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Xu QQ, Han SJ, Wei XH, You LZ, Sun LC, Shang HC. Risk factors for arrhythmias occurred in cancer patients after chemotherapy: An evidence-based systematic review and meta-analysis. Heliyon 2024; 10:e34176. [PMID: 39104480 PMCID: PMC11298829 DOI: 10.1016/j.heliyon.2024.e34176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 06/28/2024] [Accepted: 07/04/2024] [Indexed: 08/07/2024] Open
Abstract
Objectives This study aimed to summarize the existing literature on risk factors for arrhythmias after chemotherapy in cancer patients. To provide reliable evidence for treating arrhythmias after chemotherapy in oncology patients by assessing multiple biasing factors in the literature and quantifying the risk factors. Methods The risk factors for arrhythmia following tumor chemotherapy were systematically collected from various reputable databases, including PubMed, Cochrane Library, MEDLINE, EMBASE, and multiple Chinese databases, covering the period from inception to May 2023. Two independent reviewers performed rigorous article screening, data extraction, and assessment of research quality. Data analysis was conducted using Review Manager 5.4 software, ensuring a standardized and robust approach to evaluate the gathered evidence. Results The analysis of chemotherapy-induced arrhythmias included 16 articles, encompassing 14,785 cancer patients. Among the patients, 3295 belonged to the arrhythmia group, while 11,490 were in the non-arrhythmia group. These studies identified 12 significant risk factors associated with arrhythmias following chemotherapy in cancer patients. The findings of the analysis are as follows. General patient characteristics The incidence of post-chemotherapy arrhythmias was 14.33 times higher in oncology patients aged ≥60 years compared to patients <60 years of age [OR = 14.33, 95%CI (8.51, 24.13), P<0.00001]. Patients with a smoking history exhibited a 1.67-fold higher risk of arrhythmia after chemotherapy [OR = 1.67, 95%CI (1.24, 2.25), P = 0.0007]. However, there was no significant correlation between gender and body mass index (BMI) with arrhythmia after chemotherapy in oncology patients (P = 0.52; P = 0.19). Disease-related factors Patients with a history of hypertension, diabetes, and cardiovascular disease had a 1.93-fold, 1.30-fold, and 1.76-fold increased risk of arrhythmia after chemotherapy, respectively [OR = 1.93, 95%CI (1.66, 2.24), P<0.00001; OR = 1.30, 95%CI (1.10, 2.52), P = 0.002; OR = 1.76, 95%CI (1.51, 2.05), P<0.00001]. Additionally, the incidence of arrhythmia increased 1.97 times in patients with electrolyte and acid-base balance disorders following chemotherapy [OR = 1.97, 95%CI (1.41, 2.76), P<0.00001]. Chemotherapy-related factors Seven articles examined the association between chemotherapy drugs and post-chemotherapy arrhythmias. The results indicated that oncology patients were 3.03 times more likely to develop arrhythmias with chemotherapy drugs compared to non-chemotherapy drugs [OR = 3.03, 95%CI (2.59, 3.54), P<0.00001]. Notably, anthracyclines and fluorouracil chemotherapy demonstrated a 2.98-fold and 3.35-fold increased risk of arrhythmia after chemotherapy, respectively [OR = 2.98, 95%CI (2.51, 3.03), P<0.00001; OR = 3.35, 95%CI (2.20, 5.10), P<0.00001]. The risk of arrhythmia after chemotherapy was 1.72 times higher in patients with chemotherapy cycles longer than 4 weeks than those with cycles shorter than 4 weeks [OR = 1.72, 95%CI (1.30, 2.28), P = 0.0001]. Conclusion The occurrence of arrhythmia after chemotherapy in cancer patients was significantly associated with the patient's age, history of smoking, history of hypertension, history of diabetes, history of cardiovascular disease, chemotherapy drug use, and cycle. However, further high-quality evidence is needed to support these results.
