The Latest in the Emergency Management of Atrial Fibrillation: Cardioversion and more

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "The Latest in the Emergency Management of Atrial Fibrillation: Cardioversion and more"

Transcription

1 The Latest in the Emergency Management of Atrial Fibrillation: Cardioversion and more

2 Objectives Appreciate which AF patients are at risk for stroke Review latest evidence relevant to the decision to anticoagulate AF in the emergency department Discuss who should be treated with NOACs vs. warfarin, including the latest data on cardioversion

3 Disclosure of Commercial Support This program has received financial support from AstraZeneca and Bayer in the form of an educational grant, and has been co developed in conjunction with the Canadian Association of Emergency Physicians (CAEP). Potential for conflict(s) of interest: Dr. Mathieu, Dr. Cox and Dr. Nseir have all received payment from Bayer Bayer licenses a product that will be discussed in this program: Xarelto (rivaroxaban)

4 Mitigating Potential Bias Potential Biases are acknowledged and are mitigated by presenting data supported by national and international guidelines, and as follows: While Dr. Cox, Dr. Mathieu and Dr. Nseir have received an honoraria from Bayer and discuss Xarelto (rivaroxaban), the information presented provides an unbiased overview of all relevant products Information presented is evidence based Recommendations made are evidence or guidelines based rather than personal recommendations of the presenter Material has been developed and reviewed by an Educational Committee

5 Faculty/Presenter Disclosure Faculty: Anas Nseir, MD, CCFP, FCCP, B.Pharm Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: Bayer, AstraZeneca, Bohringer Ingelheim, CSL Behring Consulting Fees: None Other: None

6 Faculty/Presenter Disclosure Faculty: Bernard Mathieu, MD, CCMF Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: AstraZeneca, Lilly Consulting Fees: None Other: None

7 Faculty/Presenter Disclosure Faculty: Jafna L. Cox, BA, MD, FRCPC, FACC Relationships with commercial interests: Grants/Research Support: Bayer, Merck, Pfizer and Sanofi Aventis Speakers Bureau Member: Canadian Cardiovascular Society s Atrial Fibrillation Guidelines Panel and Chair of its Atrial Fibrillation Quality Indicator Subcommittee Honoraria: Bayer Consulting Fees: Nova Scotia Department of Health, New Brunswick Department of Health, Public Health Agency of Canada, and the Canadian Agency for Drugs and Technologies in Health Scientific Advisory Board: AstraZeneca, Bayer, Boehringer Ingelheim, BMS, Pfizer, and Sanofi Aventis

8 Case Study

9 Mr. Bertucci: Case 75 year old man History of TIA, bleeding duodenal ulcer and remote MI Hand numbness, dysarthria, lasted 15 minutes HR 80 Normal CT ECG shows AF (prior ECG suggests that this is new onset AF) Consumes 3 4 alcoholic beverages daily Your Thoughts?

10

11 CCS Algorithm Rhythm Control Strategy of rhythm control for recent onset AF/AFL Known duration < 48 h (and not high risk patients 1 ) Duration >48 h or unknown or high risk patients 1 Hemodynamically unstable Hemodynamically stable Failed CV Rate control Urgent electrical cardioversion 2 Successful CV Pharmacological or electrical cardioversion 2 Antithrombotic therapy In general, no prior or subsequent anticoagulation is required. If AF/AFL persists or recurs or if AF/AFL has been recurrent, antithrombotic therapy as appropriate (CHADS 2 score) should be initiated and continued indefinitely. Early follow up to review antithrombotic strategy. Therapeutic OAC for 3 weeks before cardioversion TEE guided cardioversion (OAC initiated with heparin bridging) 3 Antithrombotic therapy OAC continued for 4 consecutive weeks. If AF/AFL persists or recurs or if AF/AFL has been recurrent, antithrombotic therapy as appropriate (per CHADS 2 score) should be continued indefinitely. Early follow up should be arrange to review ongoing antithrombotic strategy. 1 Patients at particularly high risk of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke/tia) J biphasic waveform preferred 3 Hepharin must be initiated and continued until a therapeutic level of oral anticoagulation has been established. Stiell, I., CCS AF guidelines 2010: Management of AF and AFL in the ED, CJC 27 (2011) pp.40

12 Atrial Fibrillation Causes 20% of All Strokes 1,4 AF increases stroke risk 5 fold 1,2,3 Case Fatality Rate (%) % Mortality after ischemic stroke 5 With AF Without AF 16% 50% 5x 27% increase No AF AF 0 30 days 1 year 1. Arch Intern Med 1994;154(13): ; 2. Wolf PA et al. Stroke 1991;22(8):983 8; 3. Savelieva I et al. Ann Med 2007;39(5):371 91; 4. Singer DE et al. Chest 2008;133(6 Suppl):546S 92S; 5. Lin JH et al. Stroke 1996;27:

13 Mr. Bertucci: Case 75 year old man History of TIA, bleeding duodenal ulcer and remote MI Hand numbness, dysarthria, lasted 15 minutes HR 80 Normal CT Consumes 3 4 alcoholic beverages daily Your Thoughts? Will you initiate anticoagulation?

14 Many High Risk AF Patients Are Under Anticoagulated 2009 study: 597 high risk AF patients admitted with stroke in 12 stroke centers in Canada 1 2% Dual anti platelet therapy No Antithrombotics 29% 29% Single antiplatelet therapy Warfarin/subtherapeutic 29% 10% Warfarin/ therapeutic 2013 study: 151 AF pts with CHADS 2 > 0 in ED % discharged without appropriate AC 2 1. Gladstone D et al. Stroke 2009;40:235 40; 2. Scheuermeyer FX et al. Ann Emerg Med 2013 Dec;62(6): e2.

15 Strong recommendation, High quality evidence All AF patients should be stratified using a predictive index for stroke risk and for the risk of bleeding and most patients should receive anticoagulation CCS Guideline Update Skanes et al. CCS Guidelines. Can J Cardiol 2012;28(2):

16 What is Mr. Bertucci s Annual Risk of Stroke? % Stroke/Year* Risk Factor Score C CHF 0 H Hypertension 0 A Age 75 1 D Diabetes 0 S Stroke/TIA 2 Total Score CHADS 2 score Adapted from Cairns JA et al. Can J Cardiol 2011;27:74 90.

17 HAS BLED: Use it to Assess Bleeding Risk Feature Abnormal kidney or liver function Score 0 % Major Bleed/Year History of Stroke 1 Prior Bleed 1 Labile INRs TTR (< 60%) 0 Elderly (> 65 yrs) 1 Drugs or ETOH 1 Total Score HAS BLED Score Adapted from Cairns JA et al. Can J Cardiol 2011;27:74 90.

