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Anticoagulant therapy: Is there always a best choice?
International Journal of Cardiology 215 (2016) 291–292
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Anticoagulant therapy: Is there always a best choice? C. Consorti a, A.M. Cotruzzola b, A. Bruno c, M. Scarano a,⁎ a b c
Cardiology Unit, Emergency Dept, Hospital “Madonna del Soccorso”, San Benedetto del Tronto, Italy Hospital “Busto Arsizio”, Varese, Italy Hospital “Sant'Antonio Abate di Gallarate”, Varese, Italy
a r t i c l e
i n f o
Article history: Received 11 April 2016 Accepted 13 April 2016 Available online 25 April 2016
The use of anticoagulant therapy may be difficult in some clinical scenarios. We show the case of a 67 years old patient who underwent to cardiac evaluation because of asthenia and arrhythmia. From the youth he suffered from psoriasis and impaired carbohydrate tolerance [1–8]. In adulthood he suffered from paroxysmal atrial fibrillation treated successfully with transcatheter ablation. From six years he was diagnosed with Hodgkin lymphoma in chemotherapy. Furthermore a recent episode of pulmonary embolism was treated with Fondaparinux 5 mg/ die. The vitamin K antagonists were not usable because of interference with chemotherapy and because of labile INR. Because of a previous thrombocytopenia we didn't use Low Molecular Weight Heparin [9–13]. His ECG showed atrial fibrillation with mean ventricular rate 100 bpm Fig. 1A. The echocardiogram showed normal left ventricle with moderately depressed ejection fraction (43%) and a small mobile thrombotic stratification partially adherent to the free wall of the right
atrium Fig. 1B. For the lack of efficacy Fondaparinux was suspended and Non Fractionated Heparin infusion was started for 48 h. During infusion there was a restoration of sinus rhythm. A CCTA excluded a relapse of pulmonary embolism. Then a therapy with Rivaroxaban 20 mg/day was started in order to prevent thromboembolic events in the paroxysmal atrial fibrillation. After ten days a new echocardiogram showed no thrombotic stratification in the right atrium [14–17]. After one month no episodes of thromboembolism nor bleeding events occurred. This case focuses on the difficulties of best antithrombotic therapy in some clinical scenarios with high thromboembolic risk. In particular in neoplastic diseases the better choice can be challenging because of the interactions with chemotherapeutic drugs. In our case the concomitant presence of Hodgkin lymphoma, the previous episodes of paroxysmal atrial fibrillation and pulmonary embolism created a high cardioembolic risk making the therapy with Fondaparinux ineffective. Use of new oral anticoagulant (NOAC) could be a new choice in patients with neoplastic disease also if new studies are needed to test their efficacy. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
Fig. 1. Panel A: ECG: atrial fibrillation with mean ventricular rate 100 bpm. Panel B: Transthoracic echocardiography, 4-C view, showing a small mobile thrombotic stratification (white arrow) partially adherent to the free wall of the right atrium.
⁎ Corresponding author at: Cardiology Unit, Emergency Dept, Hospital “Madonna del Soccorso”, Via Silvio Pellico n.32, 63039 San Benedetto del Tronto, Ascoli Piceno, Italy. E-mail address: [email protected] (M. Scarano).
