Anticoagulation does not increase ICH risk in patients with brain metastases

Anna GarrettVenous thromboembolism (VTE) occurs frequently in cancer patients with brain metastases, but there is limited evidence supporting the safety of low-molecular-weight heparin use for therapeutic anticoagulation. A retrospective cohort study of 293 cancer patients with brain metastases (104 with therapeutic enoxaparin and 189 controls) was conducted to investigate the differences in rates of intracranial hemorrhage between the two groups.

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No differences were observed in the cumulative incidence of intracranial hemorrhage at one year in the enoxaparin and control cohorts for measurable and total intracranial hemorrhages. The risk of intracranial hemorrhage was four times higher in patients with melanoma or renal cell carcinoma (N=60) rather than lung cancer (N=153), but the risk was not influenced by the administration of enoxaparin.

Overall survival was similar for the enoxaparin and control cohorts. The authors concluded that intracranial hemorrhage is frequently observed in patients with brain metastases but that therapeutic anticoagulation does not increase the risk.

Source: Donato J, Campigotto F, Uhlmann EJ, et al. Intracranial hemorrhage in patients with brain metastases treated with therapeutic enoxaparin: A matched cohort study. Blood 2015. Published online before print: http://dx.doi.org/10.1182/blood-2015-02-626788.

Study seeks appropriate length of dual antiplatelet therapy

A recent meta-analysis reviewed the benefits and risks of short-term (<12 months) or extended (>12 months) dual antiplatelet therapy (DAPT) vs. standard 12-month therapy, following percutaneous coronary intervention with drug-eluting stents.

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The review included 10 trials comparing short-term (3-6 months, depending on the study) or extended (>12 months) DAPT regimens with standard 12-month duration of therapy. This represented 32,287 patients. Primary outcomes were cardiovascular mortality, myocardial infarction, stent thrombosis, major bleeding, and all-cause mortality.

Compared to 12-month DAPT, a short-term course of therapy was associated with a significant reduction in major bleeding, with no significant differences in ischemic or thrombotic outcomes. Extended vs. 12-month DAPT resulted in a significant reduction in the odds of myocardial infarction but also in more major bleeding. All-cause (but not cardiovascular) death was also significantly increased.

These results suggest that short-term DAPT could be considered for most patients. In selected patients with low bleeding risk and very high ischemic risk, extended DAPT (>12 months) may be appropriate.

Source: Navarese EP, Andreotti F, Schulze V, et al. Optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stents: Meta-analysis of randomised controlled trials. BMJ 2015;350:h1618.

Inferior vena cava filter does not prevent PE recurrence

Retrievable inferior vena cava filters (IVCF) are frequently used in addition to anticoagulation in patients with acute VTE. A recent French study examined the efficacy and safety of IVCF anticoagulation vs. anticoagulation alone for preventing pulmonary embolism (PE) recurrence in patients with acute PE and a high risk of recurrence.

Approximately 400 patients were assigned to IVCF implantation plus anticoagulation (N = 200) or anticoagulation alone, with no filter implantation (N = 199). Full-dose anticoagulation was given for at least six months in all patients. Filter retrieval was planned for three months from placement.

The primary efficacy outcome was symptomatic recurrent PE at three months. Secondary outcomes were recurrent PE at six months, symptomatic deep vein thrombosis, major bleeding, death at three and six months, and filter complications.

A filter was successfully inserted into 193 patients and was retrieved as planned in 153 of the 164 patients for whom retrieval was attempted. By three months, recurrent PE had occurred in six patients (3.0%; all fatal) in the filter group and in three patients (1.5%; 2 fatal) in the control group. Results were similar at six months. No difference was observed between the two groups regarding the other outcomes. Filter thrombosis occurred in three patients.

The authors concluded that the findings do not support the use of filters in patients who can be treated with anticoagulation alone.

Source: Mismetti P, Laporte S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs. anticoagulation alone on risk of recurrent pulmonary embolism: A randomized clinical trial. JAMA. 2015 Apr 28;313(16):1627–1635.