Case Report: Navigating anticoagulation for atrial fibrillation in a patient with cancer

Abstract

Atrial fibrillation (AF) and cancer frequently coexist. Cancer-associated hypercoagulability may exacerbate thrombogenesis in AF, while active malignancy confers elevated risks of bleeding and all-cause mortality. Consequently, the coexistence of hypercoagulability and bleeding risk in patients with AF and cancer poses a distinct clinical challenge for optimizing anticoagulation management. However, the optimal anticoagulation strategy for patients with concomitant AF and cancer remains insufficiently validated. Furthermore, tumor heterogeneity complicates the implementation of a uniform antithrombotic regimen. We report the case of a patient with AF and ulcerative-protruding, moderately differentiated rectal adenocarcinoma who underwent radical surgery (Dixon procedure). Gastrointestinal endoscopy was performed as part of postoperative oncological surveillance. Perioperative anticoagulation was managed by balancing bleeding and thrombotic risks in accordance with current guidelines and consensus statements. The postoperative antithrombotic therapy was individualized, taking into account the dynamic nature of cancer-associated thrombotic risk and the bleeding risks associated with invasive procedures during oncological follow-up. This case offers valuable insights into the management of patients with AF and cancer, highlighting the importance of an individualized treatment approach.

Keywords

Cancer / atrial fibrillation / comorbidity / anticoagulation / non-vitamin K antagonist oral anticoagulant

References

[1] Yasui T.Anticoagulation for atrial fibrillation in patients with cancer.Circ J2022;86:211-2

[2] Siontis KC,Ruddy KJ.Atrial fibrillation and cancer: where biology and epidemiology intertwine.JACC CardioOncol2021;3:233-5 PMCID:PMC8352332

[3] Shaaban A,Greenlee AN.Atrial fibrillation in cancer, anticancer therapies, and underlying mechanisms.J Mol Cell Cardiol2024;194:118-32 PMCID:PMC11500699

[4] Melloni C,Carver J.Management and outcomes of patients with atrial fibrillation and a history of cancer: the ORBIT-AF registry.Eur Heart J Qual Care Clin Outcomes2017;3:192-7

[5] Vinter N,Fenger-Grøn M,Frost L.Atrial fibrillation and risk of cancer: a danish population-based cohort study.J Am Heart Assoc2018;7:e009543 PMCID:PMC6201425

[6] Chen Q,Van Der Hulle T.Coexisting atrial fibrillation and cancer: time trends and associations with mortality in a nationwide Dutch study.Eur Heart J2024;45:2201-13 PMCID:PMC11231645

[7] Müller AD,Wasserman IH.Diseases preceding colon cancer: a case-control study among veterans.Dig Dis Sci1994;39:2480-4

[8] Kahr PC,Huber-Schönauer U.Atrial fibrillation: a new indicator for advanced colorectal neoplasia in screening colonoscopy.J Clin Med2019;8:1083 PMCID:PMC6678897

[9] Aviles RJ,Apperson-Hansen C.Inflammation as a risk factor for atrial fibrillation.Circulation2003;108:3006-10

[10] Guzzetti S,Vernocchi A,Fundarò C.First diagnosis of colorectal or breast cancer and prevalence of atrial fibrillation.Intern Emerg Med2008;3:227-31

[11] Gonçalves-Teixeira P,Fragoso I.Screening, diagnosis and management of atrial fibrillation in cancer patients: current evidence and future perspectives.Arq Bras Cardiol2022;119:328-41 PMCID:PMC9363048

[12] Fradley MG,Alomar M.Patterns of anticoagulation use in patients with cancer with atrial fibrillation and/or atrial flutter.JACC CardioOncol2020;2:747-54 PMCID:PMC8352174

[13] Wang T,Zhu Y.Antithrombotic strategy in cancer patients comorbid with acute coronary syndrome and atrial fibrillation.Front Cardiovasc Med2023;10:1325488 PMCID:PMC10756915

[14] Brown JD,Lip GYH.Risk stratification for bleeding complications in patients with venous thromboembolism: application of the HAS-BLED bleeding score during the first 6 months of anticoagulant treatment.J Am Heart Assoc2018;7:e007901 PMCID:PMC5907554

[15] Aziz J,Siegal D.Thrombotic and bleeding outcomes following the perioperative interruption of anticoagulation among patients with nonvalvular atrial fibrillation and active cancer.J Thromb Haemost2023;21:933-43

[16] Yao X,Sangaralingham LR.Comparison of the CHA₂DS₂-VASc, CHADS₂, HAS-BLED, ORBIT, and ATRIA risk scores in predicting non-vitamin K antagonist oral anticoagulants-associated bleeding in patients with atrial fibrillation.Am J Cardiol2017;120:1549-56

