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How I Treat: Unexplained Arterial Thromboembolism

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American Society of Hematology 2021 L Street NW, Suite 900, Washington, DC 20036 Phone: 202-776-0544 | Fax 202-776-0545 [email protected] How I Treat: Unexplained Arterial Thromboembolism Downloaded from https://ashpublications.org/blood/article-pdf/doi/10.1182/blood.2019000820/1746018/blood.2019000820.pdf by UNIV OF NC/ACQ SRVCS user on 29 June 2020 Tracking no: BLD-2019-000820-CR1 Jori May (University of Alabama at Birmingham, United States) Stephan Moll (University of North Carolina, United States) Abstract: Most arterial thrombotic events have a clear atherosclerotic or cardioembolic etiology, but hematologists are frequently asked to assist in the diagnosis and management of a patient with a non-atherosclerotic and non-cardioembolic arterial event, referred to herein as an unexplained arterial thrombosis. Because there is an assorted list of factors that can precipitate an arterial event, we present a systematic diagnostic approach to ensure consideration of not only primary hypercoagulable disorders, but also pro-thrombotic medications or substances, vascular and anatomic abnormalities, and undiagnosed systemic disorders, such as malignancy and autoimmune diseases. We also review existing literature of the role of hypercoagulable disorders in arterial thrombosis and discuss our approach to thrombophilia workup in patients after an unexplained arterial event. We conclude with three representative cases to both illustrate the application of the outlined diagnostic schema and discuss common management considerations, specifically the selection of anticoagulation versus anti-platelet therapy for secondary prevention. Conflict of interest: No COI declared COI notes: Preprint server: No; Author contributions and disclosures: J.E.M. developed the concept and design of the manuscript, wrote the manuscript, and gave final approval. S.M. developed the concept and design of the manuscript, wrote the manuscript, and gave final approval. Non-author contributions and disclosures: No; Agreement to Share Publication-Related Data and Data Sharing Statement: Clinical trial registration information (if any): How I treat unexplained arterial thrombosis Jori E. May,1 and Stephan Moll2 1Department of Medicine, Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL; 2Department of Medicine, Division of Hematology, Downloaded from https://ashpublications.org/blood/article-pdf/doi/10.1182/blood.2019000820/1746018/blood.2019000820.pdf by UNIV OF NC/ACQ SRVCS user on 29 June 2020 University of North Carolina School of Medicine, Chapel Hill, NC Corresponding author: Stephan Moll, MD University of North Carolina School of Medicine Department of Medicine, Division of Hematology CB 7035 Chapel Hill, NC 27599 [email protected] P: 919-966-3311 F: 919-843-4896 Cell: 919-360-6210 Jori May, MD University of Alabama at Birmingham Department of Medicine, Division of Hematology/Oncology 1720 2nd Avenue South NP 2540 Birmingham, AL 35294 [email protected] P: 205-934-0067 F: 205-934-9573 Cell: 205-602-1462 Short title: How I treat unexplained arterial thrombosis Word count, abstract: 150 Word count, text: 4690 Table/figure count: 7 Reference count: 109 1 Abstract Most arterial thrombotic events have a clear atherosclerotic or cardioembolic etiology, but hematologists are frequently asked to assist in the diagnosis and management of a patient with a non-atherosclerotic and non-cardioembolic arterial event, Downloaded from https://ashpublications.org/blood/article-pdf/doi/10.1182/blood.2019000820/1746018/blood.2019000820.pdf by UNIV OF NC/ACQ SRVCS user on 29 June 2020 referred to herein as an unexplained arterial thrombosis. Because there is an assorted list of factors that can precipitate an arterial event, we present a systematic diagnostic approach to ensure consideration of not only primary hypercoagulable disorders, but also pro-thrombotic medications or substances, vascular and anatomic abnormalities, and undiagnosed systemic disorders, such as malignancy and autoimmune diseases. We also review existing literature of the role of hypercoagulable disorders in arterial thrombosis and discuss our approach to thrombophilia workup in patients after an unexplained arterial event. We conclude with three representative cases to both illustrate the application of the outlined diagnostic schema and discuss common management considerations, specifically the selection of anticoagulation versus anti-platelet therapy for secondary prevention. Introduction The majority of arterial thromboses are not managed by hematologists. Atherosclerotic plaque rupture, atrial fibrillation, and other cardioembolic sources are responsible for most arterial events, and comprehensive consensus guidelines