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Review
. 2020 Dec;17(6):365-383.
doi: 10.1007/s11897-020-00485-9.

The Complex Management of Atrial Fibrillation and Cancer in the COVID-19 Era: Drug Interactions, Thromboembolic Risk, and Proarrhythmia

Milo Gatti  1 , Emanuel Raschi  1 , Elisabetta Poluzzi  1 , Cristian Martignani  2 , Stefania Salvagni  3 , Andrea Ardizzoni  4 , Igor Diemberger  5
Affiliations
Review

The Complex Management of Atrial Fibrillation and Cancer in the COVID-19 Era: Drug Interactions, Thromboembolic Risk, and Proarrhythmia

Milo Gatti et al. Curr Heart Fail Rep. 2020 Dec.

Abstract

Purpose of review: Cardiotoxicity by anticancer agents has emerged as a multifaceted issue and is expected to affect both mortality and morbidity. This review summarizes clinical challenges in the management of oncological patients requiring anticoagulants for atrial fibrillation (AF) also considering the current outbreak of the COVID-19 (coronavirus disease 2019) pandemic, since this infection can add challenges to the management of both conditions. Specifically, the aims are manyfold: (1) describe the evolving use of direct oral anticoagulants (DOACs) in AF patients with cancer; (2) critically appraise the risk of clinically important drug-drug interactions (DDIs) between DOACs and oral targeted anticancer agents; (3) address expected DDIs between DOACs and candidate anti-COVID drugs, with implications on management of the underlying thrombotic risk; and (4) characterize the proarrhythmic liability in cardio-oncology in the setting of COVID-19, focusing on QT prolongation.

Recent findings: AF in cardio-oncology poses diagnostic and management challenges, also due to the number of anticancer drugs recently associated with AF onset/worsening. Oral targeted drugs can potentially interact with DOACs, with increased bleeding risk mainly due to pharmacokinetic DDIs. Moreover, the vast majority of oral anticancer agents cause QT prolongation with direct and indirect mechanisms, potentially resulting in the occurrence of torsade de pointes, especially in susceptible patients with COVID-19 receiving additional drugs with QT liability. Oncologists and cardiologists must be aware of the increased bleeding risk and arrhythmic susceptibility of patients with AF and cancer due to DDIs. High-risk individuals with COVID-19 should be prioritized to target preventive strategies, including optimal antithrombotic management, medication review, and stringent monitoring.

Keywords: Anticancer agents; Atrial fibrillation; COVID-19; Direct oral anticoagulants; Drug-drug interactions; QT prolongation.

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Conflict of interest statement

AA reports fees for advisory board participation from Roche, Merck Sharp & Dohme, AstraZeneca, and Bristol Myers Squibb and research grants for spontaneous studies from Roche and Bristol Myers Squibb, all outside the scope of the present paper. ER reports personal fee from Novartis, outside the submitted work. ID reports minor speaker fees from Daiichi Sankyo, Boehringer Ingelheim, Pfizer, and Bayer, outside the submitted work.

Figures

Fig. 1
Fig. 1
Revisiting the concept of the reduced repolarization reserve in cardio-oncology during the COVID-19 era. ACovCS, acute COVID cardiovascular syndrome; ICIs, immune checkpoint inhibitors; PPIs, proton pump inhibitors; SSRIs, selective serotonin re-uptake inhibitors; TKIs, tyrosine kinase inhibitors; LQTS, long QT syndrome; AF, atrial fibrillation; HF, heart failure; ECG, Electrocardiography
See this image and copyright information in PMC

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