Disclosure Relationships with Industry

Size: px
Start display at page:

Download "Disclosure Relationships with Industry"

Transcription

1 NOACS or Not? When to Use -- and Not Use The Novel Oral Anticoagulants for Stroke Prevention in Patients with Atrial Fibrillation 6 th Annual New York State Stroke Conference Tarrytown, NY May 29, 2014 Jonathan L. Halperin, M.D. The Cardiovascular Institute Disclosure Relationships with Industry Consulting fees from the following companies involved in developing anticoagulant drugs and device-based strategies for thromboembolism prevention: Bayer HealthCare Biotronik Boehringer Ingelheim Boston Scientific Daiichi Sankyo Janssen Johnson & Johnson Medtronic Sanofi-Aventis Anticoagulation in Atrial Fibrillation Stroke Risk Reductions AFASAK SPAF BAATAF CAFA SPINAF EAFT Aggregate Warfarin Better Control Better 100% 50% 0-50% -100% Hart R, et al. Ann Intern Med 2007;146:857. 1

2 Anticoagulation in Atrial Fibrillation The Standard of Care for Stroke Prevention Warfarin Better Control Better AFASAK SPAF BAATAF CAFA SPINAF Unblinded Unblinded Unblinded Double-blind; Men only Terminated early EAFT 2 o prevention; Unblinded Aggregate 100% 50% 0-50% -100% Hart R, et al. Ann Intern Med 2007;146:857. The CHADS 2 Index Stroke Risk in Patients with Atrial Fibrillation Approximate Risk threshold for Anticoagulation Score (points) Risk of Stroke (%/year) %/year Van Walraven C, et al. Arch Intern Med 2003; 163:936. Go A, et al. JAMA 2003; 290: Gage BF, et al. Circulation 2004; 110: The CHA 2 DS 2 VASc Index Stroke Risk Score for Atrial Fibrillation Weight (points) Congestive heart failure or LVEF < 35% 1 Hypertension 1 Age >75 years 2 Diabetes mellitus 1 Stroke/TIA/systemic embolism 2 Vascular Disease (MI/PAD/Aortic plaque) 1 Age years 1 Sex category (female) 1 Moderate-High risk > 2 Low risk 0-1 Lip GYH, Halperin JL. Am J Med 2010; 123:

3 The HAS-BLED Score Risk Score to Predict Major Bleeding in Anticoagulated Patients with Atrial Fibrillation Weight (points) Hypertension (>160 mmhg systolic) 1 Abnormal renal or hepatic function 1-2 Stroke 1 Bleeding history or anemia 1 Labile INR (TTR <60%) 1 Elderly (age >75 years) 1 Drugs (antiplatelets, NSAIDs) & alcohol 1-2 High risk (>4%/year) > 4 Moderate risk (2-4%/year) 2-3 Low risk (<2%.year) 0-1 Pisters R, et al Chest 2010 (online) Risk Factors for ICH During Anticoagulation Established or likely factors Age >75 years Hypertension (systolic BP >160 mmhg) Cerebrovascular disease (prior stroke) Intensity of anticoagulation Initial period of anticoagulation Concomitant antiplatelet therapy Amyloid cerebral angiopathy Leukoaraiosis Ethnicity Tobacco and alcohol Hart RG, et al. Stroke 1995;26:1471. Sjöblom L, et al. Stroke 2001; 32: 2567 Shen AY, et al. J Am Coll Cardiol 2007; 50: 309. Target-Specific Oral Anticoagulants The NOACs 3

