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Yau CE, Low CE, Ong NY, Rana S, Chew LJR, Tyebally SM, Chai P, Yeo TC, Chan MY, Lee MX, Tan LL, Koo CY, Lee ARYB, Sia CH. Non-Vitamin K Antagonist Oral Anticoagulants versus Low Molecular Weight Heparin for Cancer-Related Venous Thromboembolic Events: Individual Patient Data Meta-Analysis. Cancers (Basel) 2023; 15:5887. [PMID: 38136433 PMCID: PMC10741613 DOI: 10.3390/cancers15245887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/09/2023] [Accepted: 12/16/2023] [Indexed: 12/24/2023] Open
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients. Low molecular weight heparin (LMWH) has been the standard of care but new guidelines have approved the use of non-vitamin K antagonist oral anticoagulants (NOAC). By conducting an individual patient data (IPD) meta-analysis of randomised controlled trials (RCTs) comparing the outcomes of NOAC versus LMWH in cancer patients, we aim to determine an ideal strategy for the prophylaxis of VTE and prevention of VTE recurrence. Three databases were searched from inception until 19 October 2022. IPD was reconstructed from Kaplan-Meier curves. Shared frailty, stratified Cox and Royston-Parmar models were fit to compare the outcomes of venous thromboembolism recurrence and major bleeding. For studies without Kaplan-Meier curves, aggregate data meta-analysis was conducted using random-effects models. Eleven RCTs involving 4844 patients were included. Aggregate data meta-analysis showed that administering NOACs led to a significantly lower risk of recurrent VTE (RR = 0.65; 95%CI: 0.50-0.84) and deep vein thrombosis (DVT) (RR = 0.60; 95%CI: 0.40-0.90). In the IPD meta-analysis, NOAC when compared with LMWH has an HR of 0.65 (95%CI: 0.49-0.86) for VTE recurrence. Stratified Cox and Royston-Parmar models demonstrated similar results. In reducing risks of recurrent VTE and DVT among cancer patients, NOACs are superior to LMWHs without increased major bleeding.
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Affiliation(s)
- Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Chen Ee Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Natasha Yixuan Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Sounak Rana
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Lucas Jun Rong Chew
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Sara Moiz Tyebally
- Division of Cardiology, Department of Medicine, Ng Teng Fong General Hospital, Singapore 609606, Singapore
| | - Ping Chai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Tiong-Cheng Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Mark Y. Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Matilda Xinwei Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore;
| | - Li-Ling Tan
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Chieh-Yang Koo
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Ainsley Ryan Yan Bin Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
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Li J, Lee ARYB, Tariq A, Lau G, Yau CE, Tan LL, Tyebally SM, Lee MX, Koo CY, Sia CH. Comparing Renin-Angiotensin-Aldosterone Blockade Regimens for Long-Term Chemotherapy-Related Cardiac Dysfunction: A Network Meta-Analysis. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07457-w. [PMID: 37314568 DOI: 10.1007/s10557-023-07457-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Cancer therapies including trastuzumab and anthracyclines are cardiotoxic and cause cardiac dysfunction. To prevent cardiotoxicity, pharmacological agents used in heart failure have been administered concomitantly with cardiotoxic cancer therapy, but few studies to date have performed a head-to-head comparison of these different agents. This systematic review and network meta-analysis of randomized-controlled trials aims to evaluate the efficacy of renin-angiotensin-aldosterone system (RAAS) blockers, namely angiotensin-converting enzyme inhibitors (ACE-Is), aldosterone receptor blockers (ARBs), and mineralocorticoid receptor antagonists (MRAs), in primary prevention against chemotherapy-related cardiac dysfunction in patients receiving anthracyclines and/or trastuzumab. METHODS A systematic search was performed in major web databases for studies from inception to 15 September 2022. A Bayesian network meta-analysis model was used to assess the relative effects of competing treatments on the primary outcomes of risk of significant decline in left ventricular ejection fraction (LVEF) and mean LVEF decline. Secondary outcomes included left ventricular diastolic function, global longitudinal strain, and cardiac biomarkers. This study is registered with PROSPERO, CRD42022357980. RESULTS AND CONCLUSION Nineteen studies reported the effects of 13 interventions (N = 1905 patients). Only enalapril (RR 0.05, 95% CI 0.00-0.20) was associated with reduced risk of patients developing significant decline in LVEF relative to placebo. Subgroup analysis showed that the beneficial effect of enalapril was driven by protection against anthracycline-associated toxicity. In addition, no RAAS-inhibiting agents showed efficacy in protection against treatment with both anthracycline and trastuzumab. The use of RAAS inhibition therapy did not conclusively impact on other markers of cardiac function, including left ventricular diastolic function and cardiac biomarkers.
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Affiliation(s)
- Jiaqi Li
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Areeba Tariq
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Grace Lau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Li Ling Tan
- Department of Cardiology, National University Heart Center Singapore, Singapore, Singapore
| | - Sara Moiz Tyebally
- Department of Cardiology, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Matilda Xinwei Lee
- Department of Hematology-Oncology, National University Cancer Institute Singapore, Singapore, Singapore
| | - Chieh Yang Koo
- Department of Cardiology, National University Heart Center Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Center Singapore, Singapore, Singapore.
