Patterns of Anticoagulation Use in Patients With Cancer With Atrial Fibrillation and/or Atrial Flutter

Michael G Fradley; Kerry Ellenberg; Mohammed Alomar; Justin Swanson; Anant Kharod; Anh Thy H Nguyen; Sara Khodor; Shreya Mishra; Linh M Duong; Nirav Shah; Merna Armanious; Isaac B Rhea; Matthew B Schabath; Kevin E Kip

doi:10.1016/j.jaccao.2020.09.008

Patterns of Anticoagulation Use in Patients With Cancer With Atrial Fibrillation and/or Atrial Flutter

JACC CardioOncol. 2020 Dec 15;2(5):747-754. doi: 10.1016/j.jaccao.2020.09.008. eCollection 2020 Dec.

Affiliations

¹ Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
² Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
³ University of South Florida College of Public Health, Tampa, Florida, USA.
⁴ Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.

Abstract

Background: Atrial fibrillation (AF) is a common cardiovascular complication affecting patients with cancer, but management strategies are not well established.

Objectives: The purpose of this retrospective cohort study was to evaluate cross-sectional patterns of anticoagulation (AC) use in patients with cancer with AF or atrial flutter (AFL) on the basis of their risk for stroke and bleeding.

Methods: Patients with cancer and electrocardiograms showing AF or AFL performed at Moffitt Cancer Center in either the inpatient or outpatient setting were included in this retrospective analysis. We described percentages of AC prescription by stroke and bleeding risk, as determined by individual CHA₂DS₂-VASc and HAS-BLED scores, respectively. Multivariable logistic regression evaluated clinical variables independently associated with anticoagulant prescription.

Results: The prevalence of electrocardiography-documented AF or AFL was 4.8% (n = 472). The mean CHA₂DS₂-VASc score was 2.8 ± 1.4. Among patients with CHA₂DS₂-VASc scores ≥2 and HAS-BLED scores <3, 44.3% did not receive AC, and of these, only 18.3% had platelet values <50,000/μl. In multivariable analysis, older age, hypertension, prior stroke, and history of venous thromboembolism were each directly associated with AC use, while current chemotherapy use, prior bleeding, renal disease, and thrombocytopenia were each inversely associated with AC use.

Conclusions: Nearly one-half of patients with cancer, the majority with normal platelet counts, had an elevated risk for stroke but did not receive AC. In addition to known predictors, current chemotherapy use was independently associated with a lower odds of AC use. This study highlights the need to improve the application of AF treatment algorithms to cancer populations.

Keywords: AC, anticoagulation; AF, atrial fibrillation; AFL, atrial flutter; CI, confidence interval; DOAC, direct oral anticoagulant agent; ECG, electrocardiogram; EMR, electronic medical record; MCC, Moffitt Cancer Center; OR, odds ratio; anticoagulation; atrial fibrillation; cancer; cardio-oncology.