Medications associated with increased risk of arterial thrombosis33-41
| Medication . | Sites . | Proposed mechanism(s) . | Notes . |
|---|---|---|---|
| Estrogens33 | Stroke, MI | Increased platelet activation and procoagulant factors, decreased anticoagulant and fibrinolysis factors | Variable risk reported, likely low absolute risk with commonly used lower estrogen doses. Higher risk in patients with HTN, smoking |
| Androgenic anabolic steroids34 | Stroke, MI | Accelerated atherosclerosis, coagulation abnormalities, elevated hematocrit | General term for performance-enhancing drugs with promyogenic and androgenic effects |
| Heparin35 | PA > stroke, MI | Autoimmune response to heparin-PF4 complex causing heparin-induced thrombocytopenia | Well-documented arterial thrombotic risk, but venous thrombosis more common |
| Intravenous immunoglobulin36 | Stroke, MI | Many proposed: hyperviscosity, platelet activation, vasospasm, factor XI content | Risk factors: older age, hypertension, hypercholesterolemia. Consider lower dose, slower infusion rate |
| Cocaine37 | Stroke, MI, PA | Platelet activation, vasoconstriction, accelerated atherosclerosis | Contributes to acute thrombosis risk and chronic arterial remodeling |
| Tobacco, cannabis38 | PA | Thromboangiitis obliterans (Buerger disease) | Inflammatory vascular disease of the small- and medium-sized vessels of the extremities |
| Erythropoiesis-stimulating agents39 | Stroke, MI | Platelet activation, hyperviscosity, hypertension, increased procoagulant factors | Risk most clearly documented in patients with renal disease treated to higher hemoglobin targets |
| Anticancer therapies40 | |||
| VEGF inhibitors* | Stroke, MI | Endothelial dysfunction, increased procoagulant factors, accelerated atherosclerosis, HTN | Also associated with hemorrhage |
| Tamoxifen | Stroke | Unknown | Initial trials suggested increased stroke risk but decreased cardiac mortality, but variable in later trials |
| Fluorouracil | MI | Vasospasm, endothelial damage, increased procoagulant factors | Cardiotoxicity incidence 4% to 19%, but role of thrombosis vs other mechanisms unclear |
| Immune checkpoint inhibitors41 | Stroke, MI, PA | Increased procoagulant factors, platelets activation, impaired fibrinolysis, accelerated atherosclerosis | Venous thrombosis more common than arterial (reported 13% vs 2%) |
| Medication . | Sites . | Proposed mechanism(s) . | Notes . |
|---|---|---|---|
| Estrogens33 | Stroke, MI | Increased platelet activation and procoagulant factors, decreased anticoagulant and fibrinolysis factors | Variable risk reported, likely low absolute risk with commonly used lower estrogen doses. Higher risk in patients with HTN, smoking |
| Androgenic anabolic steroids34 | Stroke, MI | Accelerated atherosclerosis, coagulation abnormalities, elevated hematocrit | General term for performance-enhancing drugs with promyogenic and androgenic effects |
| Heparin35 | PA > stroke, MI | Autoimmune response to heparin-PF4 complex causing heparin-induced thrombocytopenia | Well-documented arterial thrombotic risk, but venous thrombosis more common |
| Intravenous immunoglobulin36 | Stroke, MI | Many proposed: hyperviscosity, platelet activation, vasospasm, factor XI content | Risk factors: older age, hypertension, hypercholesterolemia. Consider lower dose, slower infusion rate |
| Cocaine37 | Stroke, MI, PA | Platelet activation, vasoconstriction, accelerated atherosclerosis | Contributes to acute thrombosis risk and chronic arterial remodeling |
| Tobacco, cannabis38 | PA | Thromboangiitis obliterans (Buerger disease) | Inflammatory vascular disease of the small- and medium-sized vessels of the extremities |
| Erythropoiesis-stimulating agents39 | Stroke, MI | Platelet activation, hyperviscosity, hypertension, increased procoagulant factors | Risk most clearly documented in patients with renal disease treated to higher hemoglobin targets |
| Anticancer therapies40 | |||
| VEGF inhibitors* | Stroke, MI | Endothelial dysfunction, increased procoagulant factors, accelerated atherosclerosis, HTN | Also associated with hemorrhage |
| Tamoxifen | Stroke | Unknown | Initial trials suggested increased stroke risk but decreased cardiac mortality, but variable in later trials |
| Fluorouracil | MI | Vasospasm, endothelial damage, increased procoagulant factors | Cardiotoxicity incidence 4% to 19%, but role of thrombosis vs other mechanisms unclear |
| Immune checkpoint inhibitors41 | Stroke, MI, PA | Increased procoagulant factors, platelets activation, impaired fibrinolysis, accelerated atherosclerosis | Venous thrombosis more common than arterial (reported 13% vs 2%) |
Includes bevacizumab, tyrosine kinase inhibitors (eg, sorafenib), aflibercept.
HTN, hypertension; MI, myocardial infarction; PA, peripheral artery; PF4, platelet factor 4; VEGF, vascular endothelial growth factor.