[17] Mosaad M,Cheema E.Cancer-associated thrombosis: a clinical scoping review of the risk assessment models across solid tumours and haematological malignancies.Int J Gen Med2021;14:3881-97 PMCID:PMC8318782

[18] Grewal K,Austin PC.Bleeding and new malignancy diagnoses after anticoagulation for atrial fibrillation: a population-based cohort study.Circulation2025;151:773-82

[19] Angeli F,Armillotta M.Impact of newly diagnosed cancer on bleeding events in patients with atrial fibrillation treated with direct oral anticoagulants.Am J Cardiovasc Drugs2024;24:813-21 PMCID:PMC11525436

[20] January CT,Alpert JS.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the heart rhythm society.J Am Coll Cardiol2014;64:e1-76

[21] Iftimi AA,Peiró S.Association of vitamin K and non-vitamin K oral anticoagulant use and cancer incidence in atrial fibrillation patients.Clin Pharmacol Ther2021;111:200-8 PMCID:PMC9291805

[22] Camidge R,Cassidy J.Significant effect of capecitabine on the pharmacokinetics and pharmacodynamics of warfarin in patients with cancer.J Clin Oncol2005;23:4719-25

[23] Wallentin L,Ezekowitz MD.Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial.Lancet2010;376:975-83

[24] Sherwood MW,Hellkamp AS.Gastrointestinal bleeding in patients with atrial fibrillation treated with rivaroxaban or warfarin: ROCKET AF trial.J Am Coll Cardiol2015;66:2271-81

[25] Yang P,Xu X.Efficacy and safety of oral anticoagulants in atrial fibrillation patients with cancer—a network meta-analysis.Heart Fail Rev2019;25:823-31

[26] Rutherford OW,Ghanima W,Halvorsen S.Comparison of dabigatran, rivaroxaban, and apixaban for effectiveness and safety in atrial fibrillation: a nationwide cohort study.Eur Heart J Cardiovasc Pharmacother2020;6:75-85 PMCID:PMC7073510

[27] Lopes RD,Aronson R.Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation.N Engl J Med2019;380:1509-24

[28] Naito R,Yasuda S.Rivaroxaban monotherapy vs combination therapy with antiplatelets on total thrombotic and bleeding events in atrial fibrillation with stable coronary artery disease: a post hoc secondary analysis of the AFIRE trial.JAMA Cardiol2022;7:787

[29] Cho MS,Ahn J.Edoxaban antithrombotic therapy for atrial fibrillation and stable coronary artery disease.N Engl J Med2024;391:2075-86

[30] Patti G,Marston XL.Anticoagulant treatment adherence and persistence in german patients with atrial fibrillation.Cardiol Ther2023;12:371-91

[31] Spyropoulos A,Sherwood M.Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery.J Thromb Haemost2016;14:875-85

[32] Doherty JU,Hucker WJ.2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American college of cardiology clinical expert consensus document task force.J Am Coll Cardiol2017;69:871-98

[33] Douketis JD,Kaatz S.Perioperative bridging anticoagulation in patients with atrial fibrillation.N Engl J Med2015;373:823-33

[34] Douketis JD.Perioperative management of patients taking direct oral anticoagulants: a review.JAMA2024;332:825-34.

[35] Veitch AM,Alikhan R.Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update.Gut2021;70:1611-28 PMCID:PMC8355884

[36] Ullah W,Frisch DR.Outcomes and discriminatory accuracy of the CHA₂DS₂VASc score in atrial fibrillation and cancer.JACC Adv2023;2:100609 PMCID:PMC11198258

[37] Seth L,Doss S.Atrial fibrillation and ischemic stroke in cancer: the latest scientific evidence, current management, and future directions.J Thromb Thrombolysis2025;58:1081-94

[38] Ajabnoor AM,Parisi R.Performance of CHA₂DS₂-VASc and HAS-BLED in predicting stroke and bleeding in atrial fibrillation and cancer.Eur Heart J Open2024;4:oeae053 PMCID:PMC11234295

[39] Raposeiras Roubín S,Muñoz Pousa I.Incidence and predictors of bleeding in patients with cancer and atrial fibrillation.Am J Cardiol2022;167:139-46

[40] Gerotziafas GT,Abdel-Razeq H.A predictive score for thrombosis associated with breast, colorectal, lung, or ovarian cancer: the prospective COMPASS-cancer-associated thrombosis study.Oncologist2017;22:1222-31 PMCID:PMC5634762

[41] Yao Y,Lip GYH.The effects of implementing a mobile health-technology supported pathway on atrial fibrillation-related adverse events among patients with multimorbidity: the mAFA-II randomized clinical trial.JAMA Netw Open2021;4:e2140071