Management of Arrhythmias in Cardio-Oncology: AHA Statement

Fradley MG, Beckie TM, Brown SA, et al.
Recognition, Prevention, and Management of Arrhythmias and Autonomic Disorders in Cardio-Oncology: A Scientific Statement From the American Heart Association. Circulation 2021;Jun 17:[Epub ahead of print].

This American Heart Association (AHA) Scientific Statement summarizes the current state of knowledge on the incidence and management of arrhythmias in patients receiving treatment for cancer. Here are 10 key points to remember:

  1. The mechanisms associated with arrhythmias in the setting of cancer therapy are diverse and include direct cellular effects, electrolyte abnormalities, hyperinflammatory response, and secondary to other forms of cardiac effects such as myocarditis, ischemia, and heart failure.
  2. The most commonly encountered arrhythmia in the setting of cancer therapy is atrial fibrillation, with an incidence ranging between 2–15% depending on the therapy. Ventricular arrhythmias are rare.
  3. Drug–drug interactions limit the use of non-dihydropyridine calcium channel blockers, digoxin, direct oral anticoagulants, and dronedarone in these patients given their impact on cytochrome P450 3A4, P450 2D6, and P-glycoprotein metabolism.
  4. Antiarrhythmic medications have not been specifically studied in cancer patients and must be used with caution given the potential to exacerbate QT prolongation and interact with different cancer therapies.
  5. The CHA2DS2-VASc score has not been validated in cancer patients and may underestimate the risk of stroke. It remains recommended, however, to guide anticoagulation in this patient group.
  6. The HAS-BLED score does not account for thrombocytopenia and the risk of intracerebral metastasis and should be used with caution in assessing the risk of bleeding in patients with cancer.
  7. Direct oral anticoagulants appear to be effective and safe in patients with cancer and atrial fibrillation.
  8. While QT prolongation is common in these patients (22%), the incidence of life-threatening arrhythmias is rare, occurring in <1% of patients.
  9. Bradycardia is commonly associated with certain therapies such as paclitaxel and thalidomide, occurring in up to 40% of patients, with presentations ranging from asymptomatic (paclitaxel) to requiring pacemaker placement (thalidomide).
  10. Autonomic dysfunction is associated with a wide range of cancer therapies including anthracyclines, taxanes, vinca-alkaloids, platinum-based agents, neck irradiation, and hematopoietic stem cell transplant, in which treatment is similar to that in noncancer patients.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardio-Oncology, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, Statins, Acute Heart Failure

Keywords: Anthracyclines, Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Bradycardia, Calcium Channel Blockers, Cardio-oncology, Cardiotoxicity, Electrolytes, Heart Failure, Ischemia, Long QT Syndrome, Myocarditis, Neoplasms, Pacemaker, Artificial, Pharmaceutical Preparations, Secondary Prevention, Stroke, Thrombocytopenia, Vinca Alkaloids

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