Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124 Modena, Italy.
Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, 57 Waterloo Road, London SE1 8WA, UK.
Eur J Prev Cardiol. 2021 May 22;28(6):611-621. doi: 10.1093/eurjpc/zwaa054.
In patients with active cancer and atrial fibrillation (AF) anticoagulation, thrombotic and bleeding risk still entail uncertainty.
We explored the results of an international survey examining the knowledge and behaviours of a large group of physicians.
A web-based survey was completed by 960 physicians (82.4% cardiologists, 75.5% from Europe). Among the currently available anticoagulants for stroke prevention in patients with active cancer, direct oral anticoagulants (DOACs) were preferred by 62.6%, with lower values for low molecular weight heparin (LMWH) (24.1%) and for warfarin (only 7.3%). About 46% of respondents considered that DOACs should be used in all types of cancers except in non-operable gastrointestinal cancers. The lack of controlled studies on bleeding risk (33.5% of respondents) and the risk of drug interactions (31.5%) were perceived as problematic issues associated with use of anticoagulants in cancer. The decision on anticoagulation involved a cardiologist in 27.8% of cases, a cardiologist and an oncologist in 41.1%, and a team approach in 21.6%. The patient also was involved in decision-making, according to ∼60% of the respondents. For risk stratification, use of CHA2DS2-VASc and HAS-BLED scores was considered appropriate, although not specifically validated in cancer patients, by 66.7% and 56.4%, respectively.
This survey highlights that management of anticoagulation in patients with AF and active cancer is challenging, with substantial heterogeneity in therapeutic choices. Direct oral anticoagulants seems having an emerging role but still the use of LMWH remains substantial, despite the absence of long-term data on thromboprophylaxis in AF.
在患有活动性癌症和心房颤动（AF）的患者中，抗凝治疗的血栓形成和出血风险仍然不确定。
我们探讨了一项国际调查的结果，该调查检查了一大群医生的知识和行为。
通过网络调查，有 960 名医生（82.4%为心脏病专家，75.5%来自欧洲）完成了调查。在目前可用于预防活动性癌症患者中风的抗凝药物中，直接口服抗凝剂（DOAC）被 62.6%的医生首选，而低分子肝素（LMWH）（24.1%）和华法林（仅 7.3%）的选择率较低。约 46%的受访者认为 DOAC 应该用于除不可手术的胃肠道癌症之外的所有类型的癌症。缺乏关于出血风险（33.5%的受访者）和药物相互作用风险（31.5%）的对照研究被认为是与癌症抗凝治疗相关的问题。在 27.8%的情况下，由心脏病专家决定抗凝治疗，41.1%的情况下由心脏病专家和肿瘤专家共同决定，21.6%的情况下由团队决定。根据约 60%的受访者，患者也参与了决策。对于风险分层，分别有 66.7%和 56.4%的受访者认为使用 CHA2DS2-VASc 和 HAS-BLED 评分是合适的，尽管它们并未在癌症患者中专门验证过。
这项调查强调，AF 合并活动性癌症患者的抗凝管理具有挑战性，在治疗选择方面存在很大的异质性。直接口服抗凝剂似乎具有新兴作用，但尽管缺乏 AF 中抗凝预防血栓形成的长期数据，LMWH 的使用仍然很普遍。