4 Targets for New Anticoagulants Oral TTP889 Apixaban Betrixaban Darexaban LY TAK-442 Ximelagatran Dabigatran X Fibrinogen TF/VIIa IXa VIIIa Va Xa IIa IX II (thrombin) AT Fibrin Adapted from Weitz JI, Bates SM. J Thromb Haemost 2005; 3:1843 Turpie AGG. Eur Heart J 2007; 29,155 Guertin KR, Choi YM. Curr Med Chem 2007; 14:2471 APC AT stm TF FPI Parenteral TFPI (tifacogin) APC (drotrecogin alfa) stm (ART-123) Idra(biota)parinux DX-9065a Otamixaban activated protein C antithrombin soluble thrombomodulin tissue factor tissue factor pathway inhibitor Novel Oral Anticoagulants Pharmacological Properties Feature Dabigatran Apixaban Target IIa Xa Xa Xa Molecular Weight (g/mol) Prodrug Yes No No No Bioavailability (%) Time to peak (h) Half-life (h) Renal excretion (%) CYP Metabolism (%) None 32 <32 <4 Antidote None None None None Ogata, et al. J Clin Pharmacol 2010;50:743. Mendell, et al. Am J Cardiovasc Drugs 2013;13:331. Bathala, et al. Drug Metab Dispos 2012;40:2250. New Oral Anticoagulants Phase III Trials for Stroke Prevention in Patients with AF Trial Acronym RE-LY Drug Dabigatran Dose (mg) 150 bid 110 bid Design n Risk Dose Factors adjustment (#) PROBE 18,113 1 None ROCKET-AF 20 qd 15 qd* Blinded 14, % at baseline ARISTOTLE Apixaban 5 bid 2.5 bid* Blinded 18, % at baseline ENGAGE-AF 60 qd 30 qd* Blinded 21, % at baseline >9% after * Adjusted based on renal function or other factors associated with reduced drug clearance 4

5 Trials of NOACs for AF Distribution of Stroke Risk Factors CHADS 2 Scores RE-LY (Dabigatran) Connolly SJ, et al. N Engl J Med 2009;361:1139. Patel MR, et al. N Engl J Med 2011; 365:883. Granger CB et al. N Eng J Med 2011; 365. Giugliano RP, et al. N Engl J Med 2013; 369: ROCKET-AF () ARISTOTLE (Apixaban) ENGAGE AF () # Randomized 18,113 14,264 18,201 21,105 Age, years 72 ± 9 73 [65-78] 70 [63-76] 72 [64-78] Female, % Paroxysmal AF VKA naive Aspirin use CHADS Relative Risks of Stroke and Systemic Embolism Meta-Analysis Warfarin vs. Placebo/control Warfarin vs. low-dose warfarin + ASA Warfarin vs. ASA VKA vs. ASA + clopidogrel Warfarin vs. ximelagatran Warfarin vs. dabigatran 110 mg bid Warfarin vs. dabigatran 150 mg bid Favors warfarin Favors alternative Camm AJ. European Society of Cardiology, Barcelona, August ROCKET-AF Trial Stroke and Systemic Embolism On Treatment N= 14,143 ITT N= 14,171 Warfarin Event Rates (%/year) HR (95% CI) 0.79 (0.65,0.95) 0.88 (0.74,1.03) p* better Warfarin better * p-values for superiority Patel MR, et al. N Engl J Med 2011; 365:883. 5

6 ROCKET-AF Trial Efficacy for Secondary Stroke Prevention 7 Prior stroke No Prior stroke 6 Cumulative event rate (%) Warfarin Warfarin 2 o 1 o Months from randomization *Safety population, on-treatment. Hankey GJ, et al. Lancet Neurol 2012; 11: 315. ARISTOTLE Trial Primary Outcome: All Stroke or Systemic Embolism Non-inferiority p < % RRR Apixaban 212 patients, 1.27%/year Warfarin 265 patients, 1.60%/year HR 0.79 (95% CI, ); Superiority p = No. at Risk Warfarin Apixaban Granger CB et al. N Engl J Med 2011; 365 ARISTOTLE Trial Major Bleeding Events 31% RRR Apixaban 327 patients, 2.13%/year Warfarin 462 patients, 3.09%/year HR 0.69 (95% CI, ); p <0.001 No. at Risk Warfarin Apixaban Granger CB et al. N Engl J Med 2011; 365 6

