2010 CCS AF Guidelines: Stroke Prevention. Anne PausJenssen MD MSc FRCPC General Internal Medicine University of Saskatchewan

Transcription

1 2010 CCS AF Guidelines: Stroke Prevention Anne PausJenssen MD MSc FRCPC General Internal Medicine University of Saskatchewan

2 None Disclosures

3 CCS Afib Guidelines: Stroke Prevention Website: 7 parts to afib guidelines Etiology Rate and Rhythm Management Catheter Ablation Treatment Stroke Prevention ER Management of Recent Onset Afib Surgical Therapies Afib Management after Cardiac Surgery

4 CCS Afib Guidelines: Stroke Prevention At the end of this 10 min session: The learner will appreciate: When to apply the CHA2DS2VASc score What the HASBLED score is What the guidelines suggest for anticoagulation therapy

5 CHADS2 vs CHA2DS2VASc

6 Predictive Index for Stroke Risk Factor CHADS 2 Congestive Heart Failure Score Hypertension 1 Age 75 1 Diabetes Mellitus 1 Stroke/TIA/ Thromboembolism Maximum Score Patients (n = 1733) Adjusted Stroke Rate (%/yr) 95% CI CHADS 2 Score (1.2 to 3.0) (2.0 to 3.8) (3.1 to 5.1) (4.6 to 7.3) (6.3 to 11.1) (8.2 to 17.5) (10.5 to 27.4) 6

7 CCS Afib Guidelines: Stroke Prevention Stroke risk rises with age: 1.5% in ages % in ages Stroke remains the feared outcome: Half result in major disability 20% result in death

8 CHADS 2 CHA 2 DS 2 -VASc Risk Factor Score Risk Factor Score Congestive Heart Failure 1 Hypertension 1 Age 75 1 Diabetes Mellitus 1 Stroke/TIA/Thromboembolism Stroke/TIA/Thromboembolism Maximum Score 6 2 Congestive Heart Failure 1 Hypertension 1 Age 75 2 Diabetes Mellitus 1 Vascular Disease 1 Age Female 1 Maximum Score 9 2

9 CCS Afib Guidelines: Stroke Prevention Summary: Step one: CHADS2 If score is 2 high risk score done! If less than 2 keep thinking Step two: CHA2DS2VASc If less than 2 calculate CHA2DS2VASc If 2 high risk If 0 or 1 low or intermediate risk

10 HASBLED

11 HASBLED H Hypertension A Abnormal liver or kidney function (1 point each) S - Stroke B Bleeding L Labile INRs E Elderly (> 65 yrs) D Drugs or alcohol (1 point each) Risk Score Major Bleeds % % % % % %

12 Anticoagulation Therapy

13 Overview of Thromboembolic Management Assess Thromboembolic Risk (CHADS 2 ) and Bleeding Risk (HAS-BLED) CHADS 2 = 0 CHADS 2 = 1 CHADS 2 2 aspirin OAC* OAC No antithrombotic may be appropriate in selected young patients with no stroke risk factors *Aspirin is a reasonable alternative in some as indicated by risk/benefit Dabigatran is preferred OAC over warfarin in most patients.

14 Anticoagulant Therapy RE-LY Trial NEJM , 113 patients; mean CHADS 2.1 Dabigatran 110mg BID vs Dabigatran 150mg BID vs Warfarin 20% on ASA INR therapeutic 64% Drug stopped in 16% warfarin and 20% Dabigatran Main Outcome All cause stroke or non-cns embolus Non-inferiority and superiority trial Exclusion criteria CrCL < 30mL per minute Conditions that would increase rates of bleeding Severe valvular heart disease Recent stroke, active liver disease, pregnancy

15 Anti-coagulant Therapy Results: Stroke and other embolus: Warfarin 1.6% / year Dabi 110mg 1.53% / year Dabi 150mg 1.11% / year Bleeding: Warfarin 3.36% per year Dabi 110mg 2.71% / year Dabi 150mg 3.11% / year Important considerations: More Myocardial Infarcts with Dabigatran

16 Antithrombotic Management of AF/AFL in CAD Stable CAD Recent ACS PCI Choose antithrombotic based on stroke risk Choose antithrombotic based on balance of risks and benefits Choose antithrombotic based on balance of risks and benefits CHADS 2 = 0 CHADS 2 1 CHADS 2 1 CHADS 2 2 CHADS 2 1 CHADS 2 2 Aspirin OAC* monotherapy aspirin + clopidogrel Triple antithrombotic Rx aspirin + clopidogrel Triple antithrombotic Rx * Warfarin is preferred over dabigatran for patients at high risk of coronary events

17 Anticoagulant Therapy CCS - Dabigatran preferred agent Conditional recommendation New agents topic for future guidelines Factor Xa inhibitors Rivaroxaban ROCKET-AF Apixaban ARISTOTLE Bold recommendation Remember can t reverse!

18 CCS Afib Guidelines: Stroke Prevention Summary: Use CHA2DS2VASc in those with CHADS2 score of 1 to ensure low risk status HASBLEDS good to document Decide for yourself re: Warfarin or Dabigatran