NOACs in AF. Dr Fiona Stewart. Auckland Heart Group and Auckland DHB

Transcription

1 NOACs in AF Dr Fiona Stewart Auckland Heart Group and Auckland DHB

2 NOACS for AF True/False All patients should have a CHA 2 DS 2 VASc risk assessment on diagnosis of AF NOACS are more effective than warfarin in reducing stroke Aspirin is a safer option for stroke prevention in the elderly than a NOAC or warfarin All patients with non valvular AF on warfarin should switch to a NOAC

3 CHA 2 DS 2 VASc Scoring CHA2DS2-VASc Risk Score CHF or LVEF < 40% 1 Hypertension 1 Age > 75 2 Diabetes 1 Stroke/TIA/ Thromboembolism 2 Vascular Disease 1 Age From ESC AF GuidelinesFemale 1

4 CHA 2 DS 2 VASc - Stroke Risk CHA2DS2-VASc score Patients (n = 7329) Adjusted stroke rate (%/year) From ESC AF Guidelines:

5 Swedish National Registry Annual Rates of Stroke, TIA, Systemic Embolus and Pulmonary Embolus

6

7 NOACs vs Warfarin Reduced rates of Stroke (19%) Haemorrhagic stroke (51%) Death (10%) Intracranial haemorrhage (52%) Increased rate of GI bleed (25%) 42,411 on NOACS, 29,272 on warfarin Lancet 2014;383:955-62

8 The NOACs Dabigatran Rivaroxaban Apixaban Factor targeted IIa Xa Xa Dose Indications for dose 150mg bd 110mg bd >80y egfr mg die 15mg die egfr <50 Renal clearance 80% 35% 25% Hours to max concentration Dyspepsia 5-10% no no Blister packed no yes yes 5mg bd 2.5mg bd 2 of >80y, <60kg, creat >133

9 Mrs M aged 84 Persistent AF Hypertension Diabetes A little unsteady on her feet On aspirin Won t take warfarin

10 Mrs M CHA 2 DS 2 - VASc Score = 5 Risk of stroke 6.7%/y Swedish AF cohort study Stroke risk 7.2%/y Stroke/TIA/PE/Systemic embolism 15.3%/y Anticoagulation will reduce this risk by 67%

11 Aspirin vs Apixaban AVERROES Trial Apixaban Aspirin Stroke or systemic embolism 1.6%/y 3.7%/y Disabling or fatal stroke 1% 2.3% Death 3.5%/y 4.4%/y Major bleeding 1.4%/y 1.2%/y Intracranial bleeding 11 13

12 Risk of Intracerebral Bleeding with Falls Patients need to have more than 300 falls/year before intracerebral haemorrhage risk exceeds anticoagulant benefit

13 Aspirin is not appropriate treatment for stroke prevention with AF in the elderly

14 NOACs in Over 80s Dabigatran 110mg bd (watch renal function 3/12) Rivaroxaban 15mg/d egfr < 50 Apixaban 2.5mg bd 2 of age >80, weight < 60kg, creat >133

15 Drugs to avoid with NOACs Avoid Imidazoles (Ketaconazole etc) Extreme caution with phenytoin, carbamazepine, St John s wort Rivaroxaban with Protease inhibitors

16 Who to Switch from Warfarin to a NOAC? Ms E Rheumatic heart disease St Jude (mechanical) Mitral Valve replacement Doesn t like regular blood tests

17 NOACs are contraindicated with mechanical heart valves Rheumatic heart disease is a relative contraindication Will a poorly compliant patient on warfarin become compliant on a NOAC?

18 Mr G INRs vary widely Can he switch to a NOAC? If so, how?

19 Switching from Warfarin to NOAC Excellent solution when INRs are variable or side effects on warfarin. Check creatinine and egfr egfr > 30 - consider NOAC Dose based on age, renal function and weight Start NOAC when INR < 2 Monitor renal function 3/12 ly in elderly, reduced egfr Annually otherwise

20 NOACS for AF True/False All patients should have a CHA 2 DS 2 VASc risk assessment on diagnosis of AF NOACS are more effective than warfarin in reducing stroke Aspirin is a safer option for stroke prevention in the elderly than a NOAC or warfarin All patients with non valvular AF on warfarin should switch to a NOAC