in patients with metastatic malignancies. In conclusion the prescription of ACs in patients with AF and active cancer was suboptimal, with one fourth of the patients not treated with ACs and one third using LMWH at prophylactic, non-therapeutic doses. Only few variables (BMI, valvular heart disease and previous venous thromboembolism) predicted prescription of ACs. Prescription of ACs was not associated with all-cause mortality, even in the subgroup with metastasis.
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Affiliation(s)
- Vincenzo Livio Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Elisa Fantecchi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Laura Gianolio
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Francesca Pesce
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Giuseppe Longo
- Oncology Division, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Marietta
- Hematology Division, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Stefano Cascinu
- Oncology Division, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.
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Plaja A, Berastegui E, Nieto-Moragas J, Sarrate E, Gual-Capllonch F, Quiroga V, Sorigue M. Thromboembolism and bleeding in patients with cancer and mechanical heart valves. J Thromb Thrombolysis 2018; 47:454-461. [PMID: 30560487 DOI: 10.1007/s11239-018-1790-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Mechanical heart valves (MHV) require life-long anticoagulation with vitamin K antagonists (VKA), but anticoagulation management is complex in patients with cancer due to a high risk of thrombosis and bleeding. This is a retrospective, single-center study to assess anticoagulation management and thrombotic (stroke/valve thrombosis) and bleeding events in patients with active cancer and MHV. The incidence of thrombotic complications was compared to a control group (matched 1:1) of patients with MHV but without cancer. We included 48 patients, 60% of whom had aortic prostheses, 23% mitral prostheses and 17% both types. All patients received VKA as anticoagulant. With a median follow-up of 5.12 years, we observed two arterial thrombotic events (two strokes and no heart valve thrombosis). The 5-year incidence (95% confidence interval [CI]) of stroke/valve thrombosis was 5.7% (0.9-17.9%). The control group had a similar incidence of stroke/valve thrombosis (5-year incidence 7.9% [95%CI 2-19.8], p = 0.16). There were also 15 major bleeding episodes in the cancer group, 11 of which were related to a surgical procedure. The 5-year incidence (95% CI) of major bleeding was 32.9% (18.5-48%), and that of major bleeding unrelated to any procedure was 10.3% (3-23%). We found a low incidence of thrombotic events in this series of patients with active cancer and MHV who were anticoagulated with VKA. However, the incidence of bleeding was high, particularly in relation to invasive procedures.
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Affiliation(s)
- Andrea Plaja
- Department of Oncology, Badalona-Applied Research Group in Oncology: B-ARGO Group, Catalan Institute of Oncology, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Elisabet Berastegui
- Department of Cardiovascular Surgery, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Javier Nieto-Moragas
- Clinical Laboratory ICS-Metropolitana Nord, Core-Hematology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Edurne Sarrate
- Department of Hematology, ICO-Hospital Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autònoma de Barcelona, Ctra. Canyet s/n, 08916, Badalona, Spain
| | | | - Vanesa Quiroga
- Department of Oncology, Badalona-Applied Research Group in Oncology: B-ARGO Group, Catalan Institute of Oncology, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Marc Sorigue
- Department of Hematology, ICO-Hospital Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autònoma de Barcelona, Ctra. Canyet s/n, 08916, Badalona, Spain.
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Li X, Gao P, Tan J, Xiong K, Maitz MF, Pan C, Wu H, Chen Y, Yang Z, Huang N. Assembly of Metal-Phenolic/Catecholamine Networks for Synergistically Anti-Inflammatory, Antimicrobial, and Anticoagulant Coatings. ACS APPLIED MATERIALS & INTERFACES 2018; 10:40844-40853. [PMID: 30403339 DOI: 10.1021/acsami.8b14409] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
The development of a facile and versatile strategy to endow surfaces with synergistically anti-inflammatory, antimicrobial, and anticoagulant functions is of particular significance for blood-contacting biomaterials and medical devices. In this work, we report a simple and environmentally friendly "one-pot" method inspired by byssal cuticle chemistry, namely, [Fe(dopa)3] coordination chemistry for assembly of copper ions (Cu2+) and plant polyphenol (tannic acid)/catecholamine (dopamine or norepinephrine) to form metal-phenolic/catecholamine network-based coatings. This one-pot method enabled us to easily develop a multifunctional surface based on the combination of the characteristic functions of metal ions and plant polyphenol or catecholamine. The residual phenolic hydroxyl groups on the coatings imparted the modified surface with excellent antioxidant and anti-inflammatory functions. The robust chelation of copper ions to the metal-phenolic/catecholamine networks provided not only durable antibacterial property but also glutathione peroxidase like catalytic capability to continuously and controllably produce antithrombotic nitric oxide by catalyzing endogenous S-nitrothiol. The biological functions of such coatings could be well regulated by adjusting the ratios of the feed concentration of Cu2+ ions to plant polyphenol or catecholamine. We envision that our simple, multifunctional, and bioinspired coating strategy can hold great application promise for bioengineering blood-contacting devices.
