Anticoagulation Practice in Patients with Cancer-Associated Thrombosis: Insights from GeCAT, a German Prospective Registry Study

2021 ◽  
Author(s):  
Robert Klamroth ◽  
Marianne Sinn ◽  
Christiane Pollich ◽  
Sven Bischoff ◽  
Anja Lohneis ◽  
...  
Keyword(s):  
Anticoagulant Therapy ◽  
Patient Adherence ◽  
Vitamin K Antagonists ◽  
Significant Proportion ◽  
Anticoagulation Therapy ◽  
Routine Practice ◽  
Registry Study ◽  
Patients With Cancer ◽  
Study Results

Introduction: Cancer-associated venous thrombosis (CAT) is a common and serious complication of active malignancies, increasing in frequency during systemic treatment and radiotherapy. Due to a high risk of recurrence and bleeding, the administration of anticoagulants for initial treatment and secondary prevention of CAT is challenging. We conducted a prospective registry study of patients with acute CAT to evaluate the way treatment is given to these patients in routine practice. Methods: From May 2015 to May 2017, all consecutive patients with acute venous thromboembolism (VTE) admitted to specialty or emergency departments of the participating hospitals in Berlin, Germany, were entered in the registry. Patients with cancer underwent extensive baseline evaluation including the type and location of thrombosis and use of anticoagulant therapy. Follow-up assessments were made at discharge and by telephone interviews at 3 and 6 months. Results: A total of 382 patients with acute CAT were enrolled in the study, representing 24.5% of all patients with thrombosis. 70.4% of CAT patients had deep vein thromboses (DVT), 48.2% had pulmonary embolism (PE), and 18.6% had concurrent PE and DVT. A significant proportion of VTE (27%) were asymptomatic and were diagnosed only incidentally. At baseline, 97.9% of the patients received anticoagulant therapy, predominantly with low-molecular-weight heparin (LMWH) (n=334, 87.4%). Direct oral anticoagulants (DOACs) were given to 5.8% of patients, and vitamin K antagonists (VKAs) were rarely used (<2% of patients). Changes in the prescription of antithrombotic agents were seen at discharge from hospital and during follow-up. Overall, the use of LMWH declined during follow-up, while the proportion of patients treated with DOACs increased to 32.4% at 6 months. At baseline, the most frequently used LMWH were enoxaparin and nadroparin, but many patients were switched to once daily tinzaparin prior to discharge. Initially and after discharge the majority of patients were treated by oncologists. Overall, 263 (68.8%) and 222 (58,1%) patients were still alive and could be contacted at 3 and 6 months of follow-up, respectively. Of these, 84.0% and 71.6% were still on anticoagulant therapy (58.6% and 36.5% on LMWH). Conclusion: In accordance with the guidelines, the majority of CAT patients received anticoagulation therapy for the recommended minimum duration of 3-6 months. LMWH remained the preferred option throughout the study, demonstrating good patient adherence. In deviation from guideline recommendations and available study results during the study period, more than a quarter of CAT patients were treated with DOACs. Only recently, DOACs have been established as another option for anticoagulation in CAT patients.

Duration of Anticoagulation Therapy for Venous Thromboembolism

Hematology ◽  
2008 ◽  
Vol 2008 (1) ◽  
pp. 252-258 ◽  
Author(s):  
Henri Bounameaux ◽  
Arnaud Perrier
Keyword(s):  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Odds Ratio ◽  
Vitamin K Antagonists ◽  
Initial Period ◽  
Anticoagulation Therapy ◽  
Case Fatality ◽  
Clinical Decision ◽  
Venous Thromboembolic Event ◽  
Anticoagulant Treatment

Abstract Treatment of acute deep vein thrombosis and pulmonary embolism-often denominated together as venous thromboembolism (VTE)- consists of parenteral administration of heparin (usually low-molecular-weight heparin or alternatively unfractionated heparin or fondaparinux) overlapped and followed by oral vitamin K antagonists that are administered for a certain period (usually 3 to 12 months). Recommended or suggested durations differ according to guidelines. Practically, the clinical decision in an individual patient depends upon the estimated risks of VTE recurrence and treatment-induced bleeding. The risk of VTE recurrence is higher in idiopathic events (about 10% per year during the first two years and 3% per year thereafter) (odds ratio of 2.4, compared to secondary events); in male subjects (at least before the age of 60, with an odds ratio of 2–4); in patients with persistently elevated D-dimer level (odds ratio of 2.3, compared with normal level); and during the first two years after discontinuation of treatment. The annual risk of major bleeding on anticoagulant treatment vary largely in observational studies with figures of 2% to 29%, depending on the patient characteristics. The case-fatality rate is 8% (DVT), 12% (PE) for recurrent VTE, and about 10% for major bleed. These figures do not support long-term anticoagulant therapy, except in those patients exhibiting a very high risk of recurrence and/or a very low risk of bleeding. New therapeutic aspects might impact on the duration of anticoagulant therapy after a venous thromboembolic event. They include the possibility of pursuing anticoagulant treatment at a reduced INR after an initial period with an INR 2-3, and the advent of new, more specific and orally active anticoagulants. These features might modify the risk-benefit balance of extending anticoagulant therapy beyond the usual, limited duration.

