br The American Journal of Cardiology www ajconline
786 The American Journal of Cardiology (www.ajconline.org)
Temporary interruption of rivaroxaban compared with warfarin in patients with nonvalvular AF imposed a sig-nificant risk for stroke, as demonstrated in the ROCKET-AF trial.17 More than half of the patients with new-onset cancer had a significant period of drug interruption or dis-continuation that exposed the patients to the risk of stroke. The temporary interruption could be attributed to surgery or cancer surveillance. For the patients with new-onset cancer, surgery is usually needed to eliminate the tumor. The bleeding events preceding the diagnosis of new-onset cancer complicates the use of NOACs, and a multidisciplinary AF team might be needed.10,12,18 In the present study, the interruption of NOACs, especially in those with minor bleeding or no bleeding, was signifi-cantly longer than the current recommendation.10,12,18 It remains unclear whether the recommended NOACs use in the current guideline for temporary drug interruption due to surgery or bleeding in AF patients could simply be applied to those with active or new-onset cancers.10 How-ever, the risk of stroke or embolism should not be under-estimated, as the patients with new-onset cancers also had a high stroke risk according to the CHA2DS2-VASc score, and 1 patient with recurrent stroke was also observed. If bleeding risk is high, the bridge of low molecular heparin might be probably considered due to lower bleeding rate in the cancer patients, compared with NOACs.19 NOACs with available antidotes could also be an alternative due to an increased risk of future bleeding. In conclusions, the bleeding in AF patients receiving NOACs could be an alerting sign of new-onset cancer and might prompt the Solasodine of thorough cancer sur-veillance.
The investigators have no conflicts of interest to disclose.
1. Marijon E, Le Heuzey JY, Connolly S, Yang S, Pogue J, Brueckmann M, Eikelboom J, Themeles E, Ezekowitz M, Wallentin L, Yusuf S. Causes of death and influencing factors in patients with atrial fibrilla-tion: a competing-risk analysis from the randomized evaluation of long-term anticoagulant therapy study. Circulation 2013;128:2192– 2201.
5. Kershenbaum A, Lavi I, Rennert G, Almog R. Fecal occult blood test performance indicators in warfarin-treated patients. Dis Colon Rectum 2010;53:224–229.
6. Rex DK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kal-tenbach T, Levin TR, Lieberman D, Robertson DJ. Colorectal cancer screening: recommendations for physicians and patients from the U.S. multi-society task force on colorectal cancer. Gastroenterology 2017;153:307–323.
7. Clemens A, Strack A, Noack H, Konstantinides S, Brueckmann M, Lip GY. Anticoagulant-related gastrointestinal bleeding−could Archaebacteria facili-tate early detection of benign or malignant gastrointestinal lesions? Ann Med 2014;46:672–678.
9. Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kur-ien M, Rotondano G, Hucl T, Dinis-Ribeiro M, Marmo R, Racz I, Are-zzo A, Hoffmann RT, Lesur G, de Franchis R, Aabakken L, Veitch A, Radaelli F, Salgueiro P, Cardoso R, Maia L, Zullo A, Cipolletta L, Hassan C. Diagnosis and management of nonvariceal upper gastroin-testinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2015;47:a1–46.
10. Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Des-teghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbuchel H. The 2018 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39:1330–1393.
11. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr., Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guide-lines and the Heart Rhythm Society. Circulation 2014;130:2071– 2104.
13. Chang YT, Hu YF, Liao JN, Chern CM, Lin YJ, Chang SL, Wu CH, Sung SH, Wang KL, Lu TM, Chao TF, Lo LW, Hsu LC, Chung CP, Chang PM, Hsu WH, Chiou CW, Chen SA. The assessment of antico-agulant activity to predict bleeding outcome in atrial fibrillation patients receiving dabigatran etexilate. Blood Coagul Fibrinolysis 2016;27:389–395.
14. Hu YF, Liao JN, Chern CM, Weng CH, Lin YJ, Chang SL, Wu CH, Sung SH, Wang KL, Lu TM, Chao TF, Lo LW, Chung FP, Hsu LC, Chen SA. Identification and management of noncompliance in atrial fibrillation patients receiving dabigatran: the role of a drug monitor. Pacing Clin Electrophysiol 2015;38:465–471.