Assise de l AMCAR : 27Avril Anticoagulant treatment of AF

Transcription

1 Assise de l AMCAR : 27Avril 2017

2 Cardiovascular morbidity and mortality and AF

3 The Five Domains of Integrated AF Management

4 FA: pathophysiology of thrombus formation Alteration of the atrial wall Myocytic hypertrophy Sclerosis Fibroelatosis Alteration of the extracellular matrix Hypercoagulability Thrombin-antithrombin complexes D-dimers Prothrombin 1 and 2 Inflammation Increased FVW, IL6, CRP Blood stasis Loss of atrial systole OG dilated Left Auricule +++

5 AF and thrombus formation Lancet 2009;373: Blood stasis Wall anomalies Changing circulating blood

6 AF and AVK Risk of stroke is < 2/100 patient-year We must deal with AVK > 100 patients to prevent stroke Risk of stroke is > 4/100 patient-year We must deal with AVK < 30 patients to prevent stroke

7 Stratification of thromboembolic risk FA: mitral stenosis Risk TE: 17/ year FA "non-valvular" risk TE: 2 to 10 % / year Isolated FA Age 60 years, Healthy heart (clinical, echocardiography) Risk TE: 1.3% / 15 years ¹ 1. Kopecky SL. NEJM 1987 ; 317:669-74

8 Thromboembolic score CHA 2 DS 2 -VASc mieux adapté pour stratifier le faible risque

9 HAS-BLED score H Hypertension 1 A Abnormal renal and liver function (1 point each) 1 or 2 S stroke 1 B Bleeding 1 L Labile INRs 1 E Elderly 1 D Drugs or alcohol (1 point each) 1 or 2

10 Development of anticoagulants since last century «xabans» «gatrans»

11 AVK treatment limits Unpredictable response Narrow therapeutic window (INR between 2-3) Food interactions Drugs interactions Mandatory follow-up of coagulation Resistance to AVK Frequency of dose adjustments 1st cause of hospitalization For iatrogenic cause AVK have Many Limits And are difficult to practice Slow start and end of action 1. Ansell J, et al. Chest 2008;133;160S-198S; 2. Umer Ushman MH, et al. J Interv Card Electrophysiol 2008; 22: ; 3. Nutescu EA, et al. Cardiol Clin 2008; 26:

12 TTR: mean Time in Therapeutic Range 70%

13 AVK and unstable INR Last 3 INR values before enrolment Kirchhof et al., Europace 2014

14 DOA: Mechanism of action

15 DAO

16 DOA: métanalyse Ruff CT et al, Lancet 2014; 383:

17 Ruff CT et al, Lancet 2014; 383:

18 Ruff CT et al, Lancet 2014; 383:

19 Ruff CT et al, Lancet 2014; 383:

20 Gastroenterology 2013;143:

21 DOA and bleeding

22 DOA and bleeding

23 Risk factors for overdose Low weight; Age over 75 years; Renal failure

24 Prediction stroke and bleeding risk

25 SAMe-TT 2 R 2 score Score 0-1: AVK Score 2: ADO Apostolakis S et al. Chest 2013;144:

26 Stroke prevention in patients with atrial fibrillation?

27 Stroke prevention in patients with atrial fibrillation

28 AF and ACS

29 AF and elective PCI

30 Hospitalization Related to Cardiovascular or Bleeding Event Gibson CM et al, New Engl J Med 2016

31 Occlusion or exclusion of the left atrial appendage

32 Anticoagulation in AF patients with stroke or TIA

33 Secondary stroke prevention

34 Initiation or Resumption of Anticoagulation in AF Patients After an Intracranial Bleeding Event

35 When Is it Safe to Resume Anticoagulation After Intracranial Bleeding? Benefit of OAC resumption for the prevention of ischemic stroke is higher than risk of bleeding Incidence rates of (A) new ischemic and (B) hemorrhagic events comparing all surviving patients who restarted OAC vs those who did not restart OAC. Analyses were based on all patients with complete 1- year follow- up data. Kuramatsu JB et al, JAMA 2015:313:

36 DAO and Bleeding

37 Choice of direct anticoagulant Patients preference?? Once per day dosing Age > 80 ans Rivaroxaban, edoxaban Dabigatran 110, apixaban, Rivaroxaban, edoxaban History of stroke Apixaban, Rivaroxaban Previous gatrointestinal bleeding Apixaban High stroke risk and low bleeding risk Dabigatran 150 High stroke risk, high bleedingrisk Dabigatran 110, Apixaban or edoxaban Concomitantcoronary disease Rivaroxaban Concomitantkidney disease Apikaban, Rivaroxaban, Edoxaban Intented electrocardioversion Rivaroxaban

38 Stroke prevention in atrial fibrillation

39 CHA 2 DS 2 VASC and low risk

40 Thromboembolic risk

41 Thromboembolic risk and low CHA 2 DS 2 VASC

42 Echocardiography parameters and thromboembolic risk in AF

43 Conclusion Thromboembolic risk valvular AF and non-valvular AF: CHA 2 DS 2 VASC Patient already under AVK AVK. INR stable, Mitral stenosis and Mechanical heart V, RF ADO +++ Stroke INR unstable and no contraindications SAMETTR Score >2 1st prescription of anticoagulants DAO Coronary. Diabetic. Elderly.

44

45

46

47

48 Lancet 2006,367:

49 Management of atrial flutter

50 How to reduce thromboembolic risk?