7 Apixaban vs. Aspirin: The AVERROES Trial Efficacy and Safety Event Rates Event Rate (% / y) p< p = 0.57 Apixaban Aspirin Stroke/Systemic Embolism Major Bleeding Connolly S. N Engl J Med 2011; 364: 806. ENGAGE AF TIMI-48 Trial Primary Endpoint Stroke + Systemic Embolism 60* mg QD vs warfarin 30* mg QD vs warfarin Warfarin TTR 68.4% Hazard ratio (97.5% CI) edoxaban noninferior Non-inferiority (mitt, on-treatment) p < p = * mg QD vs warfarin 30* mg QD vs warfarin edoxaban superior edoxaban inferior Superiority (ITT, Overall) p = 0.08 p = 0.10 Giugliano RP, et al. N Engl J Med 2113; 369: * mg ENGAGE AF TIMI-48 Trial Safety Outcome: Bleeding On Treatment ISTH Major Bleeding 30* mg Warfarin TTR 68.4% HR (95% CI) p <0.001 p <0.001 Fatal Bleeding p = p <0.001 ICH GI Bleeding p <0.001 p <0.001 p = 0.03 p <0.001 Giugliano RP, et al. N Engl J Med 2113; 369: edoxaban superior edoxaban inferior 7

8 Nonvalvular Atrial Fibrillation A Moving Target? Original warfarin trials excluded: Rheumatic heart disease (mitral stenosis) Prosthetic heart valves (mechanical or biological) Valve repair (rare, not considered) Thyrotoxicosis Self-limited AF due to acute illness or surgery Identifying Patients with Nonvalvular AF Valvular Disease Exclusion Criteria in Trials of NOACS Trial SPORTIF III & V RE-LY ROCKET AF AVERROES ARISTOTLE ENGAGE AF Excluded Valvular Diseases Mitral stenosis or previous valvular heart surgery Hemodynamically relevant valve disease or prosthetic valve Mitral stenosis or prosthetic heart valve Valvular disease requiring surgery or mechanical prosthetic heart valve Moderate or severe mitral stenosis or prosthetic heart valve requiring anticoagulation Moderate or severe mitral stenosis or mechanical heart valve. (Patients with bioprosthetic heart valves or valve repair could be included.) AVR or MVR Dabigatran vs. Warfarin in Patients with Mechanical Heart Valves RE-ALIGN Trial Kaplan-Meier Analysis First Thromboembolic Event <7 days 3 months Dabigatran dose 150, 220 or 300 mg bid, based on kidney function and blood levels 252 patients Trial terminated b/o excess thromboembolism and bleeding Probability of No event Probability of No event Warfarin Dabigatran Extension phase of the trial p=0.24 Days First Bleeding Event Warfarin Dabigatran Extension phase of trial p=0.01 Eikelboom JW, et al. N Engl J Med 2013; 369:1206. Days 8

9 Meta-analysis of NOACs vs. Warfarin in Non-valvular AF All Stroke + Systemic Embolism 71,683 patients enrolled in RE-LY, ROCKET AF, ARISTOTLE, and ENGAGE-AF TIMI 48 42,411 patients randomized to a NOAC 29,272 patients randomized to warfarin NOAC (events) Warfarin (events) RR (95% CI) p Favors NOAC Favors warfarin Ruff CT, et al. Lancet 2014; 383; 955. Meta-analysis of NOACs vs. Warfarin in Non-valvular AF Secondary Efficacy and Safety Outcomes Favors NOAC Favors warfarin Ruff CT, et al. Lancet 2014; 383; 955. Meta-analysis of NOACs vs. Warfarin in Non-valvular AF Major Bleeding Favors NOAC Favors warfarin Ruff CT, et al. Lancet 2014; 383;

10 Newer Oral Anticoagulants for AF Key Similarities All are noninferior to warfarin for prevention of total stroke and systemic embolism All reduce the risk of intracerebral hemorrhage Outcomes of major bleeding are generally better than with warfarin Reductions in mortality are comparable, ~10%/year, mainly related to lower rates of cardiovascular death and fatal bleeding. Newer Anticoagulants for AF Inferences from the Pivotal Trials Differences in outcomes may be due to variations in study design, sample size, intrinsic risk, concurrent treatment and other factors, rather than the drugs themselves. In the doses approved for use in the U.S., factor Xa inhibitors may have less efficacy against ischemic stroke than dabigatran but also less toxicity. Factor Xa inhibitors are less dependent on renal elimination and have fewer GI side effects than dabigatran. NOACs for Venous Thromboembolism Prophylaxis and Therapy Trials (Partial list) ODIXa-HIP ODIXa-Knee RECORD 1,2,3,4 EINSTEIN-DVT EINSTEIN-PE EINSTEIN Extension Dabigatran RE-MODEL RE-MOBILIZE RE-NOVATE RE-COVER RE-MEDY RE-SOLVE HOKUSAI-VTE STARS-S STARS-E Apixaban ADVANCE 1,2,3 AMPLIFY AMPLIFY-EXT APROPOS ADAPT APPRAISE BOTTICELLI 10