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Affiliation(s)
- Xiangyang Li
- Key Laboratory of Advanced Technology for Materials of Education Ministry, School of Materials Science and Engineering , Southwest Jiaotong University , Chengdu 610031 , China
| | - Peng Gao
- Key Laboratory of Advanced Technology for Materials of Education Ministry, School of Materials Science and Engineering , Southwest Jiaotong University , Chengdu 610031 , China
| | - Jianying Tan
- Key Laboratory of Advanced Technology for Materials of Education Ministry, School of Materials Science and Engineering , Southwest Jiaotong University , Chengdu 610031 , China
| | - Kaiqin Xiong
- Key Laboratory of Advanced Technology for Materials of Education Ministry, School of Materials Science and Engineering , Southwest Jiaotong University , Chengdu 610031 , China
| | - Manfred F Maitz
- Max Bergmann Center of Biomaterials , Leibniz Institute of Polymer Research Dresden , Hohe Strasse 6 , Dresden 01069 , Germany
| | - Changjiang Pan
- Faculty of Mechanical and Materials Engineering , Huaiyin Institute of Technology , Huai'an 223003 , China
| | - Hongkai Wu
- Division of Biomedical Engineering , The Hong Kong University of Science and Technology , Hong Kong , China
| | - Yin Chen
- Division of Biomedical Engineering , The Hong Kong University of Science and Technology , Hong Kong , China
| | - Zhilu Yang
- Key Laboratory of Advanced Technology for Materials of Education Ministry, School of Materials Science and Engineering , Southwest Jiaotong University , Chengdu 610031 , China
| | - Nan Huang
- Key Laboratory of Advanced Technology for Materials of Education Ministry, School of Materials Science and Engineering , Southwest Jiaotong University , Chengdu 610031 , China
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Fanola CL, Ruff CT, Murphy SA, Jin J, Duggal A, Babilonia NA, Sritara P, Mercuri MF, Kamphuisen PW, Antman EM, Braunwald E, Giugliano RP. Efficacy and Safety of Edoxaban in Patients With Active Malignancy and Atrial Fibrillation: Analysis of the ENGAGE AF - TIMI 48 Trial. J Am Heart Assoc 2018; 7:e008987. [PMID: 30369307 PMCID: PMC6201390 DOI: 10.1161/jaha.118.008987] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/09/2018] [Indexed: 12/21/2022]
Abstract
Background Anticoagulation in patients with malignancy and atrial fibrillation is challenging because of enhanced risks for thrombosis and bleeding and the frequent need for invasive procedures. Data on direct oral antagonists in such patients are sparse. Methods and Results The ENGAGE AF - TIMI 48 (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction Study 48) trial randomized 21 105 patients with atrial fibrillation to edoxaban or warfarin. Patients with malignancy, defined as a postrandomization new diagnosis or recurrence of remote cancer, were followed up over a median of 2.8 years. Adjusted Cox proportional hazard models were used to evaluate the safety and efficacy of edoxaban versus warfarin. Over a median of 495 days (interquartile range, 230-771 days), 1153 patients (5.5%) were diagnosed with new or recurrent malignancy, most commonly involving the gastrointestinal tract (20.6%), prostate (13.6%), and lung (11.1%). Malignancy was associated with increased risk of death (adjusted hazard ratio [HR], 3.12; 95% confidence interval [CI], 2.78-3.50) and major bleeding (adjusted HR, 2.45; 95% CI, 2.07-2.89), but not stroke/systemic embolism (adjusted HR, 1.08; 95% CI, 0.83-1.42). Relative outcomes with higher-dose edoxaban versus warfarin were consistent regardless of malignancy status for stroke/systemic embolism ( HR , 0.60 [95% CI, 0.31-1.15] for malignancy versus HR , 0.89 [95% CI, 0.76-1.05] for no malignancy; interaction P=0.25) and major bleeding ( HR , 0.98 [95% CI, 0.69-1.40] for malignancy versus HR , 0.79 [95% CI, 0.69-1.05] for no malignancy; interaction P=0.31). There was, however, a significant treatment interaction for the composite ischemic end point (ischemic stroke/systemic embolism/myocardial infarction), with greater efficacy of higher-dose edoxaban versus warfarin in patients with malignancy ( HR , 0.54; 95% CI, 0.31-0.93) compared with no malignancy ( HR , 1.02; 95% CI, 0.88-1.18; interaction P=0.026). Conclusions In patients with atrial fibrillation who develop malignancy, the efficacy and safety profile of edoxaban relative to warfarin is preserved, and it may represent a more practical alternative.
