Cases & Panel Discussion

Transcription

1 TSOACs What s the difference anyway? Controversies in selection and complications Augustus Hough, PharmD, BCPS (AQ-Cardiology) Clinical Pharmacy Specialist West Palm Beach VA Medical Center Larry Lopez Cardiovascular Seminar October 2014 Cases & Panel Discussion 1

2 Case 1 SM SM a 63 year old man with Afib, DM and HTN is has been coming to the coag clinic for about 3 years and is generally very steady with INR control (TTR 89% using Rosendaal method). Still works as executive 5-6 days per week. Comes in for routine visit and is therapeutic, but asks about switching to rivaroxaban as his friend is on it. What do you say? Time Therapeutic Range Analysis Does warfarin TTR matter? Poor TTR leads to higher stroke and bleed rates RE-LY mean 64% TTR Similar efficacy and ICH rates with various cttr Major bleeding HR increased with improved cttr (0.71 to 1.16, p=0.03) but did not become more than VKA ARISTOTLE mean 62.2% TTR Similar efficacy and safety rates with various cttr ROCKET-AF mean 55% TTR Similar efficacy with various cttr No presentation of data on ICH & Bleeding Arch Intern Med 2007;167: Lancet 2010;376: Circulation. 2013;127: NEJM 2011;365:

3 Case 2 FC FC 57 year old man with history of Afib treated with warfarin is admitted for GI bleed in part related excessive naproxen use related to chronic back pain Team is considering converting him from warfarin to a TSOAC on discharge given his travel schedule and past difficulty monitoring INR Considerations If to convert What TSOAC to use When to start therapy Case 3 Mr. C Mr. C 63 year old man playing in a golf tournament in Florida. He hooked his ball down by a lake, an alligator popped up and bit off his hand He has history of Afib and is taking dabigatran for anticoagulation ER calls asking what to do about bleeding control 3

4 Case 4 RM RM 58 year old WM admitted with symptomatic AFib over the weekend after about 3 days of palpitations and dizziness Excessive stress and EtOH during recent golf tournament Initially started on warfarin (current INR 1.6) and LMWH bridge therapy along with rate control Planned for cardioversion but gained entry into next major golf tournament in 4 weeks and is concerned about missing his trip if the cardioversion can t be done on time... TSOACs & Cardioversion RE-LY Analysis 1983 cardioversions in 1270 patients Events within 30 days after cardioversion Dabigatran 110mg Dabigatran 150mg Similar relationship seen in ARISTOTLE 743 cardioversions in 540 patients Warfarin Stroke & Systemic 0.77% 0.3% 0.6% Embolism Major Bleeding 1.7% 0.6% 0.6% J Am Coll Cardiol 2014;63: Circulation 2011;123:

5 TSOACs & Cardioversion Rivaroxaban - X-VeRT 1,504 patients randomized 2:1 to rivaroxaban or warfarin 77% (rivaroxaban) vs 36.3% (VKA) pts with cardioversion as scheduled Eur Heart J 2014;Sep 2:[Epub ahead of print] Case 4 RM continued Consistent with, or despite your recommendation, patient is initiated on dabigatran. Cardioversion fails and patient elects to be scheduled for a radiofrequency catheter ablation. Panel: How would you manage oral anticoagulation around the procedure? 5

6 Case 5- TW Patient (65 years old) with persistent atrial fibrillation, hypertension, diabetes mellitus and moderate aortic stenosis. You recommend for anticoagulation? 1.Warfarin 2.Dabigatran 3.Apixaban 4.Rivaroxaban 5.Any of the above Case 5 - TW 10 years later TW is presenting with worsening dyspnea on exertion, chest pain, and ankle edema Found to have progression of aortic valve disease and is sent for aortic valve replacement with bioprosthetic valve What do you recommend for antithrombotic therapy after valve replacement? 1. Warfarin 2. Dabigatran 3. Apixaban 4. Rivaroxaban 5. Any of the above 6

7 Case 6 TW TW has history of unprovoked DVT with strong family history of Factor V Leiden mutation He is being treated with rivaroxaban 20mg daily and tolerating well On a routine day on the course RM hears a pop after teeing off and is found to have torn his ACL He is evaluated and planned for surgical repair in the near future Case 6 TW Which is an acceptable plan for TW s anticoagulant therapy surrounding ACL repair (assuming epidural anesthesia used)? A. Stop rivaroxaban 2 days prior to surgery and resume immediately after procedure B. Stop rivaroxaban 24 hours prior to surgery and resume immediately after procedure C. Stop rivaroxaban 24 hours prior to surgery and discuss with anesthesiology about when epidural catheter was removed 7

8 Case 7 A functional, independent, 91 year old male with permanent atrial fibrillation, hypertension, prior stroke presents to your clinic. A discussion ensues regarding oral anticoagulation. All labs are normal with exception of a serum creatinine of 1.7mg/dl and egfr of 38ml/min/1.73m 2 You recommend? 1.Antiplatelet therapy 2.Warfarin 3.Dabigatran 4.Apixaban 5.Rivaroxaban Case 8 You are asked to recommend antithrombotic therapy for a 76 year old male with permanent atrial fibrillation who presented 8 weeks ago with an ischemic CVA. He is currently recovering in a rehab center and has a feeding tube placed as a residual effect of the stroke. PMH: Atrial fibrillation, CVA, hypertension, s/p total colectomy for colon cancer 2011 Which is/are the best option(s)? 1.Warfarin only 2.Apixaban or rivaroxaban 3.Apixaban, dabigatran, or rivaroxaban 4.Apixaban only 5.Warfarin & rivaroxaban 8

9 Questions/Discussion 9