11 NOACs for VTE Prevention and Treatment U.S. Regulatory Approval Status (Approved) VTE prophylaxis (orthopaedic surgery) DVT treatment PE treatment Apixaban (Approved) VTE prophylaxis (orthopaedic surgery) Dabigatran (Approved) DVT treatment PE treatment Dabigatran (Filed) VTE prophylaxis (orthopaedic surgery) Apixaban (Filed) DVT treatment PE treatment (Filed) VTE prophylaxis DVT treatment PE treatment Novel Oral Anticoagulants for AF Areas of Uncertainty Requiring Further Study Patients with AF undergoing PCI or CABG Cardioversion of AF Catheter ablation, Maze or intra-operative cryoablation Device-detected AF Bioprosthetic heart valves Valve repair Prior hemorrhagic stroke Resuming NOACs After Surgery or Invasive Procedures Timing and Dosing Considerations Depends on postoperative risk of bleeding Risks of bleeding and VTE postoperatively usually outweigh the risk of embolic stroke For major abdominal or urologic surgery: delay NOAC until drainage or active bleeding cease. For procedures with good hemostasis, resume NOAC >4-6 hours postoperatively. When bowel paralysis is present, bridging with a parenteral anticoagulant may be necessary. Dabigatran: Resume 75 mg first dose, then maintenance dose. : Resume 10 mg first dose, then maintenance dose. Apixaban: Resume 2.5 mg first dose, then maintenance dose. :? Resume 30 mg first dose, then maintenance dose. Adapted from Schulman S, et al. Blood 2012; 119:

12 Outcomes of Major Bleeding During Treatment with Dabigatran or Warfarin 1,034 Patients, 1,121 Major Bleeds in 5 Phase III Trials Majeed A, et al. Circulation (published online September 30, 2013) Development of a Specific Dabigatran Antidote adabi-fab Binding and Reversal of the Anticoagulant Effect Millar CM, Lane DA. Blood 2013; 121:3543. Schiele F, et al. Blood 2013; 121:3554. Reversal of the Anticoagulant Effect of Factor Xa Inhibitors Dose-Dependent Action of Recombinant Andexanet alfa (PRT064445) On fxa Suppression by Betrixaban, or Apixaban Lu G, et al. Nature Med 2013: 19:

13 Common Concerns about the NOACs How to choose between VKA and NOAC which NOAC to select? Lack of monitoring insecurity about dosing and adherence No simple spot-checks need-to-know occasions Short half-lives concern about missed doses No antidotes yet how to manage major bleeding? Drug-drug interactions under- and over-dosing Clinical development incomplete e.g., cardioversion, ablation, PCI Contraindications valvular AF Need to monitor renal and hepatic function Expense for health care systems and patients Modified from Camm AJ, American Heart Association Scientific Sessions, Dallas, TX, November 2013 Antithrombotic Therapy for Atrial Fibrillation ACC/AHA/HRS Guidelines, 2014 January CT, et al. Circulation 2014; (E-published March 28). Antithrombotic Therapy for Atrial Fibrillation ACC/AHA/HRS Guidelines, 2014 January CT, et al. Circulation 2014; (E-published March 28). 13

