Dr Mammen Ninan GPwSI in Cardiology

Transcription

1 Dr Mammen Ninan GPwSI in Cardiology

2 AF affects up to 835,000 people in England alone and is expected to rise year after year. AF is a known risk factor for stroke, the 3 rd highest cause of mortality in the UK and costs the NHS 2.8 billion per year The Sentinel Stroke National Audit programme (SSNAP) found in August 2013 that only 36% of patients adm itted with stroke were on anticoagulants. It is estimated that strokes per year are related to AF and AF increases the risk of stroke by 5 6 times It is estimated that 7100 strokes per year can be prevented if everyone with AF was appropriately m anaged

3 Manual pulse check Confirmed by ECG

4 Paroxysmal (Recurrent) Terminates spontaneously within 7 days and usually < 48hrs Persistent (Recurrent) Lasts > 7 days. Not self terminating, requires electrical or pharmacological conversion Permanent (Established) No further cardioversion attempts

5 Control of rate and/ or rhythm Reducing the risk of stroke associated with AF Incorporating the latest evidence and NICE guidance Do not use Aspirin as monotherapy for stroke prevention Improving patient understanding and involvement i.e shared decision making Use of CHA2DSVASc score rather than CHAS2 score

6 1. Beta blocker or rate limiting CCB as initial monotherapy 2. Digoxin monotherapy with non- paroxysmal AF only if individual is sedentary or takes little ex ercise 3. If patient still symptomatic or poor ventricular rate control combine 2 out of beta- blocker, diltiazem, digoxin 4. Do not px amiodarone for long- term rate control

7 If AF has reversible cause With HF thought to be primarily caused by AF New onset AF Atrial Flutter that might be eligible for ablation For whom rhythm control would be more suitable

8 Consider pharmacological and/ or electrical rhythm control when symptoms continue after HR has been controlled or for whom rate control has not been successful Long- term rhythm control Beta- blocker 1 st line Dronedarone an option for maintaining SR following successful cardioversion Amiodarone for people with LV impairment or HF Not Flecainide or Propafenone in IHD or structural heart disease

9 Refer people promptly at any stage if treatment fails to control their symptoms and more specialised management is needed..4/ 52

10 Congestive Heart Failure/ LVD % Hypertension % Age 75 years % Diabetes mellitus % Stroke/ TIA/ TE % Vascular disease (previous MI, PAD or aortic plaque) % Age between 65 and 74 years % Sc - Sex category - Female % HIGH risk = a score of 2 or more (antithrombotic therapy) Score of 1 recommends anticoagulant therapy in males.. Consider a risk of bleeding assessment such as the HAS- BLED score before anticoagulation.

11 Hypertension (Systolic 160mmHg) 1 Abnormal renal/ liver function 1or2 Stroke in past 1 Bleeding tendency or predisposition 1 Labile INRs 1 Elderly ( 65yrs) 1 Drugs (aspirin or NSAIDS) or alcohol 1or2 A score of 3 or more indicates increased one year bleed risk on anticoagulation sufficient to justify caution or more regular review.

12 Warfarin and NOACs have shown significant and consistent stroke risk reduction For most patients benefit of OAC therapy outweighs bleeding risk For those with increased risk of bleeding monitor bleeding risk Do not withold OAC therapy solely because of risk of falls! Do not offer OAC therapy to people < 65 & no risk factors other than gender Consider for men with CHA 2 DS 2 - VASc of 1 Otherwise if CHA 2 DS 2 - VASc is 2

13 H/ O Intracranial haemorrhage (CHADS 3 ) Unexplained major extra cranial bleed within last 6/ 12 PU within last 3/ 12 Alcohol abuse Advanced impaired cognitive function/ dementia Drug interaction Interacts with cranberry juice and foods with high amounts of Vit K e.g. cabbage, spinach, broccoli, sprouts

14 H/ O intra- cranial haemorrhage (not always a C/ I - seek specialist advice) Oesophageal varices (depends on classification) Previous hypersensitivity/ adverse reaction (consider cardiology opinion) Advanced malignancy/ terminal illness Pregnancy Significant thrombocytopenia (platelet count < 50) Acute clinically significant bleed (incl within 72hrs of major surgery with risk of severe bleeding) Severe renal impairment (egfr stage 5) Decompensated liver disease (baseline INR.1.5)