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Affiliation(s)
- Christina L. Fanola
- Division of CardiologyUniversity of MinnesotaMinneapolisMN
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Christian T. Ruff
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Sabina A. Murphy
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - James Jin
- Daiichi Sankyo Pharma DevelopmentEdisonNJ
| | | | | | - Piyamitr Sritara
- Division of CardiologyFaculty of MedicineRamathibodi HospitalMahidol UniversityBangkokThailand
| | | | | | - Elliott M. Antman
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Eugene Braunwald
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Robert P. Giugliano
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
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48
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Patients with cancer and atrial fibrillation treated with doacs: A prospective cohort study. Int J Cardiol 2018; 269:152-157. [PMID: 30077526 DOI: 10.1016/j.ijcard.2018.07.138] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/19/2018] [Accepted: 07/27/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Limited data are available on the use of direct oral anticoagulants (DOACs) in patients with cancer and atrial fibrillation (AF). METHODS Consecutive patients with non-valvular AF treated with DOACs were enrolled in a prospective cohort with the aim of evaluating thromboembolic (ischemic stroke or transient ischemic attack or systemic embolism) and major bleeding (MB) events according to presence and type of cancer. The risk of study outcomes over time was compared using Kaplan-Meier method and log-rank test or Cox proportional hazards regression. RESULTS 2304 patients with non-valvular AF receiving DOACs were enrolled and 16 excluded: 2288 analysed of whom 289 (12.6%) had cancer. Gastrointestinal (21%), genitourinary (15%), prostate (15%), haematological (14%), breast (13%), and lung (8%) were the more frequent sites of cancer. After a mean follow-up of 451 days, thromboembolic events occurred in 2.1% and 0.8% patient-year of cancer and non-cancer patients (adjusted-HR 2.58, 95% CI 1.08-6.16, p = 0.033). The rate of MB was 6.6% and 3.0% patient-year in cancer and non-cancer patients (adjusted-HR 2.02, 95% CI 1.25-3.27, p = 0.004). The differences in bleeding were mainly accounted for by bleeding at gastrointestinal and genitourinary sites. No significant differences were found concerning the rates of non-cancer-related mortality, fatal bleeding or fatal thrombotic events. CONCLUSIONS In this study, the higher bleeding risk found in cancer compared to non-cancer patients was mainly due to an excess of bleeding at gastrointestinal and at genitourinary sites. Larger studies on the optimal management of cancer patients with AF are needed.
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Niu JY, Tian T, Zhu HY, Liang JH, Wu W, Cao L, Lu RN, Wang L, Li JY, Xu W. Hyperfibrinogenemia is a poor prognostic factor in diffuse large B cell lymphoma. Ann Hematol 2018; 97:1841-1849. [PMID: 29860562 DOI: 10.1007/s00277-018-3382-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/22/2018] [Indexed: 12/15/2022]
Abstract
Diffuse large B cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphomas worldwide. Previous studies indicated that hyperfibrinogenemia was a poor predictor in various tumors. The purpose of our study was to evaluate the prognostic effect of hyperfibrinogenemia in DLBCL. Data of 228 patients, who were diagnosed with DLBCL in our hospital between May 2009 and February 2016, were analyzed retrospectively. The Kaplan-Meier method and Cox regression were performed to find prognostic factors associated with progression-free survival (PFS) and overall survival (OS). Receiver operator characteristic (ROC) curve and the areas under the curve were used to evaluate the predictive accuracy of predictors. Comparison of characters between groups indicated that patients with high National Comprehensive Cancer Network-International Prognostic Index (NCCN-IPI) score (4-8) and advanced stage (III-IV) were more likely to suffer from hyperfibrinogenemia. The Kaplan-Meier method revealed that patients with hyperfibrinogenemia showed inferior PFS (P < 0.001) and OS (P < 0.001) than those without hyperfibrinogenemia. Multivariate analysis showed that hyperfibrinogenemia was an independent prognostic factor associated with poor outcomes (HR = 1.90, 95% CI: 1.15-3.16 for PFS, P = 0.013; HR = 2.65, 95% CI: 1.46-4.79 for OS, P = 0.001). We combined hyperfibrinogenemia and NCCN-IPI to build a new prognostic index (NPI). The NPI was demonstrated to have a superior predictive effect on prognosis (P = 0.0194 for PFS, P = 0.0034 for OS). Hyperfibrinogenemia was demonstrated to be able to predict poor outcome in DLBCL, especially for patients with advanced stage and high NCCN-IPI score. Adding hyperfibrinogenemia to NCCN-IPI could significantly improve the predictive effect of NCCN-IPI.
