Anticoagulation in the Presence of Malignancy


With a plethora of ongoing oral anticoagulant drug studies and piqued patient and provider interest, direct oral anticoagulants (DOACs) represent an exciting era in vascular medicine, transforming the treatment model of thrombosis. Therapy with DOACs also has important implications on patient length of stay, decisions regarding bridging therapy, cost, outpatient management, and clinical monitoring of anticoagulation. This "paradigm shift" in antithrombotic therapy necessitates that the clinician remains up-to-date and knowledgeable of the following: 1) the pathophysiology and drug interactions of these medications; 2) the studies supporting the approval of each drug, with attention to the characteristics of patients enrolled in each study; and 3) the appropriate clinical settings to prescribe DOACs versus vitamin K antagonists (VKA) or other anticoagulants.


A 51-year-old male with a past medical history of hypertension, non-ischemic cardiomyopathy with ejection fraction of 35%, and a recent history of colon cancer status post total colectomy is readmitted for shortness of breath after a recent hospitalization for heart failure. The patient does not know the status of his cancer but says he received chemotherapy earlier this year. The patient is alert and oriented; however, he is noted to be dyspneic, and his physical findings are as shown: oxygen saturation on 2 L of oxygen is 89%, respiratory rate is 22 breaths per minute, blood pressure is 110/59 mm Hg, heart rate is 115 bpm, and he is afebrile with a temperature of 98.7 degrees Fahrenheit. His current medications include carvedilol, spironolactone, and lisinopril. His creatinine clearance is 53 mL/min, white blood cell count is 812 thou/uL, hemoglobin is 11.3 g/dL, and platelet count is 177 thou/uL. His thyroid and liver function tests are within normal limits.

Computed tomography (CT) scan with contrast is performed in the emergency room; the images are shown below. His chest X-ray reveals cardiomegaly and mild pulmonary vascular congestion but is otherwise normal; his CT head is within normal limits.

Figure 1

Figure 1
The CT angiogram (CTA) of the pulmonary arteries demonstrates bilateral segmental and subsegmental pulmonary emboli in a young patient with recent colon cancer and risk factors for provoked venous thromboembolism (VTE).

Which of the following statements describes the next best step in management with anticoagulants?

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