Lecture Atrial fibrillation role of new oral anticoagulants - Dr. Nguyen Tuan Hai

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Lecture Atrial Fibrillation and the generation of new anticoagulants presents the concept of atrial fibrillation, atrial fibrillation classification, mechanism of blood clots in atrial fibrillation, atrial fibrillation therapy, anticoagulant therapy in atrial fibrillation. Hope this is useful references for you.

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Nội dung Text: Lecture Atrial fibrillation role of new oral anticoagulants - Dr. Nguyen Tuan Hai

HANOI MEDICAL UNIVERSITY HARVARD MEDICAL SCHOOL Department of Cardiology Beth Israel Deaconess Medical Center ATRIAL FIBRILLATION ROLE OF NEW ORAL ANTICOAGULANTS For primary care doctors Dr. NGUYEN TUAN HAI
CASE REPORT  65 year – old lady  No hypertension, no diabetes  Palpitations, fatigue + shortness of breath during the past month  Physical examination: – CVS: • BP: 120/80 mmHg • HR: 130 bpm, irregular • HS: no murmurs • JVP , peripheral edema (+) – RS: • Chest clear – GIS: NAD
ECG 1. What is the diagnosis? 2. What questions should be addressed in order to manage this patient? 3. How would you manage this patient over the first 24 hours? 4. How would you manage this patient subsquently?
? ATRIAL FIBRILLATION
 Supraventricular tachycardia  Characterized by replacement of consistent P waves with rapid oscillation of fibrillatory waves, varying in amplitude, shape, and timing  Associated with an irregular and frequently rapid ventricular response (with intact AV conduction)
Types of Atrial Fibrillation European Heart Journal (2010) 31, 2369–2429
LONE ATRIAL FIBRILLATION  Absence of cardiac or other conditions predisposing to AF  Patients could have paroxysmal, persistent, or chronic AF (15 - 30 % of cases of chronic AF overall and 25 - 45 % with paroxysmal AF)  Affected patients are younger than those with structural heart disease  Good prognosis, particularly if they are under the age of 60 to 65 Causes of atrial fibrillations. www.uptodate.com
EHRA score of AF-related symptoms ( European Heart Rhythm Association) EHRA score Explanation EHRA I ‘No symptoms’ EHRA II ‘Mild symptoms’; normal daily activity not affected EHRA III ‘Severe symptoms’; normal daily activity affected EHRA IV ‘Disabling symptoms’; normal daily activity discontinued
WORK UP  Blood test: Normal • creatinin: 94 µmol/l • fasting glucose: 5,8 mmol/l • FT4: 15 pmol/l; TSH: 3,1 µU/ml  Chest X-ray: Normal cardiac silhouette, clear lungs  TTE: • Dd 52 mm; Ds 31 mm; EF 31%, • mild MR, no thrombus in LA  Coronary angiography: Normal
DIAGNOSIS Lone persistent AF (EHRA III) Tachycardiomyopathy
Clinical outcomes affected by AF Outcome parameter Relative change in AF patients 1. Death Death rate doubled. 2. Stroke (includes Stroke risk increased; AF is associated with haemorrhagic stroke and more severe stroke. cerebral bleeds) Hospitalizations are frequent in AF patients 3. Hospitalizations and may contribute to reduced quality of life. Wide variation, from no effect to major 4. Quality of life and reduction. exercise capacity AF can cause marked distress through palpitations and other AF-related symptoms. Wide variation, from no change to 5. Left ventricular tachycardiomyopathy with acute heart function failure. European Heart Journal (2010) 31, 2369–2429
