Use of Non–Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation Patients with Malignancy: Clinical Practice Experience in a Single Institution and Literature Review

Abstract

This observational study aimed to investigate the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients with malignancy. A total of 76 patients (mean age: 73.2 ± 8.9; 28 females) with AF and malignancy treated with NOAC were included in the analysis. The mean CHADS-VASc and HAS-BLED scores were 3.2 ± 1.2 and 2.2 ± 0.9, respectively. The study population was taking dabigatran 150 mg (25%) twice daily (BID), apixaban 5 mg BID (25%), dabigatran 110 mg BID (24%), rivaroxaban 20 mg (18%) once a day (OD), rivaroxaban 15 mg OD (5%), or apixaban 2.5 mg OD (3%). NOAC therapy began, on average, 248 ± 238 days before malignancy diagnosis for an average duration of 1,000 ± 289 days. Stroke, transient ischemic attack, major and minor bleeding events, other adverse effects, and major cardiovascular complications during the follow-up period were collected. In our study population, no patients experienced thromboembolic events during therapy with any NOAC. We recorded a low global incidence of major bleeding (3.9%) with a mean annual incidence of 1.4%. No hemorrhagic stroke or subarachnoid hemorrhage was observed. Only nine patients (11.8%) experienced minor bleeding. According to our data, anticoagulation therapy with NOACs seems to be an effective and safe treatment strategy for nonvalvular AF patients with malignancy.

Diagnosis and Management of Left Atrium Appendage Thrombosis in Atrial Fibrillation Patients Undergoing Cardioversion

“…NOACs are safe and effective alternatives to VKA therapy [46,47,48,49], and are currently considered as first-line therapy for long-term stroke prevention in patients with nonvalvular AF [6]. The overall safety and efficacy profile of NOACs have been confirmed in different clinical scenarios [50,51,52,53,54,55,56,57,58]. The clinical performance of NOACs in the setting of acute and elective CV has been addressed by three prospective randomized trials.…”

<p>Apixaban in a Morbid Obese Patient with Atrial Fibrillation: A Clinical Experience Using the Plasmatic Drug Evaluation</p>

“…The evaluation of apixaban serum level at peak and trough time demonstrated the therapeutic drug levels in our morbid obese patient and the stability of apixaban plasma levels even when the patient has lost weight. The use of plasma level monitoring for NOAC doseadjustment is discouraged for the vast majority of patients due to the lack of outcome data to support such an approach; however, in rare cases of potentially substantial drug-drug interactions; 23,24 in special population in which the use of NOACs is still debated, 25,26 or in case of not deferrable cardiac or non-cardiac interventional or surgical procedures, 27 a "patient-centered approach", including the plasmatic drug evaluation, might be considered for choosing the more appropriate anticoagulant molecule.…”

Atrial Fibrillation and Stroke. A Review on the Use of Vitamin K Antagonists and Novel Oral Anticoagulants

“…In this way, the induction of the anticoagulant effect is eased without having to resort to the administration of heparin [28,29]. Moreover, both the safety and efficacy of NOACs have been positively tested in a randomized clinical trial [30] and confirmed by several clinical real-world casuistries [1,31,32,33,34,35].…”

“…However, this class of drugs is burdened by the need to maintain the INR at target. In the last few years, with the advent of NOACs, several studies have assessed the safety and efficacy in this specific population [32,55,56,57,58]. Nevertheless, the limited sample size and the wide spectrum of malignancies render it necessary to conduct further in-depth studies.…”