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Three Part Question

In [an elderly carcinoma patient with multiple co-morbidities presenting in emergency room] with [Atrial Fibrillation] [Is it safe to anticoagulate prophylactically] and [What is the safer First Line anticoagulant]?

Clinical Scenario

59 year old male, presented to the emergency room with dyspnea and angina at rest. His past history was significant for Esophageal cancer on chemo-radiation, Ischemic stroke (left ACA territory – month prior to current presentation), Chronic Kidney disease, hypertension and diabetes mellitus.On examination, He had a heart rate of 192/minute and not in shock; ECG showed Atrial Fibrillation. His Blood Urea was 68 g/dl and Serum Creatinine was 2.3 mg/dl. His Troponin I was positive. Metaprolol was given at out emergency room which brought the heart rate under control.As the heart rate improved, the ECG changes were suggestive of Non-ST Elevation Myocardial Infarction. ECHO showed severe LV dysfunction with Ejection Fraction of 33%.

The dilemma of administering an anticoagulant as the patient had stroke recently and what is the anticoagulant of choice?
In this patient with abnormal renal function enoxaparin sodium is contraindicated. Warfarin is contraindicated in patients with abnormal liver function test.
Generally, anticoagulant is contraindicated in inaccessible ulceration (esophageal carcinoma in this patient).

Search Strategy

Cancer patient with Atrial Fibrillation)AND (Safe Anticoagulant) in PUBMED interface on the world wide web,was searched using the terms above. Limit was set to human species and English Language. No other limits were set. Search date - 06/07/2016.
We used the following keywords in pubmed search:
Cancer patient with Atrial Fibrillation Safe Anticoagulant
Cancer atrial fibrillation Anticoagulation in Emergency

Search Outcome

A total of 16articles were retrieved. Five articleswere relevant. In addition we did the “related articles search” for that single relevant article, but found no further articles of relevance.
Each of the above keywords gave variable number of results from 13-23. Only one literature was relevant clinically in human population.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bona RD, Sivjee KY, Hickey AD, Wallace DM, Wajcs SB october, 1995 usa	Prospective cohort study	Oral anticoagulation is safe and effective in the patient with cancer. It is more difficult to sustain a therapeutic INR in the cancer patients and they may need more frequent monitoring to achieve a low complication rate.	Oral anticoagulation can be safely administered in the cancer patients. Frequent INR monitoring is needed to achieve a low complication rate		This study is a non-randomized study involving small patient population
Nickel KF, Labberton L, Long AT, Langer F, Fuchs TA, Stavrou EX, Butler LM, Renné T. May 2016 Hamburg, Germany	Literature Review	Cancer is an established risk factor for venous thromboembolism (VTE) and VTE is the second leading cause of death in patients with cancer. Factor XII inhibitors provide thrombo-protection without impairing hemostatic mechanisms and thus, unlike currently used anticoagulants, do not increase bleeding risk. Interference with the polyphosphate/factor XII pathway may provide the novel opportunity for safe anticoagulation therapy in patients with malignancies	Factor XII inhibitors provide thrombo-protection without increasing bleeding risk		This is a literature review

Comment(s)

Specific guidelines need to be developed for anticoagulation in Cancer patients.

Clinical Bottom Line

Cancer patients are at increased risk for venous thromboembolism (VTE) and VTE is the second leading cause of death in cancer patients. Anticoagulation Prophylaxis significantly reduced the incidence of Deep Vein Thrombosis in cancer patients. Patients with malignancy treated with anticoagulants have a higher rate of bleeding and recurrent thrombosis compared with patients without malignancy. Short acting oral or parenteral anticoagulants can be initiated in cancer patients with monitoring of INR. Safer and more effective anticoagulant therapy is needed for this challenging group of patients.

References

1. Bona RD, Sivjee KY, Hickey AD, Wallace DM, Wajcs SB The efficacy and safety of oral anticoagulation in patients with cancer ThrombHaemost October 1995; 1055-58
2. Nickel KF, Labberton L, Long AT, Langer F, Fuchs TA, Stavrou EX, Butler LM, Renné T. The polyphosphate/factor XII pathway in cancer-associated thrombosis: novel perspectives for safe anticoagulation in patients with malignancies Thromb Res May 2016, S4-7