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Affiliation(s)
- Qian-Qian Xu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Song-Jie Han
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Xiao-Hong Wei
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Liang-zhen You
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Li-Chao Sun
- National Cancer Center National Clinical Research Center for Cancer State Key Laboratory of Molecular Oncology of Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Hong-Cai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
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Koraćević G, Stojković M, Stojanović M, Zdravković M, Simić D, Šalinger-Martinović S, Đorđević D, Damjanović M, Đorđević-Radojković D, Koraćević M. Less Known but Clinically Relevant Comorbidities of Atrial Fibrillation: A Narrative Review. Curr Vasc Pharmacol 2022; 20:429-438. [PMID: 35986547 DOI: 10.2174/1570161120666220819095215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The important risk factors for atrial fibrillation (AF) in the general population are not always equally important in specific and relatively prevalent diseases. OBJECTIVE The main goal of this narrative review is to focus attention on the presence and the relationship of AF with several important diseases, such as cancer or sepsis, in order to: 1) stimulate further research in the field, and 2) draw attention to this relationship and search for AF in clinical practice. METHODS We searched PubMed, SCOPUS, Elsevier, Wiley, Springer, Oxford Journals, Cambridge, SAGE, and Google Scholar for less-known comorbidities of AF. The search was limited to publications in English. No time limits were applied. RESULTS AF is widely represented in cardiovascular and other important diseases, even in those in which AF is rarely mentioned. In some specific clinical subsets of AF patients (e.g., patients with sepsis or cancer), the general risk factors for AF may not be so important. Patients with new-onset AF have a several-fold increase in relative risk of cancer, deep vein thrombosis, and pulmonary thromboembolism (PTE) during the follow-up. CONCLUSION AF presence, prognosis, and optimal therapeutic approach are insufficiently recognised in several prevalent diseases, including life-threatening ones. There is a need for a better search for AF in PTE, pulmonary oedema, aortic dissection, sepsis, cancer and several gastrointestinal diseases. Improved AF detection would influence treatment and improve outcomes.
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Affiliation(s)
- Goran Koraćević
- Department of Cardiovascular Diseases, University Clinical Center Niš, Niš, Serbia.,Faculty of Medicine, Niš University, Niš, Serbia
| | - Milan Stojković
- Department of Internal Medicine and Geriatrics, Bethel Clinic (EvKB), Bielefeld, Germany
| | | | - Marija Zdravković
- Department of Cardiology, University Hospital Medical Center Bežanijska kosa and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragan Simić
- Department of Cardiovascular Diseases, University Clinical Center Niš, Niš, Serbia
| | - Sonja Šalinger-Martinović
- Department of Cardiovascular Diseases, University Clinical Center Niš, Niš, Serbia.,Faculty of Medicine, Niš University, Niš, Serbia
| | - Dragan Đorđević
- Department of Internal Medicine and Geriatrics, Bethel Clinic (EvKB), Bielefeld, Germany
| | - Miodrag Damjanović
- Department of Cardiovascular Diseases, University Clinical Center Niš, Niš, Serbia
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Tufano A. Optimizing antithrombotic therapy for atrial fibrillation in cancer. Thromb Res 2022; 213 Suppl 1:S103-S106. [DOI: 10.1016/j.thromres.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/03/2022] [Accepted: 01/03/2022] [Indexed: 10/18/2022]
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Vasyuk YA, Shupenina EY, Vyzhigin DA, Novosel EO, Gallinger KV. Atrial Fibrillation in Cancer Patients: Who is at Risk? RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2021-12-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cancer is the second leading cause of mortality in the world, second only to cardiovascular diseases. Simultaneously cancer mortality has been steadily decreasing due to the development of new chemotherapy and targeted drugs and the improvement of existing treatment protocols. Improving the prognosis of treatment of cancer patients leads to an unexpected result - more patients are faced with side effects of cancer treatment. Cardiotoxicity, including arrhythmia, has become a significant factor to reduce the effectiveness of cancer patient’s treatment. Atrial fibrillation is frequent and persistent a rhythm disorder, affecting all categories of patients, especially the elderly. An association between these two conditions can be expected, considering the fact that in old age the prevalence of malignant neoplasms and comorbid pathology predisposing to the onset of AF is high. Therefore, AF may be an additional factor negatively influencing the prognosis and treatment tactics in patients with malignant neoplasms. A comprehensive search was conducted using the keywords “cancer”, “atrial fibrillation” and “cardiotoxicity” using the PubMed, Scopus and Cohrane databases. We reviewed publications having the relationship between AF and cancer. The literature review considered 61 publications on the prevalence of AF in cancer patients, classification, mechanisms of development, the effect of anticancer drugs and other treatment methods on this group of patients. Analyzed articles include clinical guidelines, consensus expert opinions, systematic reviews, meta-analyzes, and previously published reviews of the literature. The problem of cardiotoxic complications diagnostics is evaluated separately, incl. arrhythmias, and their monitoring in cancer patients. Therefore, the direction of medicine named "Cardio-oncology" comes to the fore. Interdisciplinary interaction will allow identify cardiotoxic manifestations at the subclinical stage and optimize anticancer treatment.