18 Major bleeding* is less often fatal and is less likely to cause serious residual effects than stroke. And, bleeding risk (HAS BLED) can be modified *Non CNS bleeding Skanes et al. Can J Cardiol 2012;28(2):

19 Mr. Bertucci: Case 75 year old man History of TIA, bleeding duodenal ulcer and remote MI Hand numbness, dysarthria, lasted 15 minutes Your Thoughts? You decided to initiate anticoagulation Which therapy will you choose: NOAC or warfarin? HR 80 ECG: new onset AF Normal CT Will moderate alcohol use

20 CCS Guidelines 2012 Update: NOACs are Preferred Overview of Stroke Management 2012 update Assess Thromboembolic Risk (CHADS 2 ) CHADS 2 = 0 CHADS 2 = 1 CHADS 2 2 Increasing stroke risk No antithrombotic ASA OAC* OAC* OAC No additional risk factors for stroke Either female sex or vascular disease Age 65 or combination of female sex and vascular disease NOACs are preferred to warfarin *ASA is a reasonable alternative in selected patients as indicated by risk/benefit Patient values and preferences should be considered Skanes et al. Can J Cardiol 2012;28(2):

21 CCS 2012 Recommendations: Most AF Patients Should Receive a NOAC When oral anticoagulation therapy is indicated, most patients should receive dabigatran, rivaroxaban, or apixaban. Skanes et al. CCS Guidelines. Can J Cardiol 2012;28(2):

22 QUESTIONS? Enter questions in the text box on Text questions to questions to IMPORTANT: When ing, please enter question in the subject line only

23 NOACs Reduce Hemorrhagic Stroke, All Cause Mortality and ICH, but Increase GI Bleeding N=71,683 EFFICACY RR (95% CL) P lschaemic stroke Haemorrhagic stroke Myocardial infarction All cause mortality 0.92 ( ) ( ) < ( ) ( ) SAFETY Intracranial haemorrhage Gastrointestinal bleeding 0.48 ( ) < ( ) High doses of dabigatran and edoxaban are incl: RE LY Dabigatran 150 mg BID ROCKET AF Rivaroxaban 20 mg OD ARISTOTLE Apixaban 5 mg BD ENGAGE AF TIMI 48 Edoxaban 60 mg OD Favours NOAC Favours warfarin Ruff CT et al. Lancet 2014;383:

24 NOACs Reduce Mortality vs Warfarin N=71,683 RR (95% CL) P All cause mortality Vascular mortality Bleeding mortality 0.89 ( ) < ( ) < ( ) < Favours NOAC Favours warfarin Meta analysis incl: RE LY Dabigatran 150 mg BID RE LY Dabigatran 110 mg BID ROCKET AF Rivaroxaban 20 mg OD ARISTOTLE Apixaban 5 mg BID ENGAGE AF TIMI 48 Edoxaban 60 mg OD ENGAGE AF TIMI 48 Edoxaban 30 mg OD Liew A et al. J Thromb Haemostasis; first published online: 25 JUL 2014.

25 Intracranial Hemorrhage Causes Most Warfarin related Fatalities 13,559 adults with AF taking warfarin 1 hospitalized 72 for ICH and 98 for ECH Severe disability or death at hospital discharge 1 :: 76% of patients with ICH 3% of those with ECH Canadian PCC Registry: 2 N=141 warfarin associated ICH 72% with INR < 1.5 within < 1h; yet 42% mortality (50% of cases) 1. Fang MC et al. Am J Med 2007;120(8):700 5; 2. Dowlatshahi D et al. Stroke 2012;43:1812.

26 In Real World, Bleeding Rates on Warfarin Are Higher than 1 3% reported in RCTs Patients (%) 16% 12% 8% 4% 0% Cumulative Incidence of Major Hemorrhage 125,195 AF patients 66 years 11,8% 3,4% 3,8% 30 days 5 years Overall First 30 days of treatment Rate of hemorrhage In All pts 12% CHADS 2 scores of 4 17% 18.1% died in hospital or within 7 days of being discharged Gomes T, et al. CMAJ 2013;185(2):E121 7.

27 What are the Benefits of NOACs vs. Warfarin? Safety Lower Rates of Intracranial Bleeding and Mortality Convenience No routine coagulation monitoring Wider therapeutic window than for warfarin Limited food and drug interactions Fixed dosing Rapid onset/offset of action Granger et al. NEJM 2011;365:981 92; Connolly et al. NEJM 2009;361(12): ; Patel et al. NEJM 2011;365(10):

28 What If Mr. Bertucci Needs Cardioversion? Cardioversion associated with higher risk of thromboembolic complications 1 Guidelines: recommend sufficient AC before and after cardioversion for AF patients 1,4 AC with cardioversion Study Periprocedural risk of thromboembolism P value No adequate AC 5 7% 2 NOAC NOAC (apixaban) ARISTOTLE post hoc 3 0% 0% NS NOAC (dabigatran) RELY post hoc % (110 mg) 0.6% NS 0.3% (150 mg) NOAC (rivaroxaban) ROCKET AF post hoc % 1.86% stroke/se NS 3.73% death NOAC (rivaroxaban) X Vert RCT % 1.02% NS VKA 1. Camm AJ et al. Eur Heart J 2010;31: ; 2. Stellbrink C et al. Circulation 2004;109: ; 3. Nagarakanti R et al. Circulation 2011;123:131 6; 4. Flaker G et al. J Am Coll Cardiol 2014;63:1082 7; 5. Piccini JP et al. J Am Coll Cardiol 2013;61: ; 6. Ezekowitz MD et al. Am Heart J 2014;167:

29 NOAC and Cardioversion: X VERT Study Inclusion: Age 18 years, non valvular AF>48 h or unknown duration Cardioversion strategy Early # Delayed R 2:1 R 2:1 Rivaroxaban 20 mg od* 1 5 days VKA Rivaroxaban 20 mg od* 21 days (max. 56 days) VKA Cardioversion Cardioversion Rivaroxaban 20 mg od* 42 days VKA Rivaroxaban 20 mg od* 42 days VKA End of study treatment OAC 30-day follow-up *15 mg if CrCl ml/min; VKA with INR 2 3 # protocol recommended only if adequate AC or immediate TEE Ezekowitz MD et al. Am Heart J 2014;167:646 52; NCT

30 X VeRT: Results 1504 patients: Rivaroxaban (N=978) VKA (N=492) % n % n Risk Reduction 95% Cl Primary efficacy endpoint Major bleeding All cause death / / Primary efficacy a composite of: Stroke and TIA Non CNS systemic embolism Myocardial infarction Cardiovascular death Results similar for Early vs Delayed strategy Cappato R et al. Eur Heart J 2014: doi: /eurheartj/ehu367.

31 X VeRT: Time to Cardioversion by Cardioversion Strategy Median time to cardioversion Patients cardioverted as scheduled* 100 Rivaroxaban VKA 100 Rivaroxaban VKA Days p= days p< days Patients (%) ,0 p< patient with inadequate AC 36,3 95 patients with inadequate AC 0 Early Delayed *Reason for not performing cardioversion as first scheduled from days primarily due to inadequate AC (indicated by drug compliance <80% for rivaroxaban or weekly INRs outside the range of 2 3 for 3 consecutive weeks before cardioversion for VKA) 0 Delayed cardioversion Cappato R et al. Eur Heart J 2014: doi: /eurheartj/ehu367.

