Atrial Fibrillation in Cancer Patients

Рассматривается современное состояние вопроса выбора антикоагулянтной терапии при фибрилляции предсердий (ФП) у онкологических больных. Отмечается, что сложность выбора антикоагулянта при злокачественных новообразованиях (ЗНО) определяется такими факторами, как коморбидные сердечно-сосудистые заболевания, нарушения функции печени и почек, метаболические дисфункции, свойственные, прежде всего, пациентам старшей возрастной группы. Приводятся актуальные данные по оценке риска геморрагических и тромбоэмболических осложнений ФП при ЗНО в аспекте возраста. Обсуждаются возможные причины увеличения риска развития ФП во время и после лечения ЗНО, в том числе и в связи с возраст-ассоциированностью этих патологий. Рассмотрены вопросы выбора антикоагулянтов у пациентов, находящихся на активной противоопухолевой терапии, особенно на препаратах из группы прямых оральных антикоагулянтов (ПОАК). Согласно данным обсервационных исследований, именно ПОАК являются перспективным, относительно безопасным и эффективным выбором для онкологических пациентов с ФП, в связи с чем их применение должно активно изучаться в рандомизированных клинических исследованиях с учетом фактора возраста. Подчеркивается, что подбор схемы антикоагулянтной терапии у пациентов с ФП и ЗНО требует междисциплинарного участия кардиологов и онкологов, а часто и гериатров, чтобы индивидуализировать лечение и предложить наиболее эффективную терапию. The current issue of the choice of anticoagulant therapy of atrial ﬁbrillation (AF) in cancer patients is considered. It is noted that the difﬁculty of choosing an anticoagulant in malignancies is largely determined by age-related factors, such as comorbid cardiovascular diseases, liver and kidney dysfunction, metabolic disorders common for in elderly patients. Current data on the risk assessment of hemorrhagic and thromboembolic complications of AF in cancer patients in the aspect of age presented. During and after cancer treatment, the risk of developing AF can increase, also in connection with the age-associated pathology. Possible reasons of it are discussed. The choice of different anticoagulants groups in patients treated with anticancer therapy, including direct oral anticoagulants (DOAC) is considered. According to available data from observational studies, it is the DOAC that is a promising, relatively safe and effective choice for cancer patients with AF, and therefore their use should be actively studied in randomized trials, considering the factor of age. It is particularly noted that solving this problem requires the interdisciplinary involvement of cardiologists, oncologists, and sometimes, geriatrics, to individualize treatment for each case and to offer the most effective therapy.

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Abstract P146: Comparative Effectiveness Of Direct Oral Anticoagulants Versus Warfarin Among Medicare Beneficiaries With Atrial Fibrillation

Circulation ◽

10.1161/circ.143.suppl_1.p146 ◽

2021 ◽

Vol 143 (Suppl_1) ◽

Author(s):

Shirin Ardeshirrouhanifard ◽

Huijun An ◽

Ravi Goyal ◽

Mukaila Raji ◽

Caleb Alexander ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Cancer Patients ◽

