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

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Presentation on theme: " AF and the New Oral Anti-Coagulants Evidenced based approach. Adapted from ESC guidelines. Dr Raj Chahal, Cardiology Trainee November 2013."— 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 to 9% at 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 CHADS 2 score and stroke rate *The adjusted stroke rate was derived from the multivariable analysis assuming no aspirin usage; these stroke rates are based on data from a cohort of hospitalised AF patients, published in 2001, with low numbers in those with a CHADS 2 score of 5 and 6 to allow an accurate judgement of the risk in these patients. Given that stroke rates are declining overall, actual stroke rates in contemporary non-hospitalised cohorts may also vary from these estimates. Adapted from Gage BF et al. AF = atrial fibrillation; CHADS 2 = cardiac failure, hypertension, age, diabetes, stroke (doubled).

8 Risk factors for stroke and thrombo-embolism in non-valvular AF AF= atrial fibrillation; EF = ejection fraction (as documented by echocardiography, radionuclide ventriculography, cardiac catheterization, cardiac magnetic resonance imaging, etc.); LV = left ventricular; TIA = transient ischaemic attack.

9 Adjusted stroke rate according to CHA 2 DS 2 -VASc score

10 The HAS-BLED bleeding risk score *Hypertension is defined as systolic blood pressure > 160 mmHg. INR = international normalized ratio.

11 European Society of Cardiology (ESC) CURRENT GUIDELINES…

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19 Choice of NOAC  All have similar large studies with evidence of non- inferiority to warfarin.  Dosing  DABIGATRAN150mg/110mg bd  RIVAROXABAN20mg/15mg od  APIXABAN5mg/2.5mg bd  Reasons for reduced dose include  Age >80  CrCl <50 for Dabigatran/Rivaroxaban  CrCl <30 for Apixaban

20 Other Considerations  Limit of CrCl  Dabigatran30  Rivaroxaban15  Apixaban15  Storage  Dabigatran cannot be put into blister packs  Drug interactions  Amiodarone, Clarithromycin, Verapamil, ‘conazoles

21 Comparison of NOAC Trials DABIGATRANRIVAROXABANAPIXABAN patients18,11314,26418,201 f/u2 yrs707 days1.8 yrs Primary outcome (Hazard ratio) 150mg- 1.11% (0.66) 110mg- 1.53% (0.74) 1.7% (0.79) 1.27% (0.79) Major bleeding (Hazard ratio) 150mg- 3.11% (0.93) 110mg- 2.71% (0.69) 3.6% (vs 3.4%) 2.13% (0.69) Haemorragic stroke (Hazard ratio) 150mg- 0.30% (0.41) 110mg- 0.23% (0.31) 0.5% (0.67) 0.24% (0.51) GI bleedingHigher

22 Bleeding…  There is no antidote…  In Dabigatran dialysis may be helpful…  No clear evidence for use of Octiplex/Beriplex/Tranaxamic Acid…

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

24 DISCONTINUATION OF DABIGATRAN Timing of discontinuation after last dose of dabigatran before surgery Renal functionHalf-lifeStandard risk High risk (CrCl mL/min)(hours) of bleedingbleeding ≥ 8013 (11-22)24 hours2 days ≥ 50 to < 8015 (12-34)24 – 48 hours2-3 days >30 to < 5018 (13-23)48 – 72 hours4 days 30*27 (22-35)2 – 5 Days> 5 days *contra-indicated

25 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.

26 DISCONTINUATION OF APIXABAN  Apixaban should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of bleeding Apixaban 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.


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