ΑΝΤΙΘΡΟΜΒΩΤΙΚΗ ΑΓΩΓΗ ΣΤΗΝ ΚΟΛΠΙΚΗ ΜΑΡΜΑΡΥΓΗ

Transcription

1 ΑΝΤΙΘΡΟΜΒΩΤΙΚΗ ΑΓΩΓΗ ΣΤΗΝ ΚΟΛΠΙΚΗ ΜΑΡΜΑΡΥΓΗ Υπερήλικοι ασθενείς με κολπική μαρμαρυγή. Μεταξύ κατευθυντήριων οδηγιών και κλινικής σωφροσύνης Ε. Ν. Σημαντηράκης MD, PhD, FESC Αναπλ. Καθηγητής Καρδιολογίας ΠΑΓΝΗ

2 Anyone who stops learning is old, whether at Ηλικιωμένος > or 80. Anyone who keeps learning stays young. The greatest Υπερήλικας thing in life >75 is to keep you mind young! Henry Ford

3 Peculiarities of the Elderly Comorbidities Polypharmacy Falls Bleeding risk

4 Copyright 2010 Pearson Education, Inc. Normal Effects of Aging on the Body

5 Recommendation ESC 2012 focused update: antithrombotic therapy In patients with CHA 2 DS 2 VASc score 2, OAC therapy with: a dose adjusted VKA (INR 2 3); or a direct thrombin inhibitor (dabigatran etexilate); or an oral Factor Xa inhibitor (e.g. rivaroxaban, apixaban*) is recommended unless contraindicated Class I Level A In patients with CHA 2 DS 2 VASc score 1, OAC therapy with: a dose adjusted VKA (INR 2 3); or a direct thrombin inhibitor (dabigatran); or an oral Factor Xa inhibitor (e.g. rivaroxaban, apixaban*) should be considered, based upon an assessment of the risk of bleeding complications and patient preferences IIa A Camm AJ et al. Eur Heart J 2012;33:

6 Atrial fibrillation a disease of the elderly Prevalence of AF increases with advancing age only 0.1% in subjects under 55 year >10% in subjects above 80 years of age Amongst patients with diagnosed AF, 45% are older than 75 years, and it is even estimated that more than half of patients with AF will be older than 80 by the year 2050

7 Η επίπτωση της ΚΜ αυξάνεται με την ηλικία Data from Heeringa J et al. Eur Heart J 2006;27:949 53

8 Η επίπτωση του εγκεφαλικού στους ασθενείς με ΚΜ αυξάνεται με την πρόοδο της ηλικίας

9 Stroke: the most feared complication of AF SingerDE, Ann Intern Med 2009; 151:

10 Gustavo Saposnik et al. Stroke. 2009;40: Stroke mortality is exceedingly high in elderly patients

11 Stroke fatality by age group Gustavo Saposnik et al. Stroke. 2009;40:

12 Warfarin vs. Placebo Stroke Death Μια μετα ανάλυση 29 μελετών σε ασθενείς έδειξε ότι η warfarin μειώνει τα ισχαιμικά ΑΕΕ και την ολική θνητότητα 64% 26% Hart RG et al. Ann Intern Med. 2007;146:

13 Antithrombotic Therapy for AF Warfarin vs ASA Warfarin vs placebo 14% to 52% RRR with warfarin vs ASA 62% to 67% RRR with warfarin vs placebo C van Walraven. JAMA 2002 Atrial Fibrillation Investigators. Arch Intern Med. 1994

14 ACTIVE W: Η διπλή αντιαιμοπεταλιακή αγωγή κατώτερη από τα αντιπηκτικά από το στόμα στην πρόληψη εμφάνισης ΑΕΕ σε ασθενείς με KΜ

15 Stroke prevention in the elderly The adjusted net clinical benefit of VKA was 0.68% per 100 patients per year (95%CI ) in the overall cohort. Whilst the net benefit was absent in young patients, it was substantial (2.34%, 95%CI ) in patients above 85 years, SingerDE, Ann Intern Med 2009

16 Ascertainments Patients with known AF who presented with ischaemic stroke and no contraindications for anticoagulation therapy, only 54% were receiving warfarin on admission Increasing age was associated with a reduced likelihood of receiving Warfarin: one of three eligible patients >85 years were receiving warfarin on admission for stroke compared with three of four patients <75 years old Elderly patients with AF might also have formal contraindications for VKA, although the proportion of truly ineligible patients is (much) lower than the perceived Partington SL,.Thromb Res 2007; 120: 63 9.

17 Underuse and poor control of VKA in the elderly Hylek EM, Stroke2006;37:

18 Μειονεκτήματα των VKA Limitation Consequence Genetic variation in metabolism Slow onset/offset of action Multiple food and drug interactions Variable dose requirements Overlap with a parenteral anticoagulant, complex management in bleeding events or interventions Frequent coagulation monitoring Narrow therapeutic index Frequent coagulation monitoring Fear of bleeding complications Sub prescription

19 Limitations of VKA to prevent stroke in elderly patients with AF

20 Efficacy and Safety of Rivaroxaban Compared With Warfarin Among Elderly Patients With Nonvalvular Atrial Fibrillation (ROCKET AF) Circulation Halperin et al.

21 Efficacy and Safety of Rivaroxaban Compared With Warfarin Among Elderly Patients With Nonvalvular Atrial Fibrillation (ROCKET AF) Circulation Halperin et al. 21

22 Clinical Implications In elderly patients with nonvalvular AF at high risk of stroke, rivaroxaban is as effective as adjusted dose anticoagulation with warfarin Rivaroxaban caused more clinically relevant non major bleeding Rivaroxaban carried less risk of intracranial bleeding, a particular concern in the elderly

23 Apixaban vs Warfarin in Patients <80 vs 80 Years*

24 Apixaban vs Warfarin According to Age (Effect on Bleeding and Net Clinical Events)

25 Primary Outcomes in Elderly ( 75 Years) in Relation to Renal Function

26 Adapted from Halvorsen S et al. Eur Heart J [epub ahead of print. DOI: /eurheartj/ehu046] Clinical Implications Compared with warfarin, apixaban reduced the risk of stroke, major bleeding, and death in patients with NVAF, regardless of age Including in patients 80 years As the absolute risks were higher in the older patent groups, the lack of interaction between treatment and age suggests that the absolute benefits of apixaban were greater in the older population There were no significant interactions between the treatment effect and the level of renal dysfunction NVAF, non valvular atrial fibrillation

27 Annual rates of stroke non CNS embolism and major bleeding according to age in RE LY

28 Annual rates of ICH according to age in RE LY

29 Clinical Implications For elderly pts 110 mg dabigatran bid is associated with similar efficacy to warfarin for preventing stroke and systemic emboli significantly less ICH and haemorrhagic stroke without increasing major bleeding

30 Conclusions Elderly patients with AF, who constitute almost half of all patients with AF, are at significantly increased risk of stroke. VKA, clearly reduce the risk of stroke in all patients including the elderly but are frequently underused in older patients. Failure to initiate VKA in elderly patients with AF is related to a number of factors, including the limitations of current therapies and the increased risk of major hemorrhage associated with advanced age and anticoagulation therapy.

31 Conclusions Novel oral anticoagulant agents that are easier to use and might offer similar or better levels of stroke prevention with a similar or reduced risk of bleeding should increase the use of antithrombotic therapy in the management of elderly patients with AF.