Risk Model ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Competing Risk ◽

Secondary Outcome ◽

Systemic Embolism ◽

Competing Risk Model

Objective: Post-hoc analysis of three pivotal clinical trials suggests no difference in risk of ischemic stroke or systemic embolism among cancer patients with atrial fibrillation treated with direct oral anticoagulants (DOACs) vs. warfarin. However, these studies were underpowered and also do not reflect the context of real-world use. We compared the effectiveness of DOACs versus warfarin for the risk of stroke or systemic embolism and all-cause death in patients with NVAF. Methods: We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2009 to 2016 and included patients aged ≥66 years diagnosed with cancer (breast, bladder, colorectal, esophagus, lung, ovary, kidney, pancreas, prostate, stomach or uterus) and NVAF. We limited the cohort to patients who newly initiated warfarin or DOACs (from 2010 to 2016) with no history of ischemic stroke or systemic embolism. The primary outcome was hospitalization due to ischemic stroke or systemic embolism and the secondary outcome was all-cause death. We used Fine and Gray’s competing risk model, while treating death as a competing risk, to determine the association of oral anticoagulants with the incidence of stroke or systemic embolism. We also adjusted the analysis using inverse probability of treatment weighted (IPTW). Additionally, an IPTW-adjusted Cox proportional hazards regression model was constructed for all-cause death. Results: Of 1,028,784 patients with cancer, 158,744 (15.4%) were diagnosed with atrial fibrillation. After applying all inclusion criteria, the final study cohort included 7,334 cancer patients diagnosed with incident NVAF who newly initiated warfarin or DOACs, of which 3,194 (43.6%) used warfarin and 4,140 (56.4%) used DOACs. The unadjusted rate of stroke or systemic embolism was similar among warfarin and DOACs users (1.20 vs. 1.32 cases per 100 person-years, p=0.27). In the IPTW weighted competing risk model, the use of DOACs was not associated with an increased risk of stroke or systemic embolism compared with warfarin users (Hazard Ratio [HR] 1.41, 95% confidence intervals [CI] 0.90-2.20). However, DOACs users had a significantly lower risk of all-cause death compared with warfarin users (HR 0.82, CI 0.74-0.91). Conclusion: Among cancer patients diagnosed with NVAF, DOACs had a similar risk for stroke or systemic embolism compared to warfarin, although DOAC use was associated with reduced risk of all-cause mortality.

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

European Journal of Internal Medicine ◽

10.1016/j.ejim.2020.08.004 ◽

2020 ◽

Vol 82 ◽

pp. 128-129

Author(s):

Matteo Toma ◽

Edlira Rrapaj ◽

Paolo Spallarossa ◽

Federico Guerra ◽

Pietro Ameri

Keyword(s):

Atrial Fibrillation ◽

Cancer Patients

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P4798Stereotactic radiotherapy for atrial fibrillation in three cancer patients

European Heart Journal ◽

10.1093/eurheartj/ehz745.1174 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M Shoji ◽

K Inaba ◽

J Itami ◽

T Iwasa ◽

M Yoshida ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cancer Patients ◽

Therapeutic Option ◽

Posterior Wall ◽

Target Dose ◽

Ablation Volume ◽

Planning Software ◽

Acute Complications ◽

Treatment Volume ◽

Circumferential Pulmonary Vein Isolation

Abstract Background Although catheter ablation is an effective therapy for atrial fibrillation (AF), risks remain and improved efficacy is desired. Stereotactic radiotherapy is a well-established therapy used to noninvasively treat malignancies with precision. Objective We sought to evaluate stereotactic arrhythmia radioablation (STAR) as a therapeutic option for treating AF. Methods Three cancer patients with drug refractory AF were enrolled. Planning software using 3-D CT of the left atrium was used to design a desired ablation volume encompassing antral circumferential pulmonary vein isolation, a roof line, and a floor line to create a “BOX” lesion set. Target dose to the treatment volume was 25 Gy, with exposure to the esophagus excluded. After planning, patients were treated in the radioablation suite. Results STAR was able to deliver the intended radiation dose to target without complication in 3 patients. No acute complications were seen for up to 6 months. One patient with paroxysmal AF died of deterioration of cancer. The autopsy revealed evidence of fibroblasts and fibrogenesis at the regions of atrial tissues targeted with radioablation. Two patients with longstanding persistent AF remained in AF at 6 months. In one patient, atrial electrograms were recorded at the atrial posterior wall from the esophagus before STAR, and it was absent at 3 months after STAR, indicating electrical isolation. BOX isolation created by STAR Conclusions Although STAR may be safe, further evaluation is warranted regarding effectiveness. For longstanding persistent AF, AF may be difficult to terminate only with a BOX lesion set without electrical cardioversion.

