Cardiovascular Update 2014 Workshop · CHADS2/CHA2DS2-VASC SCORE HAS BLED. Patient preference....

Transcript of Cardiovascular Update 2014 Workshop · CHADS2/CHA2DS2-VASC SCORE HAS BLED. Patient preference....

Cardiovascular Update 2014 Workshop

Atrial Fibrillation – Stroke, Bleeding and why is it so confusing ?

Dr Ken Butcher Dr Micha Dorsch

Högertrafikomläggningen

Presenter

Presentation Notes

Högertrafikomläggningen: The right hand traffic diversion. Hungstagan, Stockholm, Sweden 1967

Patient 1: VA• 84 year old lady

• Long history of hypertension currently well controlled on Perindopril, Bisoprolol, Chlorthalidone and Amlodipine

• Type 2 diabetes on Metformin (HBA1c: 7.4)

• Dyslipidaemia on Rosuvastatin (LDL 1.6)

• Routine office visit with family physician: no symptoms, but pulse irregularily irregular

What next ?

VA: EKG

What other tests?

Other tests

• Thyroid function test• Haemoglobin• ? Echo• ?? Ischemia work up• ??? Other tests really required

Anticoagulation?

https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=PBe6B9a4hCjVgM&tbnid=DNisVNc_yRu_qM:&ved=0CAcQjRw&url=https%3A%2F%2Fercastblog.wordpress.com%2Ftag%2Fchads-vasc%2Ffeed%2F&ei=CsIpVJj7M8TQiwLhsYGwCw&bvm=bv.76247554,d.cGU&psig=AFQjCNF0obMRsgiRb3Ffr2DHKK2LcBlpiQ&ust=1412109176753824

https://www.google.ca/imgres?imgurl=http%3A%2F%2Fvatspace.com%2Fstatic%2Fmedia%2Fimages%2Fupload%2Fissue5%2Farticle_2%2Fpicture_big%2Fid_table-1l.png&imgrefurl=http%3A%2F%2Fvatspace.com%2Fissue-5%2Fmany-af-patients-need-more-than-just-stroke-prevention%2F&docid=Z8DqkimOC52uQM&tbnid=SUZgT6rQfDj-4M%3A&w=594&h=365&ei=PCoqVP_0NsTeoATz4YDwDw&ved=0CAIQxiAwAA&iact=c

https://www.google.ca/imgres?imgurl=http%3A%2F%2Fwww.hahastop.com%2Fpictures%2FNot_At_All_Confusing.jpg&imgrefurl=http%3A%2F%2Fwww.hahastop.com%2Fpictures%2FNot_At_All_Confusing.htm&docid=wJlhWMHN_QacCM&tbnid=a4X0NKvKTG15FM%3A&w=600&h=423&ei=QCsqVL_8GcXroAT_roC4Bw&ved=0CAIQxiAwAA&iact=c

Anticoagulation ?• CHADS2 = 3, equivalent to annual stroke

risk of 5.9%

• CHA2DS2-VASC = 5, equivalent to annual stroke risk of 15.3% (2012 ESC guideline update)

• HAS-BLED = 2, equivalent to 1.88 major bleeds in 100 patient years

All calculations performed on: www.mdcalc.comMajor bleed: bleeding requiring transfusion or hospitalisation or Hb drop greater 2g/L

http://www.mdcalc.com/

Figure 1

2014-11-30

Presenter

Presentation Notes

The simplified “CCS algorithm” for deciding which patients with atrial fibrillation (AF) or atrial flutter (AFL) should receive oral anticoagulation (OAC) therapy. * We suggest that a NOAC be used in preference to warfarin for non-valvular AF. † Might require lower dosing. ASA, acetylsalicylic acid; CAD, coronary artery disease; CCS, Canadian Cardiovascular Society; CHADS2, Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack; eGFR, estimated glomerular filtration rate; INR, international normalized ratio; NOAC, novel oral anticoagulant; NSAID, nonsteroidal anti-inflammatory drug; TIA, transient ischemic attack.

http://www.elsevier.com/termsandconditions

Rate or rhythm control ?

Rate vs Rhythm control: AFFIRM

AFFIRM investigators: A comparison of rate control and rhythm control in patients with Atrial fibrillation. NEJM 2002; 347: 1825-33

Presenter

Presentation Notes

Also no indication of benefit with rhythm control strategy for other hard endpoints

What is rate control ?

