Yu Li-Ying, Liu Yen-Wen, Chou Tzu-Yu, Liu Yi-Chia, Su Pei-Fang, Liu Ping-Yen
Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 704 Tainan, Taiwan.
Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, 704 Tainan, Taiwan.
Rev Cardiovasc Med. 2022 Jun 27;23(7):242. doi: 10.31083/j.rcm2307242. eCollection 2022 Jul.
Atrial fibrillation (AF) is associated with an increased risk of heart failure, death and thromboembolism. AF is prevalent in patients with cancer. Although current guidelines suggest the application of oral anticoagulants (OACs) for thromboembolic event prevention in high-risk AF patients, owing to the high thromboembolic and bleeding risks of active-cancer patients, there is no consensus on the use of OACs in such a population. Therefore, we conducted this retrospective cohort study to investigate the applicability of the -VASc score and to evaluate the efficacy and safety outcomes of OAC therapy in active-cancer patients with AF.
This retrospective cohort study enrolled patients diagnosed with cancer at National Cheng Kung University Hospital between November 2012 and August 2019. The primary outcomes included all-cause mortality, thromboembolic events (stroke/transient ischemic attack and systemic emboli), acute myocardial infarction (AMI), hospitalization for HF and major bleeding events.
We enrolled 2429 patients with active cancer. Among these patients, 1060 patients (43.6%) had AF. After 1:2 propensity score matching, 690 cancer patients with AF were enrolled for the final analysis, grouped as follows: 225 patients taking OACs and 465 patients without OAC treatment. The OAC-treated group had lower all-cause mortality than the patients without OAC treatment (all-cause mortality rate in OAC treatment . non-OAC treatment: 24.4% . 37.4%, hazard ratio 0.58 [95% confidence interval (CI) 0.43-0.78], 0.001). However, there was no difference in thromboembolic events, myocardial infarction or heart failure hospitalization between the OAC-treated and non-OAC-treated groups. Importantly, the risk of major bleeding composition (i.e., major gastrointestinal bleeding and intracranial hemorrhage) was similar between these two groups. Moreover, the -VASc score could not predict thromboembolic events in the enrolled active-cancer patients with AF (OR 1.23, 95% CI 0.98-1.56).
OAC treatment may significantly reduce the risk of death, without safety concerns, in active-cancer patients with AF. OAC treatment may not prevent thromboembolic events in patients with active cancer and AF. However, we found that OAC treatment is associated with improved prognosis without increasing the risks of major bleeding, despite several limitations in this study. Further studies are required to determine the optimal use of anticoagulation therapy in this high-risk population.
心房颤动（AF）与心力衰竭、死亡及血栓栓塞风险增加相关。AF在癌症患者中很常见。尽管当前指南建议对高危AF患者应用口服抗凝药（OACs）以预防血栓栓塞事件，但由于活动性癌症患者血栓栓塞和出血风险高，对于在此类人群中使用OACs尚无共识。因此，我们进行了这项回顾性队列研究，以调查-CHADS2-VASc评分的适用性，并评估OAC治疗对患有AF的活动性癌症患者的疗效和安全性结局。
这项回顾性队列研究纳入了2012年11月至2019年8月在国立成功大学医院被诊断患有癌症的患者。主要结局包括全因死亡率、血栓栓塞事件（中风/短暂性脑缺血发作和全身性栓塞）、急性心肌梗死（AMI）、因心力衰竭住院及大出血事件。
我们纳入了2429例活动性癌症患者。在这些患者中，1060例（43.6%）患有AF。经过1:2倾向评分匹配后，690例患有AF的癌症患者被纳入最终分析，分组如下：225例服用OACs的患者和465例未接受OAC治疗的患者。接受OAC治疗的组全因死亡率低于未接受OAC治疗的患者（OAC治疗组的全因死亡率为24.4%，未接受OAC治疗组为37.4%，风险比为0.58[95%置信区间（CI）0.43-0.78]，P<0.001）。然而，接受OAC治疗组与未接受OAC治疗组在血栓栓塞事件、心肌梗死或因心力衰竭住院方面无差异。重要的是，两组之间大出血（即重大胃肠道出血和颅内出血）的风险相似。此外，CHADS2-VASc评分无法预测纳入的患有AF的活动性癌症患者的血栓栓塞事件（比值比为1.23，95%CI为0.98-1.56）。
OAC治疗可能显著降低患有AF的活动性癌症患者的死亡风险，且无安全性担忧。OAC治疗可能无法预防患有活动性癌症和AF的患者发生血栓栓塞事件。然而，尽管本研究存在一些局限性，但我们发现OAC治疗与改善预后相关，且不会增加大出血风险。需要进一步研究以确定在这一高危人群中抗凝治疗的最佳使用方法。