32 Anticoagulation Use In Subsets of Patients Patient characteristic CrCl < 30 ml/min Liver dysfunction with elevated INR Rheumatic mitral stenosis Mechanical prosthetic valve Patient > 75 years old Anticoagulation Warfarin Warfarin Warfarin Warfarin dabigatran 110 mg (bleeding) Patient under or over weight Exercise caution and follow product monograph Skanes et al. CCS Guidelines. Can J Cardiol 2012;28(2): ; Eliquis Product Monograph; Pradaxa Product Monograph; Xarelto Product Monograph; Granger et al. NEJM 2011;365:981 92; Connolly et al. NEJM 2009;361(12): ; Patel et al. NEJM 2011;365(10):

33 What About ACS Risk? Coronary risk of novel oral antithrombotic agents Risk of MI/ACS Apixaban Dabigatran Rivaroxaban N=43,902 N=36,767 N=44,110 OR (95% Cl) P 0.94 ( ) ( ) ( ) < Favours NOAC 1 2 Favours control ACS, acute coronary syndrome MI, myocardial infarction Mixed treatment comparison meta analysis Caution: this is not a direct trial comparison Mak K H. BMJ Open 2012;2:e

34 Always use the Highest Dose, Unless Reasons to Reduce Dose Reduced dose Apixaban 1 5 mg BID 2.5 mg BID CrCl > 25, with 2 of the following: 80 years old 60 kg 133 µmol/l Dabigatran mg BID 110 mg BID CrCl in elderly and/or patient with risk factors for bleeding CrCl > 50 and > 80 years old OR years old with one risk factor for bleeding Rivaroxaban 3 20 mg OD 15 mg OD CrCl Online tool for determining NOAC dosing: thrombosiscanada.ca Also available as an app for iphone, Blackberry and Android devices 1. Eliquis Product Monograph; 2. Pradaxa Product Monograph; 3. Xarelto Product Monograph.

35 Mr. Bertucci: Case 75 year old man History of TIA, bleeding duodenal ulcer and remote MI Hand numbness, dysarthria, lasted 15 minutes Risks and benefits of anticoagulation are discussed with the patient Xa antagonist is prescribed Mr. Bertucci is referred to a cardiologist for follow up HR 80 ECG: new onset AF Normal CT

36 QUESTIONS? Enter questions in the text box on Text questions to questions to IMPORTANT: When ing, please enter question in the subject line only

37 Key messages Certain AF patients are at a very high risk for stroke ED physicians should consider initiating anticoagulation for AF patients NOACs are preferred to warfarin by the CCS guidelines and phase III clinical trials Subsets of patients benefit from different anticoagulant options depending on their characteristics NOACs appear to be effective and safe alternatives to VKA for patients undergoing cardioversion Rivaroxaban 20 mg once daily allows safe and early (1 5 days) cardioversion

38 Thank You! Content for this program has been developed by the following steering committee: Anil Chopra, Jim Douketis, Indy Ghosh, Lyall Higginson, Eddy Lang, Josée Martineau, Anas Nseir, and Bill Semchuck COMMERCIAL SUPPORT ACKNOWLEDGEMENT: THIS EDUCATIONAL ACTIVITY IS SUPPORTED BY AN INDEPENDENT EDUCATIONAL GRANT FROM ASTRAZENECA and BAYER CANADA

Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013

Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013 Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013 Family physician with Rivergrove Medical Clinic Practice in the north end since 1985 Medical Director of the Wellness

More information

Atrial Fibrillation: A Different Perspective. Michael Heffernan MD PhD FRCPC FACC Staff Cardiologist Oakville Hospital

Atrial Fibrillation: A Different Perspective. Michael Heffernan MD PhD FRCPC FACC Staff Cardiologist Oakville Hospital Atrial Fibrillation: A Different Perspective Michael Heffernan MD PhD FRCPC FACC Staff Cardiologist Oakville Hospital Faculty/Presenter Disclosure Faculty: Dr. Michael Heffernan Relationships with commercial

More information

ΠΟΙΟ ΑΝΤΙΠΗΚΤΙΚΟ ΓΙΑ ΤΟΝ ΑΣΘΕΝΗ ΜΟΥ? ΚΛΙΝΙΚΑ ΠΑΡΑΔΕΙΓΜΑΤΑ. Σωκράτης Παστρωμάς Καρδιολόγος Νοσοκομείο Ερρίκος Ντυνάν

ΠΟΙΟ ΑΝΤΙΠΗΚΤΙΚΟ ΓΙΑ ΤΟΝ ΑΣΘΕΝΗ ΜΟΥ? ΚΛΙΝΙΚΑ ΠΑΡΑΔΕΙΓΜΑΤΑ. Σωκράτης Παστρωμάς Καρδιολόγος Νοσοκομείο Ερρίκος Ντυνάν ΠΟΙΟ ΑΝΤΙΠΗΚΤΙΚΟ ΓΙΑ ΤΟΝ ΑΣΘΕΝΗ ΜΟΥ? ΚΛΙΝΙΚΑ ΠΑΡΑΔΕΙΓΜΑΤΑ Σωκράτης Παστρωμάς Καρδιολόγος Νοσοκομείο Ερρίκος Ντυνάν The AF epidemic Mayo Clinic data (assuming a continued increase in the AF incidence) Mayo

More information

Novel OAC s : How should we use them?

Novel OAC s : How should we use them? Novel OAC s : How should we use them? Jean C. Grégoire MD, FRCP(c), FACC, FACP Associate Professor, Université de Montréal, IntervenJonal Cardiologist, InsJtut de cardiologie de Montréal Disclosures Speaker

More information

Antiplatelet and Antithrombotic Therapy. Dr Curry Grant Stroke Prevention Clinic Quinte Health Care

Antiplatelet and Antithrombotic Therapy. Dr Curry Grant Stroke Prevention Clinic Quinte Health Care Antiplatelet and Antithrombotic Therapy Dr Curry Grant Stroke Prevention Clinic Quinte Health Care Disclosure of Potential for Conflict of Interest Dr. F.C. Grant Atrial Fibrillation FINANCIAL DISCLOSURE:

More information

STROKE PREVENTION IN ATRIAL FIBRILLATION

STROKE PREVENTION IN ATRIAL FIBRILLATION STROKE PREVENTION IN ATRIAL FIBRILLATION OBJECTIVE: To guide clinicians in the selection of antithrombotic therapy for the secondary prevention of ischemic stroke and arterial thromboembolism in patients

More information

4/9/2015. Risk Stratify Our Patients. Stroke Risk in AF: CHADS2 Scoring system JAMA 2001; 285: 2864-71

4/9/2015. Risk Stratify Our Patients. Stroke Risk in AF: CHADS2 Scoring system JAMA 2001; 285: 2864-71 Anticoagulation in the 21 st Century Adam Karpman, D.O. Saint Francis Medical Center/Oklahoma State University Medical Center Disclosures: None Atrial Fibrillation Most common arrhythmia in clinical practice.