15 Ensuring understanding why oral anticoagulants are indicated in AF Ensuring patient understands that AF increases the risk of stroke by 5 6 times compared to non- AF patient Ensuring patient understands that stroke in AF is severely disabling or fatal Understanding how to use CHA2DsVASc table and to explain risk Use of Patient Decision Aids Involving family and carers in decision making, esp where there may be co- morbidity esp dementia, falls, frailty, very elderly

16 Warfarin is the commonest VKA used Recent audit data suggest the majority of CCGs are advising use of warfarin as first line data ( around 73% ) NICE guidance use of VKA or any of the available NOAC Warfarin initiation is via local pathway NOAC initiation variable across CCGs, usually secondary care led, but increasingly from prim ary care Warfarin initiation is usually done as low dose initiation, with initiating dose varying between 1 3 mg; time to reach therapeutic range of INR is usually between 14 days to 28 days High dose warfarin initiation is no longer advised, where there is need for im m ediate anticoagulation, LMWH or NOAC can be used

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18 Dabigatran Apixaban Edoxaban * Rivaroxaban Action Direct thrombin inhibitor Activated factor Xa (FXa) inhibitor Activated factor Xa (FXa) inhibitor Activated factor Xa (FXa) inhibitor Dose 150 mg BID 110 mg BID 5 mg BID 2.5 mg BID Phase III clinical trial RE-LY 1 ARISTOTLE 2 * not yet approved by EMA 1. Connolly et al, N Engl J Med 2009; 361: Ruff et al, Am Heart J 2010; 160: Granger et al, N Engl J Med 2011; 365: Patel et al, N Engl J Med 2011;365: Connolly et al, N Engl J Med 2011; 364: mg QD 30 mg QD 15 mg QD 20 mg QD 15 mg QD AVERROES 3 ENGAGE-AF 4 ROCKET-AF 5 3

19 Common Pathway Apixaban Rivaroxaban Xa Blocker Xa Dabigatran New Oral Agents Prothrombin Thrombin Clot Fibrinogen Fibrin

20 Intracranial Hemorrhage Atrial Fibrillation Trials Study NOAC VKA Outcome RE-LY Dabigatran Warfarin RR % 0.7% 95% CI P= <0.001 ARISTOTLE Apixaban Warfarin HR % 0.8% 95% CI P = <0.001 ROCKET-AF Rivaroxaban Warfarin HR % 0.7% 95% CI P = 0.02

21 Dabigatran Apixaban Edoxaban * Rivaroxaban Bioavailability 3-7% 50% 62% 66% (w/o food) ~100% with food Prodrug yes no no no Clearance: non-renal/renal of adsorbed dose if normal renal function 20%/80% 73%/27% 50%/50% 65%/35% Liver metabolism: CYP3A4 no yes (elimination; minor CYP3A4) minimal (<4% of elimination) yes (elimination) Absorption with food no effect no effect 6-22% more +39% Intake with food? no no no official recommendation yet mandatory Absorption with H2B/PPI plasma level -12 to -30% no effect no effect no effect Asian ethnicity plasma level +25% no effect no effect no effect GI tolerability dyspepsia 5-10% no problem no problem no problem Elimination half-life 12-17h 12h 9-11h 5-9h (young)/11-13h (elderly) * not approved yet 16

22 All NICE approved (Licensed for use in non- valvular AF with 1 CHA2DS2VASc) TTR < 65% (investigate) No routine monitoring No food interactions Check renal function at least annually C/ I similar to Warfarin Still risk of bleeding - monitor those at high risk Patient alert cards They are on an anticoagulant!

