Emerging Challenges In Primary Care: 2015

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1 Care Se'ng Emerging Challenges In Primary Care: 2015 Preventing Stroke in Patients with Atrial Fibrillation: New Concepts and Controversies 1 Faculty Elizabeth A. Jackson, MD, MPH Associate Professor of Medicine Division of Cardiovascular Medicine University of Michigan Health Systems Ann Arbor, MI 2 Disclosures Elizabeth A. Jackson, MD, MPH serves as an editor for the American Journal of Medicine. Dr. Jackson is a consultant for McKesson, Inc.. Dr. Jackson also serves as an investigator/ reviewer at the National Institute of Health. Dr. Jackson is an author for Up-to-Date and Spry Publishing. Dr. Jackson is also a consultant/editor for the American College of Cardiology. Dr. Jackson is an expert witness for Motley Rice, LLC. 3 Care: 2015 Atrial Fibrillation - 1

2 Learning Objectives After participating in the proposed educational activities, clinicians should be better able to: 1. Recognize the risk of cardioembolic stroke in patients with atrial fibrillation (AF) and the importance of prophylaxis 2. Discuss current recommendations for cardioembolic stroke risk reduction in individual patients 3. Recognize the need for good clinician-patient communication about the benefits and risks of antithrombotic therapy for stroke risk reduction, and the importance of persistence with therapy 4. Describe the management of bleeding in AF patients on oral anticoagulant therapy for stroke risk reduction 4 Pre-Test Questions 5 Pre-test ARS Question 1 On a scale of 1 to 5, please rate how confident you would be in managing anticoagulation in patients with atrial fibrillation. 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 6 Care: 2015 Atrial Fibrillation - 2

3 Pre-test ARS Question 2 Sarah E, a 68 y/o Hispanic female with a history of HTN, was asymptomatic until 2 days ago when she developed intermittent palpitations and presented to your office. EKG: AF at 120 bpm. Sarah s CHA 2 DS 2 -VASc score is: Not sure 7 Pre-test ARS Question 3 A 62 y/o dermatologist has recently been diagnosed with AF. He has hypertension and type 2 diabetes, both of which are well controlled. Being a physician, he asks "I've read about all the treatments; which is the best treatment for my AF?" You should answer 1. All of the newer agents are statistically superior to warfarin for stroke risk reduction 2. The major reason to provide warfarin is because overall costs with warfarin are much less than other agents 3. In the absence of head-to-head trials, it is not possible to know if any one of the newer agents is superior to another 4. Major bleeding risk with all the newer agents is markedly less than with 8 warfarin Pre-test ARS Question 4 Alice is undergoing surgery for hernia repair. She is taking Dabigatran (Pradaxa) for her non-valvular AF. CBC and basic metabolic panel are wnl; Cr is 1.0, GFR is > 50 ml/min. What should be done about her Dabigatran perioperatively? 1. Continue Dabigatran without interruption 2. Discontinue Dabigatran 1-2 days preop, resume as soon as adequate hemostasis has been established 3. Discontinue Dabigatran 3-5 days preop, resume as soon as adequate hemostasis has been established 4. Discontinue Dabigatran on the day of surgery, resume as soon as adequate hemostasis has been established 9 Care: 2015 Atrial Fibrillation - 3

4 Pre-test ARS Question 5 Beth is a 68 y/o with AF on apixaban who is admitted after a MVA. The trauma surgeon needs to operate for probable major internal bleeding. CBC is pending. What do you recommend to reduce her bleeding? 1. Hold further doses of apixaban, RBC transfusion, delay surgery for 2 hours 2. Hold further doses of apixaban, colloids, fresh frozen plasma 3. Hold further doses of apixaban, RBC transfusion, prothrombin complex concentrate 4. Hold further doses of apixaban, colloids, delay surgery for 6 hours 10 AF: Major Teaching Points Stroke reduction with antithrombotic therapy (warfarin, dabigatran, rivaroxaban, apixaban, edoxaban) is SIGNIFICANT (±66% or more) ICH risk with warfarin is VERY LOW (<1%/yr) and EVEN LOWER with DOACS Assess bleeding risk in all patients & discuss benefits/risks of different agents Perioperative regimens for antithrombotic and antiplatelet therapies are specific to individual agents & procedure Antithrombotic therapy continued indefinitely, despite restoration of sinus rhythm in most patients 11 Atrial Fibrillation Stroke Risk in AF Patients Which Patients Benefit from Anticoagulation? 12 Care: 2015 Atrial Fibrillation - 4