14 Summary of Phase III NOAC Trial Results Dabigatran Outcomes vs. warfarin Apixaban 150 mg bid 60 mg qd Stroke/systemic embolism Superiority Non-inferiority Superiority Non-inferiority Stroke Yes No Yes Yes Ischemic or unspecified Stroke Yes No No No Hemorrhagic stroke Yes Yes Yes Yes Disabling or fatal stroke Yes No Yes Yes Vascular death Yes No No Yes All-cause mortality No No Yes No Major bleeding No No Yes Yes ICH Yes Yes Yes Yes GI bleeding Yes Yes No No Treatment discontinuation No No Yes Yes Modified from Camm AJ, American Heart Association Scientific Sessions, Dallas, TX, November 2013 Considerations in NOAC Selection for AF High risk of bleeding HAS-BLED 3 Consider agent / dose with the lowest incidence of bleeding Apixaban Specific patient characteristics Previous GI bleeding or high-risk High risk of ischemic stroke, low bleeding risk Previous stroke (secondary prevention) CAD, previous MI or highrisk for ACS/MI Renal impairment GI upset / disorders Consider agent with the lowest reported incidence of GI bleed Consider agent / dose with the best reduction of ischemic stroke Consider best investigated agent or greatest reduction of 2 0 stroke Consider agent with positive effect in ACS Consider agent least dependent on renal function Consider agent / dose with fewer GI effects Apixaban Dabigatran 150 Apixaban Apixaban Patient preference Consider once daily formulation Modified after Savalieva I, Camm AJ. Clin Cardiol 2014; 37: 32 Alternatives to Anticoagulation Left Atrial Appendage Occlusion 14

15 PROTECT-AF Trial Primary Efficacy Events Stroke, Systemic Embolism and Cardiovascular Mortality Reddy VY, et al, Heart Rhythm Society Scientific Sessions, May 2013 Ischemic Stroke in PROTECT-AF Trial Mechanistic Inferences Patients with Ischemic Stroke (%) Procedure related Not Procedurerelated Reddy VY, et al, Heart Rhythm Society Scientific Sessions, May 2013 From Fermented Sweet Clover to Molecular Targeting of Thrombosis The Promise of New Oral Anticoagulants The Goal: To bring effective stroke prevention therapy to more patients. 15

16 16

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

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

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

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

Anticoagulation for NVAF: NAOs or AVKs? Giancarlo Agnelli

Anticoagulation for NVAF: NAOs or AVKs? Giancarlo Agnelli Anticoagulation for NVAF: NAOs or AVKs? Giancarlo Agnelli Medicina Interna & Cardiovascolare - Stroke Unit Scuola di Specializzazione in Medicina di Emergenza - Urgenza Università di Perugia My talk today

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

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

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

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

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

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

Rivaroxaban A new oral anti-thrombotic Dr. Hisham Aboul-Enein Professor of Cardiology Benha University 12/1/2012

Rivaroxaban A new oral anti-thrombotic Dr. Hisham Aboul-Enein Professor of Cardiology Benha University 12/1/2012 Rivaroxaban A new oral anti-thrombotic Dr. Hisham Aboul-Enein Professor of Cardiology Benha University 12/1/2012 Agenda Ideal anticoagulant. Drawbacks of warfarin. Rivaroxaban in clinical trails. Present

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 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

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

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

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

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

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

Review of Non-VKA Oral AntiCoagulants (NOACs) and their use in Great Britain

Review of Non-VKA Oral AntiCoagulants (NOACs) and their use in Great Britain Review of Non-VKA Oral AntiCoagulants (NOACs) and their use in Great Britain Dr Alexander (Ander) Cohen Guy s and St Thomas Hospitals, King s College London, UK Pavia Spring Meeting 13 June 2014 Overview

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

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

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

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

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

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

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

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

New in Atrial Fibrillation

New in Atrial Fibrillation New in Atrial Fibrillation September 2011 Stroke prevention more options Rhythm Control -drugs - alternatives to drugs; ablation Rate Control - pace + ablate A-FIB Dell Stroke Risk AFib Two Principles

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

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

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 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

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

The New Anticoagulants are Here! Do you know how to use them? Arrhythmia Winter School February 11 th, 2012. Jeff Healey

The New Anticoagulants are Here! Do you know how to use them? Arrhythmia Winter School February 11 th, 2012. Jeff Healey The New Anticoagulants are Here! Do you know how to use them? Arrhythmia Winter School February 11 th, 2012 Jeff Healey RELY: A New Era in AF Connolly SJ et al. N Engl J Med 2009;361:1139-1151 ROCKET-AF:

More information

New therapeutic approaches for the protection of AF patients from stroke: Do aspirin or warfarin have a role anymore?