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Affiliation(s)
- Yu. A. Vasyuk
- A.I. Evdokimov Moscow State University of Medicine and Dentistry
| | - E. Yu. Shupenina
- A.I. Evdokimov Moscow State University of Medicine and Dentistry
| | - D. A. Vyzhigin
- A.I. Evdokimov Moscow State University of Medicine and Dentistry
| | - E. O. Novosel
- A.I. Evdokimov Moscow State University of Medicine and Dentistry
| | - K. V. Gallinger
- A.I. Evdokimov Moscow State University of Medicine and Dentistry
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Boriani G, Lee G, Parrini I, Lopez-Fernandez T, Lyon AR, Suter T, Van der Meer P, Cardinale D, Lancellotti P, Zamorano JL, Bax JJ, Asteggiano R. Anticoagulation in patients with atrial fibrillation and active cancer: an international survey on patient management. Eur J Prev Cardiol 2020; 28:611-621. [PMID: 33624005 DOI: 10.1093/eurjpc/zwaa054] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/20/2020] [Accepted: 08/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND In patients with active cancer and atrial fibrillation (AF) anticoagulation, thrombotic and bleeding risk still entail uncertainty. AIM We explored the results of an international survey examining the knowledge and behaviours of a large group of physicians. METHODS AND RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Giuseppe Boriani
- 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
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, 57 Waterloo Road, London SE1 8WA, UK
| | - Iris Parrini
- Cardiology Division, Mauriziano Hospital, Via Magellano 1, 10128, Turin, Italy
| | - Teresa Lopez-Fernandez
- Division of Cardiology, Cardiac Imaging and Cardio-Oncology Unit, La Paz University Hospital, IdiPAZ Research Institute, CIBER CV, Calle de Pedro Rico, 6, 28029 Madrid, Spain
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton & Harefield NHS Foundation Trust and the National Heart & Lung Institute, Imperial College London, Sydney Street , Greater London, SW3 6NP, UK
| | - Thomas Suter
- Cardiology, University Hospital Inselspital, Freiburgstrasse 41G, 3010 Bern, Switzerland
| | - Peter Van der Meer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Daniela Cardinale
- Cardioncology Unit, European Institute of Oncology, I.R.C.C.S., Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Patrizio Lancellotti
- Department of Cardiology, CHU Sart Tilman, University of Liège Hospital, GIGA Cardiovascular Sciences, Avenue de L'Hòpital 1-11, 4000 Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Via Corriera, 1, 48033 Cotignola (Ravenna), and Anthea Hospital, Via Camillo Rosalba, 35/37, 70124 Bari, Italy
| | - Jose Luis Zamorano
- University Hospital Ramon y Cajal, CiberCV, Ctra. de Colmenar Viejo km. 9,100 28034 Madrid, Spain
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Riccardo Asteggiano
- School of Medicine, University of Insubria, Via Ravasi, 2, 21100 Varese, Italy.,LARC (Laboratorio Analisi e Ricerca Clinica), Corso Venezia, 10, 10155 Turin, Italy
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Sorigue M, Miljkovic MD. Atrial Fibrillation and Stroke Risk in Patients With Cancer: A Primer for Oncologists. J Oncol Pract 2020; 15:641-650. [PMID: 31825754 DOI: 10.1200/jop.18.00592] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Cancer and atrial fibrillation (AF) are common conditions, but for patients affected with both, there is a lack of data about management of anticoagulation and cerebrovascular outcomes. In the first section of this review, we summarize the most relevant studies on stroke risk and management of AF in patients with active cancer, attempting to answer questions of whether to anticoagulate, whom to anticoagulate, and what agents to use. In the second section of the review, we suggest a decision algorithm on the basis of the available evidence and provide practical recommendations for each of the anticoagulant options. In the third section, we discuss the limitations of the available evidence. On the basis of low-quality evidence, we find that patients with cancer and AF have a risk of stroke similar to that of the general population but a substantially higher risk of bleeding regardless of the anticoagulant agent used; this makes anticoagulation-related decisions complex and evidence from the general population not immediately applicable. In general, we suggest stopping anticoagulation in patients with high risk of bleeding and in those with a moderate bleeding risk without a high thromboembolic risk and recommend anticoagulation as in the general population for patients at a low risk for bleeding. However, regardless of initial therapy, we recommend reassessing whether anticoagulation should be given at each point in the clinical course of the disease. High-quality evidence to guide anticoagulation for AF in patients with cancer is needed.
