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Antithrombotic therapy in Atrial Fibrillation National treatment guideline Steen Husted Aarhus University Hospital
What is New in the 2010 Guideline? Impact on stroke prevention in DK?
Atrial Fibrillation (AF) is a common problem AF is the most common cardiac arythmia Very common in the elderly Related to co-morbidity MI Heart failure Hypertension Treatment of AF is a clinical challenge
The Management Cascade for patients with AF European Heart Journal (2010) 31, 2369 2429
Natural time course of AF. Camm A J et al. Eur Heart J 2010;eurheartj.ehq278
Decisions on Stroke Prevention in AF : Evidence based In accordance with guidelines Based on: Risk of stroke Risk reduction of stroke on antithrombotic treatment Risk of bleeding Contraindications to antithrombotic medications
Antithrombotics for stroke prevention in AF None Low risk Platelet inhibitor: Aspirin (ASA) Low risk Clopidogrel ASA intolerance ASA + Clopidogrel Contraindication for OAC OAC Vitamin K antagonists (VKA) Moderate to high risk New drugs Moderate to high risk Combinations ASA + VKA Common used in AF + IHD ASA + clopidogrel + VKA AF + Coronary artery stent/acs Heparin bridging Special conditions
Stroke Risk Estimation Clinical scoring systems: Low risk Intermediate risk High risk CHADS 2 CHA 2 DS 2 -VASc For refinement incorporate other risk factors: Age 65-74 Female gender Vascular disease
Stroke risk stratification with CHADS2 and CHA2DS2-VASc scores CHADS 2 acronym Score CHA2 DS 2 -VASc acronym Score Congestive heart failure 1 Congestive heart failure/lv dysfunction 1 Hypertension 1 Hypertension 1 Aged 75 years 1 Aged 75 years 2 Diabetes mellitus 1 Diabetes mellitus 1 Stroke/TIA/TE 2 Stroke/TIA/TE 2 Maximum score 6 Vascular disease (prior MI, PAD, or aortic plaque) Aged 65-74 years 1 Sex category (i.e. female gender) 1 Maximum score 9 1
Stroke risk assessment with CHA 2 DS 2 -VASc CHA 2 DS 2 -VASc criteria Score CHA 2 DS 2 -VASc total score Rate of stroke/other TE (%/year) (95% CI)* Congestive heart failure/ left ventricular dysfunction 1 0 0 (0 0) 1 0.6 (0.0 3.4) Hypertension 1 Age 75 yrs 2 Diabetes mellitus 1 Stroke/transient ischaemic attack/te Vascular disease (prior myocardial infarction, peripheral artery disease or aortic plaque) Age 65 74 yrs 1 Sex category (i.e. female gender) 1 TE = thromboembolism Lip GYH et al. Chest 2010;137:263-72 2 1 2 1.6 (0.3 4.7) 3 3.9 (1.7 7.6) 4 1.9 (0.5 4.9) 5 3.2 (0.7 9.0) 6 3.6 (0.4 12.3) 7 8.0 (1.0 26.0) 8 11.1 (0.3 48.3) 9 100 (2.5 100) *Theoretical rates without therapy corrected for the % of patients receiving Aspirin within each group, assuming 22% reduction in risk with Aspirin 13
Risk of Bleeding Risk of stroke and risk of bleeding is closely related OAC prescription needs to: Balance benefit from stroke prevention and risk from bleeding
Risk factors for Bleeding Hypertension Abnormal renal/liver function Stroke Bleeding history or predisposition Labile INR Elderly (>65) Drugs/alcohol concomitantly
HAS-BLED new bleeding risk scoring system Hypertension Abnormal renal/liver function Stroke Bleeding history or predisposition Labile INR Elderly (>65) Drugs/alcohol concomitantly R. Pisters and GYHL. Lip et al.. Chest; Prepublished online March 18, 2010;
HAS-BLED bleeding risk score Points Annual bleeding rate 0-1 <1.02 2 1.88 >3 >3.74 HAS-BLED score of 3, suggest caution and/or regular review
One approach - Benefits of VKA versus Risk of Bleeding CHADS 2 score Risk of Bleeding: 2 Outweighs the potential benefit of OAC if: HAS-BLED score > CHA 2 DS 2 index. 1 HAS-BLED score must exceed 2 for the potential harm caused by OAC use to offset its beneficial effect on stroke risk reduction NBV 2011