New therapeutic approaches for the protection of AF patients from stroke: Do aspirin or warfarin have a role anymore? New therapeutic approaches for the protection of AF patients from stroke: Do aspirin or warfarin have a role anymore? Dr Tina Biss Consultant Haematologist The Newcastle Hospitals NHS Foundation Trust

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

Home treatment of VTE

Home treatment of VTE Home treatment of VTE Prof. Adel El-Etriby Ain-Shams University Venous Thromboembolism (VTE): The DVT and PE Continuum Migration Embolus Thrombus VTE refers to a continuum of disease that begins with DVT

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

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

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

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 Risk Scores. CHA 2 DS 2 -VASc. CHA 2 DS 2 -VASc Scoring Table 2

Stroke Risk Scores. CHA 2 DS 2 -VASc. CHA 2 DS 2 -VASc Scoring Table 2 Bleeding/Clotting Risk Evaluation Tools for Atrial Fibrillation Patients Before prescribing anticoagulants, providers should weigh the risk of thrombosis against the risk of bleeding. The tools below can

More information

Perioperative Bridging in Atrial Fibrillation: Is it necessary?

Perioperative Bridging in Atrial Fibrillation: Is it necessary? Perioperative Bridging in Atrial Fibrillation: Is it necessary? Jason B. Thompson M.D., Ph.D. August 29, 2015 2015 NCVH Birmingham Hypothesis: When bridging, risk of bleeding < risk systemic embolism (SE).

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

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

Atrial Fibrillation: New Therapies for an Old Problem

Atrial Fibrillation: New Therapies for an Old Problem Atrial Fibrillation: New Therapies for an Old Problem Nguyen Park, MS, PA-C UNM Physician Assistant Program Dept. of Family & Community Medicine Univesity of New Mexico Lead Clinician Special Environmental

More information

AHA/ASA Scientific Statement Oral Antithrombotic Agents for the Prevention of Stroke in Atrial Fibrillation

AHA/ASA Scientific Statement Oral Antithrombotic Agents for the Prevention of Stroke in Atrial Fibrillation AHA/ASA Scientific Statement Oral Antithrombotic Agents for the Prevention of Stroke in Atrial Fibrillation A Statement for Healthcare Professionals from the American Heart Association/American Stroke

More information

AF, Stroke Risk and New Anticoagulants

AF, Stroke Risk and New Anticoagulants Carmarthen Cardiac Update Course AF, Stroke Risk and New Anticoagulants Dr Hamsaraj Shetty, B.Sc, FRCP (London & Edinburgh) Consultant Physician & Honorary Senior Lecturer University Hospital of Wales,Cardiff

More information

Novel Anticoagulation Agents DISCLOSURES. Objectives ATRIAL FIBRILLATION TRIALS. NOAC Comparison 6/12/2015

Novel Anticoagulation Agents DISCLOSURES. Objectives ATRIAL FIBRILLATION TRIALS. NOAC Comparison 6/12/2015 Novel Anticoagulation Agents DISCLOSURES James W. Haynes, MD Department of Family Medicine Univ of TN Health Science Center (Chattanooga) Objectives Understand mechanism of action behind the NOAC agents

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

Rivaroxaban (Xarelto ) by

Rivaroxaban (Xarelto ) by Essentia Health Med Moment Short Video Tune-Up A brief overview of a new medication, or important new medication information Rivaroxaban (Xarelto ) by Richard Mullvain RPH BCPS (AQC) Current - August 2011

More information

Atrial Fibrillation and Stroke. Stroke Collaborative 2012

Atrial Fibrillation and Stroke. Stroke Collaborative 2012 Atrial Fibrillation and Stroke Stroke Collaborative 2012 Robert Hart, M.D. Stroke Neurology McMaster University Hamilton Health Sciences Hamilton, Ontario Conflict Disclosure Information 2 FINANCIAL DISCLOSURES

