Abstract

Oral anticoagulants (OACs) are recommended for patients with atrial fibrillation (AFib) having CHA₂DS₂-VASc score ≥ 2. However, the benefits of OAC initiation in patients with AFib and cancer at different levels of CHA₂DS₂-VASc is unknown. We included patients with new AFib diagnosis and a record of cancer (breast, prostate, or lung) from the 2012–2019 Surveillance, Epidemiology, and End Results (SEER)-Medicare database (n = 39,915). Risks of stroke and bleeding were compared between 5 treatment strategies: (1) initiated OAC when CHA₂DS₂-VASc ≥ 1 (n = 6008), (2) CHA₂DS₂-VASc ≥ 2 (n = 8694), (3) CHA₂DS₂-VASc ≥ 4 (n = 20,286), (4) CHA₂DS₂-VASc ≥ 6 (n = 30,944), and (5) never initiated OAC (reference group, n = 33,907). Confounders were adjusted using inverse probability weighting through cloning-censoring-weighting approach. Weighted pooled logistic regressions were used to estimate treatment effect [hazard ratios (HRs) and 95% confidence interval (95% CIs)]. We found that only patients who initiated OACs at CHA₂DS₂-VASc ≥ 6 had lower risk of stroke compared without OAC initiation (HR 0.64, 95% CI 0.54–0.75). All 4 active treatment strategies had reduced risk of bleeding compared to non-initiators, with OAC initiation at CHA₂DS₂-VASc ≥ 6 being the most beneficial strategy (HR = 0.49, 95% CI 0.44–0.55). In patients with lung cancer or regional/metastatic cancer, OAC initiation at any CHA₂DS₂-VASc level increased risk of stroke and did not reduce risk of bleeding (except for Regimen 4). In conclusion, among cancer patients with new AFib diagnosis, OAC initiation at higher risk of stroke (CHA₂DS₂-VASc score ≥ 6) is more beneficial in preventing ischemic stroke and bleeding. Patients with advanced cancer or low life-expectancy may initiate OACs when CHA₂DS₂-VASc score ≥ 6.

中文翻译：

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房颤和癌症患者口服抗凝药物起始策略的益处和风险：使用 SEER-Medicare 数据库进行的目标试验模拟

摘要

_{对于 CHA 2} DS ₂ -VASc 评分 ≥ 2的房颤 (AFib) 患者，建议口服抗凝剂 (OAC) 。然而，对于不同 CHA ₂ DS ₂ -VASc 水平的 AFib 和癌症患者，开始使用 OAC 的益处是未知。我们纳入了 2012-2019 年监测、流行病学和最终结果 (SEER)-医疗保险数据库中新诊断 AFib 和癌症（乳腺癌、前列腺或肺癌）记录的患者（n  = 39,915）。比较了 5 种治疗策略之间的中风和出血风险：(1) 当 CHA ₂ DS ₂ -VASc ≥ 1 时启动 OAC ( n  = 6008)，(2) CHA ₂ DS ₂ -VASc ≥ 2 ( n  = 8694)，( 3) CHA ₂ DS ₂ -VASc ≥ 4 ( n  = 20,286)，(4) CHA ₂ DS ₂ -VASc ≥ 6 ( n  = 30,944)，以及 (5) 从未启动过 OAC（参考组，n  = 33,907）。通过克隆-审查-加权方法使用逆概率加权来调整混杂因素。使用加权汇总逻辑回归来估计治疗效果[风险比 (HR) 和 95% 置信区间 (95% CI)]。我们发现，与未启动 OAC 的患者相比，只有在 CHA ₂ DS ₂ -VASc ≥ 6 时启动 OAC 的患者中风风险较低（HR 0.64，95% CI 0.54-0.75）。与非起始治疗策略相比，所有 4 种积极治疗策略均降低了出血风险，其中在 CHA ₂ DS ₂ -VASc ≥ 6 时启动 OAC 是最有益的策略（HR = 0.49，95% CI 0.44–0.55）。在肺癌或区域性/转移性癌症患者中，任何 CHA ₂ DS ₂ -VASc 水平的 OAC 启动会增加中风风险，但不会降低出血风险（方案 4 除外）。总之，在新诊断 AFib 的癌症患者中，中风风险较高（CHA ₂ DS ₂ -VASc 评分≥ 6）时开始 OAC 对预防缺血性中风和出血更有利。当 CHA ₂ DS ₂ -VASc 评分 ≥ 6时，晚期癌症或低预期寿命患者可以开始 OAC 。