Stroke Prevention in Atrial Fibrillation An Expert Commentary With Kenneth W. Mahaffey, MD A Clinical Context Report
Stroke Prevention in Atrial Fibrillation Expert Commentary Jointly Sponsored by: and
Stroke Prevention in Atrial Fibrillation Expert Commentary Supported in part by educational grants from Bristol-Myers Squibb and Pfizer
Stroke Prevention in Atrial Fibrillation Clinical Context Series The goal of this series is to provide up-todate information and multiple perspectives on the pathogenesis, symptoms, risk factors, and complications of stroke prevention in atrial fibrillation, as well as current and emerging treatments and best practices in the management of stroke prevention in atrial fibrillation.
Stroke Prevention in Atrial Fibrillation Clinical Context Series Target Audience Electrophysiologists, cardiologists, primary care physicians, nurses, nurse practitioners, physician assistants, pharmacists, and other healthcare professionals involved in the management of stroke prevention in atrial fibrillation.
Activity Learning Objective Upon successful completion of this educational program, participants should be able to: Review the relevance and significance of the activity in the broader context of clinical care
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CME Information Credit Designation The University of Pennsylvania School of Medicine Office of CME designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Discussant Kenneth W. Mahaffey, MD Co-Director, CV Research Director, Clinical Events Classification (CEC) Group Duke Clinical Research Institute Durham, North Carolina
Disclosure Information Kenneth W. Mahaffey, MD, has disclosed the following relevant financial relationships: Served as a consultant for: AstraZeneca, Bayer HealthCare, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Johnson & Johnson, Merck, Novartis, Ortho/McNeill, Pfizer, Polymedix, sanofiaventis, Schering-Plough Received grants for clinical research from: AstraZeneca, Bayer HealthCare, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Johnson & Johnson, Merck, Momenta Pharmaceuticals, Novartis, Portola, Pozen, Regado Biotechnologies, sanofi-aventis, Schering-Plough, The Medicines Company
Disclosure Information Michael Mullen, MD, Clinical Instructor of Vascular Neurology, University of Pennsylvania; Chris Kaiser; and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner, have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity. The staff of The University of Pennsylvania School of Medicine Office of CME, MedPage Today, and Projects In Knowledge have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.
New Oral Anticoagulant Trials versus Warfarin RE-LY dabigatran (Pradaxa) versus warfarin in 18,000 patients 1 ROCKET-AF rivaroxaban (Xarelto) versus warfarin in 14,000 patients 2 ARISTOTLE apixaban (Eliquis) versus warfarin in 18,201 patients 3 AVERROES apixaban (Eliquis) bests aspirin in 5,600 patients unsuitable for warfarin 4 ACTIVE A clopidogrel (Plavix) plus aspirin better than aspirin alone in 7,554 patients not taking warfarin 5 SOURCES: 1) N Engl J Med 2009; 361:1139-1151; 2) AHA 2010; 3) N Engl J Med 2011; DOI: 10.1056/NEJMoa1107039; 4) ACC 2011; Abstract 1056-397; 5) N Engl J Med 2009; DOI: 10.1056/ NEJMoa0901301.
Bleeding Rates RE-LY major bleeding rate 2.71% for low-dose dabigatran versus 3.36% for warfarin ROCKET-AF stroke and blood clots 2.12 for rivaroxaban versus. 2.42 for warfarin per 100 patient-years ARISTOTLE stroke or systemic embolism rate 1.20% for apixaban versus 1.60 for warfarin
RE-LY Trial Dabigatran Dosages 150 mg dose twice daily was more effective than warfarin 110 mg dose twice daily was comparable to warfarin The FDA approved 75mg dose of dabigatran for patients with renal insufficiency
Potential Antidote for Factor Xa Inhibitors Phase III trial of investigational agent PRT064445 Demonstrates almost complete reversal of rivaroxaban in rats Portola Pharmaceuticals, also developing betrixaban Presented at 2011 European Society of Cardiology meeting
Warfarin Eligible and Time in Therapeutic Range 1 Overall, 48% of eligible Afib patients are on warfarin 55% of Afib patients within therapeutic INR range More patients in anticoagulation clinics versus physician setting remain in therapeutic range Source: 1) Manag Care Pharm 2009; 15(3) 244-52
Multidisciplinary Management of Afib Patients Family physicians General practitioners Cardiologists Hematologists Anticoagulation clinic
New Class of Oral Anticoagulants Dabigatran-oral direct thrombin inhibitor Rivaroxaban-oral direct factor Xa inhibitor Apixaban-oral direct factor Xa inhibitor
Summary New Oral Anticoagulants for Afib Five trials, three drugs, 55,000 patients worth of data Clear benefit in reduced bleeding Physician & patient education is key to adoption Phase III trial showed promise for factor Xa antidote New oral anticoagulants could help put more eligible patients on stroke medication Best patient management strategy is a multidisciplinary approach