A 72-year-old man is brought to the emergency department because of sudden onset shortness of breath and sharp left-sided chest pain. He denies fever, loss of consciousness, or orthopnea. He was diagnosed with metastatic pancreatic cancer three months ago.
Examination reveals clear lungs with normal first and second heart sounds. The abdomen is soft and non-tender. There is trace edema involving the right leg. Neurologic examination is within normal limits.
Laboratory results are as follows:

His chest-x ray is clear. Ultrasound of the right leg shows a thrombus in the popliteal vein. CT angiogram of the chest reveals bilateral pulmonary emboli.
Which of the following would be the most effective long-term treatment to prevent recurrent thromboembolism in this patient?

Question

A 72-year-old man is brought to the emergency department because of sudden onset shortness of breath and sharp left-sided chest pain.  He denies fever, loss of consciousness, or orthopnea.  He was diagnosed with metastatic pancreatic cancer three months ago.
Examination reveals clear lungs with normal first and second heart sounds.  The abdomen is soft and non-tender.  There is trace edema involving the right leg.  Neurologic examination is within normal limits.
Laboratory results are as follows:

His chest-x ray is clear.  Ultrasound of the right leg shows a thrombus in the popliteal vein.  CT angiogram of the chest reveals bilateral pulmonary emboli.
Which of the following would be the most effective long-term treatment to prevent recurrent thromboembolism in this patient?

Quizplus · Accepted Answer

Patients with cancer have a 4-7 fold increased risk of venous thromboembolism (VTE). Long-term VTE treatment is different in cancer patients than patients without cancer. Low molecular weight heparin (LMWH) is more effective than vitamin K antagonists (e.g., warfarin) in reducing the risk of recurrent VTE in cancer patients (while on therapy), and they do not significantly increase the risk of bleeding (Choice C). However, LMWH is not associated with improved survival in these patients. Though more effective, other factors must be taken into consideration when prescribing LMWH, such as patient preference (e.g., needle vs. pills), comorbidities (e.g., renal insufficiency), and cost (e.g., copays). (Choice B) Due to its short half-life, unfractionated heparin is used for inpatient VTE treatment in patients with a high risk of bleeding. However, it is not appropriate for long-term use. (Choice D) This patient has no contraindications for anticoagulation and an IVC filter is not needed. Educational objective: Low molecular weight heparin (LMWH) is more effective than vitamin K antagonists (e.g., warfarin) in reducing the risk of recurrent venous thromboembolism in cancer patients. However, LMWH is not associated with improved survival in these patients. __________ References: Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in cancer. (http://www.ncbi.nlm.nih.gov/pubmed/12853587) Management of venous Thromboembolism in cancer: a brief review of risk-benefit approaches and guidelines' recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/20464888)

A 72-Year-Old Man Is Brought to the Emergency Department Because