AF Treatment & Anticoagulation

Size: px

Start display at page:

Download "AF Treatment & Anticoagulation"

Peter Wilson
6 years ago
Views:

1 AF Treatment & Anticoagulation Dr Matthew Lovell, Consultant Cardiologist & Electrophysiologist! Exeter Heart & Royal Devon and Exeter Hospital

2 NICE Guidance NICE Guidance for AF Release June pages + Appendices Covers AF treatment, anticoagulation, specialist referral

3 AF Epidemiology Very common: lifetime risk for AF at >40 yrs ~ 1 in 4! 2% of total population! >1,000,000 cases in UK! Prevalence is expected to double over the next twenty five years

4 AF and AGE Framingham Study Cardiovascular Health Study 14 - Mayo Clinic Study Prevalence (%) Western Australia Study Age (years)

5 AF will Double by 2025

6 NICE Screening Perform manual pulse palpation in people with: palps/sob/cp/syncope/dizzy In patients with risk factors: Hypertension, diabetes and IHD Opportunistic assessment of such patients for the presence of AF may be prudent

7 Diagnosis requires an ECG Absolutely irregular RR intervals! No distinct P waves on the surface ECG

8 NICE Algorithm AF Diagnosis Stroke Prevention Rate Control Ongoing Symptoms Rhythm Control Ongoing Symptoms Ablation Therapy

9 AF Pathway AF Diagnosis First Line BB/Ca2+ Combine if symptoms+ Stroke Prevention Rate Control Reversible cause CCF from AF CHADSVASC Assess Bleeding risk Ongoing Symptoms New onset Avoid aspirin Assess quality of INR Warfarin or NOAC LAA Occlusion Rhythm Control PerAF: DCCV PAF: Anti-arrhythmics BB Firstline Ongoing Symptoms Flecainide/Sotalol CCF:Amiodarone Ablation Therapy AF Ablation Pace & Ablate

10 AFFIRM

11 Rhythm Control: DCCV Atrial fibrillation LEAD II AUTOGAIN DELAYED SYNC DC shock Ventricular ectopic beat Sinus rhythm 25 mm/s 360J SYNC EXTERNAL PADDLES

12 DCCV AF Recurrence

13 Failure of AAR Drugs

14 Meta-analysis KPM of Arrhythmia Free Survival Bonanno et al, J Cardiovasc Med 2010

15 Pulmonary Vein Triggers

18 AF Ablation

19 AF Ablation

20 AF Ablation

21 Risk of Ablation Improve outcomes Sinus rhythm 75-80% at 12 months Improved symptoms Risk of procedure 1 in 100 pericardial effusion 1 in 400 of CVA

22 AF and Stroke

$c\lf-ut <rcoii Fr ca A a a a= rr* S o Ol trstr- +rfl?. -. (6'5 x!y Q 5_o (!$

23 c\lf-ut <rcoii Fr ca A a a a= rr* S o Ol trstr- +rfl?. -. (6'5 x!y Q 5_o (!. tr - >irfi -' F --.-^ V v/\j -,i e.p.4= L A' 'AA --rr- ^/ e U 6,9 c) tr j Who is at Risk F a B F

24 Who is at Risk Symptomatic/asymptomatic paroxysmal, persistent or permanent AF Atrial flutter Those with continuing risk of arrhythmia recurrence after returning to sinus rhythm

25 CHADS2 vs CHA2DS2-VASc CHADS2 score of 0 does not reliably identify AF patients who are truly low-risk'! Does not include many common stroke risk factors! Use CHADS2VA2SC! If CHADS2VA2SC = 0 then use nothing! If >= 1/2 then use Warfarin/NOAC

26 CHA2DS2-VASc Risk)Factor) CCF)/)EF<40% ) ) )1) Hypertension ) ) )1) Age>75 ) ) )2) Diabetes ) ) )1) Stroke/TIA/embolism) )2) Vascular)disease ) )1) Age)65374 ) ) )1) Sex)category)(female)) )1) ) Score)))))))))Stroke)rate)(%/yr)) 0 ) )0) 1 ) )1.3) 2 ) )2.2) 3 ) )3.2) 4 ) )4.0) 5 ) )6.7) 6 ) )9.8) 7 ) )9.6) 8 ) )6.7) 9 ) )15.2) Modified)from:)Guidelines)on)the)management)of)atrial)fibrillaXon.)EHJ)2010;)31:) )

