Atrial Fibrillation and Stroke Risk in Patients With Cancer: A Primer for Oncologists

Abstract

Cancer and atrial fibrillation (AF) are common conditions, but for patients affected with both, there is a lack of data about management of anticoagulation and cerebrovascular outcomes. In the first section of this review, we summarize the most relevant studies on stroke risk and management of AF in patients with active cancer, attempting to answer questions of whether to anticoagulate, whom to anticoagulate, and what agents to use. In the second section of the review, we suggest a decision algorithm on the basis of the available evidence and provide practical recommendations for each of the anticoagulant options. In the third section, we discuss the limitations of the available evidence. On the basis of low-quality evidence, we find that patients with cancer and AF have a risk of stroke similar to that of the general population but a substantially higher risk of bleeding regardless of the anticoagulant agent used; this makes anticoagulation-related decisions complex and evidence from the general population not immediately applicable. In general, we suggest stopping anticoagulation in patients with high risk of bleeding and in those with a moderate bleeding risk without a high thromboembolic risk and recommend anticoagulation as in the general population for patients at a low risk for bleeding. However, regardless of initial therapy, we recommend reassessing whether anticoagulation should be given at each point in the clinical course of the disease. High-quality evidence to guide anticoagulation for AF in patients with cancer is needed.

Oral anticoagulation in patients with active cancer and atrial fibrillation: current challenges

“…It is essential to discuss pros and cons with the patient. We concur [26] with the international Society on Thrombosis and Haemostasis (ISTH) that one might want to continue the anticoagulant the patient was taking, if any, while DOACs are likely a first choice in patients who have to start anticoagulation and in whom no drug interactions are foreseen and gastrointestinal bleeding is not a concern [28]. The availability of a reversal agent is not a major consideration in our decision.…”

“…receiving anticoagulation are well-established, there is no way to predict what patients will suffer bleeding. Rather than more observational studies determining even more risk factors and deriving bleeding risk scores, results from treatment protocols that include well-defined risk factors to make treatment decisions (such as the one we or others have suggested [26,29]) are needed.…”

“…Nevertheless, in the last few months, several authors and societies have offered guidance for these patients and their physicians. Table 1 [14,[26][27][28][29][30][31][32][33][34] outlines them.…”

“…In the absence of strong evidence and given the apparent dynamic nature of bleeding risk in patients with active cancer, our approach is to recommend against anticoagulation in patients with major risk factors, regardless of CHA 2 DS 2 VASc(table 1), and recommend anticoagulation in patients with CHA 2 DS 2 VASc >1 and no bleeding risk factors. In patients with minor risk factors for bleeding we recommend anticoagulation when CHA 2 DS 2 VASc is very high[26]. Most importantly, however, this general recommendation is accompanied by two fundamental precepts.…”

Atrial Fibrillation in Cancer Patients: Who is at Risk?

“…[14] Возникновение ФП у онкологических больных является безусловным отрицательным прогностическим фактором даже в краткосрочной перспективе [16]. Наиболее опасным осложнением ФП является кардиоэмболический инсульт, поскольку он характеризуется наиболее высокой смертностью и функциональными последствиями [17]. По данным B.B.…”