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Patterns of anticoagulation for atrial fibrillation in cancer patients referred to cardio-oncological evaluation

Published:August 05, 2020DOI:https://doi.org/10.1016/j.ejim.2020.08.004
      Prophylaxis of atrial fibrillation (AF)-related cardioembolism in oncology is often challenging [
      • Farmakis D.
      • Parissis J.
      • Filippatos G
      Insights into onco-cardiology: atrial fibrillation in cancer.
      ]. The CHA2DS2-VASc score performs differently according to the presence or absence of cancer, with more thromboembolic and bleeding events occurring in subjects with than without malignancy and a CHA2DS2-VASc score <2 [
      • D'Souza M.
      • Carlson N.
      • Fosbøl E.
      • et al.
      CHA2DS2-VASc score and risk of thromboembolism and bleeding in patients with atrial fibrillation and recent cancer.
      ]. INR values are often out of the therapeutic range in oncological patients receiving vitamin K antagonist (VKA), and the pharmacokinetics and pharmacodynamics of direct oral anticoagulants (DOAC) may be significantly affected by antineoplastic therapies [
      • Farmakis D.
      • Parissis J.
      • Filippatos G
      Insights into onco-cardiology: atrial fibrillation in cancer.
      ]. Because of these treatment difficulties and tumor-related factors, risk of bleeding is enhanced when anticoagulation for AF is provided to cancer patients [
      • Fanola C.L.
      • Ruff C.T.
      • Murphy S.A.
      • et al.
      Efficacy and safety of edoxaban in patients with active malignancy and atrial fibrillation: analysis of the engage AF - TIMI 48 Trial.
      ]. Moreover, low molecular weight heparin (LMWH) has historically been prescribed for cancer-associated AF without supporting evidence, possibly on the grounds that this treatment is effective in preventing venous thromboembolism in the oncological population [
      • Malavasi V.L.
      • Fantecchi E.
      • Gianolio L.
      • et al.
      Atrial fibrillation in patients with active malignancy and use of anticoagulants: under-prescription but no adverse impact on all-cause mortality.
      ]. All these issues are reflected by the lack of guideline recommendations specifically on thromboprophylaxis of AF with concomitant cancer [
      • Kirchhof P.
      • Benussi S.
      • Kotecha D.
      • et al.
      ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
      ], which further complicates therapeutic decisions.

      Keywords

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