Anticoagulation for Atrial Fibrillation in Patients With Cancer

Background: Early cardiology involvement within 90 days of atrial fibrillation (AF) diagnosis is associated with greater likelihood of oral anticoagulant use and a reduced risk of stroke. Due to variation in cardiovascular care for patients with cancer, it is possible that a similar association does not exist for AF patients with cancer. Methods: We examined the association of early cardiology involvement with oral anticoagulation use among non-valvular AF patients with history of cancer (past or active), using data from 388,045 patients (mean age=68±15 years; 59% male) from the MarketScan database (2009-2014). ICD-9 codes in any position were used to identify cancer diagnosis prior to AF diagnosis. Provider specialty and filled anticoagulant prescriptions 3 months prior to and 6 months after AF diagnosis were obtained. Poisson regression models were used to compute the probability of an oral anticoagulant prescription fill and Cox regression was used to estimate the risk of stroke and major bleeding. Results: A total of 64,016 (17%) AF patients had a prior history of cancer. Cardiology involvement was less likely to occur among patients with history of cancer than those without (relative risk=0.92, 95% confidence interval (0.91, 0.93)). Similar differences were observed for cancers of the colon (0.90 (0.88, 0.92)), lung (0.76 (0.74, 0.78)), pancreas (0.74 (0.69, 0.80)), and hematologic system (0.88 (0.87, 0.90)), while no differences were observed for breast or prostate cancers. Patients with cancer were less likely to fill prescriptions for anticoagulants (0.89 (0.88, 0.90)) than those without cancer, and similar results were observed for cancers of the colon, lung, prostate, pancreas, and hematologic system. However, patients with cancer were more likely to fill prescriptions for anticoagulants (1.48 (1.45, 1.52)) if seen by a cardiology provider, regardless of cancer type. A reduced risk of stroke (hazard ratio=0.89 (0.81, 0.99)) was observed among all cancer patients who were seen by a cardiology provider than among those who were not, without an increased risk of bleeding (1.04 (0.95, 1.13)). Conclusion: AF patients with cancer were less likely to see a cardiologist, and less likely to fill an anticoagulant prescription than AF patients without cancer. However, cardiology involvement was associated with increased anticoagulant prescription fills and reduced risk of stroke, suggesting a beneficial role for cardiology providers to improve outcomes in AF patients with history of cancer.

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PREDICTING MORTALITY IN PATIENTS WITH CANCER AND ATRIAL FIBRILLATION

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(18)31012-x ◽

2018 ◽

Vol 71 (11) ◽

pp. A471

Author(s):

Alejandra Gutierrez Bernal ◽

Rushad Patell ◽

Lisa Rybicki ◽

Alok A. Khorana

Keyword(s):

Atrial Fibrillation ◽

Patients With Cancer

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P1574Predictors of mortality in hospitalized atrial fibrillation patients with cancer

European Heart Journal ◽

10.1093/eurheartj/ehz748.0334 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

A H Malik ◽

S Shetty ◽

S Malik

Keyword(s):