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Lee ARYB, Yau CE, Low CE, Li J, Tyebally SM, Lin W, Tan LL, Liao CT, Chang WT, Lee MX, Koo CY, Sia CH. Natural Progression of Left Ventricular Function following Anthracyclines without Cardioprotective Therapy: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15020512. [PMID: 36672461 PMCID: PMC9856944 DOI: 10.3390/cancers15020512] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Anthracyclines form the backbone of many systemic chemotherapy regimens but are accompanied by dose-limiting cardiotoxicity. We elucidate the progression and severity of cardiac function over time, in the absence of cardioprotection, which less is known about. METHODS This PRISMA-guideline-adherent review was registered on PROSPERO (CRD42022373496). RESULTS 26 studies met the eligibility criteria including a total of 910 patients. The overall reduction in post-anthracycline pooled mean left ventricular ejection fraction (LVEF) in placebo arms of the included randomised-controlled trials was 4.5% (95% CI, 2.6 to 6.4). The trend in LVEF showed a progressive decline until approximately 180 days, after which there was no significant change. Those receiving a cumulative anthracycline dose of 300 mg/m2 experienced a more profound reduction. The overall pooled risk of a 10% absolute decline in LVEF from baseline, or a decline to an LVEF below 50%, was 17% (95% CI: 11 to 24; I2 = 71%). Sensitivity analyses of baseline LVEF and trastuzumab treatment status did not yield significant differences. CONCLUSION While the mean LVEF decline in patients without cardioprotective therapy was clinically small, a vulnerable subset experienced significant impairment. Further research to best identify those who benefit most from cardioprotective therapies when receiving anthracyclines is required.
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Affiliation(s)
| | - Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Chen Ee Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Jiaqi Li
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK
| | - Sara Moiz Tyebally
- Division of Cardiology, Ng Teng Fong General Hospital, Singapore 609606, Singapore
| | - Weiqin Lin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Li-Ling Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Chia-Te Liao
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan 71004, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, 3000 Leuven, Belgium
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan 71004, Taiwan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan 71005, Taiwan
| | - Matilda Xinwei Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 117597, Singapore
| | - Chieh-Yang Koo
- Division of Cardiology, Ng Teng Fong General Hospital, Singapore 609606, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
- Correspondence: ; Tel.: +65-6779-5555
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Prabhu S, Ahluwalia N, Tyebally SM, Dennis ASC, Malomo SO, Abiodun AT, Tyrlis A, Dhillon G, Segan L, Graham A, Honarbakhsh S, Sawhney V, Sporton S, Lowe M, Finlay M, Earley MJ, Lambiase P, Schilling RJ, Hunter RJ. ERRATUM. J Cardiovasc Electrophysiol 2022; 33:567. [PMID: 35166413 DOI: 10.1111/jce.15312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Prabhu S, Ahluwalia N, Tyebally SM, Dennis ASC, Malomo SO, Abiodun AT, Tyrlis A, Dhillon G, Segan L, Graham A, Honarbakhsh S, Sawhney V, Sporton S, Lowe M, Finlay M, Earley MJ, Lambiase P, Schilling RJ, Hunter RJ. Long-term outcomes of index cryoballoon ablation or point-by-point radiofrequency ablation in patients with atrial fibrillation and systolic heart failure. J Cardiovasc Electrophysiol 2021; 32:941-948. [PMID: 33527562 DOI: 10.1111/jce.14923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/29/2020] [Accepted: 01/20/2021] [Indexed: 11/29/2022]
Abstract
Catheter ablation is an established effective approach for the treatment of atrial fibrillation (AF) in patients with heart failure, however, the role of cryoablation in this setting is unclear. Procedural success and left ventricular systolic dysfunction (LVEF) improvement in patients with LVEF ≤ 45% undergoing index catheter ablation with cryoablation were evaluated. Freedom from AF recurrence was seen in 43% rising to 59% following repeat procedure. There were significant improvements in LVEF and functional status at long-term follow-up. Results were comparable to a contemporaneous cohort of heart failure patients undergoing index ablation with radiofrequency ablation. Cryoablation is an effective first-line AF ablation approach in the setting of heart failure.
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Affiliation(s)
- S Prabhu
- Department of Cardiology, St Bartholomew's Hospital, London, UK.,Baker Heart and Diabetes Research Institute, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - N Ahluwalia
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - S M Tyebally
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - A S C Dennis
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - S O Malomo
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - A T Abiodun
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - A Tyrlis
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - G Dhillon
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - L Segan
- Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - A Graham
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - S Honarbakhsh
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - V Sawhney
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - S Sporton
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - M Lowe
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - M Finlay
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - M J Earley
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - P Lambiase
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - R J Schilling
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - R J Hunter
- Department of Cardiology, St Bartholomew's Hospital, London, UK
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