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6.4 Cardiac arrhythmias

6.4.1. Atrial fibrillation AF may occur in patients with cancer in different settings: it may be a marker of cancer type or occult cancer, or it may develop in patients undergoing surgery, chemotherapy, or RT.508,509 All types of cancer show an increased risk of AF compared with the control group, but the risk of AF depends on the cancer type and stage.510,511 AF during a cancer treatment may be caused by a specific therapy or interaction with a pre-existing substrate in older patients with cancer. During cancer therapy AF may occur with a frequency ranging from 2% to 16%, according to a variety of factors,4,490,508,512–514 and may present either as first-diagnosed AF or as recurrence of paroxysmal AF. The risk of developing AF is greater in patients older than 65 years and/or with pre-existing CVD.4,509,512,515 Cancer surgery is associated with a variable rate of AF occurrence, with the highest incidence reported for lung surgery, ranging from 6% to 32%, but with occurrence also in cases of non-thoracic surgery (e.g. 4–5% after colectomy).509 Many anticancer drugs have been associated with an increased risk of AF both in terms of incident and recurrent AF (Supplementary data, Table S18).251 AF may occur shortly after treatment516 or weeks or months after starting treatment.517,518 The pathophysiology of AF associated with cancer is complex and has been extensively reviewed elsewhere (Figure 30).509 In patients with cancer, the occurrence of AF is associated with a two-fold higher risk of systemic thromboembolism/stroke and a sixfold increase in the risk of HF.4,509,512 The coexistence of cancer increases the risk of all-cause mortality, major bleeding, and intracranial haemorrhage in patients with AF. The association between cancer and ischaemic stroke differs between cancer types, and in some types, the risk of bleeding seems to exceed the thromboembolic risk.519 The management of AF in patients with cancer should follow the 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation273 and the ‘ABC pathway’ (Atrial fibrillation Better Care) approach should be applied (A: Anticoagulation to avoid stroke/systemic embolism, B: Better symptom control with rate- and/or rhythm-control drugs and interventions, and C: Comorbidities and CVRF management, including lifestyle changes).273,520 The acute management of AF in patients with cancer should consider electrical cardioversion in cases of haemodynamic instability,521 while in others, the alternative between rate and rhythm control has several important considerations specific to patients with cancer. Drugs for rhythm control may lead to QT-interval prolongation,369 frequently have drug–drug interactions with cancer therapies, or may have a limited efficacy if a cancer therapy is the specific cause of the AF.508 Among rate-control drugs, beta-blockers are preferred, especially if the cancer therapies have potential CTRCD risk, whereas diltiazem and verapamil should be avoided where possible due to their drug–drug interactions and negative inotropic effects.508 The possibility of AF ablation should be discussed in selected patients with HF/LVD and/or uncontrolled symptoms, taking into consideration cancer status and prognosis in the context of a MDT approach.522

A complex issue in patients with cancer with new AF is risk stratification for stroke/systemic embolism, which according to guidelines, should be based on the CHA2DS2-VASc score (Congestive heart failure, Hypertension, Age ≥75 years [2 points], Diabetes mellitus, Stroke [2 points]—Vascular disease, Age 65–74 years, Sex category [female]).273,523,524 The CHA2DS2-VASc score has not been extensively validated in patients with cancer.525 In a large cohort of patients with AF, the predictive value of the CHA2DS2-VASc score was lower in patients with cancer than in those without, but a progressive increase in the risk of ischaemic stroke according to the CHA2DS2-VASc score was also found in AF patients with cancer (from 0.9% per year to 8.9% per year).519 However, the scope of this score is not to identify high-risk patients, but rather to identify low-risk individuals in whom anticoagulation can be avoided. A study based on the Danish healthcare system data set found that CHA2DS2-VASc scores of 0 and 1 in patients with recent cancer were linked with higher risk of stroke/thromboembolism at 2 years than in patients without recent cancer.526 This concept should be considered in defining the risk/benefit ratio of anticoagulation in individual patients with cancer. Therefore, the decision for anticoagulation in patients with an active malignancy should take into account the enhanced thrombotic and/or bleeding risk and other risk prediction scores used for general AF populations.509 For bleeding risk assessment, the HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding Labile international normalized ratio, Elderly, Drugs or alcohol) score may be considered. A proposed approach to anticoagulation therapy in cancer, based on the acronym T (thrombotic risk), B (bleeding risk), I (interactions among drugs), P (patient access and preferences), is outlined in Figure 31.519,527 Long-term anticoagulation is recommended in adult patients with CHA2DS2-VASc score ≥2 in men or ≥3 in women and must be considered also when the score is 1 in men and 2 in women.273 The clinical pattern of AF (i.e. first detected, paroxysmal, persistent, long-standing persistent, permanent, post-operative) should not influence the indication of thromboprophylaxis.273 The same approach can be proposed for patients with cancer and AF, also considering that the CHA2DS2-VASc score likely underestimates their thromboembolic risk.530 In the specific setting of cancer, decision-making on long-term oral anticoagulation should also consider the cancerrelated type, stage, prognosis and the potentially changing thromboembolic or bleeding risk.508,509 The use of vitamin K antagonists (VKA) in cancer is limited by their drawbacks in this setting; however, they remain the only indicated anticoagulants in patients with moderate to severe mitral stenosis or a mechanical prosthetic valve. LMWH constitute a viable short-term anticoagulation option, particularly in hospitalized patients with a recent cancer diagnosis, advanced cancer disease, or during some cancer treatments (e.g.

In patients with cancer developing new VHD during cancer therapy, management according to the 2021 ESC/EACTS Guidelines for the management of VHD507 is recommended, taking into consideration cancer prognosis and patient comorbidities. I C © ESC 2022

EACTS, European Association for Cardio-Thoracic Surgery; ESC, European Society of Cardiology; VHD, valvular heart disease. aClass of recommendation. bLevel of evidence.

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