Atrial Fibrillation ◽

Hospital Mortality ◽

Cancer Diagnosis ◽

Multivariate Regression ◽

Nationwide Inpatient Sample ◽

Kidney Injury ◽

Teaching Hospitals ◽

Multivariate Regression Model ◽

Patients With Cancer ◽

Diagnosis Of Cancer

Abstract Background Recent reports indicate an important interplay between Atrial fibrillation (AF) and cancer. There is little information regarding the outcomes of these patients. Hence, we performed a study to identify predictors of in-hospital mortality to help guide goals of care discussions. Methods The Nationwide Inpatient Sample was used to identify patients with a diagnosis of cancer, who were found to have AF from 2002–2014. Trend rate, patients' and hospital characteristics along with in-hospital complications and predictors of in-hospital mortality were assessed. Backward stepwise elimination technique was used to fit the multivariate regression model. Results Over the 13-year study period, 12,410,290 (national estimate) patients with a cancer diagnosis were identified. 1,013,735 had AF, and 10.2% of the AF patients with cancer died while hospitalised. A variety of comorbidities, in-hospital procedures and in-hospital complications increased the odds of in-hospital mortality in these patients. Also, weekend admissions, elective admissions, and rural hospitals in comparison to urban teaching and non-teaching hospitals were associated with higher in-hospital mortality. Conclusion Stroke, myocardial infarction, pulmonary embolism, deep venous thrombosis, acute kidney injury, congestive heart failure, sepsis, and cardiogenic shock are most significant predictors of in-hospital mortality in AF patients with cancer. Acknowledgement/Funding None

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3054Efficacy and safety of non-vitamin K oral anticoagulants in patients with atrial fibrillation and cancer

European Heart Journal ◽

10.1093/eurheartj/ehz745.0021 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

I Cavallari ◽

G Verolino ◽

G Patti

Keyword(s):

Atrial Fibrillation ◽

Venous Thromboembolism ◽

Intracranial Hemorrhage ◽

Major Bleeding ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Efficacy And Safety ◽

Systemic Embolism ◽

Patients With Cancer ◽

All Cause Mortality

Abstract Background Anticoagulation in patients with cancer and atrial fibrillation (AF) is particularly challenging given the higher risk of both thrombotic and bleeding complications in this setting. Data regarding the efficacy and safety of non-vitamin K oral anticoagulants (NOACs) in AF patients with malignancy remain unclear. Purpose In the present meta-analysis we further investigate the efficacy and safety of NOACs compared to warfarin in patients with AF and cancer assuming that available studies may be individually underpowered for endpoints at low incidence, i.e. stroke, major and intracranial bleeding. Methods We performed a systematic review and meta-analysis of studies comparing the use of NOACs vs. warfarin in AF patients with cancer. Efficacy outcome measures included stroke or systemic embolism, venous thromboembolism and mortality. Safety outcome measures were major bleeding and intracranial hemorrhage. Results We pooled data from 6 identified studies enrolling a total of 31,756 AF patients with cancer. Mean follow-up was 1.7 years. Patients with cancer had significantly increased annualized rates of venous thromboembolism (1.38% vs. 0.74%), major bleeding (9.01% vs. 5.13%), in particular major gastrointestinal bleeding (2.38% vs. 1.60%), and all-cause mortality (17.73% vs. 8.50%) vs. those without (all P values <0.001), whereas the incidence of stroke or systemic embolism and intracranial hemorrhage did not differ. Compared with warfarin, treatment with NOACs nominally decreased the risk of stroke or systemic embolism (5.41% vs. 2.70%; odds ratio, OR; 95% confidence intervals, CI 0.51, 0.26–1.01; P=0.05; Figure), mainly of ischemic stroke (OR 0.56; 95% CI 0.35–0.89; P=0.01), and the risk of venous thromboembolism (OR 0.51; 95% CI 0.42–0.61; P<0.001). In cancer patients receiving NOACs there was a significant reduction of major bleeding (3.95% vs. 4.66%; OR 0.66, 95% CI 0.46–0.94; P=0.02; Figure) and intracranial hemorrhage (0.26% vs. 0.66%; OR 0.25, 95% CI 0.08–0.82; P=0.02) vs. warfarin, with no difference in gastrointestinal major bleeding rates. Conclusion AF patients on oral anticoagulation and concomitant cancer are at higher risk of venous thromboembolism, major bleeding and all-cause mortality. NOACs may represent a safer and more effective alternative to warfarin also in this setting of patients.

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P675Current status of anticoagulation in patients with breast cancer and atrial fibrillation

European Heart Journal ◽

10.1093/eurheartj/ehz747.0281 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

A Pardo Sanz ◽

L M Rincon ◽

P Guedes Ramallo ◽

L Belarte ◽

G De Lara ◽

...

