. Følgende dias er fremlagt ved DCS / DTS Fællesmøde 13. januar 2011 og alle rettigheder tilhører foredragsholderen. Gengivelse må kun foretages ved tilladelse
Antithrombotic therapy in Atrial Fibrillation National treatment guideline Steen Husted Aarhus University Hospital
What is New in the 2010 Guideline? Impact on stroke prevention in DK?
Atrial Fibrillation (AF) is a common problem • AF is the most common cardiac arythmia • Very common in the elderly • Related to co-morbidity • MI • Heart failure • Hypertension • Treatment of AF is a clinical challenge
The Management Cascade for patients with AF European Heart Journal (2010) 31, 2369 – 2429
‘Natural’ time course of AF. Camm A J et al. Eur Heart J 2010;eurheartj.ehq278
Decisions on Stroke Prevention in AF : • Evidence based • In accordance with guidelines • Based on: • Risk of stroke • Risk reduction of stroke on antithrombotic treatment • Risk of bleeding • Contraindications to antithrombotic medications
Antithrombotics for stroke prevention in AF • None • OAC • Low risk • Vitamin K antagonists (VKA) • Moderate to high risk • Platelet inhibitor: • New drugs • Aspirin (ASA) • Moderate to high risk • Low risk • Combinations • Clopidogrel • ASA + VKA • ASA intolerance • Common used in AF + IHD • ASA + Clopidogrel • ASA + clopidogrel + VKA • Contraindication for OAC • AF + Coronary artery stent/ACS • Heparin ”bridging” • Special conditions
Stroke Risk Estimation • Clinical scoring systems: • Low risk • Intermediate risk • High risk • CHADS 2 • CHA 2 DS 2 -VASc • For refinement incorporate other risk factors: • Age 65-74 • Female gender • Vascular disease
Stroke risk stratification with CHADS2 and CHA2DS2-VASc scores Score CHADS 2 acronym CHA 2 DS 2 -VASc acronym Score Congestive 1 Congestive heart failure/LV dysfunction 1 heart failure Hypertension 1 Hypertension 1 Aged ≥75 years Aged ≥75 years 1 2 Diabetes mellitus 1 Diabetes mellitus 1 Stroke/TIA/TE 2 Stroke/TIA/TE 2 Vascular disease Maximum score 6 1 (prior MI, PAD, or aortic plaque) Aged 65-74 years 1 Sex category (i.e. female gender) 1 Maximum score 9
Stroke risk assessment with CHA 2 DS 2 -VASc CHA 2 DS 2 -VASc Rate of stroke/other TE CHA 2 DS 2 -VASc criteria Score total score (%/year) (95% CI)* 0 0 (0 – 0) C ongestive heart failure/ 1 left ventricular dysfunction 1 0.6 (0.0 – 3.4) 2 1.6 (0.3 – 4.7) H ypertension 1 3 3.9 (1.7 – 7.6) A ge 75 yrs 2 4 1.9 (0.5 – 4.9) D iabetes mellitus 1 5 3.2 (0.7 – 9.0) S troke/transient ischaemic 2 attack/TE 6 3.6 (0.4 – 12.3) V ascular disease (prior myocardial 7 8.0 (1.0 – 26.0) infarction, peripheral artery 1 disease or aortic plaque) 8 11.1 (0.3 – 48.3) A ge 65 – 74 yrs 1 9 100 (2.5 – 100) S ex c ategory (i.e. female gender) 1 *Theoretical rates without therapy corrected for the % of patients receiving Aspirin within each group, TE = thromboembolism assuming 22% reduction in risk with Aspirin 13 Lip GYH et al. Chest 2010;137:263-72
Risk of Bleeding • Risk of stroke and risk of bleeding is closely related • OAC prescription needs to: • Balance benefit from stroke prevention and risk from bleeding
Risk factors for Bleeding • Hypertension • Abnormal renal/liver function • Stroke • Bleeding history or predisposition • Labile INR • Elderly (>65) • Drugs/alcohol concomitantly
HAS-BLED new bleeding risk scoring system • H ypertension • A bnormal renal/liver function • S troke • B leeding history or predisposition • L abile INR • E lderly (>65) • D rugs/alcohol concomitantly R. Pisters and GYHL. Lip et al.. Chest ; Prepublished online March 18, 2010;
HAS-BLED bleeding risk score Points Annual bleeding rate 0-1 <1.02 2 1.88 >3 >3.74 HAS-BLED score of ≥3, suggest caution and/or regular review
One approach - Benefits of VKA versus Risk of Bleeding CHADS 2 score Risk of Bleeding: ≥ 2 Outweighs the potential benefit of OAC if: HAS-BLED score > CHA 2 DS 2 index. HAS-BLED score must exceed 2 1 for the potential harm caused by OAC use to offset its beneficial effect on stroke risk reduction NBV 2011