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Affiliation(s)
- Jun-Ying Niu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210029, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, 210029, China
| | - Tian Tian
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210029, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, 210029, China
| | - Hua-Yuan Zhu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210029, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, 210029, China
| | - Jin-Hua Liang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210029, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, 210029, China
| | - Wei Wu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210029, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, 210029, China
| | - Lei Cao
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210029, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, 210029, China
| | - Rui-Nan Lu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210029, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, 210029, China
| | - Li Wang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210029, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, 210029, China
| | - Jian-Yong Li
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210029, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, 210029, China
| | - Wei Xu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China. .,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210029, China. .,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, 210029, China.
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50
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Kamphuisen PW, Lee AYY, Meyer G, Bauersachs R, Janas MS, Jarner MF, Khorana AA. Clinically relevant bleeding in cancer patients treated for venous thromboembolism from the CATCH study. J Thromb Haemost 2018; 16:1069-1077. [PMID: 29573330 DOI: 10.1111/jth.14007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Indexed: 12/13/2022]
Abstract
Essentials Cancer patients receiving anticoagulants for venous thromboembolism have an elevated bleeding risk. This secondary analysis of CATCH assessed characteristics of clinically relevant bleeding (CRB). CRB occurs in 15% of cancer patients with thrombosis using therapeutic doses of anticoagulation. After multivariate analysis, risk factors for CRB were age >75 years and intracranial malignancy. SUMMARY Background Cancer patients with acute venous thromboembolism (VTE) receiving anticoagulant treatment have an increased bleeding risk. Objectives We performed a prespecified secondary analysis of the randomized, open-label, Phase III CATCH trial (NCT01130025) to assess the rate and sites of and the risk factors for clinically relevant bleeding (CRB). Patients/Methods Patients with active cancer and acute, symptomatic VTE received either tinzaparin 175 IU kg-1 once daily or warfarin (target International Normalized Ratio [INR] of 2.0-3.0) for 6 months. Fisher's exact test was used to screen prespecified clinical risk factors; those identified as being significantly associated with an increased risk of CRB then underwent competing risk regression analysis of time to first CRB. Results Among 900 randomized patients, 138 (15.3%) had 180 CRB events. CRB occurred in 60 patients (81 events) in the tinzaparin group and in 78 patients (99 events) in the warfarin group (hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.45-0.89). Common bleeding sites were gastrointestinal (36.7%; n = 66), genitourinary (22.8%; n = 41), and nasal (10.0%; n = 18). In multivariate analysis, the risk of CRB increased with age > 75 years (HR 1.83, 95% CI 1.14-2.94) and intracranial malignancy (HR 1.97, 95% CI 1.07-3.62). In the warfarin group, 40.4% of CRB events occurred in patients with with an INR of < 3.0. A lower time in therapeutic range was associated with a higher risk of CRB. Conclusions CRB is a frequent complication in cancer patients with VTE during anticoagulant treatment, and is associated with age > 75 years and intracranial malignancy.
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Affiliation(s)
- P W Kamphuisen
- Department of Internal Medicine, Tergooi Hospital, Hilversum, the Netherlands
- Department of Vascular Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - A Y Y Lee
- Division of Hematology, University of British Columbia and British Columbia Cancer Agency, Vancouver, BC, Canada
| | - G Meyer
- Respiratory Department, Georges Pompidou European Hospital, Université Paris Descartes Sorbonne Paris Cité, INSERM UMRS 970, CIC 1418, Paris, France
| | - R Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt, Germany
- Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | | | | | - A A Khorana
- Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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