Gatti Milo, Raschi Emanuel, Poluzzi Elisabetta, Martignani Cristian, Salvagni Stefania, Ardizzoni Andrea, Diemberger Igor
Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
Curr Heart Fail Rep. 2020 Dec;17(6):365-383. doi: 10.1007/s11897-020-00485-9.
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.
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. 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.
抗癌药物引起的心脏毒性已成为一个多方面的问题，预计会影响死亡率和发病率。本综述总结了在管理因心房颤动（AF）需要抗凝治疗的肿瘤患者时面临的临床挑战，同时也考虑了当前2019冠状病毒病（COVID-19）大流行的情况，因为这种感染会给这两种疾病的管理带来更多挑战。具体而言，目标是多方面的：（1）描述直接口服抗凝剂（DOACs）在癌症合并房颤患者中的使用演变；（2）严格评估DOACs与口服靶向抗癌药物之间临床上重要的药物相互作用（DDIs）风险；（3）探讨DOACs与候选抗COVID药物之间预期的药物相互作用，及其对潜在血栓形成风险管理的影响；（4）描述在COVID-19背景下心脏肿瘤学中致心律失常的可能性，重点关注QT间期延长。
心脏肿瘤学中的房颤带来了诊断和管理挑战，这也归因于最近与房颤发作/恶化相关的抗癌药物数量。口服靶向药物可能与DOACs相互作用，主要由于药代动力学药物相互作用导致出血风险增加。此外，绝大多数口服抗癌药物通过直接和间接机制导致QT间期延长，可能导致尖端扭转型室速的发生，特别是在患有COVID-19且易患的患者中，这些患者还接受了具有QT间期延长风险的其他药物。肿瘤学家和心脏病学家必须意识到，由于药物相互作用，房颤合并癌症患者的出血风险和心律失常易感性增加。应优先对COVID-19高危个体采取预防策略，包括优化抗栓管理、药物审查和严格监测。
