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Untreated emboli may increase risk for recurrent venous thromboembolism
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SAN FRANCISCO — Untreated incidentally diagnosed pulmonary embolism (PE) in cancer patients was associated with a higher risk of recurrent venous thromboembolism (VTE) compared to treated patients, according to results of a meta-analysis presented here.
Tom van der Hulle, MD, of the Department of Thrombosis and Hemostasis at Leiden University Medical Center in Leiden, the Netherlands, aimed to identify clinical characteristics and prognoses associated with incidental pulmonary embolism (IPE) in cancer patients in a systematic review of the literature.
Tom van der Hulle
The researchers pooled data for incidence rates of objectively diagnosed symptomatic incidental recurrent VTE, major bleeding and mortality during 6-month follow-up. The analysis included 926 individual patients from 11 observational studies and ongoing registries.
“We evaluated outcomes depending on the type of anticoagulant treatment [patients were or were not receiving],” van der Hulle said. “and we were also interested at looking at the clinical relevance of subsegmental incidental pulmonary embolism.”
Baseline data indicated that 79% of the cohort was treated with low molecular weight heparin (LMWH), 11% received vitamin K agonists and 6% were treated with no oral anticoagulants.
Recurrent VTE occurred in 6.2% (3.5-9.6) of patients in the LMWH group, compared with 6.4% (2.2-12) in the vitamin K agonist group and 12% (4.7-23) in the no-treatment group. The rates of recurrent VTE were comparable for both intervention strategies (HR=0.9; 0.3-3.1), but the VTE risk was higher for no treatment compared with treatment (HR=2.6; 0.9-7.3). “Our study demonstrates the high risk of recurrent VTE when incidental PE is left untreated,” van der Hulle said.
Major bleeding rates were 3.9% (2.3-5.9) in the LMWH group compared with 13% (6.4-20) in the vitamin K agonist group. A recurrent VTE occurred in 7.8% (2.8-15) of patients with a subsegmental IPE, and in 5.5% (2.9-8.8) of the cohort (HR=1.1; 0.5-2.4).
“Treatment with vitamin K agonists conferred a higher risk of bleeding complications in this cohort,” van der Hulle said.
However, according to the researchers, “the most important finding of this study is the 12% 6-month risk of symptomatic recurrent VTE in patients with cancer-associated IPE who did not receive anticoagulant treatment, which is more than double the risk of patients who were anticoagulated. These numbers recall the effect size of anticoagulants used in symptomatic PE and support the judicious initiation of anticoagulant treatment in cancer-associated IPE.”
van der Hulle reiterated that these findings support the use of current guidelines to treat incidental pulmonary embolism in the same way as symptomatic PE.
For more information:
van der Hulle. Abstract #590. Presented at: ASH Annual Meeting and Exhibition; Dec. 6-9, 2014; San Francisco.
Disclosure: van der Hulle reports no relevant financial disclosures.
Perspective
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Mary Cushman, MD
Cancer patients get imaging analyses throughout their treatment to determine the status of their disease, and we often find incidental pulmonary emboli, some of which can be large and some of which can be small. We know in general that about 40% of all venous thrombosis events are asymptomatic. In this study, we see data that gives us a better understanding of the natural course of these incidents of pulmonary emboli and suggest that cancer patients who develop these clots should receive anticoagulation therapy.
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