More information

The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era. CCRN State of the Heart 2012 June 2, 2012

The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era. CCRN State of the Heart 2012 June 2, 2012 The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era CCRN State of the Heart 2012 June 2, 2012 Disclosures I have I have been involved in trials of new anticoagulants and have received

More information

The author has no disclosures

The author has no disclosures Mary Bradbury, PharmD, BCPS Clinical Pharmacy Specialist, Cardiac Surgery September 18, 2012 Mary.bradbury@inova.org This presentation will discuss unlabeled and investigational use of products The author

More information

Novel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations

Novel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations Novel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations Dardo E. Ferrara MD Cardiac Electrophysiology North Cascade Cardiology PeaceHealth Medical Group Which anticoagulant

More information

Management of atrial fibrillation. Satchana Pumprueg, MD Sirin Apiyasawat, MD Thoranis Chantrarat, MD

Management of atrial fibrillation. Satchana Pumprueg, MD Sirin Apiyasawat, MD Thoranis Chantrarat, MD Management of atrial fibrillation Satchana Pumprueg, MD Sirin Apiyasawat, MD Thoranis Chantrarat, MD Antithrombotic therapy in atrial fibrillation Satchana Pumprueg, MD AF has serious consequences Independent

More information

Financial Disclosures

Financial Disclosures Financial Disclosures Consulting: AstraZeneca, Bayer, Boehringer Ingleheim, Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly, Glaxo Smith Kline, Johnson & Johnson, Merck, Novartis, Ortho/McNeill, Pfizer,

More information

None. Dual Antiplatelet Therapy Plus Systemic Anticoagulation: Bleeding Risk and Management. 76 year old male LINGO 1/5/2015

None. Dual Antiplatelet Therapy Plus Systemic Anticoagulation: Bleeding Risk and Management. 76 year old male LINGO 1/5/2015 Financial Disclosure Information Dual Antiplatelet Therapy Plus Systemic Anticoagulation: Bleeding Risk and Management Robert D. McBane, M.D. Division of Cardiology Mayo Clinic Rochester Dual Antiplatelet

More information

STROKE PREVENTION IN ATRIAL FIBRILLATION. TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: ABBREVIATIONS: BACKGROUND:

STROKE PREVENTION IN ATRIAL FIBRILLATION. TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: ABBREVIATIONS: BACKGROUND: STROKE PREVENTION IN ATRIAL FIBRILLATION TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To guide clinicians in the selection of antithrombotic therapy for the secondary prevention

More information

New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation. Joy Wahawisan, Pharm.D., BCPS April 25, 2012

New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation. Joy Wahawisan, Pharm.D., BCPS April 25, 2012 New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation Joy Wahawisan, Pharm.D., BCPS April 25, 2012 Stroke in Atrial Fibrillation % Stroke 1991;22:983. Age Range (years) CHADS 2 Risk

More information

Goals 6/6/2014. Stroke Prevention in Atrial Fibrillation: New Oral Anti-Coagulants No More INRs. Ashkan Babaie, MD

Goals 6/6/2014. Stroke Prevention in Atrial Fibrillation: New Oral Anti-Coagulants No More INRs. Ashkan Babaie, MD Stroke Prevention in Atrial Fibrillation: New Oral Anti-Coagulants No More INRs Ashkan Babaie, MD Arrhythmia Service Providence Heart Clinic June 8 th, 2014 Goals Discuss the data behind approval of NOACs

More information

Elisabetta Toso, MD Dipartment of Medical Sciences University of Turin

Elisabetta Toso, MD Dipartment of Medical Sciences University of Turin Security and efficacy of Rivaroxaban in real life in the prevention of the stroke in non valvular AF patients: presentation of the results of the international study Xantus Elisabetta Toso, MD Dipartment

More information

Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial

Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial Camillo Autore Università di Roma Sapienza II Facoltà di Medicina e Chirurgia

More information

Failure or significant adverse effects to all of the alternatives: Eliquis and Xarelto

Failure or significant adverse effects to all of the alternatives: Eliquis and Xarelto This policy has been developed through review of medical literature, consideration of medical necessity, generally accepted medical practice standards, and approved by the IEHP Pharmacy and Therapeutics

More information

Anticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014

Anticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014 Anticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014 Atrial Fibrillation 2 Atrial Fibrillation The most common arrhythmia encountered

More information

Cardiology Update 2014

Cardiology Update 2014 Cardiology Update 2014 Update on the Novel Oral Anticoagulants (NOACS) Raymond Kawasaki, MD AMG Cardiology December 6, 2014 Disclosures I have no disclosures relevant to this presentation Contents I. The

More information

Analyzing Clinical Trial Findings of the Efficacy and Safety Profiles of Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation

Analyzing Clinical Trial Findings of the Efficacy and Safety Profiles of Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation Analyzing Clinical Trial Findings of the Efficacy and Safety Profiles of Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation Drew Baldwin, MD Virginia Mason Seattle, Washington NCVH May 29,

More information

New Treatments for Stroke Prevention in Atrial Fibrillation. John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013

New Treatments for Stroke Prevention in Atrial Fibrillation. John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 New Treatments for Stroke Prevention in Atrial Fibrillation John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 Classification Paroxysmal atrial fibrillation (AF) Last < 7

More information

3/25/14. To Clot or Not What s New In Anticoagulation? Clotting Cascade. Anticoagulant drug targets. Anita Ralstin, MS CNS CNP. Heparin.

3/25/14. To Clot or Not What s New In Anticoagulation? Clotting Cascade. Anticoagulant drug targets. Anita Ralstin, MS CNS CNP. Heparin. To Clot or Not What s New In Anticoagulation? Anita Ralstin, MS CNS CNP 1 Clotting Cascade 2 Anticoagulant drug targets Heparin XI VIII IX V X VII LMWH II Warfarin Fibrin clot 1 Who Needs Anticoagulation

More information

Non- Valvular Atrial Fibrillation and Stroke Prevention: Which OAC Do I Choose. Warfarin vs the NOACs

Non- Valvular Atrial Fibrillation and Stroke Prevention: Which OAC Do I Choose. Warfarin vs the NOACs Non- Valvular Atrial Fibrillation and Stroke Prevention: Which OAC Do I Choose Warfarin vs the NOACs Dr. Lori McIntosh D.O. Board Certified Neurologist Objectives Be able to list the current options of

More information

New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation Jafna L. Cox, MD, FRCPC, FACC

New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation Jafna L. Cox, MD, FRCPC, FACC New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation Jafna L. Cox, MD, FRCPC, FACC Heart and Stroke Foundation of Nova Scotia Endowed Chair in Cardiovascular Outcomes Research Director

More information

Treating AF: The Newest Recommendations. CardioCase presentation. Ethel s Case. Wayne Warnica, MD, FACC, FACP, FRCPC

Treating AF: The Newest Recommendations. CardioCase presentation. Ethel s Case. Wayne Warnica, MD, FACC, FACP, FRCPC Treating AF: The Newest Recommendations Wayne Warnica, MD, FACC, FACP, FRCPC CardioCase presentation Ethel s Case Ethel, 73, presents with rapid heart beating and mild chest discomfort. In the ED, ECG

More information

Novel OACs: How should we use them?"