One approach - Benefits of VKA versus Risk of Bleeding CHA 2 DS 2 -VAScscore Risk of Bleeding: 2 Outweighs the potential benefit of OAC if: HAS-BLED score > CHA 2 DS 2 -VASc index. 1 HAS-BLED must be low 0-1, good quality VKA therapy with expected annual bleeding rate <2% or time in therapeutic interval more than 2/3 of time R. Pisters and GYHL Lip et al.. Chest; Prepublished online March 18, 2010;
Conclusion on VKA in AF Thromboprophylaxis in AF requires a beneficial balance between stroke and bleeding risk Initially, consider CHADS 2 score, or for more comprehensive stroke risk assessment CHA 2 DS 2 -VASc score If score 2, OAC is clearly indicated For simple and easy bleeding risk assessment use: HAS-BLED score If score 3, clearly at risk - caution
AF - Special situations Paroxysmal AF Perioperative anticoagulation Stable vascular disease Acute stroke Elective PCI ACS and/or PCI NSTEMI STEMI with primary PCI
Paroxysmal AF Stroke risk in paroxysmal AF Not different from that in persistent or permanent AF Patients with paroxysmal AF should receive OAC according to their risk score
Perioperative anticoagulation Many surgeons require: INR < 1.5 or even INR normalization before undertaking surgery What to do? Temporary interruption of VKA treatment before surgery or an invasive procedure: Warfarin pause 4 days before procedure Phenprocoumon interrupted 7 days before procedure Pause for 48 h without bridging PRAB report, www.dsth.dk
Perioperative anticoagulation Mechanical heart valve or AF at high risk for thrombo-embolism (CHADS-score 4+) Bridging with therapeutic doses of LMWH PRAP raport, www.dsth.dk
Perioperative anticoagulation VKA resumed at the usual maintenance dose: without a loading dose on the evening of surgery PRAB raport, www.dsth.dk
Stable vascular disease Many anticoagulated AF patients have stable coronary disease carotid artery disease and/or PAD Common practice: VKA + one antiplatelet drug usually ASA Adding ASA to VKA does not reduce the risk of stroke or vascular events (including MI) But substantially increases bleeding events!
Acute Stroke Acute stroke is a common first presentation AF Limited trial data to guide management Concern that patients within the first 2 weeks after cardioembolic stroke have: greatest risk of recurrent stroke because of further thrombo-embolism Anticoagulation in the acute phase may result in intracranial haemorrhage or haemorrhagic transformation of a cerebral infarct
AF presenting with an acute stroke What to do: Treat uncontrolled hypertension before antithrombotic treatment is started, Cerebral imaging should be performed to exclude haemorrhage CT MRI If no haemorrhage: anticoagulation should begin within 2 weeks usually after 1-2 weeks If presence of haemorrhage anticoagulation should not be given
In AF presenting with acute TIA Anticoagulation treatment should begin as soon as possible in the absence of cerebral infarction or haemorrhage
Acute coronary syndrome and/or PCI Current guidelines for ACS and/or PCI recommend ASA clopidogrel combination therapy after: ACS and a stent 4 weeks for a bare-metal stent 6 12 months for a drug-eluting stent 12 months after ACS
ACS and/or PCI VKA non-treatment in high risk AF is associated with an increase in mortality and an increase major adverse cardiac events
Acute coronary syndrome and/or PCI The prevalence of major bleeding with triple therapy: VKA, ASA, and clopidogrel 2.6 4.6% at 30 days 7.4 10.3% at 12 months Acceptable risk benefit ratio for 4 weeks if the bleeding risk is low
Antithrombotic strategies in coronary artery stenting in high risk AF European Heart Journal (2010) 31, 2369 2429
How to chose the right OAC strategy in the future Important task for the Scientific societies
Thank you for your attention