Keyword(s):

Breast Cancer ◽

Atrial Fibrillation ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Bleeding Risk ◽

Bleeding Events ◽

Patients With Cancer ◽

Oncologic Patients

Abstract Aims Balance between embolic and bleeding risk is challenging in patients with cancer. There is a lack of specific recommendations for the use of antithrombotic therapy in oncologic patients with atrial fibrillation (AF). We compared the embolic and bleeding risk, the preventive management and the incidence of events between patients with and without cancer. We further evaluated the effectiveness and safety of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) within patients with cancer. Methods The AMBER-AF registry is an observational multicentre study that analysed patients with non-valvular AF treated in Oncology and Cardiology Departments in Spain. 1237 female patients with AF were enrolled: 637 with breast cancer and 599 without cancer. Mean follow-up was 3.1 years. Results Both groups were similar in age, CHA2DS2-VASc and HASB-LED scores. Lack of guidelines recommended therapies was more frequent among patients with cancer. Compared with patients without cancer, adjusted rates of stroke (hazard ratio [95% confidence interval]) in cancer patients were higher (1.56 [1.04–2.35]), whereas bleeding rates remained similar (1.25 [0.95–1.64]). Within the group of patients with cancer, the use of DOACs vs VKAs did not entail differences in the adjusted rates of stroke (0.91 [0.42–1.99]) or severe bleedings (1.53 [0.93–2.53]). Follow-up events Conclusions Antithrombotic management of AF frequently differs in patients with breast cancer. While breast cancer is associated with a higher risk of incident stroke, bleeding events remained similar. Patients with cancer treated with DOACs experienced similar rates of stroke and bleeding as those with VKAs.

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Efficacy and Safety of Nonvitamin K Oral Anticoagulants in Patients with Atrial Fibrillation and Cancer: A Study-Level Meta-Analysis

Thrombosis and Haemostasis ◽

10.1055/s-0039-3400300 ◽

2019 ◽

Vol 120 (02) ◽

pp. 314-321 ◽

Cited By ~ 3

Author(s):

Ilaria Cavallari ◽

Giuseppe Verolino ◽

Silvio Romano ◽

Giuseppe Patti

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Venous Thromboembolism ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Intracranial Bleeding ◽

Efficacy And Safety ◽

Systemic Embolism ◽

Primary Analysis ◽

Patients With Cancer

Abstract Objectives In this study-level meta-analysis, we evaluated the clinical outcome with nonvitamin K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients with cancer. Background Anticoagulation in AF patients with cancer is challenging given the coexistence of elevated thrombotic and bleeding risk. The efficacy and safety of NOACs in this setting remain unclear. Methods We included three randomized trials in our primary analysis (N = 2,661 patients) and three observational studies in our secondary, confirmatory analysis (N = 21,112 patients). Outcome measures were: the composite of any stroke or systemic embolism, ischemic stroke, venous thromboembolism, major bleeding, intracranial bleeding; and all-cause death. Mean follow-up duration was 2.2 years. Results In the primary analysis, the use of NOACs was associated with similar incidence of stroke/systemic embolism (odds ratio [OR] 0.70, 95% confidence interval 0.45–1.09; p = 0.11), ischemic stroke (OR 0.71, 0.31–1.64; p = 0.42), venous thromboembolism (OR 0.91, 0.33–2.53; p = 0.86), all-cause death (OR 1.02, 0.72–1.42; p = 0.93), and major bleeding (OR 0.81, 0.61–1.06; p = 0.13) compared with VKAs. The occurrence of intracranial bleeding was significantly lower in the NOACs versus VKAs group (OR 0.11, 0.02–0.63; p = 0.01). These results were overall confirmed in the secondary analysis, where there was additionally a significant reduction of stroke/systemic embolism, ischemic stroke, and venous thromboembolism with NOACs. Conclusion In AF patients with malignancy, NOACs appear at least as effective as VKAs in preventing thrombotic events and reduce intracranial bleeding. NOACs may represent a valid and more practical alternative to VKAs in this setting of high-risk patients.

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