http://dx.doi.org/10.1016/j.ijcard.2016.04.122 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
292
Correspondence
Acknowledgments The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
[8]
[9] [10]
References [1] A. Kaifie, M. Kirschner, D. Wolf, C. Maintz, M. Hänel, N. Gattermann, E. Gökkurt, U. Platzbecker, W. Hollburg, J.R. Göthert, S. Parmentier, F. Lang, R. Hansen, S. Isfort, K. Schmitt, E. Jost, H. Serve, G. Ehninger, W.E. Berdel, T.H. Brümmendorf, S. Koschmieder, Study Alliance Leukemia (SAL). Bleeding, thrombosis, and anticoagulation in myeloproliferative neoplasms (MPN): analysis from the German SAL-MPN-registry, J. Hematol. Oncol. 9 (1) (Mar 5 2016) 18. [2] N. Mansencal, M. El Hajjam, A. Vieillard-Baron, J.P. Pelage, P. Lacombe, O. Dubourg, Recurrent pulmonary embolism with non-mobile thrombus in a patient with leiomyosarcoma of the left renal vein, Int. J. Cardiol. 112 (2) (Sep 20 2006) 247–248. [3] T. van der Hulle, P.L. den Exter, P. van den Hoven, J.J. van der Hoeven, F.J. van der Meer, J. Eikenboom, M.V. Huisman, F.A. Klok, Cohort study on the management of cancer-associated venous thromboembolism aimed at the safety of stopping anticoagulant therapy in patients cured from cancer, Chest 149 (5) (2016 May) 1245–1251. [4] S. Mosca, P. Gargiulo, N. Balato, L. Di Costanzo, A. Parente, S. Paolillo, F. Ayala, B. Trimarco, F. Crea, P. Perrone-Filardi, Ischemic cardiovascular involvement in psoriasis: a systematic review, Int. J. Cardiol. 178 (Jan 15 2015) 191–199. [5] G. Dattilo, A. Lamari, M. Scarano, G. Di Bella, E. Imbalzano, P. Busacca, S. Coglitore, Coronary artery disease and psoriasis, Minerva Cardioangiol. 62 (1) (Feb 2014) 119–121. [6] E. Imbalzano, M. Casale, M. D'Angelo, G. Mandraffino, V. Giugno, G. Di Bella, S. Carerj, G. Dattilo, Cardiovascular risk and psoriasis: a role in clinical cardiology? Angiology 66 (2) (Feb 2015) 101–103. [7] N. Matsuura, C. Asano, K. Nagasawa, S. Ito, Y. Sano, Y. Minagawa, Y. Yamada, T. Hattori, S. Watanabe, T. Murohara, K. Nagata, Effects of pioglitazone on cardiac
[11]
[12]
[13]
[14]
[15]
[16]
[17]
and adipose tissue pathology in rats with metabolic syndrome, Int. J. Cardiol. 179 (Jan 20 2015) 360–369. G. Dattilo, A. Lamari, S. Crosca, S. Tavella, P. Fugà, A. Conti, M. Scarano, P. Busacca, Correlation between insulin resistance and endothelial dysfunction assessed by flow-mediated dilation, Recenti Prog. Med. 103 (9) (Sep 2012) 328–332. S. Patanè, F. Marte, G. Dattilo, M. Sturiale, Changing axis deviation during atrial fibrillation, Int. J. Cardiol. 154 (1) (Jan 12 2012) e1–e3. Q. Xiong, S. Chen, K. Senoo, M. Proietti, K. Hong, G.Y. Lip, The CHADS2 and CHA2DS2VASc scores for predicting ischemic stroke among East Asian patients with atrial fibrillation: a systemic review and meta-analysis, Int. J. Cardiol. 195 (Sep 15 2015) 237–242. A. Lee, V.A. See, T.W. Lim, J. Descallar, W. Chik, D.L. Ross, S.P. Thomas, L. Thomas, Atrial fibrillation ablation by single ring isolation versus wide antral isolation: effects on left atrial size and function, Int. J. Cardiol. 206 (Mar 1 2016) 1–6. D. Tulino, E. Imbalzano, M. Casale, M. D'Angelo, S. Coglitore, G. Di Bella, G. Dattilo, Treatment failure of low molecular weight heparin in diabetic patient, Int. J. Cardiol. 168 (2) (Sep 30 2013) e63–e64. C. Rusconi, C. Oneglia, T. Sabatini, Failure of low dosage thrombolytic therapy with streptokinase to treat heparin-induced thrombocytopenic-thrombotic syndrome, Int. J. Cardiol. 62 (1) (Oct 31 1997) 87–89. E. Imbalzano, G. Di Bella, A. Lamari, M. Scarano, M. Casale, P. Busacca, S. Carerj, G. Dattilo, Right ventricular myocardial deformation in young healthy subjects: a comparison study between 2D strain and traditional parameters, J. Exp. Clin. Cardiol. 