P4766Edoxaban Treatment in routiNe clinical prActice for patients with atrial fibrillation (AF) in Europe (ETNA-AF-Europe): 1-year follow-up according to body mass index

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T Weiss ◽  
R De Caterina ◽  
P Kelly ◽  
P Monteiro ◽  
J C Deharo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Body Weight ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Normal Weight ◽  
Routine Practice ◽  
Group 3 ◽  
Group 2 ◽  
Group 1

Abstract Background Non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) have substantially improved anticoagulation therapy for prevention of stroke and systemic embolism in patients with atrial fibrillation (AF), and available routine care data have so far broadly confirmed the safety of different NOACs in routine practice. However, such data for edoxaban are scarce, especially in extremely low and high body weight (BW). These extreme BWs may affect the bioavailability, distribution, and half-life of NOACs and, consequently, outcomes of treatment. Methods We analysed outcomes in normal-weight (BMI 18.5–25) vs overweight (BMI 25–30) and obese (BMI >30) patients enrolled into the ETNA-AF-Europe observational study (NCT02944019) collecting information on patients treated with edoxaban in 825 sites in 10 European countries. This snapshot analysis set includes data of 7,672 patients (56.3% of all enrolled patients) which have completed their 1-year follow-up visit (mean follow-up: 343.5 days). Results Median patient age was 74 years for all patients, 76 years for patients with a BMI 18.5–25 (group 1), 75 years for patients with BMI 25–30 (group 2), and 72 for patients with a BMI >30 (group 3). CrCl was 64 mL/min for patients with a BMI 18.5–25, 68 mL/min for patients with BMI 25–30, and 72 mL/min for patients with a BMI >30. The CHA2DS2-VASc (mean 3.1±1.38) and HAS-BLED (mean 2.5±1.10) score did not differ significantly between groups. As expected, diabetes and hypertension were significantly less prevalent in leaner patients and - accordingly - inversely correlated to age. There was no correlation between body weight and life-threatening bleeding (group 1: 0.28%; group 2: 0.40%; group 3: 0.14%). Also, stroke rates (group 1: 0.74%; group 2: 0.81%; group 3: 0.76%) did not differ between groups. Conclusion BMI, within the range here assessed, does not affect 1-year outcomes in European AF patients treated with edoxaban. Acknowledgement/Funding Daiichi Sankyo Europe GmbH, Munich, Germany

scholarly journals Residual Pulmonary Hypertension More than 20 Years after Repair of Shunt Lesions

Medicina ◽  
2020 ◽  
Vol 56 (6) ◽  
pp. 297
Author(s):  
Dovilė Jančauskaitė ◽  
Virginija Rudienė ◽  
Gabrielius Jakutis ◽  
Laurie W Geenen ◽  
Jolien W Roos-Hesselink ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Surgical Repair ◽  
Significant Proportion ◽  
University Hospital ◽  
Right Heart ◽  
Long Term Outcome ◽  
Right Heart Catheterisation ◽  
Study Results

