Insights Into Onco-Cardiology

Abstract

Atrial fibrillation (AF) has been found to occur with an increased frequency in patients with malignancies, particularly in those undergoing cancer surgery. The occurrence of AF in cancer may be related to comorbid states or a direct tumor effect or may represent a complication of cancer surgical or medical therapy, whereas inflammation may be a common denominator for both conditions. Treating AF in patients with malignancies is a challenge, especially in terms of antithrombotic therapy, because cancer may result in an increased risk of either thrombosis or hemorrhage and an unpredictable anticoagulation response, whereas thromboembolic risk prediction scores such as CHADS2 (Cardiac Failure, Hypertension, Age, Diabetes, and Stroke [doubled]) may not be applicable. The general lack of evidence imposes an individualized approach to the management of AF in those patients, although some general recommendations based on current guidelines in noncancer patients and the existing evidence in cancer patients, where available, may be outlined.

Efficacy and Safety of Edoxaban in Patients With Active Malignancy and Atrial Fibrillation: Analysis of the ENGAGE AF‐TIMI 48 Trial

“…Use of DOACs in patients with AF is increasing in clinical practice and the aging population 36, 37. Older patients receiving DOACs may develop a new or recurrent malignancy because of shared risk factors with aging 3, 4, 5, 6. We anticipate, therefore, an increase in use of DOACs in patients with cancer and a need for efficacy and safety data.…”

“…Although data on patients with AF with malignancy are limited, observational studies suggest an association between AF and cancer,2, 3, 4, 5 likely because of systemic inflammation, shared risk factors, and common disease states underlying both conditions in aging populations 4, 6. Although 20‐year incident malignancy in patients with new‐onset AF has been reportedly low at 10%,4 incident AF may occur in up to 30% of patients with certain types of malignancy (eg, thoracic) 6. Cancer‐associated thrombosis has been well described,7, 8 and AF in patients with malignancy may independently double the risk of venous or arterial thromboembolism compared with either condition alone 9.…”

“…Cancer‐associated thrombosis has been well described,7, 8 and AF in patients with malignancy may independently double the risk of venous or arterial thromboembolism compared with either condition alone 9. Some malignancies may also inherently increase the risk for major bleeding in patients with AF (eg, hematologic cancer),6 which is potentiated further with anticoagulant therapy 10, 11…”

“…Patients with active malignancies were mostly excluded in trials of DOACs versus warfarin in AF given concerns of increased bleeding and thrombotic risk, rapid changes in renal and hepatic function, hematologic derangements, and potential for chemotherapeutic agent interactions via CYP3A4 and P‐glycoprotein 6, 14, 15. Malignancy is not incorporated in the CHADS 2 or CHA 2 DS 2 VASc thromboembolic risk prediction score to guide anticoagulant therapy,16, 17 and thus the approach to anticoagulant management in patients with AF with malignancy remains highly individualized 18.…”

Cardiovascular Oncologic Emergencies

“…The role of anticoagulation in patients with atrial fibrillation and cancers is gaining importance considering that cancer creates a thromboembolic state, while the nature of the tumor and metastasis inherently increase the risk of bleeding. No clear practice guidelines have been formulated for this population, and all the clinical trials on the novel oral anticoagulants have excluded cancer patients [64]. Hence, initiation of anticoagulants to prevent thromboembolic events in patients with atrial fibrillation has to be individualized, weighing in the risk-benefit profile.…”