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

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

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

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

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

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

How To Compare Warfarin To Dabigatran

How To Compare Warfarin To Dabigatran Page 1 WOMEN AT RISK Anticoagulation Issues In Atrial Fibrillation WOMEN AT RISK Anticoagulation Issues In Atrial Fibrillation J E A N N A P P I, P H A R M. D., F C C P, B C P S Accreditation: Pharmacists:

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

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

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

Current and new oral Anti-coagulation. Lancashire and Cumbria Network 2 February 2012

Current and new oral Anti-coagulation. Lancashire and Cumbria Network 2 February 2012 Current and new oral Anti-coagulation Lancashire and Cumbria Network 2 February 2012 Question Warfarin is an abbreviation What does the W stand for? What is this plant and what is the connection with warfarin?

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

How To Understand How The Brain Can Be Affected By Cardiac Problems

How To Understand How The Brain Can Be Affected By Cardiac Problems Workshop 2e: Atrial Fibrillation, Heads and Hearts how the brain can be affected by cardiac problems Matthew Walters Heads and Hearts Cardiac disease and stroke Matthew Walters University of Glasgow Why

More information

2/17/2015 ANTICOAGULATION UPDATE OBJECTIVES BRIEF REVIEW: CLASSES OF ORAL ANTICOAGULANTS

2/17/2015 ANTICOAGULATION UPDATE OBJECTIVES BRIEF REVIEW: CLASSES OF ORAL ANTICOAGULANTS ANTICOAGULATION UPDATE C AR R I E P AL M E R, D N P, RN, AN P - BC OBJECTIVES At the end of the presentation, the NP will be able to: Identify new indications for target-specific oral anticoagulants (TSOACs),

More information

What You Should NOAC About the New Anticoagulants. Dr Calum Young Cardiologist

What You Should NOAC About the New Anticoagulants. Dr Calum Young Cardiologist What You Should NOAC About the New Anticoagulants Dr Calum Young Cardiologist Overview The Burden of AF What s Wrong With Warfarin? The Era of NOACs NOACs in New Zealand Clinical Trials with NOACs Potential

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

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

The Role of the Newer Anticoagulants

The Role of the Newer Anticoagulants The Role of the Newer Anticoagulants WARFARIN = Coumadin DAGIBATRAN = Pradaxa RIVAROXABAN = Xarelto APIXABAN = Eliquis INDICATION DABIGATRAN (Pradaxa) RIVAROXABAN (Xarelto) APIXABAN (Eliquis) Stroke prevention

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

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

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

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

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

New Anticoagulants: When and Why Should I Use Them? Disclosures

New Anticoagulants: When and Why Should I Use Them? Disclosures Winship Cancer Institute of Emory University New Anticoagulants: When and Why Should I Use Them? Christine L. Kempton, MD, MSc Associate Professor of Pediatrics and Hematology and Medical Oncology Hemophilia

More information

Atrial Fibrillation and Heart Failure: A Cause or a Consequence

Atrial Fibrillation and Heart Failure: A Cause or a Consequence Atrial Fibrillation and Heart Failure: A Cause or a Consequence Rajat Deo, MD, MTR Assistant Professor of Medicine Division of Cardiology, Electrophysiology Section University of Pennsylvania November

More information

Will Next Generation Oral Anticoagulants Replace Warfarin as Mainstay Therapy?

Will Next Generation Oral Anticoagulants Replace Warfarin as Mainstay Therapy? Brochure More information from http://www.researchandmarkets.com/reports/1869007/ Will Next Generation Oral Anticoagulants Replace Warfarin as Mainstay Therapy? Description: Will Next Generation Oral Anticoagulants

More information

Time of Offset of Action The Trial

Time of Offset of Action The Trial New Antithrombotic Agents DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau - None Consultant Amgen Tom DeLoughery, MD FACP FAWM Oregon Health and Sciences University What I am Talking About

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

How To Treat Aneuricaagulation

How To Treat Aneuricaagulation 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

USE OF THE DIRECT ORAL ANTICOAGULANTS IN CLINICAL PRACTICE. Gail Pokorney, MD AKAFP Winter Update March 12, 2016