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The role of surgery type in postoperative atrial fibrillation and in-hospital mortality in esophageal cancer patients with preserved left ventricular ejection fraction

World Journal of Surgical Oncology ◽

10.1186/s12957-020-02011-6 ◽

2020 ◽

Vol 18 (1) ◽

Author(s):

Laite Chen ◽

Lu Zhang ◽

Lu Shi ◽

Guosheng Fu ◽

Chenyang Jiang

Keyword(s):

Atrial Fibrillation ◽

Esophageal Cancer ◽

Hospital Mortality ◽

Cancer Patients ◽

Left Ventricular ◽

Postoperative Atrial Fibrillation ◽

Left Ventricular Ejection ◽

Short Term ◽

Term Survival ◽

Ventricular Ejection Fraction

Abstract Background Postoperative atrial fibrillation (POAF) is one of the most common complications of esophagectomy, which may extend the inpatient hospital stay. Minimally invasive esophagectomy (MIE) has been increasingly used in clinical practice; however, its POAF risk and short-term mortality remain unclear. This study aimed to examine the POAF risk and in-hospital mortality rate between patients receiving MIE and open esophagectomy (OE). Methods Esophageal cancer patients who underwent MIE or OE from a retrospective cohort study were evaluated. A multivariate logistic regression model was built to assess the associations between esophagectomy (MIE vs. OE) and various outcomes (POAF, in-hospital mortality). Covariates included age, sex, body mass index, neoadjuvant therapy, tumor stage, surgery incision type, comorbidities, cardia conditions, peri-operative medication, and complications. Results Of the 484 patients with esophageal cancer, 63 received MIE. A total of 53 patients developed POAF. Compared to patients receiving OE, MIE patients had 81% reduced odds of POAF (adjusted odds ratio [aOR] 0.185, 95% CI 0.039–0.887, P = 0.035). No statistically significant association was found for in-hospital mortality (aOR 0.709, 95% CI 0.114–4.409, P = 0.712). Conclusions MIE is associated with a lower risk of POAF, compared to traditional surgery. No significant short-term survival benefit was found for MIE.

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280: HIGHER MORTALITY IN NEW-ONSET ATRIAL FIBRILLATION IN CANCER PATIENTS WITH SEPTIC SHOCK

Critical Care Medicine ◽

10.1097/01.ccm.0000619476.69801.ed ◽

2020 ◽

Vol 48 (1) ◽

pp. 122-122

Author(s):

John Cuenca ◽

Andres Laserna ◽

Peyton Martin ◽

Nirmala Manjappachar ◽

Keara O’Connell ◽

...

Keyword(s):

Atrial Fibrillation ◽

Septic Shock ◽

Cancer Patients ◽

Onset Atrial Fibrillation ◽

New Onset

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Anticoagulation in Cancer Patients with Atrial Fibrillation and Grade 3-4 Thrombocytopenia

Blood ◽

10.1182/blood-2021-150782 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 4272-4272

Author(s):

Genady Drozdinsky ◽

Noam Arad ◽

Galia Spectre ◽

Nir Livneh ◽

Itamar Poran ◽

...

Keyword(s):