A common but serious arrhythmia  AF increases the risk of stroke 5-fold1  The increase in risk of stroke is similar for paroxysmal, persistent and permanent AF2  Strokes associated with AF are usually more severe than those from other causes, conferring an increased risk of morbidity, mortality and poor functional outcome1 1. Savelieva et al. Ann Med 2007;39:371–391 2. Hart R et al. JACC 2000; 35:183-187
Mechanisms of thrombogenesis in AF  Abnormal changes in vessel walls and anatomical and structural defects  Abnormal changes in flow (stasis)  abnormal changes in blood constituents
Management of AF Rate control ? Rhythm control Prevention of thromboembolism
Management cascade for patients with AF Presentation Atrial fibrillation Record 12 EHRA score lead ECG Associated disease Initial assessment Oral anticoagulant Assess TE Aspirin Anticoagulation isssues risk None Rate control AF type Rhythm control Rate and rhythm control Symptoms Antiarrhythmic drugs Ablation Consider ACEIs/ARBs Treatment of underlying disease Statins/PUFAs “upstream” therapy referral Others
Risk Stratification in AF Stroke Risk Factors High risk factors Moderate-Risk Factors • Mitral stenosis • Age >75 years • Prosthetic heart valve • Hypertension • History of stroke or TIA • Diabetes mellitus • Heart failure or ↓ LV function Less Validated Risk Factors Dubious Factors • Age 65–75 years • Duration of AF • Coronary artery disease • Pattern of AF (persistent vs. • Female gender paroxysmal) • Thyrotoxicosis • Left atrial diameter Singer DE, et al. Chest 2004;126:429S. Fang MC, et al. Circulation 2005; 112: 1687.
THE CHADS2 Index Stroke Risk Score for AF CHADS2 Risk Score CHADS2 Patients Adjusted score (n = 1733) stroke rate CHF 1 %/year 0 120 1.9 Hypertension 1 1 463 2.8 2 523 4.0 Age > 75 1 3 337 5.9 Diabetes 1 4 220 8.5 5 65 12.5 Stroke or TIA 2 6 5 18.2 Low – risk: 0 – 1 Van Walraven C, et al. Arch Intern Med 2003; 163:936. Moderate – high risk: ≥ 2 Go A, et al. JAMA 2003; 290: 2685. Gage BF, et al. Circulation 2004; 110: 2287.
CHA2DS2VASc score CHA2DS2-VASc Risk Score CHA2DS2- Patients Adjusted VASc (n = 7329) stroke score rate CHF or LVEF < 40% 1 (%/year) 1 0 1 0 Hypertension 1 422 1.3 Age > 75 2 2 1230 2.2 Diabetes 1 3 1730 3.2 Stroke/TIA/ 2 4 1718 4.0 Thromboembolism 5 1159 6.7 Vascular Disease 1 6 679 9.8 Age 65 - 74 1 7 294 9.6 Sex category (Female) 1 8 82 6.7 9 14 15.2 Low – risk: 0 – 1 Moderate – high risk: ≥ 2 Lip GYH, Halperin JL. Am J Med 2010; 123: 484.
CHA2DS2VASc vs CHADS2  CHADS2 has some limitations: – Some risk factors are not recognized → underestimating stroke risk – Age is not a binary risk factor – rather, it is a continuum, with risk increasing with each decade from the age of 65 years onwards – CHADS2 classifies a substantial proportion of patients with AF as being at ‘moderate risk’ of stroke → their stroke risk may be underestimated → leading them to receive inadequate antithrombotic therapy for stroke prevention  CHA2DS2-VASc: – More reliably identifies patients at low risk, with validation studies showing very few stroke events in patients categorized as being at low risk of stroke – Categorizes a small proportion of patients as intermediate risk – Simplifies selection of patients for anticoagulation, helping to remove much of the uncertainty regarding the optimal form of thromboprophylaxis Olesen JB et al. BMJ 2011;342:d124
Anticoagulation in AF Stroke Risk Reductions Warfarin Better Control Better AFASAK Reduction of all SPAF cause mortality BAATAF RRR = 26% CAFA SPINAF Reduction of stroke EAFT RRR = 64% Aggregate 100% 50% 0 -50% -100% Hart R, et al. Ann Intern Med 1999;131:492