Oncological Diseases and Atrial Fibrillation

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Active oncological disease is the period during which adverse events and complications related to cancer most commonly occur.

• For example haemorrhage, thromboembolism, newly diagnosed atrial fibrillation (AF).

Active oncological disease is defined as:

• The patient is currently undergoing oncological treatment (chemotherapy, radiotherapy).
• The patient has metastases, even if no active treatment is ongoing.
• The diagnosis was established within the previous 6 months.
• Recurrence occurred within the previous 6 months.

Oncological disease leads to chronic inflammation, resulting in atrial remodelling. Radiotherapy and chemotherapy also promote atrial remodelling; therefore, the oncological disease itself and its treatment create a substrate for AF.

AF is present in 2–28% of oncological patients.

Oncological surgery is a risk factor for newly diagnosed AF.

The incidence of newly diagnosed AF is:

• 6–32% after oncological lung surgery
• 5% after non-pulmonary oncological surgery (e.g. colectomy)

Oncological disease causes chronic inflammation with the release of cytokines and coagulation factors that may exert procoagulant or prohaemorrhagic effects. Therefore, oncological patients have an increased risk of both bleeding and thrombosis. A paradoxical situation may occur where an oncological patient develops thrombosis and bleeds simultaneously.

• Bleeding mainly results from thrombocytopenia due to bone marrow suppression and prohaemorrhagic cytokines.
• Thrombosis mainly results from procoagulant cytokines that stimulate the coagulation cascade.

The risk of thromboembolism in oncological patients is 2–10%.

• The risk increases with polymorbidity.

The risk of thromboembolism in oncological patients with AF is 2.13%:

• without anticoagulation therapy and with CHA₂DS₂-VA score 0–2.

Bleeding manifestations (epistaxis, gingival bleeding, haematuria, blood in stool) during adequate anticoagulation therapy in patients with AF

• raise suspicion of oncological disease.

Anticoagulation therapy should not be administered in oncological patients with AF who have a high bleeding risk:

• Intracranial tumour
• Thrombocytopenia (< 50 × 10⁹/l)
• Tumour with invasion into the vascular system

Thrombocytopenia and anticoagulation therapy in atrial fibrillation
Platelets	Recommendation
>50 × 109/l	Administer a NOAC or LMWH.
30 – 50 × 109/l	LMWH is preferred; dose reduction may be considered.
<30 × 109/l	Do not administer anticoagulation therapy; administer platelet transfusion.

NOAC – Non-vitamin K Oral Anticoagulant (Dabigatran, Rivaroxaban, Apixaban, Edoxaban). LMWH – Low-Molecular-Weight Heparin (Enoxaparin, Dalteparin, Nadroparin)

The preferred anticoagulation therapy in oncological patients is LMWH (Dalteparin, Enoxaparin). Advantages of LMWH:

• Subcutaneous administration (administration is not affected by nutritional status: absorption, diarrhoea).
• No need to monitor INR.
• Rapid onset and offset of action.
• Safe during chemotherapy (LMWH is not metabolized in the liver).

LMWH is preferred in gastrointestinal and genitourinary tumours.

The preferred anticoagulation therapy in oncological patients with AF is:

• LMWH (preferably: Dalteparin, Enoxaparin) or NOAC (preferably: apixaban, edoxaban, rivaroxaban).
• Initial therapy is LMWH; after 2–4 months, transition to a NOAC is possible (if the patient has no bleeding manifestations).

Oncological patients and atrial fibrillation	Class
Preferred anticoagulation therapy in oncological patients with AF is LMWH or NOAC.	I
Anticoagulation therapy in AF is safe if the patient has >50 × 109/l platelets and no bleeding manifestations.	I
Anticoagulation therapy in patients with AF should be administered at a reduced dose after consultation with an oncologist if the patient has: Intracranial tumour Platelets <50 × 109/l Tumour with invasion into the vascular system	I
Anticoagulation therapy should not be administered if the patient has <30 × 109/l platelets.	III
Anticoagulation therapy may be considered in patients with CHA2DS2-VA score 0.	IIb

LMWH - Low Molecular Weight Heparin (Enoxaparin, Nadroparin), NOAC – Non-vitamin K oral anticoagulants (Dabigatran, Rivaroxaban, Apixaban, Edoxaban)

These guidelines are unofficial and do not represent formal guidelines issued by any professional cardiology society. They are intended for educational and informational purposes only.