AF & CAD. Management and prognosis

Transcription

1 AF & CAD Management and prognosis Maria Agelaki Cons. Cardiologist Red Cross GN Hosp.

2 AF and CAD share in common Most common arrhythmia and cardiovascular disease respectively High prevalence in general population Associated risk factors age ANGINA AF y 5-7% Up to 4% y 10-14% >80 y 14% HTN, DM, S. APNEA, OBESITY, SMOKING Inflammation plays a causative role in both

3 What is the prevalence of CAD in AF pts ROCKET AF & RELY trials estimated at 17% 13% with stable CAD 21% requiring intervention Kralev S et al, PLoS One 2011;6:e24964; 46% Lip et al BMJ 1995;18(7016): What is the prevalence of AF in CAD pts 0.2% to 5% Cameron A et al. Am J Cardiol 1988;6:714 7 Otterstad JE et al. Scand Cardiovasc J 2006;40(3):152 9.

4 A C S A F one half of first-ever documented AF cases after AMI are developed in the first month Jabre P. et al. Circulation 2011;17(19): Jabre P. et al. Circulation 2011;19(15): Schmitt J et al. Eur Heart J 2009;30(9):

5 Prognostic implications Am J Cardiol 2016;15(8):

6 AF may cause AMI through Thromboembolic mechanism Garg R et al. Int J Cardiol 2007;123(1):e Type II MI in AF with rapid ventricular response Sandoval Y et al. Am Coll Cardiol 2014;63: AF after CABG Occurs in 20-40% of the cases Associated with thromboembolic events, stroke and prolonged hospitalization Aranki SF et al. Circulation 1996;94(3):390 7.

7 Management of patients with AF and CAD in the setting of 1. First diagnosed AF 2. ACS in AF pts 3. Stable CAD in AF pts

8 Work up of newly diagnosed AF Do we need to screen for CAD? No on regular basis ST depression was seen in 38% of the patients with rapid AF and half of them had CAD at angiography 4% of the patients without ST depression during rapid AF had positive noninvasive tests for myocardial ischemia and CAD at angiography Troponin release in 15% of AF patients with symptoms of myocardial ischemia, usually in the absence of CAD at angiography European Heart Journal (2016) 37, doi: /eurheartj/ehw210 ESC GUIDELINES

9 Management of patients with AF and ACS

10 A patient with AF due to AMI provided that he is re-vascularized completely, does he need anticoagulation on long term basis?

11 Management of patients with AF and ACS Danish Registry in pt with MI Risk of bleeding with antithrombotic therapies

12 1.87% In the CathPCI registry, analysing data from in-hospital 3.3 million PCI procedures ( ): mortality rate: non-bleeding (95% CI: ) P< % in-hospital mortality rate: non-bleeding risk difference = 3.39% (95% CI: ) P< % in-hospital mortality rate: major bleeding Bleeding is the most common non-cardiac com Antithrombotic therapy that minimizes the risk of b might be expected to result in better short- and lon What combination of therapy is optimal for patients with AF undergoing PCI? PCI, percutaneous coronary intervention; Chhatriwalla et al. JAMA 2013 Bleeding is the most common non-cardiac complication of PCI Antithrombotic therapy that minimizes the risk of bleeding complications therefore AF might be expected to result in better short- and long-term clinical outcomes after PCI Anticoagulant AF and PCI therapy PCI, percutaneous coronary intervention; Chhatriwalla et al. JAMA 2013 For prevention of stroke in patients with additional risk factors DUAL THERAPY: anticoagulant and single antiplatelet? 4 PCI Antiplatelet therapy For prevention of stent thrombosis following PCI Dual antiplatelet therapy superior to ASA alone OR TRIPLE THERAPY: anticoagulant and dual antiplatelet therapy?

