Usefulness of CHADS2 and CHA2DS2-VASc Scores for Stroke Prediction in Patients With Cancer and Atrial Fibrillation

Patell, Rushad; Gutiérrez, Alejandra; Rybicki, Lisa; Khorana, Alok A.

doi:10.1016/j.amjcard.2017.08.038

Cited by 56 publications

(42 citation statements)

References 18 publications

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“…Yet, although not uniformly, retrospective data [16,18,19,22,37] largely support an increase in stroke risk with increasing CHA 2 DS 2 VASc and that patients with CHA 2 DS 2 VASc 0-1 are at low risk of stroke, which is in line with the idea that strokes in patients with AF and cancer are of similar mechanism than in the general population (predominantly due to cardioembolism [38]) and that cancer is not a major contributor to stroke risk in patients with AF. Data from the Mayo Clinic, in some of the largest single center studies published of patients with cancer and AF, show a x1.2 risk of stroke per CHA 2 DS 2 VASc 1 point increase (and 1.4x per CHADS 2 1 point increase) [19,37]. There is also evidence that, similar to the general population, patients with cancer and AF with a low CHA 2 DS 2 VASc score do not benefit from anticoagulation while those with a high CHA 2 DS 2 VASc score do so [39].…”

Section: Assessment Of Stroke and Bleeding Risk In Patients Withmentioning

confidence: 57%

“…The published evidence suggests that AF present at the time of cancer diagnosis (baseline AF) behaves similarly to AF in the general population. Aside from the indirect evidence provided by the predictive power of the CHA 2 DS 2 VASc score in these patients [18,19,39], there is also indirect evidence from randomized trials. A post-hoc substudy of the ENGAGE AF-TIMI48, which randomized patients with AF to edoxaban or warfarin, compared the two drugs in patients with active cancer developed (or recurring) after randomization.…”

Section: Does Stroke Risk Depend On Whether Af Was Present At Baseline?mentioning

confidence: 99%

“…This is compounded by the fact that the risk of stroke in patients with AF and active cancer is not clearly increased over those in patients with AF in the general population [16,17]. Although studies have shown somewhat inconsistent results, likely due to different inclusion criteria and study populations, the totality of the evidence indicates that, if the risk of cardioembolic stroke is increased, the effect size is very small [9,[16][17][18][19][20][21][22][23][24][25] and far smaller than the increase in bleeding risk. This state of affairs leads to uncertainty regarding the clinical benefit of anticoagulation for patients with AF and cancer.…”

mentioning

confidence: 99%

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

Sorigué

2020

Polish Archives of Internal Medicine

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This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License (CC BY-NC-SA 4.0), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited, distributed under the same license, and used for noncommercial purposes only.

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Section: Assessment Of Stroke and Bleeding Risk In Patients Withmentioning

confidence: 57%

Section: Does Stroke Risk Depend On Whether Af Was Present At Baseline?mentioning

confidence: 99%

mentioning

confidence: 99%

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

Sorigué

2020

Polish Archives of Internal Medicine

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“…However, looking at low-grade CHADSVASC scores (i.e., 0 [ 1 ••]), patients with cancer had an increased risk of both thromboembolic and bleeding events, according to the Danish registry [ 14 ]. As such, it remains unclear which scoring system (CHA2DS2-VASc or CHADS2) is preferable in the cancer population [ 15 ].…”

Section: Evolving Use Of Doacs In Af Patients With Cancer: An Updatementioning

confidence: 99%

The Complex Management of Atrial Fibrillation and Cancer in the COVID-19 Era: Drug Interactions, Thromboembolic Risk, and Proarrhythmia

