Anticoagulation Strategies in Patients With Cancer: JACC Review Topic of the Week

Abstract

Patients with active cancer are at an increased risk of arterial and venous thromboembolism (VTE) and bleeding events. Historically, in patients with cancer, low molecular weight heparins have been preferred for treatment of VTE, whereas warfarin has been the standard anticoagulant for stroke prevention in patients with atrial fibrillation (AF). More recently, direct oral anticoagulants (DOACs) have been demonstrated to reduce the risk of venous and arterial thromboembolism in large randomized clinical trials of patients with VTE and AF, respectively, thus providing an attractive oral dosing option that does not require routine laboratory monitoring. In this review, we summarize available clinical trial data and guideline recommendations, and outline a practical approach to anticoagulation management of VTE and AF in cancer.

Keywords: anticoagulation; atrial fibrillation; bleeding; cancer; cardio-oncology; venous thromboembolism.

FIGURE 1. Factors Contributing to Increased Thrombotic Risks in Cancer

Three components of Virchow’s Triad (stasis, endothelial injury, and hypercoagulability) intersect and contribute to excess cancer-associated thrombotic risks.

CENTRAL ILLUSTRATION. Approach to Anticoagulation in Patients With Active Cancer

*For all patients, measure safety laboratory studies, assess potential drug–drug interactions, determine individual patient bleeding risks and preferences, and use bleeding reduction strategies. †Patients with multiple myeloma receiving thalidomide or lenalidomide-based regimens with chemotherapy and/or dexamethasone should receive thromboprophylaxis with aspirin or low molecular weight heparins (LMWH) for low-risk patients and LMWH for high-risk patients. ‡The Khorana score (21) is a validated risk score to assess thrombotic risk among ambulatory patients with cancer. The score ranges from 0 to 6 and is based on site of cancer (2 points for stomach, pancreas; 1 point for lung, lymphoma, gynecological, genitourinary excluding prostate), 1 point for platelet counts ≥350,000 per mm³, 1 point for leukocyte count ≥11,000 per mm³, 1 point for hemoglobin <10 g/dl or use of erythropoiesis-stimulating agents, and 1 point for body mass index ≥35 kg/m². Khorana scores ≥2 identify patients at intermediate-to-high risk for venous thromboembolism who may benefit from thromboprophylaxis with direct oral anticoagulants.