Background and Objectives: After successful surgical repair of a congenital shunt lesion, pulmonary hypertension (PH) often disappears. However, PH can persist long-term after the closure. This study aimed to assess the prevalence of PH long-term after surgical repair of congenital heart disease (CHD), and to evaluate the outcomes and preoperative factors related to residual PH. Materials and Methods: In this retrospective cohort study, we reviewed patients who underwent right heart catheterisation in Vilnius University Hospital Santaros Klinikos during the period of 1985–2007. Among 4118 right heart catheterisations performed, 160 patients underwent congenital systemic-to-pulmonary shunt repair at a young age (<18 years) and had pre-operative PH. Half of the patients were foreigners whose follow-up data were unavailable. Eventually, 88 patients with available follow-up data were included in this study. Results: The median age at diagnosis of CHD with PH was 0.8 (0.6–3.0) and 1.1 (0.6–3.9) years at surgery (50% females). Residual PH was assessed 9.5 years after surgery and observed in 30.7% (n = 27) of the patients. It was associated with having more than one shunt (44.4% (n = 12), p = 0.016) and higher median pulmonary vascular resistance (3.4 (2.5–6.5) vs. 2.2 (1.0–3.7), p = 0.035) at baseline. After a median follow-up of 21 (15–24) years, 9.1% of the patients were deceased. Kaplan–Meier survival analysis revealed significantly higher mortality in the residual PH group (p = 0.035). Conclusions: Residual PH affects a significant proportion of patients after surgical repair of a shunt lesion and is associated with worse long-term outcome.

P675Current status of anticoagulation in patients with breast cancer and atrial fibrillation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A Pardo Sanz ◽  
L M Rincon ◽  
P Guedes Ramallo ◽  
L Belarte ◽  
G De Lara ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Atrial Fibrillation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Bleeding Events ◽  
Patients With Cancer ◽  
Oncologic Patients

Abstract Aims Balance between embolic and bleeding risk is challenging in patients with cancer. There is a lack of specific recommendations for the use of antithrombotic therapy in oncologic patients with atrial fibrillation (AF). We compared the embolic and bleeding risk, the preventive management and the incidence of events between patients with and without cancer. We further evaluated the effectiveness and safety of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) within patients with cancer. Methods The AMBER-AF registry is an observational multicentre study that analysed patients with non-valvular AF treated in Oncology and Cardiology Departments in Spain. 1237 female patients with AF were enrolled: 637 with breast cancer and 599 without cancer. Mean follow-up was 3.1 years. Results Both groups were similar in age, CHA2DS2-VASc and HASB-LED scores. Lack of guidelines recommended therapies was more frequent among patients with cancer. Compared with patients without cancer, adjusted rates of stroke (hazard ratio [95% confidence interval]) in cancer patients were higher (1.56 [1.04–2.35]), whereas bleeding rates remained similar (1.25 [0.95–1.64]). Within the group of patients with cancer, the use of DOACs vs VKAs did not entail differences in the adjusted rates of stroke (0.91 [0.42–1.99]) or severe bleedings (1.53 [0.93–2.53]). Follow-up events Conclusions Antithrombotic management of AF frequently differs in patients with breast cancer. While breast cancer is associated with a higher risk of incident stroke, bleeding events remained similar. Patients with cancer treated with DOACs experienced similar rates of stroke and bleeding as those with VKAs.

scholarly journals Anticoagulation therapy in the elderly with non-valvular atrial fibrillation: a double-edged sword

2017 ◽  
Vol 3 (2) ◽  
Author(s):  
Francesco Vetta ◽  
Gabriella Locorotondo ◽  
Giampaolo Vetta
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Anticoagulant Therapy ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Treatment Strategies ◽  
The Elderly ◽  
Hemorrhagic Events

Prevalence of non-valvular atrial fibrillation is increasing over time. Particularly in elderly population, treatment strategies to reduce the rate of stroke are challenging and still represent an unsolved cultural question. Indeed, the risk of thromboembolism increases in the elderly in parallel with the risk of bleeding. The frequent coexistence of several morbidities, frailty syndrome, polypharmacy, chronic kidney disease and dementia strengthens the perception that risk-benefit ratio of anticoagulant therapy could be unfavorable, and explains why such treatment is underused in the elderly. Recently, the introduction of non-vitamin K oral anticoagulants (NOACs) has allowed us to overcome the large number of limitations imposed by the use of vitamin K antagonists. In this manuscript, the benefits of individual NOACs in comparison with warfarin in elderly patients are reviewed. Targeted studies on complex elderly patients are needed to test usefulness of a geriatric comprehensive assessment, besides the scores addressing risk of thromboembolic and hemorrhagic events. In the meantime, it is mandatory that use of anticoagulant therapy in most elderly people, currently excluded from randomized controlled trials, is prudent and responsible.