Novel OACs: How should we use them? Novel OACs: How should we use them?" Iqwal Mangat, MD FRCPC" Director, Arrhythmia Service, St. Michaelʼs Hospital" Assistant Professor of Medicine, University of Toronto" Presenter Disclosure Dr. Iqwal

More information

Practical everyday use of NOACs. Dr. Elisabetta Toso SOC Cardiologia Ospedale Cardinal Massaia - Asti

Practical everyday use of NOACs. Dr. Elisabetta Toso SOC Cardiologia Ospedale Cardinal Massaia - Asti Practical everyday use of NOACs Dr. Elisabetta Toso SOC Cardiologia Ospedale Cardinal Massaia - Asti THE NEW ANTICOAGULANTS HISTORY Oral Inhibitors Edoxaban Apixaban Betrixaban EXPLORE-Xa Phase II trial

More information

New Anticoagulants and GI bleeding

New Anticoagulants and GI bleeding New Anticoagulants and GI bleeding DR DANNY MYERS MD FRCP(C) CLINICAL ASSISTANT PROFESSOR OF MEDICINE, UBC Conflicts of Interest None I am unbiased in the use of NOAC s vs Warfarin based on risk benefit

More information

Antiplatelet and Antithrombotics From clinical trials to guidelines

Antiplatelet and Antithrombotics From clinical trials to guidelines Antiplatelet and Antithrombotics From clinical trials to guidelines Ashraf Reda, MD, FESC Prof and head of Cardiology Dep. Menofiya University Preisedent of EGYBAC Chairman of WGLVR One of the big stories

More information

Appendix C Factors to consider when choosing between anticoagulant options and FAQs

Appendix C Factors to consider when choosing between anticoagulant options and FAQs Appendix C Factors to consider when choosing between anticoagulant options and FAQs Choice of anticoagulant for non-valvular* atrial fibrillation: Clinical decision aid Patients should already be screened

More information

Atrial Fibrillation: Stroke and Thromboprophylaxis. Derek Waller

Atrial Fibrillation: Stroke and Thromboprophylaxis. Derek Waller Atrial Fibrillation: Stroke and Thromboprophylaxis Derek Waller Atrial Fibrillation in the Elderly: Risk of Stroke Framingham study AGE 50-59 60-69 70-79 80-89 Prevalence of AF % Attributable Risk of AF

More information

Anticoagulants in Atrial Fibrillation

Anticoagulants in Atrial Fibrillation Anticoagulants in Atrial Fibrillation Starting and Stopping Them Safely Carmine D Amico, D.O. Overview Learning objectives Introduction Basic concepts Treatment strategy & options Summary 1 Learning objectives

More information

Anticoagulation For Atrial Fibrillation

Anticoagulation For Atrial Fibrillation Anticoagulation For Atrial Fibrillation New Agents In A New Era Arjun V Gururaj, MD Arrhythmia and Electrophysiology Nevada Heart and Vascular Center Disclosures Biotronik Speaker Clinical investigator

More information

A focus on atrial fibrillation

A focus on atrial fibrillation A focus on atrial fibrillation Is being female really a risk factor for stroke? Dr Justin Mariani MBBS BMedSci PhD FRACP FCSANZ Consultant Cardiologist and Interventional Heart Failure Specialist Alfred

More information

Xarelto (Rivaroxaban)

Xarelto (Rivaroxaban) Xarelto (Rivaroxaban) Hightly selective, reversible, direct oral FXa inhibitor Maxium concentratiion after 2 to 4 hrs High bioavailability(66%),increase with food ( suggest with food) 1/3 from renal excretion,

More information

Prevention of thrombo - embolic complications

Prevention of thrombo - embolic complications Update on atrial fibrillation Prevention of thrombo - embolic complications Felicita Andreotti Dept of Cardiovascular Science Catholic University, Rome, IT Consultant or speaker in past 2 years for Amgen,

More information

RR 0.88 (95% CI: 0.77 1.00) P=0.051 (superiority) 3.75

RR 0.88 (95% CI: 0.77 1.00) P=0.051 (superiority) 3.75 ALL-CAUSE MORTALITY RR 0.88 (95% CI: 0.77 1.00) P=0.051 (superiority) Rate per year (%) 5.0 4.0 3.0 2.0 1.0 0 3.64 D150 mg BID 3.75 D110 mg BID RR 0.91 (95% CI: 0.80 1.03) P=0.13 (superiority) 4.13 Warfarin

More information

PGY1 Pharmacy Practice St. Vincent Hospital PGY2 Ambulatory Care St. Vincent Primary Care Center

PGY1 Pharmacy Practice St. Vincent Hospital PGY2 Ambulatory Care St. Vincent Primary Care Center Speaker Introduction Jessica Wilhoite, PharmD, BCACP Doctor of Pharmacy: Purdue University Postgraduate Residency Training: PGY1 Pharmacy Practice St. Vincent Hospital PGY2 Ambulatory Care St. Vincent

More information

Time in the Therapeutic Range 2015-02-11. Conflict Disclosure Information. 'As The Clot Thickens' A NOAC (Novel Anticoagulant Update)

Time in the Therapeutic Range 2015-02-11. Conflict Disclosure Information. 'As The Clot Thickens' A NOAC (Novel Anticoagulant Update) Conflict Disclosure Information Kevin J. Pistawka NOAC S New Oral Anti-Coagulants Dr. K. Pistawka - KGH FINANCIAL DISCLOSURE Grants/Research Support: None Research Trial involvment RELY, RELYABLE Speakers

More information

New Oral Anticoagulants

New Oral Anticoagulants New Oral Anticoagulants Tracy Minichiello, MD Associate Professor of Medicine Chief, San FranciscoVA Anticoagulation and Thrombosis Service Ansell, J. Hematology Copyright 2010 American Society of Hematology.

More information

Introduction. Methods. Study population

Introduction. Methods. Study population New Technologies, Diagnostic Tools and Drugs Schattauer 2012 1 Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a real world atrial fibrillation

More information

What s New in Stroke?

What s New in Stroke? 5 th McMaster University Review Course in INTERNAL MEDICINE What s New in Stroke? Robert Hart, M.D. HHS / McMaster Stroke Program Department of Medicine (Neurology) McMaster University Hamilton, Ontario

More information

HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below

HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below Name: generic (trade) Rivaroxaban (Xarelto ) HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below What it is Indications

More information

22-Oct-14. Oral Anticoagulation Which Drug for Which Patient in the era of New Oral Anti-coagulants. Atrial Fibrillation. AF as an embolic risk factor

22-Oct-14. Oral Anticoagulation Which Drug for Which Patient in the era of New Oral Anti-coagulants. Atrial Fibrillation. AF as an embolic risk factor Oral Anticoagulation Which Drug for Which Patient in the era of New Oral Anti-coagulants Dr Scott McKenzie BSc MBBS FRACP FCSANZ Cardiologist, Vascular Physician, Telehealth Specialist, Advanced Heart

More information

Breadth of indications matters One drug for multiple indications

Breadth of indications matters One drug for multiple indications Breadth of indications matters One drug for multiple indications Sylvia Haas, MD, PhD Formerly of the Technical University of Munich Munich, Germany Disclosures: Sylvia Haas 1 Novel oral anticoagulants:

More information

New Oral AntiCoagulants (NOAC) in 2015

New Oral AntiCoagulants (NOAC) in 2015 New Oral AntiCoagulants (NOAC) in 2015 William R. Hiatt, MD Professor of Medicine and Cardiology University of Colorado School of Medicine President CPC Clinical Research Disclosures Received research

More information

Anticoagulation in Atrial Fibrillation

Anticoagulation in Atrial Fibrillation Anticoagulation in Atrial Fibrillation Parag P. Patel, MD FACC Disclosures Eliquis Speakers Bureau 1 Clinical Scenario Ms. L is a 76F admitted to the stroke service with a dense right sided hemiparesis