20 (1) (2014) 2729–2743. L. Wang, J. Wang, T.O. Cheng, M. Xie, X. Wang, Y. Song, J. Liu, F. Wei, Giant left coronary artery aneurysms: review of the literature and report of a rare case diagnosed by transthoracic echocardiography, Int. J. Cardiol. 189 (Jun 15 2015) 267–271. G. Dattilo, G. Falanga, M. Casale, M. D'Angelo, S. Quattrocchi, A. Lamari, M. Scarano, E. Imbalzano, P. Busacca, Oral anticoagulants: old and new therapy (Book Chapter), Adv. Med. Biol. 83 (January 01, 2015) 13–70. J. Takasugi, H. Yamagami, T. Okata, K. Toyoda, K. Nagatsuka, Dissolution of the left atrial appendage thrombus with rivaroxaban therapy, Cerebrovasc. Dis. 36 (4) (2013) 322–323.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Anticoagulant therapy: Is there always a best choice? C. Consorti a, A.M. Cotruzzola b, A. Bruno c, M. Scarano a,⁎ a b c
Cardiology Unit, Emergency Dept, Hospital “Madonna del Soccorso”, San Benedetto del Tronto, Italy Hospital “Busto Arsizio”, Varese, Italy Hospital “Sant'Antonio Abate di Gallarate”, Varese, Italy
a r t i c l e
i n f o
Article history: Received 11 April 2016 Accepted 13 April 2016 Available online 25 April 2016
The use of anticoagulant therapy may be difficult in some clinical scenarios. We show the case of a 67 years old patient who underwent to cardiac evaluation because of asthenia and arrhythmia. From the youth he suffered from psoriasis and impaired carbohydrate tolerance [1–8]. In adulthood he suffered from paroxysmal atrial fibrillation treated successfully with transcatheter ablation. From six years he was diagnosed with Hodgkin lymphoma in chemotherapy. Furthermore a recent episode of pulmonary embolism was treated with Fondaparinux 5 mg/ die. The vitamin K antagonists were not usable because of interference with chemotherapy and because of labile INR. Because of a previous thrombocytopenia we didn't use Low Molecular Weight Heparin [9–13]. His ECG showed atrial fibrillation with mean ventricular rate 100 bpm Fig. 1A. The echocardiogram showed normal left ventricle with moderately depressed ejection fraction (43%) and a small mobile thrombotic stratification partially adherent to the free wall of the right
atrium Fig. 1B. For the lack of efficacy Fondaparinux was suspended and Non Fractionated Heparin infusion was started for 48 h. During infusion there was a restoration of sinus rhythm. A CCTA excluded a relapse of pulmonary embolism. Then a therapy with Rivaroxaban 20 mg/day was started in order to prevent thromboembolic events in the paroxysmal atrial fibrillation. After ten days a new echocardiogram showed no thrombotic stratification in the right atrium [14–17]. After one month no episodes of thromboembolism nor bleeding events occurred. This case focuses on the difficulties of best antithrombotic therapy in some clinical scenarios with high thromboembolic risk. In particular in neoplastic diseases the better choice can be challenging because of the interactions with chemotherapeutic drugs. In our case the concomitant presence of Hodgkin lymphoma, the previous episodes of paroxysmal atrial fibrillation and pulmonary embolism created a high cardioembolic risk making the therapy with Fondaparinux ineffective. Use of new oral anticoagulant (NOAC) could be a new choice in patients with neoplastic disease also if new studies are needed to test their efficacy. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
Fig. 1. Panel A: ECG: atrial fibrillation with mean ventricular rate 100 bpm. Panel B: Transthoracic echocardiography, 4-C view, showing a small mobile thrombotic stratification (white arrow) partially adherent to the free wall of the right atrium.
⁎ Corresponding author at: Cardiology Unit, Emergency Dept, Hospital “Madonna del Soccorso”, Via Silvio Pellico n.32, 63039 San Benedetto del Tronto, Ascoli Piceno, Italy. E-mail address: [email protected] (M. Scarano).