One approach - Benefits of VKA versus Risk of Bleeding CHA 2 DS 2 - VAS c- Risk of Bleeding: score ≥ 2 Outweighs the potential benefit of OAC if: HAS-BLED score > CHA 2 DS 2 - VASc index. 1 HAS-BLED must be low 0-1, good quality VKA therapy with expected annual bleeding rate <2% or time in therapeutic interval more than 2/3 of time R. Pisters and GYHL Lip et al.. Chest ; Prepublished online March 18, 2010;
Conclusion on VKA in AF • Thromboprophylaxis in AF requires a beneficial balance between stroke and bleeding risk • Initially, consider CHADS 2 score, or for more comprehensive stroke risk assessment CHA 2 DS 2 -VASc score • If score ≥2, OAC is clearly indicated • For simple and easy bleeding risk assessment use: • HAS-BLED score • If score ≥3, clearly ‘at risk’ - caution
AF - Special situations • Paroxysmal AF • Elective PCI • Perioperative anticoagulation • ACS and/or PCI • NSTEMI • Stable vascular disease • STEMI with primary PCI • Acute stroke
Paroxysmal AF • Stroke risk in paroxysmal AF • Not different from that in persistent or permanent AF • Patients with paroxysmal AF • should receive OAC according to their risk score
Perioperative anticoagulation • Many surgeons require: • INR < 1.5 or even INR normalization before undertaking surgery • What to do? • Temporary interruption of VKA treatment before surgery or an invasive procedure: • Warfarin pause 4 days before procedure • Phenprocoumon interrupted 7 days before procedure • Pause for 48 h without bridging PRAB report, www.DSTH.dk
Perioperative anticoagulation • Mechanical heart valve or • AF at high risk for thrombo-embolism (CHADS-score 4+) • Bridging with therapeutic doses of • LMWH PRAP raport, www.DSTH.dk
Perioperative anticoagulation • VKA resumed at the ‘usual’ maintenance dose: • without a loading dose • on the evening of surgery PRAB raport, www.DSTH.dk
Stable vascular disease • Many anticoagulated AF patients have • stable coronary disease • carotid artery disease and/or • PAD • Common practice: • VKA + one antiplatelet drug • usually ASA • Adding ASA to VKA does not reduce the risk of • stroke or • vascular events (including MI) • But substantially increases bleeding events !
Acute Stroke • Acute stroke is a common first presentation AF • Limited trial data to guide management • Concern that patients within the first 2 weeks after cardioembolic stroke have: • greatest risk of recurrent stroke • because of further thrombo-embolism • Anticoagulation in the acute phase may result in • intracranial haemorrhage or • haemorrhagic transformation of a cerebral infarct
AF presenting with an acute stroke • What to do: • Treat uncontrolled hypertension • before antithrombotic treatment is started, • Cerebral imaging should be performed to exclude haemorrhage • CT • MRI • If no haemorrhage: • anticoagulation should begin within 2 weeks – usually after 1-2 weeks • If presence of haemorrhage • anticoagulation should not be given
In AF presenting with acute TIA • Anticoagulation treatment should begin as soon as possible • in the absence of cerebral infarction or haemorrhage
Acute coronary syndrome and/or PCI • Current guidelines for ACS and/or PCI recommend • ASA – clopidogrel combination therapy after: • ACS and a stent • 4 weeks for a bare-metal stent • 6 – 12 months for a drug-eluting stent • 12 months after ACS
ACS and/or PCI • VKA non-treatment in high risk AF is associated with • an increase in mortality and • an increase major adverse cardiac events
Acute coronary syndrome and/or PCI • The prevalence of major bleeding with triple therapy: • VKA, ASA, and clopidogrel • 2.6 – 4.6% at 30 days • 7.4 – 10.3% at 12 months • Acceptable risk – benefit ratio for 4 weeks • if the bleeding risk is low
Antithrombotic strategies in coronary artery stenting in high risk AF European Heart Journal (2010) 31, 2369 – 2429
How to chose the right OAC strategy in the future • Important task for the Scientific societies
Thank you for your attention
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