exist on the evaluation and management of organ-specific arterial thrombotic disorders (Table 1). However, the approach to non-atherosclerotic and non-cardioembolic arterial thrombosis, referred to herein as unexplained arterial thrombosis, is less clear. When an 2 arterial event occurs without clear provoking factors, a hematologist is often called upon to address two common questions. First, does this patient have an underlying thrombophilia? Second, should this patient be placed on anti-platelet therapy, anticoagulation, or both? Downloaded from https://ashpublications.org/blood/article-pdf/doi/10.1182/blood.2019000820/1746018/blood.2019000820.pdf by UNIV OF NC/ACQ SRVCS user on 29 June 2020 In this article, we first propose a three-step conceptual framework for the evaluation and management of patients with unexplained arterial thrombosis (Table 2). We then apply this framework to three cases to emphasize its utility in clinical management. Conceptual framework for diagnosis and management Step 1: Defining the clot The first step in the management of an arterial thromboembolism is to confirm its anatomic location and resultant end-organ damage, often necessitating dedicated review of imaging studies with an expert radiologist. An assessment of the patient’s symptoms as they correlate with the thrombosis location is also helpful. While some arterial events are incidentally identified, they still require thorough diagnostic evaluation. Discussion with a subspecialist who cares for the affected organ is also recommended, as the diagnostic approach to thrombosis in each organ system varies significantly. For example, when considering thrombosis in the cerebral vasculature, the location of the thrombus or ischemic territory can be suggestive of an embolic versus atherosclerotic etiology. Also, an ischemic cerebral lesion that does not correlate with an anatomical arterial territory, particularly if associated with hemorrhage, raises concern for 3 venous sinus thrombosis, requiring dedicated imaging.12 Splenic and renal infarcts can result from arterial or venous occlusion – wedge-shaped infarcts suggest an arterial origin, whereas diffuse ischemic areas suggest a venous etiology. Retinal vessel thrombosis also requires particular attention, as distinction between retinal artery Downloaded from https://ashpublications.org/blood/article-pdf/doi/10.1182/blood.2019000820/1746018/blood.2019000820.pdf by UNIV OF NC/ACQ SRVCS user on 29 June 2020 occlusion (RAO) and retinal venous occlusion (RVO) is key, as is central versus branch vessel involvement.13 A discussion with ophthalmology may be necessary to clarify exam findings, including the bilaterality of changes or signs of a local thrombotic or systemic process (vasculitis, sarcoidosis, hyperviscosity, etc). Defining the vascular obstruction – based on clinical symptomatology, physical examination, imaging studies, and discussion with expert consultants – is an essential first step, as thrombosis location and extent of organ damage determine diagnostic considerations and management. Step 2: Performing a diagnostic evaluation The potential contributors to an arterial thrombotic event are vast and, therefore, a structured diagnostic evaluation is helpful (Table 3). Because thrombotic events are frequently multifactorial, it is important to identify ALL potential atherosclerotic and thrombotic risk factors. The most common causes of arterial events, atherosclerosis and cardioembolism, must first be excluded (Table 3, section A-B). Evaluation for paroxysmal atrial fibrillation should include electrocardiography (EKG) and ambulatory cardiac rhythm monitoring, the optimal duration of which is debated10,14; two to four weeks is reasonable. Evaluation for patent foramen ovale (PFO) is frequently indicated; because the diagnosis and 4 management of PFO is a complex and evolving field, co-evaluation with a knowledgeable cardiologist and neurologist is advisable. Evaluation frequently starts with transthoracic echocardiography (TTE) with an agitated saline study performed while the patient is coughing and/or performing a Valsalva maneuver.15 Transesophageal echocardiography Downloaded from https://ashpublications.org/blood/article-pdf/doi/10.1182/blood.2019000820/1746018/blood.2019000820.pdf by UNIV OF NC/ACQ SRVCS user on 29 June 2020 (TEE) is considered the gold standard for evaluation of PFO, but increasing evidence supports the use of transcranial Doppler as non-invasive option.16 Imaging should be re-reviewed with a radiologist, as diagnostic reports may lack necessary details. Potential questions to discuss include whether (a) the quality of the study is sufficient for vasculature evaluation, (b) there is evidence of atherosclerosis or anatomical abnormalities, and (c) there are features of the damaged organ
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