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Affiliation(s)
- Marc Sorigue
- ICO-Hospital Germans Trias i Pujol.IJC, UAB, Badalona, Spain
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Galderisi M, Esposito R, Sorrentino R, Mura LL, Santoro C, Tufano A. Atrial Fibrillation, Cancer and Echocardiography. J Cardiovasc Echogr 2020; 30:S33-S37. [PMID: 32566464 PMCID: PMC7293868 DOI: 10.4103/jcecho.jcecho_8_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/23/2019] [Accepted: 10/03/2019] [Indexed: 01/05/2023] Open
Abstract
Nonvalvular atrial fibrillation (AF) is a relatively frequent arrhythmia in cancer patients; it is possibly due to direct effect of cancer or consequence of cancer therapies. AF creates important problems for both therapeutic management and prognosis in cancer patients. The anticoagulation of cancer patients presenting AF is a main issue because of the difficult balance between thromboembolic and bleeding risks, both elevated in this clinical setting. A comprehensive echo Doppler examination is mandatory to identify the eventual sources of emboli in left atrial (LA) cavity, mainly the transesophageal echocardiography (TEE), but also to predict the subsequent development of heart failure. This evaluation is particularly important to graduate anticoagulation and to prevent and manage symptoms/signs of heart failure. The performance of a TEE precardioversion is highly encouraged to detect possible thrombi in LA appendage. A careful assessment of LA size (LA volume index) and function (LA emptying fraction and/or LA strain) should always be planned to predict the possible recurrence of AF paroxysmal episodes. This is in fact a key action, not only from the cardiologic point of view but also for the oncologic perspectives in individual situations. Patients with larger left atrium and more impaired LA function should be addressed toward a less aggressive cancer treatment, with drugs which are not associated or are poorly related with the risk of AF development. A correct and comprehensive echocardiographic assessment could even induce the oncologist to change the cancer management balancing the oncologic and the cardiac risk.
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Affiliation(s)
- Maurizio Galderisi
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Roberta Esposito
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Regina Sorrentino
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Lucia La Mura
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
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Sorigue M. On cancer and atrial fibrillation: Nuances and limitations. Eur J Intern Med 2019; 62:e22-e23. [PMID: 30987744 DOI: 10.1016/j.ejim.2018.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/26/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Marc Sorigue
- Hematology Laboratory, ICO-Hospital Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Spain.
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9
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Heart rate variability for rapid risk stratification of emergency patients with malignant disease. Support Care Cancer 2018; 26:3289-3296. [DOI: 10.1007/s00520-018-4144-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
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10
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Elbadawi A, Elgendy IY, Ha LD, Baig B, Saad M, Adly H, Ogunbayo GO, Olorunfemi O, Mckillop MS, Maffett SA. In-Hospital Cerebrovascular Outcomes of Patients With Atrial Fibrillation and Cancer (from the National Inpatient Sample Database). Am J Cardiol 2018; 121:590-595. [PMID: 29352566 DOI: 10.1016/j.amjcard.2017.11.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/17/2017] [Accepted: 11/21/2017] [Indexed: 12/12/2022]
Abstract
Limited data are available regarding the impact of cancer on cerebrovascular accidents in patients with atrial fibrillation (AF). We queried the Nationwide Inpatient Survey Database to identify patients who have diagnostic code for AF. We performed a 1:1 propensity matching based on the CHA2DS2VASc score and other risk factors between patients with AF who had lung, breast, colon, and esophageal cancer, and those who did not (control). The final cohort included a total of 31,604 patients. The primary outcome of in-hospital cerebrovascular accidents (CVA) was lower in the cancer group than in the control group (4% vs 7%, p < 0.001), but with only a weak association (ф = -0.067). In-hospital mortality was higher in the cancer group than in the control group (18% vs 11%, p < 0.001; ф = -0.099). A subgroup analysis according to cancer type showed similar results with a weak association with lower CVA in breast cancer (4% vs 7%; ф = -0.066, p < 0.001), lung cancer (4% vs 6%; ф = -0.062, p < 0.001), colon cancer (4% vs 6%; ф = -0.062, p < 0.001), and esophageal cancer (3% vs 7%; ф = -0.095, p < 0.001) compared with the control groups. A weak association with higher in-hospital mortality was demonstrated in lung cancer (20% vs 11%; ф = -0.127, p < 0.001), colon cancer (16% vs 11%; ф = -0.076, p < 0.001), and esophageal cancer (20% vs 12%; ф = -0.111, p < 0.001) compared with the control groups, but no significant difference between breast cancer and control groups in mortality (11% vs 11%; ф = -0.002, p = 0.888). In conclusion, in patients with AF, cancer diagnosis may not add a predictive role for in-hospital CVA beyond the CHADS2VASc score.
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Mery B, Guichard JB, Guy JB, Vallard A, Barthelemy JC, Da Costa A, Magné N, Bertoletti L. Atrial fibrillation in cancer patients: Hindsight, insight and foresight. Int J Cardiol 2017; 240:196-202. [DOI: 10.1016/j.ijcard.2017.03.132] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/21/2017] [Accepted: 03/28/2017] [Indexed: 10/19/2022]
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