27 CHA2DS2-VASc=2, One Yr Risk Risk 2.2%/yr 1:50

28 CHA2DS2-VASc=2, 5 Yr Risk Risk 10% 1:10

29 Aspirin Not Worth the Risk Evidence for stroke prevention with aspirin is weak, with potential for harm! Major bleeding or ICH not significantly different to that of OAC! Use limited to the few patients who refuse any form of OAC! ASA + Clopidogrel better efficacy with greater risk of bleeding

30 Aspirin Data Ischemic Strokes Hemorrhagic Strokes χ 2 = 29.5, P<.001 χ 2 = 2.7, P =.19 Oral Anticoagulants Aspirin van Walraven et al, JAMA 2002,

31 Aspirin NICE 2014 Do not offer aspirin for stroke prevention Only consider dual antiplatelet therapy Aspirin and clopidogrel for stroke prevention If anticoagulation is contraindicated Not tolerated and CHA2DS2-VASc score of =>2

32 Anticoagulation NICE 2014 Anticoagulation may be with NOAC or warfarin In those CHA2DS2-VASc score of >=2 Consider for men CHA2DS2-VASc score = 1 Taking bleeding risk into account

33 Warfarin is Effective AFASAK I (1) SPAF (3) BAATAF (6) CAFA (7) SPINAF (8) EAFT (9) Adjusted-dose warfarin compared with placebo Relative risk reduction (95% CI) All trials ( n=6) 100% 50% 0 50% 100% Warfarin better Warfarin worse

Vitamin K antagonist II X IX VIIa/TF IIa Va Xa Fibrinogen Fibrin IXa VIIIa Xa inhibitor Thrombin inhibitor Potentiate Warfarin Acetaminophen Amiodarone Aspirin Antibiotics (particularly)

34 Vitamin K antagonist II X IX VIIa/TF IIa Va Xa Fibrinogen Fibrin IXa VIIIa Xa inhibitor Thrombin inhibitor Potentiate Warfarin Acetaminophen Amiodarone Aspirin Antibiotics (particularly) Cephalosporins, ciprofloxacin, erythromycin metronidazole, trimethoprim-sulfamethoxazole, macrolides Cimetidine Excessive ETOH Fluconazole NSAIDs Sulfonamides Gingko biloba, ginseng Congestive heart failure Inhibit Warfarin Azathioprine Carbamazepine Haloperidol Oral contraceptives Phenobarbital Rifampin Vitamin K-containing foods (green leafy vegetables): spinach, broccoli, avocado Coenzyme Q St. John s wort Hypothyroidism Nephrotic syndrome Edema Hereditary coumadin resistance

35 OR Benefit vs Risk

36 Labile INRs Reassess anticoagulation for a person with poor anticoagulation control shown by any of the following: 2 INR values > 5 or 1 INR value> 8 within the past 6 months 2 INR values less than 1.5 within the past 6 months TTR less than 65%

37 NOACS Novel Oral Anticoagulants Alternative to Warfarin Stroke prevention in non-valvular AF Dabigatran 110/150 mg bd Apixaban 5mg bd Rivaroxaban 20 mg od

38 NOACs vs Warfarin NOACs Less interactions, predictable, no monitoring Rapid onset/offset 20-30% less RR in CVA/embolism 30-60% less RR in ICH 10-15% less RR in death No specific antidotes 1. RE%LY.(NEJM(2009;(361:(1139%1151( 2. ROCKET%AF(NEJM(2011;(365:(883%891( 3. ARISTOTLE(NEJM(2011;(365:(981%992(

39 Study RR (95% CI) n/n, NOA n/n, Warfarin % Weight A All stroke/embolism RE-LY 0.66 (0.53, 0.82) 134/ / ROCKET AF 0.88 (0.75, 1.03) 269/ / ARISTOTLE 0.80 (0.67, 0.95) 212/ / Subtotal (I-squared = 55.9%, p = 0.104) 0.78 (0.67, 0.92) 615/ / B Ischaemic stroke RE-LY 0.77 (0.61, 0.99) 111/ / ROCKET AF 0.91 (0.73, 1.13) 156/ / ARISTOTLE 0.92 (0.75, 1.14) 162/ / Subtotal (I-squared = 0.0%, p = 0.522) 0.87 (0.77, 0.99) 429/ / C Haemorrhagic stroke RE-LY 0.26 (0.14, 0.50) 12/ / ROCKET AF 0.58 (0.37, 0.92) 29/ / ARISTOTLE 0.51 (0.35, 0.75) 40/ / Subtotal (I-squared = 52.2%, p = 0.124) 0.45 (0.31, 0.68) 81/ / Favors NOA Therapy Favors Warfarin Therapy Figure 2. Forest plot for (A) all-cause stroke and systemic embolism, (B) ischemic and unspecified stroke, and (C) hemorrhagic stroke, new oral anticoagulants (NOA) versus warfarin in patients with AF.

