Anticoagulation for atrial fibrillation in active cancer (Review)

Abstract

Atrial fibrillation (AF) may often pre-exist in patients with newly diagnosed cancer or occur with increased frequency shortly after cancer diagnosis. Patients with active cancer and AF have a particularly high risk of thromboembolic complications, as both conditions carry a risk of thrombosis. Thromboembolic risk is determined by several factors, including advanced age, sex (females), cancer histology (adenocarcinomas), location (e.g., pancreas, stomach), advanced stage, anticancer regimens (e.g., platinum compounds, anti-angiogenic therapies, immune modulators), comorbidities (e.g., obesity, kidney disease) and concurrent therapies (e.g., surgery, central catheters). Physicians are often reluctant to prescribe anticoagulants to patients with active cancer and AF, mainly due to fear of bleeding complications, which is partly related to the paucity of evidence in the field. Decision making regarding anticoagulation for the prevention of ischemic stroke and systemic embolism in patients with active cancer and AF may be challenging and should not simply rely on the risk prediction scores used in the general AF population. By contrast, the administration and choice of anticoagulants should be based on the comprehensive, individualized and periodic evaluation of thromboembolic and bleeding risk, drug-drug interactions, patient preferences and access to therapies.

Current Data and Future Perspectives on Patients with Atrial Fibrillation and Cancer

“…Regarding the assessment of the bleeding risk, the HAS-BLED was quite accurate [47], although the HEMORR2HAGES score also includes a history of malignancy and thrombocytopenia in the risk assessment (Table 3) [48]. The latter is an important finding, as it has been shown that platelets < 100,000 × 10 9 /L increase the risk of bleeding for cancer patients taking anticoagulants and tumors together with cancer treatments may cause thrombocytopenia [33,49]. Farmakis et al proposed an alternative approach for risk stratification that includes the following acronyms: T (thrombotic risk), B (bleeding risk), I (drug interactions), and P (patient access and preferences) [50].…”

Anti-Inflammatory and Anticancer Effects of Anticoagulant Therapy in Patients with Malignancy

“…For bleeding risk assessment, the HAS-BLED score may be considered [ 62 ]. A proposed approach to anticoagulant therapy in cancer is based on the acronym T (thrombotic risk), B (bleeding risk), I (drug interactions), P (access and patient preferences) [ 71 ].…”

Outcome of Atrial Fibrillation Ablation in Cancer Patients: A Review

“…Active malignancy amplifies the thromboembolic risk in patients with AF due to its hypercoagulable state, creating a challenge in anticoagulation [15]. Thrombocytopenia due to chemotherapy-induced bone marrow suppression can further complicate this situation.…”