More information

Optimizing Anticoagulation Selection for Your Patient. C. Andrew Brian MD, FACC NCVH 2015

Optimizing Anticoagulation Selection for Your Patient. C. Andrew Brian MD, FACC NCVH 2015 Optimizing Anticoagulation Selection for Your Patient C. Andrew Brian MD, FACC NCVH 2015 Who Needs to Be Anticoagulated and What is the Patient s Risk? 1. Atrial Fibrillation ( nonvalvular ) 2. What regimen

More information

Dorset Cardiac Centre

Dorset Cardiac Centre P a g e 1 Dorset Cardiac Centre Patients with Atrial Fibrillation/Flutter undergoing DC Cardioversion or Ablation procedures- Guidelines for Novel Oral Anti-coagulants (NOACS) licensed for this use February

More information

Cardiovascular Subcommittee of PTAC Meeting held 27 February 2014. (minutes for web publishing)

Cardiovascular Subcommittee of PTAC Meeting held 27 February 2014. (minutes for web publishing) Cardiovascular Subcommittee of PTAC Meeting held 27 February 2014 (minutes for web publishing) Cardiovascular Subcommittee minutes are published in accordance with the Terms of Reference for the Pharmacology

More information

WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION. Van Crisco, MD, FACC, FSCAI First Coast

WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION. Van Crisco, MD, FACC, FSCAI First Coast WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION Van Crisco, MD, FACC, FSCAI First Coast Conflicts of Interest I have been a paid consultant and speaker for AstraZeneca, makers of

More information

Management of Antithrombotics with Procedures. Jordan Weinstein, MD

Management of Antithrombotics with Procedures. Jordan Weinstein, MD Management of Antithrombotics with Procedures Jordan Weinstein, MD Presenter Disclosure Information Cardiology Update 2013 I have no relevant financial interest and/or arrangement with industry. Novel

More information

1/7/2012. Objectives. Epidemiology of Atrial Fibrillation(AF) Stroke in AF. Stroke Risk Stratification in AF

1/7/2012. Objectives. Epidemiology of Atrial Fibrillation(AF) Stroke in AF. Stroke Risk Stratification in AF Objectives Atrial Fibrillation and Prevention of Thrombotic Complications: Therapeutic Update Andrea C. Flores Pharm.D Pharmacy Resident at the Miami VA Healthcare System Review the epidemiology, pathophysiology

More information

Thrombosis and Hemostasis

Thrombosis and Hemostasis Thrombosis and Hemostasis Wendy Lim, MD, MSc, FRCPC Associate Professor, Department of Medicine McMaster University, Hamilton, ON Overview To review the important developments in venous thromboembolism

More information

Stroke prevention in AF: Insights from Clinical Trials and Real Life Experience

Stroke prevention in AF: Insights from Clinical Trials and Real Life Experience Stroke prevention in AF: Insights from Clinical Trials and Real Life Experience A. John Camm St. George s University of London and Imperial College London, UK Approval Number G.MA.GM.XA.10.2015.0723 Disclosure

More information

Atrial Fibrillation 2014 How to Treat How to Anticoagulate. Allan Anderson, MD, FACC, FAHA Division of Cardiology

Atrial Fibrillation 2014 How to Treat How to Anticoagulate. Allan Anderson, MD, FACC, FAHA Division of Cardiology Atrial Fibrillation 2014 How to Treat How to Anticoagulate Allan Anderson, MD, FACC, FAHA Division of Cardiology Projection for Prevalence of Atrial Fibrillation: 5.6 Million by 2050 Projected number of

More information

Anticoagulation before and after cardioversion; which and for how long

Anticoagulation before and after cardioversion; which and for how long Anticoagulation before and after cardioversion; which and for how long Sameh Samir, MD Cardiovascular medicine dept. Tanta faculty of medicine Atrial fibrillation goals of management Identify and treat

More information

Apixaban Plus Mono vs. Dual Antiplatelet Therapy in Acute Coronary Syndromes: Insights from the APPRAISE-2 Trial

Apixaban Plus Mono vs. Dual Antiplatelet Therapy in Acute Coronary Syndromes: Insights from the APPRAISE-2 Trial Apixaban Plus Mono vs. Dual Antiplatelet Therapy in Acute Coronary Syndromes: Insights from the APPRAISE-2 Trial Connie N. Hess, MD, MHS, Stefan James, MD, PhD, Renato D. Lopes, MD, PhD, Daniel M. Wojdyla,

More information

Bridging the Gap: How to Transition from the NOACs to Warfarin

Bridging the Gap: How to Transition from the NOACs to Warfarin Bridging the Gap: How to Transition from the NOACs to April 24 th 2015 UAN: 0048-0000-15-034-L01-P Amanda Styer, Pharm.D. Marion General Hospital, OhioHealth Objectives: 1. Review labeling regarding transition

More information

1/12/2016. What s in a name? What s in a name? NO.Anti-Coagulation. DOACs in clinical practice. Practical aspects of using

1/12/2016. What s in a name? What s in a name? NO.Anti-Coagulation. DOACs in clinical practice. Practical aspects of using What s in a name? Practical aspects of using DOACs (Direct Oral Anticoagulants) James L. Sebastian, MD, MACP Professor of Medicine (GIM) Medical College of Wisconsin February 5, 2016 DOAC NOAC NOAC ODI

More information

Rivaroxaban. Practical Experience in the Cardiology Setting. Bernhard Meier, Bern Bayer Satellite Symposium Cardiology Update Davos February 11, 2013

Rivaroxaban. Practical Experience in the Cardiology Setting. Bernhard Meier, Bern Bayer Satellite Symposium Cardiology Update Davos February 11, 2013 Rivaroxaban Practical Experience in the Cardiology Setting Bernhard Meier, Bern Bayer Satellite Symposium Cardiology Update Davos February 11, 2013 Overview of phase III clinical trials of new oral anticoagulants

More information

The Anti coagulated Patient: The Cardiologist s View. February 28, 2015

The Anti coagulated Patient: The Cardiologist s View. February 28, 2015 The Anti coagulated Patient: The Cardiologist s View February 28, 2015 Conflicts Dr. McMurtry has no conflicts to disclose. CanMeds Medical Expert (as Medical Experts, physicians integrate all of the CanMEDS

More information

STARTING, SWITCHING OR STOPPING NEW ORAL ANTICOAGULANTS: A Practical Approach

STARTING, SWITCHING OR STOPPING NEW ORAL ANTICOAGULANTS: A Practical Approach STARTING, SWITCHING OR STOPPING NEW ORAL ANTICOAGULANTS: A Practical Approach Jeffrey I Weitz, MD, FRCP(C), FACP Professor of Medicine and Biochemistry McMaster University Canada Research Chair in Thrombosis

More information

Anticoagulation Therapy Update

Anticoagulation Therapy Update Anticoagulation Therapy Update JUDY R. WALLING, FNP-BC ARRHYTHMIA MANAGEMENT MUSC CARDIOLOGY Outline Who do we anticoagulate? Review classes of Anticoagulants Review examples of Anticoagulants Review CHADS2

