ESC guidelines on managing pulmonary embolism (PE) in cancer patients: Dr. Monish Raut
M3 India Newsdesk Mar 16, 2020
Dr. Monish Raut answers questions on managing pulmonary embolism (PE) in cancer patients and secondary prevention basis the recent European Society of Cardiology (ESC) guidelines.
Patients with cancer carry higher risk of developing venous thromboembolism and pulmonary embolism and PE is the second most important cause of death in such patients.
Key points
Recent PE guidelines recommend low-molecular-weight heparin (LMWH) for the first 6 months over vitamin K antagonists (VKAs).
- Edoxaban and rivaroxaban can be considered as an alternative to subcutaneous LMWH in patients without gastrointestinal cancer.
- Extended anticoagulation after 6 months can be in the form of continuation of LMWH or conversion to novel oral anticoagulants (NOACs) such as edoxaban or rivaroxaban.
- Current literature does not support the role of venous filter instead of anticoagulation in cancer patients and anticoagulation should be initiated once it is safe to do so irrespective of insertion of vena cava filter.
Case presentation
A 55-year-old male patient, with a known case of carcinoma stomach, had shortness of breath over the last few months. Computed tomography scan of pulmonary angiography revealed pulmonary embolism. How should this patient be managed?
Patients with active cancer carry 3 to 5 times more risk of developing thromboembolism. Cancer itself is associated with coagulation abnormalities. Along with that, radiotherapy, chemotherapy, surgery, age group, and obesity also act as significant risk factors. Incidence of symptomatic or asymptomatic thromboembolic disease in cancer patients is approximately 15%. Mortality risks in such patients raises from 15 to 80% in 6 months. Thromboembolic disease is the 2nd most important cause of mortality in patients with cancer.
How should pulmonary embolism be managed in cancer patients?
Incidental pulmonary embolism in cancer patients should be treated in a similar way like patients with symptomatic pulmonary embolism.*
- Haemodynamics and respiratory stabilisation are priorities in acute phase of pulmonary embolism, but, it should be kept in mind that reperfusion remains the definitive treatment
- Pulmonary embolism affects not only oxygenation but the right ventricle also, and pharmacological management of right ventricular failure needs utmost importance
- Anticoagulation forms the backbone of pulmonary embolism treatment, therefore, knowledge of conventional and novel anticoagulants helps in better management with lesser side effects
- Reperfusion by systemic thrombolysis is most effective if started within 48 hours of symptom onset
- Vena cava filters are indicated in patients with recent proximal deep venous thrombosis and absolute contraindications to anticoagulation therapy
- Recent guideline encourages the formation of pulmonary embolism response teams (PERTs) in making appropriate clinical decisions
After the first episode of PE, what should be the treatment in such patients?
A network meta-analysis comparing efficacy and safety of anticoagulants found LMWHs to reduce the risk of recurrent thromboembolism by 40%. LMWH carries a similar risk of bleeding complications as that of vitamin K antagonists.
Accordingly, recent PE guidelines 2019 recommend sub-cutaneous LMWHs for the first 6 months over VKAs (Class IIa A). However, LMWH carries a cost concern and burden for patients. The recently published NOAC trials in cancer patients found edoxaban and rivaroxaban as noninferior to LMWH in the secondary prevention of VTE.
Advantages of NOACs:
- They are more convenient for patients
- They have fixed-dose regimens
- They are lower in cost when compared to LMWH
At the same time, it is important to note that - Hokusai VTE cancer trial and SELECT-D have observed a high rate of bleeding in patients with GI malignancies receiving edoxaban and rivaroxaban respectively. Hence, the guidelines consider edoxaban and rivaroxaban as an alternative to subcutaneous LMWH in patients without gastrointestinal cancer (Class IIa B) (IIa C).
Patients with gastrointestinal cancer should be advised to continue LMWH for ≥3 to 6 months. LMWH should also be preferred in patients with unpredictable gastric absorption, poor oral intake, and severe kidney dysfunction.
In all other patients without GI malignancies and low risk of bleeding, the clinician can choose between LMWH and edoxaban or rivaroxaban depending upon the patient’s preference. Extended anticoagulation after 6 months can be in the form of continuation of LMWH or conversion to NOACs such as edoxaban or rivaroxaban.
How can we predict the risk of recurrence of PE in cancer patients ?
Risk of recurrence of PE can be predicted using the following scoring system:
| Parameters | Score Value |
| Breast cancer | -1 |
| Tumour node metastasis stage I or II | -1 |
| Female gender | +1 |
| Lung cancer | +1 |
| Previous VTE | +1 |
Score ≤0 carries a low risk (≤4.5%) and score ≥1 carries a high (≥19%) risk of venous thromboembolism recurrence over the first 6 months.
Can we use vena cava filter rather than anticoagulation for preventing PE recurrence ?
Vena cava filters are particularly indicated in patients with contraindications for anticoagulation such as active bleeding or raised haemorrhagic risk.
However, it can not be ignored that cancer patients carry higher risk of thromboembolism without anticoagulation. Therefore, anticoagulation should be initiated once it is safe to do so irrespective of insertion of vena cava filter. Current literature does not support the role of venous filter use instead of anticoagulation in cancer patients.
*To learn more on the management of pulmonary embolism, click How to treat acute phase of PE: Excerpts from 2019 ESC guidelines
Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
The author, Dr. Monish S Raut is a Consultant in Cardiothoracic Vascular Anaesthesiology. His area of expertise is perioperative management and echocardiography with numerous publications in various national and international indexed journals.
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