Tricky Cases in Primary Care Anticoagulation in AF

Transcription

1 Tricky Cases in Primary Care Anticoagulation in AF Dr John Wong GPwSI Cardiology & GP Principal Leatherhead Hospital Ashlea Medical Practice 54 year old F Case 1 PMH CREST Syndrome calcinosis finger tips etc Undiagnosed PR bleeding (2008) Palpitations PAF on 24 hr ECG On esomeprazole 40mg once daily (hiatus hernia) Documented low magnesium with recurrent palpitations requiring iv infusion of magnesium when attending A & E with palpitations (despite being on oral magnesium supplements 10 x 500mg daily) 1

2 Warfarin started following admission with TIA/ stroke. Problems with INR checks (INR star uses finger prick blood tests in primary care) as calcium deposits in finger tips What would you do next? 1. Stop warfarin and start NOACs 2. Offer left atrial appendage device closure (Watchman Device) 3. Offer pace and ablate strategy 4. Offer PVI ablation for PAF 2

3 Esomeprazole was stop with normalisation of magnesium levels (2012) No longer has palpitations for at least 2 years Wants to stop warfarin (2014) What would you do next? 1. Stop warfarin as requested 2. Refer for 24 hr ECG monitor 3. Refer for R- Test ( week-long holter ECG monitor) 4. Implant reveal device (Loop recorder) 3

4 R- Test 82 y o Female patient Hypertension Paroxysmal AF Case 2 Current Rx : Sotalol 160 mg od, Levothyroxine 100 mcg od, Lercanidipine 20mg od, Atorvastatin 20mg od. Aspirin 75mg od Decline warfarin has mental block to taking rat poison 4

5 What would you do next? 1. Prescribe Dabigatran 110 mg bd 2. Prescribe Dabigatran 150mg bd 3. Prescribe Rivaroxaban 20mg od 4. Prescribe Apixaban 2.5mg bd 4. Add clopidogrel 75mg od to aspirin 75mg od Continued Discussed warfarin versus dabigatran. Insists that she does not wish to take warfarin and prefers dabigatran. Has long history of episodic dyspepsia requiring prn antacids. OGD arranged 5

6 What next? 1. Stop aspirin? 2. Stop aspirin & start PPI? 3. Stop aspirin & start Dabigatran with PPI cover? 4. Stop aspirin & start warfarin with PPI cover? 6

7 84 y o Female Case 3 Long history hypertension poorly controlled CKD3 - stable Multiple drug intolerance: on candesartan 16 mg od and nitrazepam 5mg nocte. Had ablation Rx for AVNRT Required permanent pacemaker implant for intermittent 2 nd degree AV block May require addition of amlodipine for HTN. Shall require warfarin for documented atrial flutter (Consultant Letter). Pacing check post implant shows PAF/ atrial tachy. Case 3 (continued) BP 220/130 (16 Sep 2013). Start Bisoprolol 1.25mg od HAS-BLED score = CHA 2 DS 2 VaSc score = Would you start warfarin? Admitted to Hospital collapse. Clopidogrel 75mg od added to Rx. + verapamil 40mg tds. Candesartan increased to 32 mg od (14 Oct 2013) Tel call from Family (17 Oct 2013)- transient dysphasia improved after 15 mins. Advice to attend A& E CT brain: bilateral subdural haematomas with recent bleed on right. 7

8 HAS-BLED Hypertension ( systolic BP > 160 mm Hg) Abnormal renal or liver function test Stroke (previous) Bleeding (prior major or predisposition) Liable INR (< 60% in therapeutic range) Elderly (Age > 65) Drugs (NSAIDS, anti-platelets) or Alcohol (> 8 drinks per week) Score = or > 3 increased risk of bleeding Contra-indications to Warfarin 1 Few absolute contra-indications- risk v benefit reviewed at least annually Haemorrhagic CVA/ intracranial haemorrhage Uncontrolled hypertension (> 180/100 mm Hg) Thrombocytopenia (< 100 or < 80 x 10 9 /L in high risk patients) Significant impaired renal or hepatic function Excess or erratic alcohol intake 8

9 Continued.. Risk of clinically significant bleed within 72 hrs of major surgery, 48 hrs post- partum, history of GI haemorrhage or haematuria in previous 6 months Drug interactions- e.g. regular use of NSAIDS Poor compliance Dementia Pregnancy Caution- recurrent falls and fits Take Home Messages Do use HAS-BLED score (Apps available for iphones and Smart phones). Contra-indications to warfarin therapy is the same as contra-indications to anti-platelet agents e.g. aspirin, clopidogrel Do decline to initiate warfarin therapy if you feel risk of bleeding is unacceptable, even if recommended by hospital consultants (including Consultant Cardiologist) but must be able to justify decision GP able to justify decision in case 3 to patient and consultant colleague. 9

10 References 1. HAST CCG (March 2014): Warfarin Guidelines for Primary Care 2. W. Fred Miser (2011). Appropriate aspirin use for primary prevention of cardiovascular disease Am Fam Physicians, Vol 83(12) pp