Cancer begets atrial fibrillation … and vice versa?

The bidirectional association between atrial fibrillation (AF) and cancer. Common risk factors may pave the way to both conditions simultaneously, with one or the other being diagnosed first. Cancer may predispose to AF by the infiltration of or pressure on cardiac structures by primary or metastatic tumours, by causing inflammatory or other systemic effects, and by the toxicity of anticancer treatment, including surgery and systemic anticancer therapies. On the other hand, AF may unmask a pre-existing tumour due to bleeding caused by anticoagulation therapy (detection bias), while recent experimental findings indicate mechanisms that promote or facilitate carcinogenesis motivated by cardiovascular disease. The coexistence of the cancer and AF has important clinical consequences: AF may increase the risk of cancer therapy-related cardiovascular disease (CTR-CVD) and the presence of cancer may complicate anticoagulation therapy and further AF management. In terms of clinical management, baseline cardiovascular risk stratification before anticancer therapy can be guided by the risk proformas suggested by the 2022 European Society of Cardiology guidelines on Cardio-Oncology; the anticoagulation strategy should be based on the periodic assessment of the risk of thrombosis, bleeding, drug–drug interactions, and patient preferences, as indicated by the acronym TBIP; decision regarding rhythm and rate control strategies should consider the prognosis and life expectancy of cancer and again drug–drug interactions