Anticoagulation for atrial fibrillation in active cancer

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.

Keywords: anticoagulation; atrial fibrillation; cancer; direct oral anticoagulants; low molecular weight heparins.

Figure 1.

Risk factors for thrombosis in patients with cancer (content modified from ref. 23).

Figure 2.

The complex interplay among cancer, anticancer therapy and AF. Cancer and its therapy may lead to AF. At the same time, cancer and AF share common risk factors, including aging, cardiometabolic comorbidities such as hypertension, diabetes mellitus and obesity, and genetic predisposition. All the above, cancer, anticancer therapy, AF and their common patient-related risk factors, are predisposing factors for thromboembolic complications including stroke. AF, atrial fibrillation.

Figure 3.

A proposed approach to anticoagulation for AF in patients with active cancer (Farmakis D: Anticoagulation for atrial fibrillation in active cancer: What the cardiologists think. Eur J Prev Cardiol, 2020, 28: 608–610 (reference 1) by permission of Oxford University Press). AF, atrial fibrillation.