23 Card can be downloaded in a printer-ready form or in a ppt format that can be configured to the local language from 5

24 Three levels of alert: Red contraindicated/not recommended for use Orange adapt NOAC dose dabigatran: 150 mg to 110 mg BID rivaroxaban: 20 mg to 15 mg QD apixaban: 5 mg to 2.5 mg BID Yellow consider dose reduction if two concomitant yellow interactions Where no data available, NOACs not recommended yet 18

25 Dabigatran Apixaban Edoxaban Rivaroxaban Atorvastatin P-gp/ CYP3A4 +18% no data yet no effect no effect Digoxin P-gp no effect no data yet no effect no effect Verapamil P-gp/ wk CYP3A % no data yet + 53% (slow release) minor effect Diltiazem P-gp/ wk CYP3A4 no effect +40% No data minor effect Quinidine P-gp +50% no data yet +80% +50% Amiodarone P-gp % no data yet no effect minor effect Dronedarone P-gp/CYP3A % no data yet +85% no data yet Ketoconazole; itraconazole; voriconazole; posaconazole; P-gp and BCRP/ CYP3A % +100% no data yet up to +160% Red contraindicated; orange reduce dose; yellow consider dose reduction if another yellow factor present; hatching no data available; recommendation made from pharmacokinetic considerations 19

26 Dabigatran Apixaban Edoxaban Rivaroxaban Atorvastatin P-gp/ CYP3A4 +18% no data yet no effect no effect Digoxin P-gp no effect no data yet no effect no effect Verapamil P-gp/ wk CYP3A % no data yet + 53% (slow release) minor effect Diltiazem P-gp/ wk CYP3A4 no effect +40% No data minor effect Quinidine P-gp +50% no data yet +80% +50% Amiodarone P-gp % no data yet no effect minor effect Dronedarone P-gp/CYP3A % no data yet +85% no data yet Ketoconazole; itraconazole; voriconazole; posaconazole; P-gp and BCRP/ CYP3A % +100% no data yet up to +160% Red contraindicated; orange reduce dose; yellow consider dose reduction if another yellow factor present; hatching no data available; recommendation made from pharmacokinetic considerations 19

27 All NOACs are anticoagulants and hence can cause serious bleeding. All NOACs have some drug-drug interactions (DDIs). AF population is a fragile patient population. Patients should return for ongoing review according to a predetermined schedule. Follow-up can be undertaken by specialist or GP with experience in the field and/or appropriate secondary care physicians. Nurse co-ordinated AF clinics may be used Berti et al, Eur Heart J, 2013 (Epub ahead of print) 6

28 All NOACs are anticoagulants and hence can cause serious bleeding. All NOACs have some drug-drug interactions (DDIs). AF population is a fragile patient population. Patients should return for ongoing review according to a predetermined schedule. Follow-up can be undertaken by specialist or GP with experience in the field and/or appropriate secondary care physicians. Nurse co-ordinated AF clinics may be used Berti et al, Eur Heart J, 2013 (Epub ahead of print) 6

29 Compliance Interval Each visit Comments Inspect remaining medication Stress importance of compliance Inform about compliance aids Thrombo-embolism Each visit Cerebral, systemic and pulmonary circulation Bleeding Each visit Nuisance bleeding prevention possible? Bleeding with risk or impact on QoL prevention possible? Need to revise dose? Side effects Each visit Continuation? Temporary cessation with bridging? Change of anticoagulant drug? Co-medications Blood sampling Each visit Yearly 6-monthly 3-monthly on indication Prescription or over-the counter drugs? Even temporary use can be risky Haemoglobin, renal, liver function Renal function if CrCl ml/min or if on dabigatran and aged >75 years or fragile If CrCl ml/min If intercurring condition may impact renal or hepatic function. 8

30 Stroke awareness and measures to prevent stroke Rate control Assessment of symptoms for rhythm control Who to contact for advice if needed Psychological support if needed Up- to- date comprehensive information on: Causes, effects and complications of AF Management of rate and rhythm control Anticoagulation Support networks

31 Individual approach - making each contact count Population approach - employing strategies to improve detection of AF and increasing anticoagulation rates in this cohort

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33 Especially in the over 65 s Those with symptoms:- Breathlessness, palpitations, dizziness Flu clinics NHS Health Check Housebound Care Homes Hypertensives Diabetics Existing CVD Opportunistically Targeted