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14 European Heart Journal (2016) 37, doi: /eurheartj/ehw210 ESC GUIDELIN ES 2016 ESC Guidelines for the management of atrial fibrillation developed incollaboration with EACTS The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC Endorsed by the European Stroke Organisation (ESO) Authors/Task Force Members: Paulus Kirchhof * (Chairperson) (UK/Germany), Stefano Benussi* 1 (Co-Chairperson) (Switzerland), Dipak Kotecha (UK), Anders Ahlsson 1 (Sweden), Dan Atar (Norway), Barbara Casadei (UK), Manuel Castella 1 (Spain), Hans-Christoph Diener 2 (Germany), Hein Heidbuchel (Belgium), Jeroen Hendriks (The Netherlands), Gerhard Hindricks (Germany), Ant onis S. Manolis (Gr eece), Jonas Oldgr en (Sweden), Bogdan Alexandr u Popescu (Romania), Ulrich Schott en (The Netherlands), Bart Van Putte 1 (The Netherlands), and Panagiotis Vardas (Greece) Document Reviewers: Stefan Agewall (CPG Review Co-ordinat or) (Norway), John Camm (CPG Review Co-ordinator) (UK), Gonzalo Baron Esquivias (Spain), W erner Budts (Belgium), Scipione Carerj (Italy), Filip Casselman (Belgium ), Ant onio Coca (Spain), Raffaele De Cat er ina (It aly), Spir idon Deft er eos (Gr eece), Dobromir Dobrev (Germany), José M. Ferro (Port ugal), Gerasimos Filippatos (Greece), Donna Fitzsimons (UK), * Correspondingauthors: Paulus Kirchhof, Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHStrusts, IBR, Room 136, Wolfson Drive, Birmingham B15 2TT, United Kingdom, Tel: , p.kirchhof@bham.ac.uk; Stefano Benussi, Department of Cardiovascular Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland, Tel: + 41(0) , stefano.benussi@usz.ch. 1 Representing the European Association for Cardio-Thoracic Surgery (EACTS) 2 Representing the European Stroke Association (ESO) ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies Reviewers can be found in the Appendix.

15 Cumulative incidence of clinically significant bleeding (%) Patients (%) PIONEER AF-PCI compared regimens of rivaroxaban with single or dual antiplatelet therapy Multicentre, randomized, open-label trial Rivaroxaban 15 mg /10 mg OD + clopidogrel Group 1 Paroxysmal, persistent or permanent AF, undergoing PCI (with stent placement) 1:1:1 R Rivaroxaban 2.5 mg BID + DAPT* Rivaroxaban 15 mg/10 mg OD + low-dose ASA Group 2 N=2124 VKA (INR ) + DAPT* VKA + low-dose ASA Group 3 End of treatment PIONEER Primary AF-PCI demonstrated endpoint: a clinically-significant lower rate of the primary bleeding endpoint (12 months) in both rivaroxaban groups vs the triple therapy group PIONEER AF-PCI showed similar rates of thromboembolic even Rivaroxaban 2.5 mg BID has not been tested or approved across for stroke treatment prevention groups, in AF with low power to demonstrate effica Composite of bleeding events* Rivaroxaban 15 mg OD regimen has been tested in 1474 in patients with moderate renal dysfunction (ROCKET-AF) Rivaroxaban 15/10 mg OD regimen has been tested in 639 Japanese patients for stroke prevention in AF (J-ROCKET) Group % *DAPT duration 1, 6 or 12 months (physician choice); ASA, acetylsalicylic acid; HR: 1.08; DAPT, 95% CI: ; dual antiplatelet P=0.75 therapy; R, Group 2 Group 2 8 randomization; Gibson et al. Am Heart J. 2015; Gibson et al. N Engl J Med 2016; Fox et al. Eur Heart J 2011; Hori et al. Group Circ 3 6,5 J ,0 5,6 18.0% Group % 10 6 HR: 0.93; 95% CI: ; P=0.76 Group 1 n=694 n=704 n= *Composite of major bleeding or minor bleeding according to TIMI criteria or bleeding requiring medical attention; Trial not powered to definitively establish superiority or noninferiority. TIMI, Thrombolysis in Myocardial Infarction; Gibson et al. N Engl J Med 2016 Days Group 1 vs 2: HR: 0.59; 95% CI: ); P<0.001 Group 2 vs 3: HR: 0.63; 95% CI: ; P< MACE HR: 1.44; 95% CI: ; P=0.57 HR: 1.20; 95% CI: ; P=0.79 0,8 0,9 Stent thrombosis The study was not powered to show superiority or non-inferiority betwe treatments in efficacy endpoints 0,7 MACE, major adverse cardiac event (composite of CV death, MI, and stroke); Gibson et al. N Engl J Med 2016

16 High ischaemic risk is considered as an acute clinical presentation or anatomical/procedural features which might increase the risk for myocardial infarction. Bleeding risk can be estimated by HAS-BLED or ABC score.

