1 / 26

AF and the New Oral Anti-Coagulants

AF and the New Oral Anti-Coagulants. Evidenced based approach. Adapted from ESC guidelines. Dr Raj Chahal, Cardiology Trainee November 2013. Current State Of Play. Atrial Fibrillation (AF) is not a benign condition. Increased risk of stroke. Risk of stroke varies with risk factors.

selia
Download Presentation

AF and the New Oral Anti-Coagulants

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. AF and the New Oral Anti-Coagulants Evidenced based approach. Adapted from ESC guidelines. Dr Raj Chahal, Cardiology Trainee November 2013

  2. Current State Of Play • Atrial Fibrillation (AF) is not a benign condition. • Increased risk of stroke. • Risk of stroke varies with risk factors. • Increase mortality hazard ratio aside from stroke risk.

  3. Clinical Events (outcomes) affected by AF

  4. Prevalence • The most common sustained cardiac arrhythmia • Hospital based prevalence data probably underestimates as often asymptomatic. • Prevalence doubles with each decade of age from 0.5% at age 50-59 to 9% at 80-89 years. • Risks factors of developing AF: • Age (OR 2.1 Men, 2.2 Women) • Diabetes (OR 1.4 Men, 1.6 Women) • Hypertension (OR 1.5 Men, 1.4 Women) • Valve disease (OR 1.8 Men, 3.4 Women)

  5. Conditions predisposing to, or encouraging progression of AF

  6. Stroke Risk • CHADS2 • Cardiac Failure • Hypertention • Age over 75 • Diabetes • Stroke/TIA (2 points)

  7. CHADS2 score and stroke rate *The adjusted stroke rate was derived from the multivariable analysis assuming no aspirin usage; these stroke rates arebased on data from a cohort of hospitalised AF patients, published in 2001, with low numbers in those with a CHADS2 scoreof 5 and 6 to allow an accurate judgement of the risk in these patients. Given that stroke rates are declining overall, actualstroke rates in contemporary non-hospitalised cohorts may also vary from these estimates. Adapted from Gage BF et al. AF = atrial fibrillation; CHADS2 = cardiac failure, hypertension, age, diabetes, stroke (doubled).

  8. Risk factors for stroke andthrombo-embolism in non-valvular AF AF= atrial fibrillation; EF = ejection fraction (as documented by echocardiography, radionuclideventriculography, cardiaccatheterization, cardiacmagneticresonanceimaging, etc.); LV = leftventricular; TIA = transientischaemicattack.

  9. Adjusted stroke rate according to CHA2DS2-VASc score

  10. The HAS-BLED bleeding risk score *Hypertension isdefined as systolicblood pressure > 160 mmHg. INR = international normalized ratio.

  11. European Society of Cardiology (ESC) CURRENT GUIDELINES…

  12. Choice of NOAC • All have similar large studies with evidence of non-inferiority to warfarin. • Dosing • DABIGATRAN 150mg/110mg bd • RIVAROXABAN 20mg/15mg od • APIXABAN 5mg/2.5mg bd • Reasons for reduced dose include • Age >80 • CrCl <50 for Dabigatran/Rivaroxaban • CrCl <30 for Apixaban

  13. Other Considerations • Limit of CrCl • Dabigatran 30 • Rivaroxaban15 • Apixaban 15 • Storage • Dabigatran cannot be put into blister packs • Drug interactions • Amiodarone, Clarithromycin, Verapamil, ‘conazoles

  14. Comparison of NOAC Trials

  15. Bleeding… • There is no antidote… • In Dabigatran dialysis may be helpful… • No clear evidence for use of Octiplex/Beriplex/TranaxamicAcid…

  16. Discontinuation of NOACs “Hi is that the medics?… Surgeons here… just wanted some advice about…”

  17. DISCONTINUATION OF DABIGATRAN Timing of discontinuation after last dose of dabigatran before surgery Renal function Half-life Standard risk High risk (CrCl mL/min) (hours) of bleeding bleeding ≥ 80 13 (11-22) 24 hours 2 days ≥ 50 to < 80 15 (12-34) 24 – 48 hours 2-3 days >30 to < 50 18 (13-23) 48 – 72 hours 4 days 30* 27 (22-35) 2 – 5 Days > 5 days *contra-indicated

  18. DISCONTINUATION OF RIVAROXABAN • If an invasive procedure or surgical intervention is required, rivaroxaban should be stopped at least 24 hours before the intervention, if possible and based on the clinical judgement of the physician.If the procedure cannot be delayed the increased risk of bleeding should be assessed against the urgency of the intervention. • Rivaroxaban should be restarted after the invasive procedure or surgical intervention as soon as possible provided the clinical situation allows and adequate haemostasis has been established.

  19. DISCONTINUATION OF APIXABAN • Apixabanshould be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of bleedingApixaban should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding including interventions for which any bleeding that occurs is expected to be minimal, non-critical in its location or easily controlled. • If surgery or invasive procedures cannot be delayed, appropriate caution should be exercised, taking into consideration an increased risk of bleeding against the urgency of intervention.Apixaban should be restarted after the invasive procedure or surgical intervention as soon as possible provided the clinical situation allows and adequate haemostasis has been established.

More Related