Platelet transfusion and anticoagulation in hematological cancer‐associated thrombosis and thrombocytopenia: The CAVEaT multicenter prospective cohort

Abstract

Background Venous thromboembolism (VTE) in patients with thrombocytopenia represents a complex management challenge. Objectives To describe practice, document outcomes, and compare management to national guidelines. Methods We present a prospective multicenter cohort of 105 patients with hematological cancer, VTE within 28 days, and platelets <50 × 109/L from May 14, 2019 to April 24, 2021 from 20 sites. Results Median age was 64 and median initial platelet count 28 × 109/L. Thromboses were: 46% catheter‐associated, 11% lower limb, 33% pulmonary emboli (PE), and 10% other sites. Management was according to International Society on Thrombosis and Haemostasis (ISTH) guidance in 30 (47%) of 64 patients with high‐risk thrombosis and 2 (5%) of low‐risk thrombosis (catheter‐associated or asymptomatic subsegmental PE). Twelve patients (11%) received no anticoagulation. At 28 days mortality was 15%, 8% experienced VTE progression, 7% experienced major bleeding, and 25% experienced clinically relevant non‐major bleeding. Four inferior vena cava filters were placed, two were later removed. The median number of platelet units transfused was 5 (range 0–53). Twenty‐seven percent of patients had a change of management strategy by 28 days. There was no clear relationship among platelet transfusion threshold, anticoagulant dose reduction threshold, and risk of thrombosis progression or major bleeding. Conclusions This data set demonstrates the heterogeneity of approaches used in patients presenting with severe thrombocytopenia and acute thrombosis and confirms the high rates of bleeding in this cohort with thrombosis progression rates similar to the wider cancer‐associated thrombosis population. Randomized data is required to inform the optimal management.

Cancer complicated by thrombosis and thrombocytopenia: still a therapeutic dilemma

“…Two international studies have recently demonstrated the heterogeneity in the management of this cohort, the key findings of which are summarized in Table 2. 23,24 The Cancer-Associated Venous Thrombosis and Thrombocytopenia (CAVEaT) UK study in patients with hematological malignancies showed that 47% of patients with higher risk thrombosis and 5% with lower risk thrombosis were managed according to the ISTH guidance. There was variation in the use of platelet transfusions.…”

“…Changes in anticoagulation were observed in 51% of patients by 90 days. Mortality was 15% at 28 days and significant morbidity was 24 The North American Thrombocytopenia Related Outcomes with Venous thromboembolism (TROVE) study also found that changes in anticoagulation choice were frequent, with less frequent alterations in anticoagulation intensity. 23 Interestingly, the two studies revealed different findings.…”

HaemSTAR—Growing Experience From a National, Trainee-led Research Network

“…Extrapolated, this supports annual cost‐savings of over £1 million per year in England 7 . The second flash‐mob audit looked at care and outcomes of patients with thrombotic thrombocytopenic purpura and has generated data that has been used to support the commissioning of specialist centers across the United Kingdom 14 . The third flash‐mob project is in late development and will audit the real‐world use of reversal agents for direct oral anticoagulants.…”

“… 7 The second flash-mob audit looked at care and outcomes of patients with thrombotic thrombocytopenic purpura and has generated data that has been used to support the commissioning of specialist centers across the United Kingdom. 14 The third flash-mob project is in late development and will audit the real-world use of reversal agents for direct oral anticoagulants. This project has attracted nearly £100,000 funding from industry in the form of academic grants and administration support.…”

Objective indexes for comparing platelet usage among peer hospitals during the COVID‐19 pandemic: A cross‐sectional study

“…Although platelet transfusion is essential for preventing or treating bleeding, 9 , 10 the cost of platelet products is high, and unnecessary frequent platelet transfusions may increase the risk of transfusion reactions. 11 , 12 , 13 , 14 , 15 , 16 , 17 Therefore, it is necessary to comprehensively analyze and monitor the proper use of platelets.…”