Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Epidemiology Department, Maastricht University, Maastricht, the Netherlands.
Eur J Intern Med. 2020 Jul;77:86-96. doi: 10.1016/j.ejim.2020.03.005. Epub 2020 Mar 13.
Thrombocytopenia in cancer patients with an indication for anticoagulation poses a unique clinical challenge. There are guidelines for the setting of venous thromboembolism but not atrial fibrillation (AF). Evidence is lacking and current practice is unclear.
To identify patient and physician characteristics associated with anticoagulation management in hematological malignancy and thrombocytopenia.
A clinical vignette-based experiment was designed. Eleven hematologists were interviewed, identifying 5 relevant variable categories with 2-5 options each. Thirty hypothetical vignettes were generated. Each physician received 5 vignettes and selected a management strategy (hold anticoagulation; no change; transfuse platelets; modify type/dose). The survey was distributed to hematologists and thrombosis specialists in 3 countries. Poisson regression models with cluster robust variance estimates were used to calculate relative risks for using one management option over the other, for each variable in comparison to a reference variable.
168 physicians answered 774 cases and reported continuing anticoagulation for venous thromboembolism or AF in 607 (78%) cases, usually with dose reduction or platelet transfusion support. Overall, management was affected by platelet count, anticoagulation indication, time since indication, type of hematological disease and treatment, and prior major bleeding, as well as physician demographics and practice setting. The CHADS-VASc score and time since AF diagnosis affected anticoagulation management in AF.
This study indicates what the widely accepted management strategies are. These strategies, and possibly others, should be assessed prospectively to ascertain effectiveness. The decision process is intricate and compatible with current venous thromboembolism guidelines.
癌症伴抗凝指征的血小板减少症患者面临独特的临床挑战。有静脉血栓栓塞症的指南，但没有心房颤动（AF）的指南。缺乏证据，目前的实践也不清楚。
确定与血液恶性肿瘤和血小板减少症的抗凝管理相关的患者和医生特征。
设计了基于临床病例的实验。采访了 11 名血液科医生，确定了 5 个相关变量类别，每个类别有 2-5 个选项。生成了 30 个假设病例。每位医生收到 5 个病例，并选择管理策略（停止抗凝；不改变；输血小板；调整类型/剂量）。该调查在 3 个国家的血液科医生和血栓专家中进行。使用带有聚类稳健方差估计的泊松回归模型，计算每个变量与参考变量相比，使用一种管理方案而不是另一种管理方案的相对风险。
168 名医生回答了 774 个病例，并报告了在 607 个（78%）病例中继续抗凝治疗静脉血栓栓塞或 AF，通常采用剂量减少或血小板输注支持。总体而言，管理受到血小板计数、抗凝指征、指征出现时间、血液系统疾病和治疗类型以及既往大出血、医生人口统计学和实践环境的影响。CHADS-VASc 评分和 AF 诊断后的时间影响 AF 的抗凝管理。
本研究表明了广泛接受的管理策略是什么。这些策略，以及其他可能的策略，应该前瞻性评估，以确定其有效性。决策过程复杂，与现行的静脉血栓栓塞症指南一致。