Gatti

Raschi

Poluzzi

et al. 2020

Curr Heart Fail Rep

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Purpose of Review Cardiotoxicity by anticancer agents has emerged as a multifaceted issue and is expected to affect both mortality and morbidity. This review summarizes clinical challenges in the management of oncological patients requiring anticoagulants for atrial fibrillation (AF) also considering the current outbreak of the COVID-19 (coronavirus disease 2019) pandemic, since this infection can add challenges to the management of both conditions. Specifically, the aims are manyfold: (1) describe the evolving use of direct oral anticoagulants (DOACs) in AF patients with cancer; (2) critically appraise the risk of clinically important drug-drug interactions (DDIs) between DOACs and oral targeted anticancer agents; (3) address expected DDIs between DOACs and candidate anti-COVID drugs, with implications on management of the underlying thrombotic risk; and (4) characterize the proarrhythmic liability in cardio-oncology in the setting of COVID-19, focusing on QT prolongation. Recent Findings AF in cardio-oncology poses diagnostic and management challenges, also due to the number of anticancer drugs recently associated with AF onset/worsening. Oral targeted drugs can potentially interact with DOACs, with increased bleeding risk mainly due to pharmacokinetic DDIs. Moreover, the vast majority of oral anticancer agents cause QT prolongation with direct and indirect mechanisms, potentially resulting in the occurrence of torsade de pointes, especially in susceptible patients with COVID-19 receiving additional drugs with QT liability. Summary Oncologists and cardiologists must be aware of the increased bleeding risk and arrhythmic susceptibility of patients with AF and cancer due to DDIs. High-risk individuals with COVID-19 should be prioritized to target preventive strategies, including optimal antithrombotic management, medication review, and stringent monitoring.

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“…DOACs are the preferred option for stroke prevention in patients with nonvalvular AF, whereas LMWHs are not routinely recommended in this setting due to a lack of evidence (ie, large‐scale trials of LMWH in AF) . Use of the most effective anticoagulation therapy is particularly important in these patients because cancer further increases stroke risk in patients with AF . A large Danish nationwide cohort study demonstrated that the absolute risks of thromboembolic and bleeding complications were similar in patients with AF with and without cancer, irrespective of VKA or DOAC prescription .…”

Section: Rationale For Studying the Use Of Doacs For Catmentioning

confidence: 99%

Cancer‐associated venous thromboembolism: Treatment and prevention with rivaroxaban

Bauersachs¹,

Khorana

Lee

et al. 2020

Research and Practice in Thrombosis and Haemostasis

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Cancer‐associated venous thromboembolism (VTE) is a frequent, potentially life‐threatening event that complicates cancer management. Anticoagulants are the cornerstone of therapy for the treatment and prevention of cancer‐associated thrombosis (CAT); factor Xa–inhibiting direct oral anticoagulants (DOACs; apixaban, edoxaban, and rivaroxaban), which have long been recommended for the treatment of VTE in patients without cancer, have been investigated in this setting. The first randomized comparisons of DOACs against low‐molecular‐weight heparin for the treatment of CAT indicated that DOACs are efficacious in this setting, with findings reflected in recent updates to published guidance on CAT treatment. However, the higher risk of bleeding events (particularly in the gastrointestinal tract) with DOACs highlights the need for appropriate patient selection. Further insights will be gained from additional studies that are ongoing or awaiting publication. The efficacy and safety of DOAC thromboprophylaxis in ambulatory patients with cancer at a high risk of VTE have also been assessed in placebo‐controlled randomized controlled trials of apixaban and rivaroxaban. Both studies showed efficacy benefits with DOACs, but both studies also showed a nonsignificant increase in major bleeding events while on treatment. This review summarizes the evidence base for rivaroxaban use in CAT, the patient profile potentially most suited to DOAC use, and ongoing controversies under investigation. We also describe ongoing studies from the CALLISTO (Cancer Associated thrombosis—expLoring soLutions for patients through Treatment and Prevention with RivarOxaban) program, which comprises several randomized clinical trials and real‐world evidence studies, including investigator‐initiated research.

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Usefulness of CHADS2 and CHA2DS2-VASc Scores for Stroke Prediction in Patients With Cancer and Atrial Fibrillation

Cited by 56 publications

References 18 publications

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

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

The Complex Management of Atrial Fibrillation and Cancer in the COVID-19 Era: Drug Interactions, Thromboembolic Risk, and Proarrhythmia

Cancer‐associated venous thromboembolism: Treatment and prevention with rivaroxaban

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