Follow-Up Evaluation on Oral Antidiabetic Drug Use: A Study of Effectiveness, Safety and Patient Adherence in Surabaya Primary Health Care

2018 ◽  
Vol 9 (4) ◽  
Author(s):  
Lisa Aditama ◽  
Umi Athiyah ◽  
Wahyu Utami ◽  
Abdul Rahem
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Drug Therapy ◽  
Patient Adherence ◽  
Adherence Behavior ◽  
Primary Health ◽  
Oral Antidiabetic ◽  
Study Results ◽  
Gastrointestinal Problems

Medication non-adherence is one of the biggest causes of leftover medicines. Up to 50% of patients worldwide do not take their prescribed medicines as recommended. Optimising the use of medication is beneficial to improving clinical outcomes for patients with chronic disease. Purpose: The aim of this study was to determine the effectiveness and safety of drug therapy, evaluate patient adherence, and identify of the patient's non-adherence behavior for oral antidiabetic drugs (OADs). Methods: This study using non-experimental design, with mixed-methods (explanatory sequential design). A total of 32 patients with type 2 diabetes mellitus in referral program of national health care security system (BPJS Kesehatan) were included in this study from Primary Health Care in the north region of Surabaya. There are 6 domains of adherence behavior developed in this study. Results: The effectiveness of drug therapy in this study was 56,25%. About 68,75% of patients experienced to hypoglycemia and 6,25% had gastrointestinal problems caused by drug therapy. The adherence assessment found that 43,75% patients non adherence to medication. Leftover medicines found in the patient's home comes from multiple visits to health care facilities (53,12%) and patient non-adherence (37,5%). Conclusion: Follow-up evaluation as the continuous process in medication management services, led pharmacist in the strategic position to evaluates the patient's response to drug therapies in terms of effectiveness, safety, adherence and also avoiding unnecessary leftover medicines.

scholarly journals Impact of anticoagulation therapy on valve haemodynamic deterioration following transcatheter aortic valve replacement

Heart ◽  
2018 ◽  
Vol 104 (10) ◽  
pp. 814-820 ◽  
Author(s):  
María Del Trigo ◽  
Antonio J Muñoz-García ◽  
Azeem Latib ◽  
Vincent Auffret ◽  
Harindra C Wijeysundera ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Vitamin K Antagonists ◽  
Anticoagulation Therapy ◽  
Transcatheter Aortic Valve ◽  
Increased Risk ◽  
The Mean

ObjectiveTo evaluate the changes in transvalvular gradients and the incidence of valve haemodynamic deterioration (VHD) following transcatheter aortic valve replacement (TAVR), according to use of anticoagulation therapy.Methods and resultsThis multicentre study included 2466 patients (46% men; mean age 81±7 years) who underwent TAVR with echocardiography performed at 12-month follow-up. Anticoagulation therapy was used in 707 patients (28.7%) following TAVR (AC group). A total of 663 patients received vitamin K antagonists, and 44 patients received direct oral anticoagulants. A propensity score matching analysis was performed to adjust for intergroup (AC vs non-AC post-TAVR) differences. A total of 622 patients per group were included in the propensity-matched analysis. VHD was defined as a ≥10 mm Hg increase in the mean transprosthetic gradient at follow-up (vs hospital discharge). The mean clinical follow-up was 29±18 months. The mean transvalvular gradient significantly increased at follow-up in the non-AC group within the global cohort (P=0.003), whereas it remained stable over time in the AC group (P=0.323). The incidence of VHD was significantly lower in the AC group (0.6%) compared with the non-AC group (3.7%, P<0.001), and these significant differences remained within the propensity-matched populations (0.6% vs 3.9% in the AC and non-AC groups, respectively, P<0.001). The occurrence of VHD did not associate with an increased risk of all-cause death (P=0.468), cardiovascular death (P=0.539) or stroke (P=0.170) at follow-up.ConclusionsThe lack of anticoagulation therapy post-TAVR was associated with significant increments in transvalvular gradients and a greater risk of VHD. VHD was subclinical in most cases and did not associate with major adverse clinical events. Future randomised trials are needed to determine if systematic anticoagulation therapy post-TAVR would reduce the incidence of VHD.

