1. Stroke Prophylaxis Oral anticoagulation Lauren Butler
Dr Pervez Muzaffar

2. symptoms AF – most common arrhythmia Asymptomatic/exercise intolerance
chest pain/palpitation/fainting
CCF/TIA
weight loss/diarrhoea
Light-headedness

3. Diagnosis History Examination (inc manual pulse check)
ECG (essential for diagnosis)
Case specific bloods
Echocardiogram
Cxr

4. Classification Timing and termination based classification
1st detected - only one diagnosed episode
Paroxysmal - recurrent self terminates < 7 days
Persistent - recurrent lasts for > 7 days
Permanent - on-going long term
Other categories:
Lone AF – age under 60 no h/o CVD/HT/Pulmonary disease
Non-valvular AF – absence of Rheumatic MVD/prosthetic valve or MV repair
Secondary AF – MI/cardiac surgery/pericarditis/myocarditis/hyperthyroidism/PE/Pneumonia

5. We need to improve Our prevalence of AF is below national average
1.12% BwD
1.74% England
In BwD we only anticoagulate 42% of High risk AF cases, England 56%, we should aim for 85%!

6. Stroke in AF 14% of all strokes are due to AF
AF increases risk of stroke five-fold
strokes per year occur in AF patients,
of these are directly attributable to the AF
AF strokes tend to be bigger and more disabling
Warfarin reduces stroke risk by around 2/3

7. Atrial fibrillation (AF) Points Pay stage
AF1. The practice can produce a register of patients with atrial fibrillation 5
AF5. The percentage of patients with atrial fibrillation in whom
stroke risk has been assessed using the CHADS2 risk
stratification scoring system in the preceding 15 months
(excluding those whose previous CHADS2 score is greater than 1) 10
40–90 %
AF6. In those patients with atrial fibrillation in whom there is a
record of a CHADS2 score of 1(latest in the preceding 15
months), the percentage of patients who are currently treated
with anti-coagulation drug therapy or anti-platelet therapy 6
50-90%
AF7. In those patients with atrial fibrillation whose latest record
of a CHADS2 score is greater than 1, the percentage of patients
who are currently treated with anti-coagulation therapy
40-70%

8. Capturing information
Grasp tool- how does it work?
Works on all GP software
Set of MIQUEST queries on AF patients
Calculates stroke risk using CHADS2
With option to use latest CHA2DS2-VASc scoring tool
Highlights those who would benefit from a medication review
Does not assess C/I to warfarin
Results in spread sheet/dashboard format

10. Classic Grasp-AF tool view

11. CHADS2 Score Congestive Heart failure 1 Hypertension 1 Age ≥ 75 1
Diabetes
Previous Stroke or TIA
Consider anticoagulation if ≥ 2
Use CHA2DS2VASc assessment tool if < 2

12. Yet under prescribed
NICE estimate that approximately 40% of patients in whom warfarin is indicated are not receiving it.
RCPE % of people with AF should be considered for this treatment

13. Aspirin vs. Warfarin Warfarin represents a 64% reduced stroke risk
BAFTA - Warfarin did not increase haemorrhage risk in comparison with aspirin (Warfarin 1.4% Aspirin 1.6%)
Falls - Older patients taking warfarin must fall about 295 times in one year for warfarin not to be optimal therapy and the propensity to fall is not a contraindication to the use of antithrombotic agents (especially warfarin) in elderly persons with AF.
NB current guidance suggests that Aspirin should not be used for stroke prevention in AF. (RCPE UK 2012)

14. CHA2DS2-VASc Score Congestive Heart Failure/ LVD 1 Hypertension 1
Age ≥ 75 years
Diabetes mellitus
Stroke/TIA/TE
Vascular disease (MI, PAD or aortic plaque)
Age between 65 and 74 year
Sc - Sex category - Female
Score of ≥ 2 anticoagulation therapy
Score of 1 consider risk/benefit and HAS-BLED score to aid decision for anticoagulation or antiplatelet therapy

15. HAS-BLED Score
Annual Hypertension, Uncontrolled Sys >160mmHg 1pt
Abnormal Kidney (Cr > 200) and/or liver function 1pt each
Stroke pt
Bleeding, previous history, anaemia or predisposition 1pt
Labile INR, high INR or poor time in Therapeutic range 1pt
Elderly, age ≥ 65yrs 1pt
Drugs and/or alcohol, antiplatelets, more than drinks per week pt each
A score of 3 or more is not a contraindication to oral anticoagulation but these patients require extra care

16. CHADS 2 vs HAS – BLED Risk score Risk score
0 1.9%
1 2.8%
2 4.0%
3 5.9%
4 8.5%
5 12.5%
6 18.2%
0 1.1% % % % % %

17. Using both….. Lancashire & Cumbria Guidelines
Calculate CHADS2 score ………
CHADS2 > 1 anti-coagulate
CHADS2 ≤ 1 calculate CHA2DS2-VASC
CHA2DS2-VASC >1 anti-coagulate
CHA2DS2-VASC ≤1no treatment (or aspirin)
Consider a risk of bleeding assessment such as the
HAS-BLED score before anticoagulation

18. New oral anticoagulant drugs
Dabigatran, RivaroXaban, ApiXaban
Dabigatrin (Pradaxa ) 150mg bd or 110 mg bd
Rivaroxaban (Xarelto ) 20mg od
Apixaban 5mg bd (not yet licensed for stroke prevention in AF)
NOACs are recommended as an treatment option where warfarin is either contraindicated or where the patient has a documented hypersensitivity to or intolerance of coumarin anticoagulants severe enough to cause treatment withdrawal
Studies show similar or better efficacy than warfarin with less risk of bleeding
No monitoring required
Few drug and diet interactions
Very expensive (but savings on monitoring)

19. New oral anticoagulant drugs (2)
Still black triangle drugs – Amber rating in BwD
No simple antidote (but short half life)
In RE-LY trial, Dabigatran higher drop out rate than warfarin
Higher rate of GI bleeding, lower rate of ICH
Warfarin is still likely to remain drug of choice for those who are well controlled (TTR 65%)
However NOACs do have advantages, and will benefit a proportion of the population

20. Warfarin or NOAC ? Where to refer ?
Warfarin Anticoag clinic
NOAC Community cardiology (Mammen)
Remember – NOACs still carry bleeding risk, black triangle drugs with no antidote

21. Key points Aspirin is ineffective in stroke prevention for AF
If warfarin can not be controlled and compliance is not the issue then a NOAC should be commenced
Where compliance is the issue, then is it preferable to at least be able to monitor this?
Watch NOACs in the elderly and those with poor renal function
Remember – BwD anticoag service has domiciliary service for patients unable to attend clinic

22. case
66 years old female presented with sob/tiredness feels skipping beat occasionally when playing golf
no cough no chest pain no fainting no other symptoms
PMH: nil
No allergy

23. Examination/tests
BP 132/70 pulse 104/min irregular no murmur no ankle oedema no carotid bruits CNS- normal Chest- sats 98% RR 20/min no wheeze mild basal crepts apyrexial ECG AF 112/min Requested bloods

24. Diagnosis?
CHADS2 Score??
What would you next?

25. Anticoagulate?
CHA2DS2-VASc Score ??
What is next?

26. NOAC
After discussion she decides to be referred to anticoagulation clinic
She comes back in a week time with her consultant surgeon son who says he does not want her to go on warfarin – but like her to go on Dabigatran (NOAC)
Your response to his request?
He wishes to pay for private prescription?