Abstract
Objectives In this study-level meta-analysis, we evaluated the clinical outcome with nonvitamin
K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) in atrial
fibrillation (AF) patients with cancer.
Background Anticoagulation in AF patients with cancer is challenging given the coexistence of
elevated thrombotic and bleeding risk. The efficacy and safety of NOACs in this setting
remain unclear.
Methods We included three randomized trials in our primary analysis (N = 2,661 patients) and three observational studies in our secondary, confirmatory
analysis (N = 21,112 patients). Outcome measures were: the composite of any stroke or systemic
embolism, ischemic stroke, venous thromboembolism, major bleeding, intracranial bleeding;
and all-cause death. Mean follow-up duration was 2.2 years.
Results In the primary analysis, the use of NOACs was associated with similar incidence of
stroke/systemic embolism (odds ratio [OR] 0.70, 95% confidence interval 0.45–1.09;
p = 0.11), ischemic stroke (OR 0.71, 0.31–1.64; p = 0.42), venous thromboembolism (OR 0.91, 0.33–2.53; p = 0.86), all-cause death (OR 1.02, 0.72–1.42; p = 0.93), and major bleeding (OR 0.81, 0.61–1.06; p = 0.13) compared with VKAs. The occurrence of intracranial bleeding was significantly
lower in the NOACs versus VKAs group (OR 0.11, 0.02–0.63; p = 0.01). These results were overall confirmed in the secondary analysis, where there
was additionally a significant reduction of stroke/systemic embolism, ischemic stroke,
and venous thromboembolism with NOACs.
Conclusion In AF patients with malignancy, NOACs appear at least as effective as VKAs in preventing
thrombotic events and reduce intracranial bleeding. NOACs may represent a valid and
more practical alternative to VKAs in this setting of high-risk patients.
Keywords
atrial fibrillation - cancer - anticoagulation - stroke - bleeding