http://dx.doi.org/10.1016/j.ijcard.2016.04.122 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
292
Correspondence
Acknowledgments The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
[8]
[9] [10]
References [1] A. Kaifie, M. Kirschner, D. Wolf, C. Maintz, M. Hänel, N. Gattermann, E. Gökkurt, U. Platzbecker, W. Hollburg, J.R. Göthert, S. Parmentier, F. Lang, R. Hansen, S. Isfort, K. Schmitt, E. Jost, H. Serve, G. Ehninger, W.E. Berdel, T.H. Brümmendorf, S. Koschmieder, Study Alliance Leukemia (SAL). Bleeding, thrombosis, and anticoagulation in myeloproliferative neoplasms (MPN): analysis from the German SAL-MPN-registry, J. Hematol. Oncol. 9 (1) (Mar 5 2016) 18. [2] N. Mansencal, M. El Hajjam, A. Vieillard-Baron, J.P. Pelage, P. Lacombe, O. Dubourg, Recurrent pulmonary embolism with non-mobile thrombus in a patient with leiomyosarcoma of the left renal vein, Int. J. Cardiol. 112 (2) (Sep 20 2006) 247–248. [3] T. van der Hulle, P.L. den Exter, P. van den Hoven, J.J. van der Hoeven, F.J. van der Meer, J. Eikenboom, M.V. Huisman, F.A. Klok, Cohort study on the management of cancer-associated venous thromboembolism aimed at the safety of stopping anticoagulant therapy in patients cured from cancer, Chest 149 (5) (2016 May) 1245–1251. [4] S. Mosca, P. Gargiulo, N. Balato, L. Di Costanzo, A. Parente, S. Paolillo, F. Ayala, B. Trimarco, F. Crea, P. Perrone-Filardi, Ischemic cardiovascular involvement in psoriasis: a systematic review, Int. J. Cardiol. 178 (Jan 15 2015) 191–199. [5] G. Dattilo, A. Lamari, M. Scarano, G. Di Bella, E. Imbalzano, P. Busacca, S. Coglitore, Coronary artery disease and psoriasis, Minerva Cardioangiol. 62 (1) (Feb 2014) 119–121. [6] E. Imbalzano, M. Casale, M. D'Angelo, G. Mandraffino, V. Giugno, G. Di Bella, S. Carerj, G. Dattilo, Cardiovascular risk and psoriasis: a role in clinical cardiology? Angiology 66 (2) (Feb 2015) 101–103. [7] N. Matsuura, C. Asano, K. Nagasawa, S. Ito, Y. Sano, Y. Minagawa, Y. Yamada, T. Hattori, S. Watanabe, T. Murohara, K. Nagata, Effects of pioglitazone on cardiac
[11]
[12]
[13]
[14]
[15]
[16]
[17]
and adipose tissue pathology in rats with metabolic syndrome, Int. J. Cardiol. 179 (Jan 20 2015) 360–369. G. Dattilo, A. Lamari, S. Crosca, S. Tavella, P. Fugà, A. Conti, M. Scarano, P. Busacca, Correlation between insulin resistance and endothelial dysfunction assessed by flow-mediated dilation, Recenti Prog. Med. 103 (9) (Sep 2012) 328–332. S. Patanè, F. Marte, G. Dattilo, M. Sturiale, Changing axis deviation during atrial fibrillation, Int. J. Cardiol. 154 (1) (Jan 12 2012) e1–e3. Q. Xiong, S. Chen, K. Senoo, M. Proietti, K. Hong, G.Y. Lip, The CHADS2 and CHA2DS2VASc scores for predicting ischemic stroke among East Asian patients with atrial fibrillation: a systemic review and meta-analysis, Int. J. Cardiol. 195 (Sep 15 2015) 237–242. A. Lee, V.A. See, T.W. Lim, J. Descallar, W. Chik, D.L. Ross, S.P. Thomas, L. Thomas, Atrial fibrillation ablation by single ring isolation versus wide antral isolation: effects on left atrial size and function, Int. J. Cardiol. 206 (Mar 1 2016) 1–6. D. Tulino, E. Imbalzano, M. Casale, M. D'Angelo, S. Coglitore, G. Di Bella, G. Dattilo, Treatment failure of low molecular weight heparin in diabetic patient, Int. J. Cardiol. 168 (2) (Sep 30 2013) e63–e64. C. Rusconi, C. Oneglia, T. Sabatini, Failure of low dosage thrombolytic therapy with streptokinase to treat heparin-induced thrombocytopenic-thrombotic syndrome, Int. J. Cardiol. 62 (1) (Oct 31 1997) 87–89. E. Imbalzano, G. Di Bella, A. Lamari, M. Scarano, M. Casale, P. Busacca, S. Carerj, G. Dattilo, Right ventricular myocardial deformation in young healthy subjects: a comparison study between 2D strain and traditional parameters, J. Exp. Clin. Cardiol. 20 (1) (2014) 2729–2743. L. Wang, J. Wang, T.O. Cheng, M. Xie, X. Wang, Y. Song, J. Liu, F. Wei, Giant left coronary artery aneurysms: review of the literature and report of a rare case diagnosed by transthoracic echocardiography, Int. J. Cardiol. 189 (Jun 15 2015) 267–271. G. Dattilo, G. Falanga, M. Casale, M. D'Angelo, S. Quattrocchi, A. Lamari, M. Scarano, E. Imbalzano, P. Busacca, Oral anticoagulants: old and new therapy (Book Chapter), Adv. Med. Biol. 83 (January 01, 2015) 13–70. J. Takasugi, H. Yamagami, T. Okata, K. Toyoda, K. Nagatsuka, Dissolution of the left atrial appendage thrombus with rivaroxaban therapy, Cerebrovasc. Dis. 36 (4) (2013) 322–323.