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Anticoagulation of Cardiovascular Conditions in the Cancer Patient: Review of Old and New Therapies

  • Isaac B. Rhea
  • Alexander R. Lyon
  • Michael G. FradleyEmail author
Cardio-oncology (EH Yang, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Cardio-oncology

Abstract

Purpose of Review

The anticoagulation strategies for various cardiac-specific pathologies including atrial fibrillation are changing. Applying these strategies in patients with concomitant active cancer requires additional considerations. Here, we review the most recent changes in the anticoagulation management of common cardiac diseases and their application in cancer patients.

Recent Findings

There are a range of indications for therapeutic anticoagulation in cancer patients including venous thromboembolism (VTE), atrial fibrillation/flutter (AF/AFL), prosthetic heart valves, and intracardiac thrombi. Certain cancer therapeutics such as ibrutinib and anthracycline chemotherapy increase the risk of developing AF/AFL and pose unique challenges in anticoagulation management. Anticoagulation decisions for AF/AFL often utilize the CHADS2 or the CHA2DS2-VASc score with annualized stroke risk; however, these risk stratification models may be inadequate in cancer patients. Cancer type, stage, prognosis, and bleeding risk are all relevant when considering whether to initiate therapeutic anticoagulation. Moreover, thrombocytopenia may limit the ability to provide anticoagulation. Subsequent analyses of direct oral anticoagulants (DOACs) show fewer bleeding complications and thromboembolic events compared to warfarin in AF/AFL with apixaban and edoxaban particularly promising in this population for VTE, pulmonary embolism, and AF/AFL. There is a lack of data regarding ablation therapy and left atrial occlusion devices in this population. There is a growing experience of DOACs for intracardiac thrombi. Warfarin is still appropriate for patients with prosthetic heart valves and left ventricular assist devices.

Summary

Anticoagulation management in the cancer patient can be challenging. DOACs are often a safe alternative to warfarin in cancer-associated DVT/PE and AF/AFL, and may be preferable in certain circumstances. Other cardiac indications for anticoagulation including the presence of a mechanical heart valve remain unchanged and dependent on warfarin or heparin-based products.

Keywords

Anticoagulation Cancer Atrial fibrillation Cardio-oncology 

Notes

Compliance with Ethical Standards

Conflict of Interest

Isaac B. rhea declares that he has no conflict of interest. Alexander R. Lyon has received research funding from Pfizer and has received compensation from Servier, Pfizer, Novartis, Roche, Takeda, Boehringer Ingelheim, Amgen, Clinigen Healthcare, Ferring Pharmaceuticals, Eli Lilly, Bristol-Myers Squibb, Eisai, and Stealth BioTherapeutics for service as a consultant. Michael G. Fradley has received compensation from Novartis for service as a consultant.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Isaac B. Rhea
    • 1
  • Alexander R. Lyon
    • 2
  • Michael G. Fradley
    • 1
    Email author
  1. 1.Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center and Research InstituteUniversity of South Florida Morsani College of MedicineTampaUSA
  2. 2.Cardio-Oncology Service, London UK and National Heart and Lung Institute, Imperial College LondonRoyal Brompton HospitalLondonUK

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