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Direct oral anticoagulants versus enoxaparin in patients with atrial fibrillation and active cancer

      Atrial fibrillation (AF) is the most prevalent sustained arrhythmia. Benefits of anticoagulation therapy in reducing the risk of ischemic stroke in the majority of patients with AF are well-established [
      • Patel NJ
      • Deshmukh A
      • Pant S
      • Singh V
      • Patel N
      • Arora S
      • et al.
      Contemporary trends of hospitalization for atrial fibrillation in the United States, 2000 through 2010: implications for healthcare planning.
      ,
      • Lip GYH
      • Banerjee A
      • Boriani G
      • Chiang CE
      • Fargo R
      • Freedman B
      • et al.
      Antithrombotic therapy for atrial fibrillation: CHEST guideline and expert panel report.
      ]. AF incidence is suggested to be increased in cancer patients and they are hypothesized to be at a higher risk of ischemic stroke [
      • Chu G
      • Versteeg HH
      • Verschoor AJ
      • Trines SA
      • Hemels MEW
      • Ay C
      • et al.
      Atrial fibrillation and cancer - an unexplored field in cardiovascular oncology.
      ]. The efficacy of prophylactic anticoagulation in cancer patients has lately been assessed in several studies, reporting divergent results [
      • Malavasi VL
      • Fantecchi E
      • Gianolio L
      • Pesce F
      • Longo G
      • Marietta M
      • et al.
      Atrial fibrillation in patients with active malignancy and use of anticoagulants: under-prescription but no adverse impact on all-cause mortality.
      ,
      • Atterman A
      • Friberg L
      • Asplund K
      • Engdahl J.
      Net benefit of oral anticoagulants in patients with atrial fibrillation and active cancer: a nationwide cohort study.
      ]. In the last decade, four direct oral anticoagulants (DOACs) designed to reduce the risk of stroke and systemic embolism have been approved. Some studies, evaluating the efficacy and safety of DOACs relative to vitamin K antagonists (VKA) in cancer patients with AF, have shown a lower or similar risk of stroke and bleeding in patients on DOACs compared to VKA users [
      • Mariani MV
      • Magnocavallo M
      • Straito M
      • Piro A
      • Severino P
      • Iannucci G
      • et al.
      Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and cancer a meta-analysis.
      ,
      • Cavallari I
      • Verolino G
      • Romano S
      • Patti G.
      Efficacy and safety of nonvitamin k oral anticoagulants in patients with atrial fibrillation and cancer: a study-level meta-analysis.
      ]. Low-molecular-weight-heparin (LMWH) is considered superior to VKA for the prevention of venous thromboembolism (VTE) recurrence in cancer patients [
      • Lee AY
      • Levine MN
      • Baker RI
      • Bowden C
      • Kakkar AK
      • Prins M
      • et al.
      Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer.
      ]. Recently, a number of studies have demonstrated that direct Xa inhibitors are also safe and efficacious in cancer-related VTE [
      • Mulder FI
      • Bosch FTM
      • Young AM
      • Marshall A
      • McBane RD
      • Zemla TJ
      • et al.
      Direct oral anticoagulants for cancer-associated venous thromboembolism: a systematic review and meta-analysis.
      ]. According to these findings, DOACs appear to be a reasonable choice in the cancer setting. Given the complexity of the clinical scenario and the scarcity of data on superiority or non-inferiority of DOACs versus LMWH in patients with AF and a coexistent malignancy, the current study has aimed to compare the efficacy and safety of these two types of anticoagulants in such challenging setting.

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