Download Click to add your title

February 10, 2018 | Author: Anonymous | Category: , Science, Health Science, Cardiology
Share Embed


Short Description

Download Download Click to add your title...

Description

Mind the Gap: AF and the Evolving Strategies in Anticoagulation

In Cooperation with

Faculty Disclosures Fred M. Kusomoto, MD, FACC Mayo Clinic Consulting Fees/Honoraria: Medtronic

Ralph J. Verdino, MD, FACC University of Pennsylvania Consulting Fees/Honoraria: Biosense Webster; Biotronic, Inc.; Boston Scientific; Medtronic; St. Jude Medical; Zoll Officer, Director, Trustee or Other Fiduciary Role: LifeWatch, Inc.

Acknowledgement

Boehringer Ingelheim Pharmaceuticals, Inc. is a Founding Sponsor for the Mind the Gap Forums.

“Atrial Fibrillation is the Low Back Pain of Cardiology.” Mike Crawford

Program Objectives Upon completion of this session, attendees should be able to — •Implement evidence-based anticoagulation regimens for atrial fibrillation patients based on individual risks and patients’ preferences •Recognize common barriers associated with managing chronic anticoagulation in atrial fibrillation patients

Atrial Fibrillation (AF) in the U.S 2.2 million people have AF – 3.3 million in 2020; 5.6 million by 2050 – Above age 70: 10% incidence – Lifetime risk: 25% – Risk increases with increasing age

Future of Atrial Fibrillation ATRIA Study Projected Number of Adults With AF in the US 1995 to 2050

Adults With AF (millions)

7.0 6.0 5.0 4.34

4.0

4.78

5.16

5.42 5.61

3.80 3.0 2.0

2.08 2.26

2.44 2.66

2.94

3.33

1.0 0 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 Year

Go et al. JAMA. 2001;285;2370-2375.

Prevalence

Incidence Ann Int Med 1995

Biennial rate/1000 person exams

Age Benjamin EJ JAMA 1994; Framingham Heart Study

Atrial Fibrillation in the U.S. (Cont.) Risks/causative factors: – HTN, DM, CHF, age, valvular heart disease, MI, pulmonary embolus, cardiomyopathy, pulmonary disease, hyperthyroidism – Genetics: Most common in “Lone AF” • Connexin-40 • Potassium channels: KCNQ1, KCNE2, KCNJ2, KCNH2 • ANF peptide frame shift mutation

Atrial Fibrillation (AF) and Stroke • Stroke is the most common and devastating complication of AF1,2 • Incidence of all-cause stroke in patients with AF is 5%1 • AF is an independent risk factor for stroke2 • Approximately 15% of all strokes in the US are caused by AF3 1. Fuster V, et al. Circulation. 2006;114:e257-354. 2. Benjamin EJ, et al. Circulation. 1998;98:946-52. 3. Lloyd-Jones D, et al. Circulation. 2009;119:e21-181.

Stroke (%)

Stroke Rates in Placebo-Treated Patients With AF*

AFASAK

SPAF

BAATAF

CAFA

SPINAF

EAFT†

*This represents patients who are not anticoagulated; †Secondary prevention. Hart et al. Ann Intern Med. 1999;131:492-501.

Atrial Fibrillation and Stroke (Cont.) • Risk of stroke increases with age1 • Ischemic stroke associated with AF is often more severe than stroke of other etiologies4 • Stroke risk persists even in asymptomatic AF5 • Asymptomatic AF implicated as a cause of cryptogenic stroke6 4. Dulli DA, et al. Neuroepidemiology. 2003;22:118-23. 5. Page RL, et al. Circulation. 2003;107:1141-5 6. Bhatt A, et al. Stroke Res Treat. 2011; 2011: 1-5

CHADS2 Congestive heart failure Hypertension Age >75 years Diabetes mellitus Prior Stroke or TIA (*2 points)

Gage, BF, et al. JAMA. 2001;285:2864-70

Stroke Risk in AF ACP/AAFP Guidelines CHADS2 Score

Adjusted Stroke Rate* (95% CI)

CHADS2 Risk Level

0

1.9 (1.2-3.0)

Low

Aspirin

1

2.8 (2.0-3.8)