P5590Temporal trends in first-line anticoagulation therapy for cancer-associated venous thromboembolism

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J M King ◽  
T Delate ◽  
M Charlu ◽  
S Zhu ◽  
A Pai ◽  
...  
Keyword(s):  
United States ◽  
Venous Thromboembolism ◽  
Hospital Discharge ◽  
Anticoagulant Therapy ◽  
Controlled Trial ◽  
Vitamin K Antagonists ◽  
Temporal Trends ◽  
Anticoagulation Therapy ◽  
The United States ◽  
First Line

Abstract Background Knowledge of the comparative safety and efficacy of anticoagulant classes for the treatment of cancer-associated venous thromboembolism (VTE) has evolved over the past 20 years with recent evidence from randomized trials suggesting that direct oral anticoagulants (DOACs) may be a safe and effective oral alternative therapy to low-molecular-weight heparin (LMWH). Purpose To characterize the temporal trends in first-line outpatient anticoagulation therapy for cancer-associated VTE. Methods We conducted a retrospective cohort study of patients who were hospitalized for a cancer-associated VTE between 2000 and 2017. Patients were identified from the cancer registries of two regions of a large, integrated healthcare system in the United States. The primary outcome was the age- and sex-adjusted incidence rates of first-line anticoagulant therapy according to the year in which the VTE occurred. We determined each patient's anticoagulant regimen according to her/his outpatient pharmacy dispensing records during the first 30 days post-hospital discharge. Regimens were categorized as 1) LMWH, 2) warfarin ± an injectable anticoagulant, 3) fondaparinux, or 4) DOAC ± an injectable anticoagulant. Patients were excluded if they had history of VTE prior to cancer diagnosis, used an anticoagulant during the 6-months pre-hospitalization, did not initiate an anticoagulant after hospital discharge, or had a skin carcinoma. Results Overall, 9,816 patients were included with a mean age of 66±13 years and 5,238 (54%) were female. From 2000 to 2003, prior to publication of the first randomized controlled trial demonstrating LMWHs were superior to vitamin K antagonists for cancer-associated VTE, warfarin was first-line anticoagulant in ≈90% of cases (Figure). After 2003, there was a slow, steady decline in warfarin use corresponding with an increased use in LMWH: from 11% in 2003 to 55% in 2017. Since 2012, fondaparinux has accounted for <1% of first-line anticoagulant therapies. DOACs, which first became commercially available in the United States in 2010, have seen exponential growth since 2014, accounting for 20% of first-line anticoagulant therapies in 2017. First-line anticoagulant use in cancer Conclusion From 2000 to 2017, first-line anticoagulant therapy for cancer-associated VTE has seen significant changes characterized by an increase in LMWH and DOAC use, and a decline in warfarin use. Acknowledgement/Funding Kaiser Permanente Northern California Community Benefit Grant, Agency for Health Research and Quality R18HS026156

scholarly journals Impact of Venous Thromboembolism and Anticoagulation on Cancer and Cancer Survival

2009 ◽  
Vol 27 (29) ◽  
pp. 4902-4911 ◽  
Author(s):  
Nicole M. Kuderer ◽  
Thomas L. Ortel ◽  
Charles W. Francis
Keyword(s):  
Clinical Trials ◽  
Venous Thromboembolism ◽  
Vitamin K Antagonists ◽  
Anticoagulation Therapy ◽  
Tumor Type ◽  
Metastasis Formation ◽  
Tumor Cell Adhesion ◽  
Patients With Cancer ◽  
The Impact

Changes in the hemostatic system and chronic hemostatic activation are frequently observed in patients with cancer, even in the absence of venous thromboembolism (VTE). VTE is a leading cause of death among patients with cancer and contributes to long-term mortality in patients with early as well as advanced-stage cancer. Mounting evidence suggests that components of the clotting cascade and associated vascular factors play an integral part in tumor progression, invasion, angiogenesis, and metastasis formation. Furthermore, there are intriguing in vitro and animal findings that anticoagulants, in particular the low molecular weight heparins (LMWHs), exert an antineoplastic effect through multiple mechanisms, including interference with tumor cell adhesion, invasion, metastasis formation, angiogenesis, and the immune system. Several relatively small randomized controlled clinical trials of anticoagulation as cancer therapy in patients without a VTE diagnosis have been completed. These comprise studies with LMWH, unfractionated heparin, and vitamin K antagonists, with overall encouraging but nonconclusive results and some limitations. Meta-analyses performed for the American Society of Clinical Oncology VTE Guidelines Committee and the Cochrane Collaboration suggest overall favorable effects of anticoagulation on survival of patients with cancer, mainly with LMWH. However, definitive clinical trials have been elusive and questions remain regarding the importance of tumor type and stage on treatment efficacy, the impact of fatal thromboembolic events, optimal anticoagulation therapy, and safety with differing chemotherapy regimens. Although the LMWHs and related agents hold promise for improving outcomes in patients with cancer, additional studies of their efficacy and safety in this setting are needed.

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