More information

Devang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical

Devang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical Devang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical Center A.Fib affects 2.2 million Americans. The lifetime

More information

L'aspirina è diventata obsoleta nell'era dei nuovi inbitori P2Y12? Leonardo Bolognese MD, FESC, FACC Cardiovascular Department, Arezzo, Italy ISO 9001

L'aspirina è diventata obsoleta nell'era dei nuovi inbitori P2Y12? Leonardo Bolognese MD, FESC, FACC Cardiovascular Department, Arezzo, Italy ISO 9001 L'aspirina è diventata obsoleta nell'era dei nuovi inbitori P2Y12? Leonardo Bolognese MD, FESC, FACC Cardiovascular Department, Arezzo, Italy Scientific Advances and Cardiovascular Mortality Nabel and

More information

9/5/14. Objectives. Atrial Fibrillation (AF)

9/5/14. Objectives. Atrial Fibrillation (AF) Novel Anticoagulation for Prevention of Stroke in Patients with Atrial Fibrillation Objectives 1. Review current evidence on use of warfarin in individuals with atrial fibrillation 2. Compare the three

More information

New Anticoagulants. Stroke Prevention in AF Commencing Novel Oral Anticoagulants (NOACs) in the GP Setting. 30-Oct-14

New Anticoagulants. Stroke Prevention in AF Commencing Novel Oral Anticoagulants (NOACs) in the GP Setting. 30-Oct-14 Stroke Prevention in AF Commencing Novel Oral Anticoagulants (NOACs) in the GP Setting A/Prof Michael Nguyen Fremantle Hospital Access Cardiology General Practice Education Day Oct 2014 ORAL TTP889 Rivaroxaban

More information

Anticoagulation at the end of life. Rhona Maclean Rhona.maclean@sth.nhs.uk

Anticoagulation at the end of life. Rhona Maclean Rhona.maclean@sth.nhs.uk Anticoagulation at the end of life Rhona Maclean Rhona.maclean@sth.nhs.uk Content Anticoagulant Therapies Indications for anticoagulation Venous thromboembolism (VTE) Atrial Fibrillation Mechnical Heart

More information

Objectives. New and Emerging Anticoagulants. Objectives (continued) 2/18/2014. Development of New Anticoagulants

Objectives. New and Emerging Anticoagulants. Objectives (continued) 2/18/2014. Development of New Anticoagulants Objectives New and Emerging Anticoagulants Adraine Lyles, PharmD, BCPS Clinical Pharmacy Specialist VCU Medical Center Describe the pharmacology of the novel oral anticoagulants Discuss the clinical evidence

More information

The Anticoagulated Patient A Hematologist s Perspective

The Anticoagulated Patient A Hematologist s Perspective The Anticoagulated Patient A Hematologist s Perspective Deborah M. Siegal MD MSc FRCPC Clinical Scholar Division of Hematology and Thromboembolism Thrombosis Canada Research Fellow McMaster University

More information

NOAC S For Stroke Prevention in. Atrial Fibrillation. Peter Cohn M.D FACC Associate Physician in Chief Cardiovascular Care Center Southcoast Health

NOAC S For Stroke Prevention in. Atrial Fibrillation. Peter Cohn M.D FACC Associate Physician in Chief Cardiovascular Care Center Southcoast Health NOAC S For Stroke Prevention in Atrial Fibrillation Peter Cohn M.D FACC Associate Physician in Chief Cardiovascular Care Center Southcoast Health New Oral Anti Coagulant Formal Definition: Atrial Fibrillation

More information

Limitations of VKA Therapy

Limitations of VKA Therapy Fibrillazione Atriale Non Valvolare Ischemia o Emorragia le Due Utopie Rivali nella Scelta dei NAO Gianluca Botto, MD, FESC, UO Elettrofisiologia, Dip Medicina Limitations of VKA Therapy Unpredictable

More information

Dual Antiplatelet Therapy. Stephen Monroe, MD FACC Chattanooga Heart Institute

Dual Antiplatelet Therapy. Stephen Monroe, MD FACC Chattanooga Heart Institute Dual Antiplatelet Therapy Stephen Monroe, MD FACC Chattanooga Heart Institute Scope of Talk Identify the antiplatelet drugs and their mechanisms of action Review dual antiplatelet therapy in: The medical

More information

NICE clinical guideline 180: Atrial fibrillation Prescribing and medicines optimisation issues

NICE clinical guideline 180: Atrial fibrillation Prescribing and medicines optimisation issues NICE clinical guideline 180: Atrial fibrillation Prescribing and medicines optimisation issues Andy Hutchinson Medicines Education Technical Adviser NICE Medicines and Prescribing Centre Note: this is

More information

Getting smart about dyspnea and life saving drug therapy in ACS patients. Kobi George Kaplan Medical Center Rehovot

Getting smart about dyspnea and life saving drug therapy in ACS patients. Kobi George Kaplan Medical Center Rehovot Getting smart about dyspnea and life saving drug therapy in ACS patients Kobi George Kaplan Medical Center Rehovot 78 year old female Case description Presented with resting chest pain and dyspnea Co morbidities:

More information

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF)

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) Key priorities Identification and diagnosis Treatment for persistent AF Treatment for permanent AF Antithrombotic

More information

How to manage a patient who needs thrombolysis in acute stroke, ablation or angioplasty/stenting? Janet M McComb Freeman Hospital Newcastle upon Tyne

How to manage a patient who needs thrombolysis in acute stroke, ablation or angioplasty/stenting? Janet M McComb Freeman Hospital Newcastle upon Tyne How to manage a patient who needs thrombolysis in acute stroke, ablation or angioplasty/stenting? Janet M McComb Freeman Hospital Newcastle upon Tyne What do the guidelines say? What happens with warfarin

More information

Unrestricted grant Boehringer Ingelheim

Unrestricted grant Boehringer Ingelheim ED Management of Recent Onset tat Atrial Fibrillation and Flutter (RAFF) Canadian Cardiovascular Society Guidelines 2010 CAEP St John s 2011 Ian Stiell MD MSc FRCPC Professor and Chair, Dept of Emergency

More information

New Anticoagulants: Are we Ready to Replace Warfarin? Carole Goodine, RPh Horizon Health Network Stroke Conference 2011

New Anticoagulants: Are we Ready to Replace Warfarin? Carole Goodine, RPh Horizon Health Network Stroke Conference 2011 New Anticoagulants: Are we Ready to Replace Warfarin? Carole Goodine, RPh Horizon Health Network Stroke Conference 2011 Warfarin Decreases stroke risk by 60-70% Superior to ASA and ASA plus clopidogrel

More information

Xarelto (Rivaroxaban): Effective in a broad spectrum. Joep Hufman, MD Medical Scientific Liason

Xarelto (Rivaroxaban): Effective in a broad spectrum. Joep Hufman, MD Medical Scientific Liason Xarelto (Rivaroxaban): Effective in a broad spectrum Joep Hufman, MD Medical Scientific Liason Xarelto : Effective in a broad spectrum Introduction Therapeutic areas SPAF VTE Prevention VTE treatment Practical

More information

Bios 6648: Design & conduct of clinical research

Bios 6648: Design & conduct of clinical research Bios 6648: Design & conduct of clinical research Section 1 - Specifying the study setting and objectives 1. Specifying the study setting and objectives 1.0 Background Where will we end up?: (a) The treatment

More information

Venous Thromboembolism: Long Term Anticoagulation. Dan Johnson, Pharm.D.