Atrial Fibrillation ◽

Acute Leukemia ◽

Cancer Patients ◽

Major Bleeding ◽

Cumulative Incidence ◽

Competing Risk ◽

Newly Diagnosed ◽

Thrombotic Risk ◽

Significant Difference ◽

Grade 3

Abstract Introduction: Atrial fibrillation (AF) is not uncommon in cancer patients with grade 3-4 thrombocytopenia (platelets <50x10 9/L). The risk of bleeding appears to outweigh the risk of thrombosis in acute leukemia patients. There are no published data regarding management of anticoagulation (AC) and rates of bleeding and thrombosis in other cancer types. Aim: To assess AC management and incidence of bleeding and thrombosis in thrombocytopenic cancer patients with AF. Methods: Single-center retrospective cohort study. The study included adults with active cancer, grade 3-4 thrombocytopenia (platelets <50x10 9/L) and AF with CHA 2DS 2-VASc ≥1, irrespective of AC status prior index. Patients with acute leukemia were excluded. Patients were indexed when platelets <50x10 9/L. AC management was classified as either "No-AC", if AC was withheld (i.e., stopped or not started) at index, or "Continue-AC", if AC was continued. Arterial thromboembolism (ATE; ischemic stroke, transient ischemic attack or systemic embolism) and ISTH-defined major bleeding were recorded over 30 days. The 30-day cumulative incidence of composite and individual outcomes with corresponding 95% confidence intervals (CI) was calculated for each management group (death as competing risk). A Cox proportional hazards model was used to calculate hazard ratios (HR) and corresponding 95% CI for outcomes between the No-AC and Continue-AC groups, with death as a competing risk (Fine and Gray model). Results: The eligibility criteria were met by 131 patients. At study index, AC was not given in 90 (69%) patients and continued in 41 (31%). Table 1 shows patient characteristics overall and stratified for management. The median age was 80 years )IQR 70-82) and 55 (42%) were females. Most patients were inpatients at index (70%) and had newly diagnosed cancer (70%). 64% had solid malignancy, and the remainder had hematological malignancy. The majority (92%) had AF prior to study index, while 8% had AF newly diagnosed at index. The median CHA 2DS 2-VASc score was 4 [IQR 3-5] and 18% had a prior stroke. Median platelet counts were 42 x 10 9/L at index and the median HASBLED score was 5 [3-5]. Only 44% of the No-AC group were receiving AC prior index, compared with 95% in the Continue-AC group, at shorter median duration. The type of prior AC differed between groups. Antiplatelet therapy (54%) and major bleeding prior index (13%) were more frequent in the No-AC group. There was a median [IQR] of 4 [0-60] and 4 [1-26] days of grade 3-4 thrombocytopenia in the No-AC and Continue-AC groups, respectively. Platelet nadirs (x10 9/L) were numerically higher in the No-AC group (31 [3-50] vs. 21 [6-50]; p=0.09). A median [IQR] of 12 [6-17.25] and 10 [5-12] platelet transfusions were given to 29 (32.2%) patients in the No-AC group and 11 (26.8%) in the Continue-AC group, respectively (p>0.2). In the Continue-AC group, AC was subsequently held in 12/41 (29%) and dose-reduced in 4/41 (10%) during the 30 days post-index. The 30-day cumulative incidence [95% CI] of the composite outcome (major bleeding or ATE) was 10% [4.88-17.27] in the No-AC group and 4.88% [0.86-14.7] in the Continue-AC group (HR 2.142 [0.47-9.609]). The 30-day cumulative incidence of ATE (Figure 1A) was 3.33% [0.88-8.66] in the No-AC group (n=3), and 4.88% [0.85-14.7] in the Continue-AC group (n=2), corresponding with a HR of 0.70 [0.12-4.10]. The 30-day cumulative incidence of major bleeding (Figure 1B) was 7.8% [3.40-14.52] in the No-AC group, and 2.44% [0.18-11.22] in the Continue-AC group (HR 3.29 [0.42-26.04]). The 30-day overall survival was 64.4% in the No-AC and 73.2% in the Continue-AC groups (HR 1.39 (95% CI 0.7-2.76). Conclusions: In a cohort of cancer patients with grade 3-4 thrombocytopenia (<50x10 9/L) and AF (median CHA 2DS 2-VASc = 4), the majority had anticoagulation held. Baseline thrombotic and bleeding risk factors were generally balanced, but a higher rate of prior bleeding and lower rates of anticoagulation prior index in the No-AC group, suggest confounding by indication. No statistically significant difference in outcomes was detected between management groups, but 95% CI's were wide. The high bleeding and low ATE incidence in the No-AC group suggests that holding AC during time-limited periods of grade 3-4 thrombocytopenia may be a reasonable approach in many cancer patients with AF. Continuing AC should be investigated in a subset of patients with lower bleeding and higher thrombotic risk. Figure 1 Figure 1. Disclosures Falanga: Pfizer: Honoraria; Bayer: Honoraria; Sanofi: Honoraria; Leo Pharma: Honoraria. ten Cate: Bayer AG: Other; Pfizer: Other; LEO Pharma: Other; Gideon Pharmaceuticals: Other; Alveron Pharma: Other. Leader: Bayer: Honoraria; Leo Pharma: Honoraria; Novartis: Honoraria; Pfizer: Consultancy, Honoraria; Sanofi: Honoraria.

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