Van Gelder et al. Lenient vs. strict rate control in patients with atrial fibrillation. NEJM 2010;362: 1363-73

Rate control: Strict vs lenient

Presenter

Presentation Notes

Composite endpoint: death from CV causes, hospitalisation for heart failure, stroke, systemic embolism, bleeding and life threatening arrhythmia

Not so confusing at all, is it?• Started on Coumadin, opted for rate

control

• No further cardiac testing

• 12 months follow-up– Pt remains asymptomatic– Changed from coumadin to rivaroxaban by

family physician (difficult to control INR)

Patient 2: JA• 56 year old lady• Paroxysmal atrial fibrillation since 2001• Very symptomatic with one episode every 3-6

months• 18 admissions requiring DCCV, 5 Cardiologists• Intolerant of Sotalol, Dronedarone, Atenolol,

Warfarin, Rivaroxaban and Dabigatran• On Diltiazem 90 mg bid and ASA (sometimes)• 19. admission RAH ER Jan 2014

Admission 19, Cardiologist Nr 6

• Woke up at 05.00 with palpitations and dizziness

• Called EMS at 07.00

• EMS: A fib, rate 160, BP: 86/45

What next ?

Acute Management

• Attempted DCCVx3 by EMS, remains in Afib

• Procainamide i.v.: worsening hypotension

• CCU admission: spontaneous cardioversion

A fib – possible longterm strategies

• Continuous antiarrhythmic drug therapy

• Pill in the pocket approach

• Invasive management: pulmonary vein isolation

Pharmacotherapy - options

• Sotalol

• Dronedarone

• Propafenone/Fleccainide

• Amiodarone

Anticoagulation ?• CHADS2 = 0, equivalent to annual stroke

risk of 1.9%

• CHA2DS2-VASC = 1, equivalent to annual stroke risk of 2% (2012 ESC guideline update)

• HAS-BLED = 0, equivalent to 1.13 major bleeds in 100 patient years

All calculations performed on: www.mdcalc.com

JA: further management

• Changed Diltiazem bid to Tiazac XC 240 mg daily

• Started on Apixaban

• Propafenone 600mg (pill in the pocket approach)

OA review: Sep 2014• D/C Apixaban after 2 weeks for side effects and

restarted ASA

• Tolerates Tiazac XC and takes it regularly

• 2 episodes of paroxysmal A fib since, terminated by Propafenone

• Offered her workup for pulmonary vein isolation: currently not interested

Pill in the pocket approach

• 268 patient with paroxysmal atrial fibrillation and structurally normal heart

• Treated in ER with Propafenone or Fleccainide as per site investigator`s preference

• 210 treated successfully and without side effects were given pill in the pocket

• 84% success rate, no serious side effects

Alboni et al.: Out-patient management of recent onset atrial fibrillation with the pill in the pocket approach. NEJM2004; 351:2384-91.

A Fib management

Anticoagulant/Antiplatelettherapies

CHADS2/CHA2DS2-VASC SCORE

HAS BLED

Patient preference

Rhythm vs Rate control

Symptoms

Probability of maintaining SR

Patient preference

Treatable aetiological factors

Structural heart disease

Sleep disordered breathing

Hyperthyroidism…

A Fib: My approach

Figure 2

2014-11-30

Presenter

Presentation Notes

Decision algorithm for management of oral anticoagulation (OAC) therapy for patients who present to the emergency department (ED) with recent-onset atrial fibrillation (AF) requiring rate control or cardioversion (CV) in the ED. † Immediate OAC = a dose of OAC should be given just before cardioversion; either a novel direct oral anticoagulant (NOAC) or a dose of heparin or low molecular weight heparin with bridging to warfarin if a NOAC is contraindicated. ASA, acetylsalicylic acid; CAD, coronary artery disease; CHADS2, Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack; TIA, transient ischemic attack.

Figure 3

2014-11-30

Presenter

Presentation Notes

Approach to rate and/or rhythm control of atrial fibrillation (AF) in patients presenting with symptomatic AF. QOL, quality of life.

Atrial Fibrillation – Stroke, Bleeding and why is it so confusing ?

Cardiovascular Update 2014 Workshop · CHADS2/CHA2DS2-VASC SCORE HAS BLED. Patient preference....

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