MODUL: NA DOKAZIH TEMELJEČA MEDICINA. ZD SLOV.KONJICE Lucija Kračun, dr.med Loče,

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1 MODUL: NA DOKAZIH TEMELJEČA MEDICINA ZD SLOV.KONJICE Lucija Kračun, dr.med Loče,

2 Opis problema vključno z opisom populacije, na katero se problem nanaša Ali je bolnike starejše od 80 let smiselno zdraviti z varfarinom? Ali terapija z aspirinom prepreči možgansko kap in druge trombemolične zaplete v enaki meri kot antikoagulantna terapija?

3 Relevantnost problema za delo v ambulanti Zdravniki v splošni ambulanti obravnavamo veliko število pacientov s KAF Zaradi vedno višje življenjske dobe bo KAF postala pogostejša in zaradi tega vedno večji javnozdravstveni problem Kljub visokemu riziku za možgansko kap pri starejših in kljub ogromni prednosti antikoagulantne terapije so starejši skupina, kjer je raba tromboprofilakse z varfarinom suboptimalna zaradi večje komorbidnosti, interakcij z ostalimi zdravili in pogostejšimi večjimi krvavitvami

4 primer V ambulanto pride 80 letna gospa. Odkrijem ji KAF. Zdravi se že zaradi AH,IBS, srčnega popuščanja, SB tip 2 na inzulinu. Srčna akcija je aritmična, frekvenca pa je urejena z b- blokatorjem. Je v dobri kondiciji. Ali naj ji uvedem antikoagulantno zaščito ali pustim samo aspirin? Naj jo seznanim s svojo dilemo, zapleti antikoagulantne tp. in ji pustim soodločanje

5 Pregled relevantnih člankov in virov Clinical guidelines for chronic atrial fibrillation Hart RG, Benavente O, McBride R et al. Antitrombotic therapy to prevent stroke in patients with atrial fibrillation: a metaanalysis/anals of internal medicine/ 1999;131(7) Segal JB, McNamara RI, Miller MR et al.anticoagulants or antiplatelet therapy for non-rheumatic atrial fibrillation and flutter.the Cohrane library 2004;(1) Benavente O, HartR,Koudstaal P et al. Oral anticoagulants for preventing stroke in patients with non valvular atrial fibrillation and no previous history of stroke or transient ishemic attacks. The Cohrane library.2003( 4) Van Walraven C, Hart RG, Singer DE et al.oral anticoagulants vs aspirin in nonvalvular atrial fibrillation: an individual patient meta-analysis. Journal of American Medical Assosiation.2002;288(19): Taylor FC, Cohen H, Ibrahim S.Systematic review of long-term anticoagulation or antiplatelet treatment in patients with non rheumatic atrial fibrillation ( erraun appears in BMJ 2001 Mar 10;322 (7286):587. British Medical Journal 2001;322

6 Perrez-Guillaume C, Wahl DG. Low dose warfarin in atrial fibrillation leads to more thrombembolic events wizhout reducing major bleeding when compared to adjusted dose. Thrombosis.2004:91( 2) Hylek EM, Go AS,Chang Y et al.effect of intensitiy of oral anticoagulation on stroke sevirity and mortality in atrial fibrillation. New England Yournal of Medicine.2003;349(11): Perrez-Gomez F,Alegria E, Berjan J et al. Comparative effects of antiplatelet, anticoagulant or combined therapy in patients with valvular and non valvular atrial fibrillation: a randomized multicentric study.journal of the American College of Cardiology, 2004;44(8):

7 Povzetek virov in osnovnih dilem Dokazali so, da je uporaba varfarina povezana z večjim rizikom za večje krvavitve, hkrati pa so dokazali, da ni pomembne razlike v splošni umrljivosti Prilagojena doza varfarina je v primerjavi z aspirinom povezana s pomembnim zmanjšanjem incidence ishemične kapi Varfarin v primerjavi z aspirinom pomembno zmanjša absolutni rizik za ishemično kap Dokazali so, da varfarin zmanjša verjetnost za nefatalno možgansko kap, ne vpliva pa na splošno umrljivost v primerjavi z aspirinom

8 Metaanaliza je pokazala, da je prilagodljiva doza varfarina povezana z zmanjšanim rizikom za možgansko kapv primerjavi s fiksno dozo varfarina.nobene razlike ni bilo pri splošni umrljivosti, smrti zaradi žilnih zapletov in krvavitev S študijami niso dokazali pomembne razlike med antitrombotično terapijo z Aspirinom ali dipyradimolom ali placebom pri: Splošni umrljivosti, vaskularni smrti, AMI, sistemski emboliji,žilnih dogodkih in večjih krvavitvah Ena meta-analiza je pokazala, da je zaščita z aspirinom povezana z redukcijo absolutnega rizika za kapi za 1,9% ( 24% relativni rizik), 2 manjši metaanalizi pa nista dokazali pomembne razlike

9 zaključki Oralna antikoagulantna terapija z varfarinom je najučinkovitejša terapija za preprečitev embolične možganske kapi. Tarčni INR je med 2 in 3 za večino pacientov Sama doza aspirina za profilakso AF je kontroverzna. Relativni rizik pri pacientih z AF se zmanjša za 22%, kar je podobno kot pri splošni populaciji za zmanjšanje vaskularnih dogodkov z antitrombocitno terapijo Dokazali so, da samo 325mg aspirina /dan zmanjša pojavnost kapi za 42%. Manjše doze niso učinkovite. Poleg tega tako visoka doza aspirina ni primerna za starejše od 75 let zaradi zapletov in ne prepreči recidivov in hudih oblik možganske kapi. Pri starejših z visoko komorbidnostjo je izbira terapije stvar klinične presoje

10 priporočila Najučinkovitejša terapija za KAF je varfarin dokaz A Tarčni INR je med 2 in 3 dokaz A Kjer varfarin ni primeren, damo aspirin v dozi mg/ dan dokaz B Aspirin ni primeren skupaj z varfarinom samo za tromboprofilakso dokaz B

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