40 n/n, n/n, % Study RR (95% CI) NOA Warfarin Weight A Major bleeding RE-LY 0.94 (0.82, 1.07) 399/ / ROCKET AF 1.03 (0.89, 1.18) 395/ / ARISTOTLE 0.70 (0.61, 0.81) 327/ / Subtotal (I-squared = 87.2%, p = 0.000) 0.88 (0.71, 1.09) 1121/ / B ICH RE-LY 0.41 (0.28, 0.60) 36/ / ROCKET AF 0.66 (0.47, 0.92) 55/ / ARISTOTLE 0.42 (0.31, 0.59) 52/ / Subtotal (I-squared = 54.9%, p = 0.109) 0.49 (0.36, 0.66) 143/ / C GI Bleeding RE-LY 1.50 (1.20, 1.89) 182/ / ROCKET AF 1.46 (1.19, 1.78) 224/ / ARISTOTLE 0.88 (0.68, 1.14) 105/ / Subtotal (I-squared = 82.5%, p = 0.003) 1.25 (0.91, 1.72) 511/ / Favors NOA Therapy Favors Warfarin Therapy Figure 3. Forest plot for (A) major bleeding, (B) intracranial bleeding, and (C) gastrointestinal bleeding, new oral anticoagulants (NOA) versus warfarin in patients with AF.

41 NICE Approved All 3 NOACS approved for anticoagulation in nonvalvular AF Dabigatran Rivoroxaban Apixaban No preferences

42 Peninsula Heart & Stroke Network Guidance Novel oral anticoagulants for the prevention of stroke and systemic embolism in atrial fibrillation PENINSULA HEART & STROKE NETWORK NOACS useful: Allergy/intolerance INR monitoring impractical INR labile Those at risk of drug interactions People who have never used warfarin (don t need to try warfarin prior to NOAC)

43 Bleeding Warfarin vs Rivaroxaban No difference in bleeding No difference in outcomes Piccini et al 2014, Euro Heart Journal

44 Majeed et al, Circulation day Mortality after Major Bleeding

45 Bleeding Risk Use the HAS-BLED score to assess the risk of bleeding in people who are starting or have started anticoagulation. Offer modification and monitoring of the following risk factors: Uncontrolled hypertension Poor control of international normalised ratio (INR) ('labile INRs') Concurrent medication, e.g., aspirin or NSAID Harmful alcohol consumption

46 Bleeding Risk: HAS-BLED Letter Clinical characteristic a Points awarded 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 (e.g. age >65 years) 1 D Drugs or alcohol (1 point each) 1 or 2 Maximum 9 points

47 Patient Attitude To Risk of Anticoagulation Patients required 15% relative risk reduction in the risk of stroke to consider anticoagulation Patients were willing to endure 4.4 major bleeds in order to prevent one stroke LaHaye et al, Thromb Haemost. 2014

48 Falls Do not withhold anticoagulation solely because the person is at risk of having a fall Am J Med (2012) 125, Figure Unadjusted time to first major bleeding event curves according to risk of falls (n 515).

49 GRASP-AF Data 2012 Only 56% high risk patients on OAC 35% high risk on anti-platelet only 9% high risk not on anything 13% high risk coded as contraindicated or declined

50 Benefits of Better Anticoagulation

51 Summary AF and stroke are major health problems In AF assess risk with CHA2DS2VASc Use Warfarin or NOACs Reduce strokes by screening for AF and improving anticoagulation Step wise approach for symptom control

Question 1: Between 1 July 2014 and 30 June 2015, in the area covered by your CCG:

Atrial Fibrillation in Your Area Question 1: Between 1 July 2014 and 30 June 2015, in the area covered by your CCG: a) What was the prevalence of atrial fibrillation (AF)? 6636 (as of 22/10/2015) 2.1%