Nicolò Graziano Ciavaroli (1), Mihail Celeski (1), Anna Di Cristo (1), Agostino Spanò (1), Annunziata Nusca (1), Rosetta Melfi (1), Elisabetta Ricottini (1), Fabio Mangiacapra (1), Nino Cocco (1), Paolo Gallo (1), Raffaele Rinaldi (1), Gian Paolo Ussia (1), Francesco Grigioni (1). 

(1) Unit of Cardiovascular Science, Fondazione Policlinico Universitario Campus Bio-medico, Rome

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Introductio: Patients with cancer undergoing percutaneous coronary intervention (PCI) face both high cardiovascular and bleeding risks. Consequently, they are less likely to receive aggressive antithrombotic therapies and other secondary prevention strategies compared to non-cancer patients receiving coronary stenting. Moreover, due to their generally poorer prognosis, cancer patients are often excluded from clinical trials and registries investigating long-term PCI outcomes. Therefore, we analyzed real-world data on cancer patients following PCI, focusing on differences in cardiovascular drug prescriptions between cancer and non-cancer patients, and comparing clinical practice with current evidence and guidelines.

Methods: This retrospective analysis included 1,199 patients (379 with cancer vs. 820 controls) with acute or chronic coronary syndrome undergoing PCI between 2009 and 2023. We collected discharge therapy data from both groups, analyzing differences in antithrombotic prescriptions, lipid-lowering therapies, anticoagulation for atrial fibrillation (AF) and PCI, beta-blockers, ARNI, and SGLT2 inhibitors.

Results: Despite the percentage of patients with acute coronary syndromes receiving 12-month DAPT was similar between the two groups (28% vs. 31%, p = 0.198), a higher number of neoplastic patients received only 1-month DAPT (32% vs. 9%, p < 0.001). Most cancer patients were prescribed clopidogrel regardless of clinical syndromes, with fewer receiving more potent P2Y12 inhibitors (8% vs. 14%, p = 0.004). Additionally, despite a higher prevalence of atrial fibrillation in the cancer group (20% vs. 13%), only 13% of these patients received triple antithrombotic therapy with anticoagulation. Statin and ezetimibe prescriptions were also significantly lower in cancer patients (86% vs. 92%, p = 0.005 and 12% vs. 36%, p < 0.0001, respectively). Beta-blocker therapy was significantly underused in cancer patients (68% vs. 75%, p = 0.012), as well as ARNI prescriptions (0.8% vs. 4%, p < 0.001). Furthermore, although both groups had similar rates of diabetes mellitus and heart failure, only a small number of cancer patients received SGLT2 inhibitors (0.8% vs. 3.1%, p = 0.069).

Conclusion: In our cohort, DAPT duration was in line with current guidelines for both cancer and non-cancer patients. However, the higher bleeding risk in cancer patients significantly influenced antithrombotic management, as evidenced by the under-prescription of more potent antiplatelet drugs in the acute setting. Furthermore, a reduced percentage of cancer patients with atrial fibrillation did not receive appropriate triple therapy after PCI. Other secondary prevention strategies were also underutilized in the cancer group, potentially increasing their cardiovascular risk. Lastly, the cautious use of ARNI and SGLT2 inhibitors in cancer patients after PCI underscores a tendency to fall short of optimal medical therapy in oncologic patients with heart failure.