USE OF THE DIRECT ORAL ANTICOAGULANTS IN CLINICAL PRACTICE. Gail Pokorney, MD AKAFP Winter Update March 12, 2016 USE OF THE DIRECT ORAL ANTICOAGULANTS IN CLINICAL PRACTICE Gail Pokorney, MD AKAFP Winter Update March 12, 2016 NO DISCLOSURES OBJECTIVES Review the efficacy and safety of the direct oral anticoagulants

More information

Cardiovascular Disease

Cardiovascular Disease Cardiovascular Disease 1 Cardiovascular Disease 1. More target specific oral anticoagulants (TSOAC) 2. Vorapaxar (Zonivity) 3. Continued noise about a polypill 4. WATCHMAN 3 1 2 3 4 Left Atrial Appendage

More information

Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Brief Comparison of Four Agents

Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Brief Comparison of Four Agents Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Brief Comparison of Four Agents Abbreviations AF: Atrial fibrillation ARISTOTLE: Apixaban for Reduction in Stroke and Other Thromboembolic

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

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

Managing Anticoagulation for Atrial Fibrillation 2015

Managing Anticoagulation for Atrial Fibrillation 2015 Managing Anticoagulation for Atrial Fibrillation 2015 Vikranth Gongidi, DO FACC FACOI Indian River Medical Center Vero Beach, FL Atrial Fibrillation Background and Guidelines Decisions to anticoagulate

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

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

OAC and NOAC with or without platelet inhibition

OAC and NOAC with or without platelet inhibition Zürich 11.06.2015 Preoperative antithrombotic management OAC and NOAC with or without platelet inhibition Miodrag Filipovic miodrag.filipovic@kssg.ch Anästhesiologie & Intensivmedizin Case 1 76 yr old

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

Stroke Prevention for Atrial Fibrillation. Joseph A Manfredi, MD, FACC, FHRS AnMed Health Arrhythmia Specialists February 22 nd, 2014

Stroke Prevention for Atrial Fibrillation. Joseph A Manfredi, MD, FACC, FHRS AnMed Health Arrhythmia Specialists February 22 nd, 2014 Stroke Prevention for Atrial Fibrillation Joseph A Manfredi, MD, FACC, FHRS AnMed Health Arrhythmia Specialists February 22 nd, 2014 Disclosures Speaker honorariums: STJM, BS, Medtronic Stock: Boston Scientific

More information

ABOUT XARELTO CLINICAL STUDIES

ABOUT XARELTO CLINICAL STUDIES ABOUT XARELTO CLINICAL STUDIES FAST FACTS Xarelto (rivaroxaban) is a novel, oral direct Factor Xa inhibitor. On September 30, 2008, the European Commission granted marketing approval for Xarelto for the

More information

Managing the Patient with Atrial Fibrillation

Managing the Patient with Atrial Fibrillation Pocket Guide Managing the Patient with Atrial Fibrillation Updated April 2012 Editor Stephen R. Shorofsky, MD, Ph.D. Assistant Editors Anastasios Saliaris, MD Shawn Robinson, MD www.hrsonline.org DEFINITION

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

The speakers have attested that their presentation will be free of all commercial bias toward a specific company and its products.

The speakers have attested that their presentation will be free of all commercial bias toward a specific company and its products. Update on New Anticoagulants (Apixaban, Dabigatran and Rivaroxaban) Patient Safety Daniel B. DiCola, MD and Paul Ament,, Pharm.D Excela Heath, Latrobe, PA Disclosures: Paul Ament discloses that he receives

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

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

Old Agent, New Agent or No Agent? The Decision to Anticoagulate Patients with Atrial Fibrillation. Daniel E. Singer, MD

Old Agent, New Agent or No Agent? The Decision to Anticoagulate Patients with Atrial Fibrillation. Daniel E. Singer, MD AHA International Stroke Conference, Pre-Con Symposium, February 5, 2013 Old Agent, New Agent or No Agent? The Decision to Anticoagulate Patients with Atrial Fibrillation Daniel E. Singer, MD Massachusetts

More information