Venous and Arterial Thromboembolism in Patients With Cancer

Gervaso L, Dave H, Khorana AA.
Venous and Arterial Thromboembolism in Patients With Cancer: JACC: CardioOncology State-of-the-Art Review. JACC CardioOnc 2021;3:173-190.

This state-of-the-art review thoroughly examines the literature on venous and arterial thromboembolism in patients with cancer. The authors summarize the data in light of recommendations from guidelines on the management and prevention of thromboembolism in this high-risk patient population. Here are 14 key points to remember:

  1. Venous thromboembolism (VTE) rates in patients with cancer are about four- to seven-fold higher compared to healthy individuals, with approximately 15% of patients with cancer experiencing VTE. Conversely, 20% of unprovoked VTEs are the first sign of an underlying malignancy.
  2. The incidence of arterial thromboembolism (ATE) at 6 months was 4.7% in all patients with cancer compared to 2.2% in a matched control cohort. ATE predominantly manifests as myocardial infarction and cerebrovascular accident.
  3. Patient-related risk factors for VTE in patients with cancer include increasing age, poor performance status, and genetic risk factors.
  4. Cancer-related risk factors for VTE or ATE include type of malignancy, metastatic spread and stage of cancer, and time from diagnosis with the highest risk being earliest.
  5. Treatment-related risk factors include recent surgery, recurrent transfusions, erythropoietic stimulating agents, cisplatin-based chemotherapy, thalidomide, lenalidomide, pomalidomide, bevacizumab, sorafenib, and sunitinib.
  6. The Khorana score (KS) is a prediction model for VTE in ambulatory cancer patients that relies on five variables (type of cancer, hemoglobin, platelet count, white blood cell count, and body mass index).
  7. All patients with malignant disease undergoing major surgery should receive pharmacologic thromboprophylaxis with heparin for up to 4 weeks post-surgery depending on their risk.
  8. Hospitalized patients with cancer and acute medical illness should receive thromboprophylaxis, but not those admitted for routine chemotherapy infusions.
  9. High-risk outpatients (KS >2) can be considered for thromboprophylaxis using direct oral anticoagulants (DOACs) or low molecular weight heparin (LMWH).
  10. LMWH or DOAC for ≥6 months is preferred for the treatment of VTE; incidental or symptomatic. LMWH is preferred for patients with gastrointestinal cancer given their high risk of bleed with DOACs.
  11. LMWH is the preferred therapy for recurrent VTE, with increase in dosing by 25% should VTE recur in the setting of its use.
  12. Full-dose anticoagulation is recommended for patients with a platelet count >50x109/L, with dose reduction at lower platelet counts. Anticoagulation should be held for platelet counts <25x109/L.
  13. Data are lacking on the safety of anticoagulation in patients with brain metastasis. One large case control study showed no difference in the incidence of intracranial hemorrhage between LMWH and control.
  14. In patients with acute coronary syndrome, aspirin should be used in patients with platelet counts >10x109, and dual antiplatelet therapy with clopidogrel for those with >30x109. Other P2Y12 inhibitors should only be used with platelet counts >50x109/L.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardio-Oncology, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and ACS, Anticoagulation Management and Venothromboembolism

Keywords: Acute Coronary Syndrome, Anticoagulants, Brain Neoplasms, Cardiotoxicity, Factor V, Gastrointestinal Neoplasms, Hemoglobins, Heparin, Heparin, Low-Molecular-Weight, Intracranial Hemorrhages, Myocardial Infarction, Neoplasms, Platelet Aggregation Inhibitors, Platelet Count, Risk Factors, Secondary Prevention, Stroke, Thromboembolism, Venous Thromboembolism, Vascular Diseases

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