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Wee B, Lai J, Khattak Z, Kwok A, Donarelli C, Ho P, Lim HY, Lui B. A ten-year comparison of treatment and outcomes of cancer-associated thrombosis to non-cancer venous thromboembolism: from traditional anticoagulants to direct oral anticoagulants. J Thromb Thrombolysis 2024; 57:658-667. [PMID: 38393675 DOI: 10.1007/s11239-023-02943-2] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/25/2023] [Indexed: 02/25/2024]
Abstract
DOACs have emerged as first-line treatment in most cancer-associated thrombosis (CAT), representing a paradigm shift in its management. However, CAT management remains challenging and requires careful risk-benefit considerations. A retrospective analysis of CAT presentations to a tertiary referral centre from January 2011 to December 2020. Outcomes in CAT patients were compared to VTE patients without malignancy. Subgroup analysis was also conducted for CAT according to anticoagulation type. 514 CAT cases from 491 patients were identified from 3230 total VTE cases. CAT patients had higher rates of major VTE (PE and/or proximal DVT) compared to patients without malignancy (78.4% vs. 66.8%, p < 0.001). CAT patients also had higher rates of VTE recurrence (HR 1.66, 95%CI 1.23-2.26), major bleeding (HR 3.41, 95%CI 2.36-4.93), VTE-related mortality (HR 2.59, 95%CI 1.46-4.62) and bleeding-related mortality (HR 2.66, 95%CI 1.05-6.73). There were no significant differences in rates of VTE recurrence, major bleeding, VTE-related mortality or fatal bleeding between CAT patients treated with DOACs, enoxaparin or warfarin. In the subgroup of CAT treated with DOACs, there was no significant difference in rates of GI bleeding compared to the enoxaparin subgroup (HR 0.17, 95%CI 0.02-1.26). CAT was associated with a larger clot burden and higher rates of VTE recurrence, major bleeding and mortality compared to VTE patients without malignancy in this large real-world study. This study demonstrated no significant differences in complication rates for CAT patients treated with DOACs over enoxaparin, suggesting that DOACs can be safely used in most cases of CAT.
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Affiliation(s)
- Benjamin Wee
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia.
| | - Jeffrey Lai
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | - Zille Khattak
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | - Anna Kwok
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | | | - Prahlad Ho
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
- Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Hui Yin Lim
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
- Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Brandon Lui
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
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Lui B, Wee B, Lai J, Khattak Z, Kwok A, Donarelli C, Ho P, Lim HY. A ten-year review of the impact of the transition from warfarin to direct oral anticoagulant - Has venous thromboembolism treatment become safer? Thromb Res 2022; 219:112-120. [PMID: 36162254 DOI: 10.1016/j.thromres.2022.09.006] [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: 04/06/2022] [Revised: 08/20/2022] [Accepted: 09/09/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The introduction of direct oral anticoagulants (DOAC) has resulted in a paradigm shift in the management of venous thromboembolism (VTE). We evaluate the impact of the transition to DOAC, over the last decade, on overall VTE clinical outcomes including in first unprovoked major VTEs. METHOD A retrospective analysis of all VTE admissions in non-cancer patients from January 2011 to December 2020 at Northern Health, Victoria, Australia. "Warfarin era" included events that occurred between January 2011 and December 2014 and "DOAC era" from January 2016. RESULTS There were 2687 cases involving 2508 patients (45.9 % males; median age 63 years). 98 % were symptomatic and 1261 events (47 %) were unprovoked. 1003 events occurred during the warfarin era (79 % warfarin, 6 % DOAC) and 1479 during the DOAC era (18 % warfarin, 70 % DOAC). While recurrent thrombosis during the acute phase of treatment was comparable, there were fewer recurrences during the long-term preventative phase of treatment in the DOAC era compared to warfarin era (HR 0.602, 95 % CI: 0.393-0.924, p0.020). Clinically significant bleeding events were lower in the DOAC era (HR 0.623, 95 % CI: 0.395-0.985, p = 0.043). A subanalysis of first unprovoked major VTE events (n = 602) demonstrated a significant reduction in recurrent VTE during the long-term preventative phase of treatment in the DOAC era (HR 0.296, 95 % CI: 0.097-0.901, p = 0.032) with no difference in clinically significantly bleeding rates (HR 0.529, 95 % CI 0.219-1.280, p = 0.158) between the eras. CONCLUSION Treatment outcomes for VTE appear to have improved over time with reduced rate of thrombotic and clinically significant bleeding complications in the DOAC era.
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Affiliation(s)
- Brandon Lui
- Department of Haematology, Northern Health, Epping, VIC, Australia.
| | - Benjamin Wee
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | - Jeffrey Lai
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | - Zille Khattak
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | - Anna Kwok
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | | | - Prahlad Ho
- Department of Haematology, Northern Health, Epping, VIC, Australia; Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Hui Yin Lim
- Department of Haematology, Northern Health, Epping, VIC, Australia; Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
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Vlachadis Castles A, Khattak Z. Changes in Non-Invasive Investigations for Ischaemic Heart Disease in Australia During the COVID-19 Pandemic. Heart Lung Circ 2021. [PMCID: PMC8608277 DOI: 10.1016/j.hlc.2021.06.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Sutherland N, Khattak Z, Octavia Y, Nandal S, Asrar ul Haq M. 428 Utility of Echocardiography in the Real-World Management of Pulmonary Embolism. A Single Centre Experience of Pulmonary Embolism. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.435] [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] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Salha R, Khattak Z, Avery C. Conservative management of high output chyle leak in difficult to manage cases. Br J Oral Maxillofac Surg 2015. [DOI: 10.1016/j.bjoms.2015.08.047] [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] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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