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Cancer Plus Afib Means Less Cardiology Care, Anticoagulation

Cardiology involvement in the treatment of atrial fibrillation (Afib, AF) appears underutilized among people with a history of cancer, but was associated with better rates of anticoagulation and other outcomes, a large commercial claims database study found.

AF patients with a history of cancer were less likely to see a cardiologist (54%) than were those without a history of cancer (62%), reported Wesley O’Neal, MD, of Emory University in Atlanta, and colleagues in the Journal of the American College of Cardiology.

A history of cancer was also associated with fewer prescription fills for anticoagulants (RR 0.89, 95% CI 0.88-0.90).

A reduced risk of stroke (HR 0.89, 95% CI 0.81-0.99) was found among such cancer patients who were seen by a clinician specializing in cardiology, without an increased risk of bleeding (HR 1.04, 95% CI 0.95-1.13).

The findings “suggest that suboptimal antithrombotic care exists in AF patients who have a history of cancer, and early cardiology involvement appears to favorably influence oral anticoagulant prescription fills and AF-related outcomes in this subset of AF patients,” the investigators wrote.

“The management of cancer patients must extend beyond their primary malignancy and will require an interdisciplinary approach from oncologists, primary care providers, and other subspecialists,” commented Sean Chen, MD, and Chiara Melloni, MD, MHS, both of Duke University Medical Center in Durham, North Carolina, in an editorial accompanying the study.

“The increase in survivorship is a testament to the dramatic improvement in cancer therapy, but continued emphasis on patient’s diagnosis of cancer can shift significant attention away from other essential aspects of care,” Chen and Melloni continued.

The reason for differences between specialties might have been because cardiologists “are more focused on stroke prevention than oncologists or primary care doctors,” Eric Bates, MD, of the University of Michigan School of Medicine in Ann Arbor, who was not involved in the study, told MedPage Today.

While the findings might not be surprising, he said, “this is another population health reminder that anticoagulation for Afib is underutilized and that there is a potential to further decrease stroke rates by treating more patients with guideline-directed anticoagulation therapy despite increasingly complex comorbidities.”

The researchers evaluated 388,045 non-valvular AF patients, of whom 17% had cancer and 59% were male. The mean age of the study patients was 68.

While there were some differences in anticoagulant prescription fills and cardiology involvement across types of cancer, the findings were similar for active cancer versus remote history history of it. Notably, differences “were not observed for cancers that are more likely to be detected at an earlier stage (breast and prostate),” the investigators reported.

Risks seen with cardiology care in the cohort compared with primary care alone were similar for MI but higher for heart failure (HR 1.30, 95% CI 1.20-1.41) and AF hospitalization (HR 1.44, 95% CI 1.34-1.55).

The latter findings “possibly were related to more aggressive cardiovascular care for patients who were seen by cardiology providers,” as indicated by greater use of rhythm control therapies in those seen by cardiologists, but also could be due to medication side effects or more severe disease preferentially being referred to cardiologists.

“Further studies are needed to determine optimal management strategies for patients with AF and a history of cancer, including those that encourage early inclusion of a cardiologist on the care team,” the researchers concluded.

The study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health, the National Institute on Aging of the National Institutes of Health, and the American Heart Association.

O’Neal reported no conflicts of interest.

2018-08-10T00:00:00-0400

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anticoagulants Cancer cardiology Wesley O'Neal
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