Assise de l AMCAR : 27Avril 2017
Cardiovascular morbidity and mortality and AF
The Five Domains of Integrated AF Management
FA: pathophysiology of thrombus formation Alteration of the atrial wall Myocytic hypertrophy Sclerosis Fibroelatosis Alteration of the extracellular matrix Hypercoagulability Thrombin-antithrombin complexes D-dimers Prothrombin 1 and 2 Inflammation Increased FVW, IL6, CRP Blood stasis Loss of atrial systole OG dilated Left Auricule +++
AF and thrombus formation Lancet 2009;373:155-66 Blood stasis Wall anomalies Changing circulating blood
AF and AVK Risk of stroke is < 2/100 patient-year We must deal with AVK > 100 patients to prevent stroke Risk of stroke is > 4/100 patient-year We must deal with AVK < 30 patients to prevent stroke
Stratification of thromboembolic risk FA: mitral stenosis Risk TE: 17/ year FA "non-valvular" risk TE: 2 to 10 % / year Isolated FA Age 60 years, Healthy heart (clinical, echocardiography) Risk TE: 1.3% / 15 years ¹ 1. Kopecky SL. NEJM 1987 ; 317:669-74
Thromboembolic score CHA 2 DS 2 -VASc mieux adapté pour stratifier le faible risque
HAS-BLED score 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 1 D Drugs or alcohol (1 point each) 1 or 2
Development of anticoagulants since last century «xabans» «gatrans»
AVK treatment limits Unpredictable response Narrow therapeutic window (INR between 2-3) Food interactions Drugs interactions Mandatory follow-up of coagulation Resistance to AVK Frequency of dose adjustments 1st cause of hospitalization For iatrogenic cause AVK have Many Limits And are difficult to practice Slow start and end of action 1. Ansell J, et al. Chest 2008;133;160S-198S; 2. Umer Ushman MH, et al. J Interv Card Electrophysiol 2008; 22:129-137; 3. Nutescu EA, et al. Cardiol Clin 2008; 26:169-187.
TTR: mean Time in Therapeutic Range 70%
AVK and unstable INR Last 3 INR values before enrolment Kirchhof et al., Europace 2014
DOA: Mechanism of action
DAO
DOA: métanalyse Ruff CT et al, Lancet 2014; 383: 955 62
Ruff CT et al, Lancet 2014; 383: 955 62
Ruff CT et al, Lancet 2014; 383: 955 62
Ruff CT et al, Lancet 2014; 383: 955 62
Gastroenterology 2013;143:105-112
DOA and bleeding
DOA and bleeding
Risk factors for overdose Low weight; Age over 75 years; Renal failure
Prediction stroke and bleeding risk
SAMe-TT 2 R 2 score Score 0-1: AVK Score 2: ADO Apostolakis S et al. Chest 2013;144:1555-63
Stroke prevention in patients with atrial fibrillation?
Stroke prevention in patients with atrial fibrillation
AF and ACS
AF and elective PCI
Hospitalization Related to Cardiovascular or Bleeding Event Gibson CM et al, New Engl J Med 2016
Occlusion or exclusion of the left atrial appendage
Anticoagulation in AF patients with stroke or TIA
Secondary stroke prevention
Initiation or Resumption of Anticoagulation in AF Patients After an Intracranial Bleeding Event
When Is it Safe to Resume Anticoagulation After Intracranial Bleeding? Benefit of OAC resumption for the prevention of ischemic stroke is higher than risk of bleeding Incidence rates of (A) new ischemic and (B) hemorrhagic events comparing all surviving patients who restarted OAC vs those who did not restart OAC. Analyses were based on all patients with complete 1- year follow- up data. Kuramatsu JB et al, JAMA 2015:313:824 836
DAO and Bleeding
Choice of direct anticoagulant Patients preference?? Once per day dosing Age > 80 ans Rivaroxaban, edoxaban Dabigatran 110, apixaban, Rivaroxaban, edoxaban History of stroke Apixaban, Rivaroxaban Previous gatrointestinal bleeding Apixaban High stroke risk and low bleeding risk Dabigatran 150 High stroke risk, high bleedingrisk Dabigatran 110, Apixaban or edoxaban Concomitantcoronary disease Rivaroxaban Concomitantkidney disease Apikaban, Rivaroxaban, Edoxaban Intented electrocardioversion Rivaroxaban
Stroke prevention in atrial fibrillation
CHA 2 DS 2 VASC and low risk
Thromboembolic risk
Thromboembolic risk and low CHA 2 DS 2 VASC
Echocardiography parameters and thromboembolic risk in AF
Conclusion Thromboembolic risk valvular AF and non-valvular AF: CHA 2 DS 2 VASC Patient already under AVK AVK. INR stable, Mitral stenosis and Mechanical heart V, RF ADO +++ Stroke INR unstable and no contraindications SAMETTR Score >2 1st prescription of anticoagulants DAO Coronary. Diabetic. Elderly.
Lancet 2006,367:1903-12
Management of atrial flutter
How to reduce thromboembolic risk?