4Prevalence 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)
5Conditions predisposing to, or encouraging progression of AF 5
6Stroke Risk CHADS2 Cardiac Failure Hypertention Age over 75 Diabetes Stroke/TIA (2 points)
7CHADS2 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 CHADS2 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; CHADS2 = cardiac failure, hypertension, age, diabetes, stroke (doubled).7
8Risk 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.8
9Adjusted stroke rate according to CHA2DS2-VASc score 9
10The HAS-BLED bleeding risk score *Hypertension is defined as systolic blood pressure > 160 mmHg.INR = international normalized ratio.10
11European Society of Cardiology (ESC) CURRENT GUIDELINES…
19Choice of NOACAll have similar large studies with evidence of non- inferiority to warfarin.DosingDABIGATRAN 150mg/110mg bdRIVAROXABAN 20mg/15mg odAPIXABAN 5mg/2.5mg bdReasons for reduced dose includeAge >80CrCl <50 for Dabigatran/RivaroxabanCrCl <30 for Apixaban
20Other Considerations Limit of CrCl Storage Drug interactions Dabigatran 30Rivaroxaban 15Apixaban 15StorageDabigatran cannot be put into blister packsDrug interactionsAmiodarone, Clarithromycin, Verapamil, ‘conazoles
22Bleeding… There is no antidote… In Dabigatran dialysis may be helpful… No clear evidence for use of Octiplex/Beriplex/Tranaxamic Acid…
23Discontinuation of NOACs “Hi is that the medics?… Surgeons here… just wanted some advice about…”
24DISCONTINUATION OF DABIGATRAN Timing of discontinuation after last dose of dabigatran before surgeryRenal function Half-life Standard risk High risk(CrCl mL/min) (hours) of bleeding bleeding≥ (11-22) 24 hours 2 days≥ 50 to < (12-34) 24 – 48 hours 2-3 days>30 to < (13-23) 48 – 72 hours 4 days30* 27 (22-35) 2 – 5 Days > 5 days*contra-indicated
25DISCONTINUATION 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.
26DISCONTINUATION 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.