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

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

2 Who Needs to Be Anticoagulated and What is the Patient s Risk? 1. Atrial Fibrillation ( nonvalvular ) 2. What regimen to use after coronary stenting in a patient with atrial fibrillation 3. DVT/PTE

3 Risk Assessment for Use of Anticoagulation in Atrial Fibrillation CHADS2- risk assessment of stroke in pts with atrial fibrillation CHADS2-VASc- newest risk assessment of stroke in pts with atrial fibrillation HAS-BLED- major bleeding risk ( intracranial hemorrhage, bleeding requiring hospitalization, Hgb drop of more than 2g/dL ) for systemic anticoagulation in pts with atrial fibrillation

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7 Interpretation of CHADS2/CHADS2-VASc Score Score Therapy 0 No oral anticoagulant or Aspirin needed 1 Aspirin or oral anticoagulant > Or = 2 Oral anticoagulant

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11 Hemorrhagic and thrombotic events according to HAS-BLED core., abnormal renal/liver function, stroke, bleeding and thrombotic events according to HAS- BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR [international normalized ratio], elderly, drugs/alcohol concomitantly) score. or predisposition, labile INR [international normalized ratio], elderly, drugs/alcohol concomitantly) score. Hemorrhagic and thrombotic events according to HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR [international normalized ratio], elderly, drugs/alcohol concomitantly) score. orrhagic and thrombotic events according to HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR [international normalized ratio], elderly, drugs/alcohol concomitantly) score. Pilar Gallego et al. Circ Arrhythm Electrophysiol. 2012;5: Copyright American Heart Association, Inc. All rights reserved.

12 CHOICES OF NEW ANTICOAGULANTS Dabigatran (Pradaxa) - direct thrombin inhibitor Rivaroxaban (Xarelto) - Factor Xa inhibitor Apixaban (Eliquis) - Factor Xa inhibitor Edoxaban (Savaysa) - Factor Xa inhibitor

13 Nonvalvular Atrial Fibrillation Why use one to the newer agents over warfarin? Class Advantages Noninferiority to warfarin Less intracranial bleeding Trend for reduced mortality No need for regular blood monitoring Far less drug interactions

14 Disadvantages of New Oral Anticoagulant Agents Cost.Cost.Cost Previously no way to reverse anticoagulant effect acutely

15 Best choices of Anticoagulant for Different Clinical Situations for Patients in Atrial Fibrillation Characteristic Drug choice Rationale Mechanical valve or valvular afib Warfarin New agents not studied Stable on warfarin Warfarin Consider switch at pts choice CrCl < 30 ml/min Warfarin Essentially pts excluded from new drug trial CrCl of ml/min Rivaroxaban or apixaban or edoxaban Oral factor Xa are less affected by impaired renal fxn Dyspepsia Rivaroxaban or apixaban 10% rate of dyspepsia with dabigatran

16 Best choices of Anticoagulant for Different Clinical Situations for Patients in Atrial Fibrillation Characteristic Drug choice Rationale Recent GI bleed Apixaban More GI bleeds with dabigatran or rivaroxaban than warfarin Recent ischemic stroke on warfarin Recent acute coronary syndrome Poor compliance with twice daily regimen Dabigatran Apixaban/Edoxaban or Rivaroxaban Rivaroxaban or Edoxaban Dabigatran associated with lower risk of ischemic stroke than warfarin Slight increase in MI with dabigatran

17 Anticoagulation Therapy with Stents and Atrial Fibrillation Less risk of bleeding with clopidogrel (Plavix) as antiplatelet agent rather than prasugrel (Effient) Less bleeding risk with clopidogrel and ASA or clopidogrel and oral anticoagulant versus triple therapy ( ASA, clopidogrel and oral anticoagulant ) Best evidence for less ischemic cardiac events is with clopidogrel and oral anticoagulant by meta-analysis.

18 Anticoagulation Therapy with Stents and Atrial Fibrillation If CHADS-VASc score > or = 2, consider dual therapy with clopidogrel (Plavix) and warfarin/new oral anticoagulant only and drop ASA If they have CHADS-VASc score of 2 or more, try to place bare metal stent due shorten duration of need for dual antiplatelet therapy If CHADS-VASc score is 0 or 1, consider standard therapy of ASA and clopidogrel after stent placement

19 Threat of lawsuits against each of the new anticoagulants

20 New Anticoagulants in DVT/PTE Each of the newer agents have indication for treatment of acute DVT and/or PTE Rivaroxaban and Apixaban can be started initially without overlap of parental or low molecular weight Heparin ( single agent use ) Dabigatran and Edoxaban are indicated with 5-10 days of parental or low molecular weight Heparin first after initial diagnosis of DVT/PTE

21 Conclusions 1. New Anticoagulants are improvement in certain patient population for treatment of nonvalvular atrial fibrillation, DVT, and PTE 2. Assess who needs anticoagulation 3. Risk assessment tools for stroke in atrial fibrillation 4. Objectively assess risk of bleeding to help justify use or nonuse of anticoagulants. 5. Still need clinical judgement

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