Venous Thromboembolism: Long Term Anticoagulation. Dan Johnson, Pharm.D. Venous Thromboembolism: Long Term Anticoagulation Dan Johnson, Pharm.D. Disclosures No financial relationships with products discussed Off-label use of drug therapy always discussed Objectives Review clinical

More information

New Oral Anticoagulants. How safe are they outside the trials?

New Oral Anticoagulants. How safe are they outside the trials? New Oral Anticoagulants How safe are they outside the trials? Objectives The need for anticoagulant therapy Indications for anticoagulation Traditional anticoagulant therapies Properties of new oral anticoagulants

More information

COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS. TARGET AUDIENCE: All Canadian health care professionals.

COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS. TARGET AUDIENCE: All Canadian health care professionals. COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS AND PHYSICIANS TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVES: To provide a comparison of the new

More information

FDA Approved Oral Anticoagulants

FDA Approved Oral Anticoagulants FDA Approved Oral Anticoagulants Generic (Trade Name) Warfarin (Coumadin, Jantoven ) 1 FDA approved indication Prophylaxis and treatment of venous thromboembolism (VTE) Prophylaxis and treatment of thromboembolic

More information

Atrial Fibrillation, Chronic - Antithrombotic Treatment - OBSOLETE

Atrial Fibrillation, Chronic - Antithrombotic Treatment - OBSOLETE Atrial Fibrillation, Chronic - Antithrombotic Treatment - OBSOLETE Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with

More information

Out with the Old and in with the New? Target Specific Anticoagulants for Atrial Fibrillation

Out with the Old and in with the New? Target Specific Anticoagulants for Atrial Fibrillation Out with the Old and in with the New? Target Specific Anticoagulants for Atrial Fibrillation Goal Statement Pharmacists and technicians will gain knowledge in the use of target specific oral anticoagulants

More information

NIL. Dr Chuks Ajaero FMCP FRACP Cardiologist QEH, NALHN, SA Heart & Central Districts. Approach. Approach. 06-Nov-14

NIL. Dr Chuks Ajaero FMCP FRACP Cardiologist QEH, NALHN, SA Heart & Central Districts. Approach. Approach. 06-Nov-14 Stroke Prevention in Atrial Fibrillation: Commencing Non- Oral Anticoagulants in GP setting Dr Chuks Ajaero FMCP FRACP Cardiologist QEH, NALHN, SA Heart & Central Districts Disclosures NIL Classification

More information

Atrial Fibrillation and Stroke 2014

Atrial Fibrillation and Stroke 2014 Atrial Fibrillation and Stroke 2014 Andrew Thornton Sunninghill Hospital Management of AF Why do we treat Symptoms Fast Irregular Loss of atrial contraction (10-20% of cardiac output) Thromboembolism risk

More information

Adherence to NOACs. Disclosure. Patricia van den Bemt EAHP Hamburg 2015

Adherence to NOACs. Disclosure. Patricia van den Bemt EAHP Hamburg 2015 Adherence to NOACs Patricia van den Bemt EAHP Hamburg 2015 Disclosure Unrestricted research grants from Glaxo-SmithKline Boehringer Ingelheim Daiichi Sankyo Bayer Pfizer For research on medication safety

More information

Atrial Fibrillation: New Approaches to an Old Friend PETER JESSEL, MD ASSISTANT PROFESSOR

Atrial Fibrillation: New Approaches to an Old Friend PETER JESSEL, MD ASSISTANT PROFESSOR Atrial Fibrillation: New Approaches to an Old Friend PETER JESSEL, MD ASSISTANT PROFESSOR Disclosures None relevant to this presentation Outline Introduction Natural History and Stroke Risk Stroke/Bleeding

More information

Ensuring adherence to prescribed oral anticoagulant intake Γεώργιος Σ. Γκουμάς MD, PhD, FESC

Ensuring adherence to prescribed oral anticoagulant intake Γεώργιος Σ. Γκουμάς MD, PhD, FESC Ensuring adherence to prescribed oral anticoagulant intake Γεώργιος Σ. Γκουμάς MD, PhD, FESC Αν. Διευθυντής Καρδιολογικής Κλινικής, Ευρωκλινική Αθηνών ΔΗΛΩΣΗ ΣΥΓΚΡΟΥΣΗΣ ΣΥΜΦΕΡΟΝΤΩΝ Τα προηγούμενα δύο χρόνια

More information

MEETING THE CHALLENGES IN ATRIAL FIBRILLATION MANAGEMENT: THE ROLE OF NEW ANTICOAGULANTS

MEETING THE CHALLENGES IN ATRIAL FIBRILLATION MANAGEMENT: THE ROLE OF NEW ANTICOAGULANTS MEETING THE CHALLENGES IN ATRIAL FIBRILLATION MANAGEMENT: THE ROLE OF NEW ANTICOAGULANTS Summary of Presentations from the Daiichi Sankyo Satellite Symposium, held at the Annual ESC Congress, Barcelona,

More information

Disclosures. New Developments in Oral Anticoagulants: Treating and Preventing Embolic Events in the 21 st Century

Disclosures. New Developments in Oral Anticoagulants: Treating and Preventing Embolic Events in the 21 st Century New Developments in Oral Anticoagulants: Treating and Preventing Embolic Events in the 21 st Century David Stewart, PharmD, BCPS Associate Professor of Pharmacy Practice East Tennessee State University

More information

PHARMACOLOGICAL Stroke Prevention in Atrial Fibrillation STROKE RISK ASSESSMENT SCORES Vs. BLEEDING RISK ASSESSMENT SCORES.

PHARMACOLOGICAL Stroke Prevention in Atrial Fibrillation STROKE RISK ASSESSMENT SCORES Vs. BLEEDING RISK ASSESSMENT SCORES. PHARMACOLOGICAL Stroke Prevention in Atrial Fibrillation STROKE RISK ASSESSMENT SCORES Vs. BLEEDING RISK ASSESSMENT SCORES. Hossam Bahy, MD (1992 2012), 19 tools have been identified 11 stroke scores 1

More information

Current Controversies in Management of Anticoagulation for Atrial Fibrillation

Current Controversies in Management of Anticoagulation for Atrial Fibrillation Current Controversies in Management of Anticoagulation for Atrial Fibrillation Cheri Silverstein Fadlon, MD MSCR Assistant Professor of Internal Medicine, COMP Cardiologist, Western Diabetes Institute

More information

A PRACTICAL REVIEW OF THE NOVEL ORAL ANTICOAGULANTS

A PRACTICAL REVIEW OF THE NOVEL ORAL ANTICOAGULANTS A PRACTICAL REVIEW OF THE NOVEL ORAL ANTICOAGULANTS BRIAN CRYDER, PHARMD BCACP LEARNING OBJECTIVES AS A RESULT OF THIS PRESENTATION, THE AUDIENCE WILL BE ABLE TO 1. DISCUSS THE KEY DIFFERENCES BETWEEN

More information