Low

Aspirin/Warfarin

2

4.0 (3.1-5.1)

Moderate

3

5.9 (4.6-7.3)

Moderate

4

8.5 (6.3-11.1)

5

12.5 (8.2-17.5)

High

6

18.2 (10.5-27.4)

High

*Expected

High

Warfarin

rate of stroke per 100 patient-years Snow V, et al. Ann Intern Med. 2003;139:1009-17

CHADS2 Congestive heart failure Hypertension Age >75 years Diabetes mellitus Prior Stroke or TIA (*2 points)

Gage, BF, et al. JAMA. 2001;285:2864-70

CHADS2 Congestive heart failure Hypertension Age >75 years Diabetes mellitus Prior Stroke or TIA (*2 points) CHADS2 did not consider other important risk factors: – – – – –

Female gender (not confirmed in all studies) Thyrotoxicosis LA size HOCM Valvular heart disease

Gage, BF, et al. JAMA. 2001;285:2864-70

CHADS2

Lip et al Chest 2010

CHA2DS2-VASc Clinical Feature CHF HTN Age ≥ 75 Diabetes mellitus Stroke, TIA, or embolism Female gender Age 65 - 74 Vascular disease (prior MI, PVD, aortic plaque

Points 1 1 2 1 2 1 1 1

CHADS2 vs. CHA2DS2-VASc

Lip et al Chest 2010

CHA2DS2VASc score

Adjusted stroke rate (%/year)

Recommended antithrombotic therapy

0

0

ASA 75-325mg or no therapy. No therapy preferred

1.3

Either oral anticoagulation or ASA 75-325mg daily, anticoagulation preferred

2

2.2

Oral anticoagulation

3

3.2

Oral anticoagulation

4

4.0

Oral anticoagulation

5

6.7

Oral anticoagulation

6

9.8

Oral anticoagulation

7

9.6

Oral anticoagulation

8

6.7

Oral anticoagulation

9

15.2

Oral anticoagulation

1

ESC Guidelines for Antithrombotic Therapy

Europace 2010; 12: 1360-1420

Stroke Prevention: Coumadin Warfarin AFASAK BAATAF SPAF CAFA SPINAF

Warfarin/ASA EAFT SPAF II AFASAK

Warfarin: Risk-Benefit Profile 20 Ischemic Stroke

Odds Ratio

15

Intracranial Bleeding

10

5

1 1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

INR Fuster V, et al. Circulation. 2006;114:e257-354.

Warfarin and Drug Interactions Warfarin is metabolized by the hepatic P450 enzyme CYP2C9 Warfarin concentration (and therefore INR) is increased by drugs that inhibit CYP2C9. INR must be closely followed and warfarin dosage decreased CYP2C9 inhibitors include: • • • • •

Amiodarone Statins simvastatin and rosuvastatin (not atorvastatin, pravastatin) Fibrates (fenofibrate, gemfibrozil) Antibiotics (sulfamethoxazole/trimethoprim, metronidazole) Azole antifungals (fluconazole, miconazole, voriconazole)

Warfarin and Drug Interactions (Cont.) Drugs that induce CYP2C9: warfarin’s effectiveness is decreased, reducing INR - Rifampin • Other drugs interactions not via CYP2C metabolism Thyroid hormone

For more information visit www.qtdrugs.org (Arizona CERT) or http://medicine.iupui.edu/clinpharm/ddis/table.asp (Indiana University, Prof D.A. Flockhart)

Time Spent in Therapeutic INR Range (%)

Quality of Warfarin Control in AF Patients on Chronic Anticoagulation 55%

63% 51%

Only 48% of eligible patients in this analysis received warfarin Baker WL, et al. J Manag Care Pharm. 2009;15:244-52.

Time Spent in Therapeutic INR Range and Clinical Outcomes





Groups stratified by time spent in therapeutic INR range (2.0-3.0) All patients had a CHADS2 score ≥ 2

Morgan CL, et al. Thromb Res. 2009;124:37-41.

Warfarin in Eligible Patients

% Use in Eligible Patients

ATRIA Study

View more...

Comments

Copyright © 2017 HUGEPDF Inc.