The Complex Management of Atrial Fibrillation and Cancer in the COVID-19 Era: Drug Interactions, Thromboembolic Risk, an
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CARDIO-ONCOLOGY (P AMERI, SECTION EDITOR)
The Complex Management of Atrial Fibrillation and Cancer in the COVID-19 Era: Drug Interactions, Thromboembolic Risk, and Proarrhythmia Milo Gatti 1 & Emanuel Raschi 1 & Elisabetta Poluzzi 1 & Cristian Martignani 2 & Stefania Salvagni 3 & Andrea Ardizzoni 4 & Igor Diemberger 2
# The Author(s) 2020
Abstract Purpose of Review 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. Recent Findings 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. Summary 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. Keywords Anticancer agents . Direct oral anticoagulants . Atrial fibrillation . QT prolongation . COVID-19 . Drug-drug interactions
Background In parallel with the advancements of chemotherapy, targeted therapy, immunotherapy, and radiotherapy, cardio-oncology
has become a recognized medical specialty and clinicians are increasingly facing the multifaceted spectrum of cardiovascular toxicities by anticancer agents, with risk stratification, prevention, and early recognition being major emerging challenges [1••, 2].
Milo Gatti and Emanuel Raschi contributed equally to this work. This article is part of the Topical Collection on Cardio-Oncology * Igor Diemberger [email protected] 1
Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
2
Cardiology Unit,
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