17 RE-DUAL PCI tested the safety and efficacy of two regimens of dual therapy with dabigatran without ASA vs triple therapy with warfarin Dabigatran 150 mg BID + P2Y12 inhibitor Patients with AF undergoing PCI with stenting R Dabigatran 110 mg BID + P2Y12 inhibitor Primary endpoint: ISTH major or CRNM bleeding N=2725 Randomization 120hours post-pci* Warfarin (INR ) + P2Y12 inhibitor + ASA 6-month minimum treatment duration, maximum treatment duration 30 months (mean follow-up ~14 months) Summary of RE-DUAL PCI results RE-DUAL PCI was a multicentre, open-label trial following a prospective, randomized, open, blinded end-point design; P value *Study drug should be administered 6 hours after sheath removal and no later than 120 hours post-pci( 72 hours is preferable). ASA discontinued after 1 month after bare-metal stent and 3 months after drug-eluting stent; ASA, acetylsalicylic acid; CRNM, clinically relevant non-major; R, randomization; Cannon et al. Clin Cardiol 2016; Cannon <0.001 D110 Time to first ISTH major or CRNM bleeding event et al. N Engl J Med D150 Time to first ISTH major bleeding event < D110/D150 combined data 9 Intracranial haemorrhage Composite endpoint of thromboembolic events, death, or unplanned revascularization 0.005* Favours dabigatran dual therapy Favours warfarin triple therapy HR (95% CI) *Noninferiority p value. Cannon et al. N Engl J Med

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23 Management of patients with AF and stable CAD (>1y from acute episode) Risk of Bleeding IIaB All cause mortality

24 Survival Probability * Correspondingauthors: Paulus Kirchhof, Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHStrusts, IBR, Room 136, Wolfson Drive, Birmingham B15 2TT, United Kingdom, Tel: , p.kirchhof@bham.ac.uk; Stefano Benussi, Department of Cardiovascular Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland, Tel: + 41(0) , stefano.benussi@usz.ch. European Heart Journal (2016) 37, doi: /eurheartj/ehw210 What about AF it self? ESC GUIDELIN ES 2016 ESC Guidelines for the management of atrial fibrillation developed incollaboration with EACTS The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC) Rhythm control strategy is indicated for symptom relief despite adequate rate control Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC Endorsed by the European Stroke Organisation (ESO) Results-CASTLE AF Authors/Task Force Members: Paulus Kirchhof Primary * (Chairperson) Composite (UK/Germany), Endpoint Stefano Benussi* 1 (Co-Chairperson) (Switzerland), 1 Dipak Kotecha (UK), Anders Ahlsson 1 (Sweden), Dan Atar (Norway), 0,8 Barbara Casadei (UK), Manuel Castella 1 (Spain), Hans-Christoph Diener 2 Ablation 0,6 (Germany), Hein Heidbuchel HR, 0.62 (95% CI, ); (Belgium), Jeroen Hendriks (The Netherlands), Gerhard P= ,4 Hindricks (Germany), Conventional Log-rank test: P=0.006 Ant onis S. Manolis (Gr eece), Jonas Oldgr en (Sweden), Bogdan Alexandr u Popescu 0,2 (Romania), Ulrich Schott en (The Netherlands), Bart Van Putte 1 (The Netherlands), 0 and Panagiotis Vardas (Greece) Document Reviewers: Stefan Agewall (CPG Review Co-ordinat or) (Norway), John Follow-Up Camm Time (CPG (Months) Review Co-ordinator) (UK), Gonzalo Baron Esquivias (Spain), W erner Budts (Belgium), Scipione Carerj (Italy), Patients at Risk Filip Casselman (Belgium ), Ant onio Coca (Spain), Raffaele Ablation De Cat er179 ina (It aly), 141 Spir idon 114 Deft er 76 eos (Gr58 eece), 22 Dobromir Dobrev (Germany), José M. Ferro (Port ugal), Convent Gerasimos ional 184 Filippatos 145 (Greece), 111 Donna 70 Fitzsimons 48 (UK), 12

25 Conclusion AF and CAD share many things in common. AF has a huge impact on the prognosis and management of CAD pts. more and more clinical data suggest that we need to revise our preview clinical practice.