5 Atrial Fibrillation Circulation 2006;114: Atrial Fibrillation and Stroke Severity Greater mortality and disability for ischemic strokes due to AF Higher mortality (AF vs. non-af): OR = 1.84, CI:1: Larger infarcts (52 ml vs. 16 ml, p=0.05) More severe hemorrhagic transformation (29% vs. 5%, p=0.002) Dulli DA et al. Neuroepidemiology. 2003;22: , Gage BF et al. JAMA. 2001;285: , Lin HJ et al. Stroke.1996;27: Ischemic Stroke Morbidity/ Mortality (%) Strokes not due to AF Strokes due to AF 41% 25% P = % P< % n Death Neurologically 14 Bedridden Assess Stroke Risk: Current AHA/ACC guidelines recommend the CHA 2 DS 2 -VASc Score 15 Care: 2015 Atrial Fibrillation - 5

6 CHA 2 DS 2 -VASc Case Study Tina is a 72 y/o woman with incidentally discovered atrial fibrillation when pulse irregularity was noted. She is asymptomatic, and takes no chronic medications. Her only chronic medical problem is tinnitus, for which she receives no treatment. What is the CHA 2 DS 2 -VASc score? 16 Tina, a 72 y.o. White Female What is Tina s CHA 2 DS 2 -VASc Score? Unsure 17 CHA 2 DS 2 -VASc Risk Factor Score C CHF 1 H HTN 1 A 2 Age 75 years 2 D Diabetes mellitus 1 S 2 History of stroke or TIA 2 V Vascular disease (MI, peripheral arterial disease, aortic atherosclerosis) 1 A Age years old 1 S c Sex category (female) 1 Lip GY, et al. Am J Med. 2010;123(6): Camm AJ, et al. Eur Heart J. 2010;31(19): Care: 2015 Atrial Fibrillation - 6

7 Use CHA 2 DS 2 -VASc for risk stratification Chest Feb;137(2): Ann Intern Med. 2007;146: Circulation April 10 (epub) Level I, ACC/AHA Atrial Fibrillation CHA 2 DS 2 -VASc Stroke Risk ESC Recommendation ACC/AHA Recommendation 2+ High Anticoagulate Anticoagulate 1 Intermediate Anticoagulate None, anticoagulate or ASA 0 Low None None 20 Anticoagulation in Care: 2015 Atrial Fibrillation - 7

8 Stroke/yr (%) AF Warfarin Trials: Reduction in Stroke Rates and Mortality N=2,900 Mean age = 69 20% > age 75 Stroke rates reduced 62% All cause mortality RRR = 26%.. placebo warfarin AFASAK SPAF BAATAF CAFA SPINAF EAFT Hart et al. Ann Intern Med. 1999;131: Warfarin Reality Odds Ratio Adjusted Odds in Relation to Intensity of Anticoagulation Stroke Therapeutic Range INR Bleeding Risk Adapted from N Engl J Med 1996;335:540. Fuster et al. J Am Coll Cardiol. 2001;38: Unfractionated Heparin XII XI IX Low Molecular Weight Heparin FDA-Approved Antithrombotics VIII X V II I Fibrin Clot VII Oral Xa Inhibitors Rivaroxaban Apixaban, Edoxaban Warfarin Oral IIa (Direct Thrombin) Inhibitor Dabigatran 24 Care: 2015 Atrial Fibrillation - 8

9 DOACS/NOACS 1. DOACs Direct Oral Anticoagulants (preferred term) 2. NOACs New Oral Anticoagulants 25 Characteristics of the DOAC s Mechanism of Action Dabigatran Rivaroxaban Apixaban Thrombin inhibitor Factor Xa inhibitor Factor Xa inhibitor Edoxaban Factor Xa inhibitor T1/ hours 5-9 hours 12 hours 6-12 hours Regimen BID QD BID QD Time to Peak (hrs) Renal Excretion ~3 80% 36%-45% 25%-30% 35% Metabolism and Uptake P-gp CYP3A4, P-gp CYP3A4, P-gp CYP3A4, P-gp CYP3A4 = cytochrome P450 3A4; P=gp = P-glycoprotein Usman MH et al. Curr Treat Cardiovasc Med 2008;10: Piccini JP et al. Curr Opin Cardiol 2010;25: RE-LY Stroke/Systemic Embolism Warfarin Dabigatran 110 mg Dabigatran 150 mg HR RR = 0.66 p < 0.00l Months 27 Connolly SJ et al Dabigatran vs Warfarin in Patients with AF NEJM 2009;361: Care: 2015 Atrial Fibrillation - 9

10 RE-LY Major Endpoints N=18,113 patients HR 0.93 (95% CI 0.81, 1.07) P=0.32 P=0.13 HR 0.66 (95% CI 0.53, 0.82) P<0.001 P=0.35 P<.001 P<.001 Efficacy Safety All p values are superiority of dabigatran AF=Atrial fibrillation, GI=Gastrointestinal, MI=Myocardial infarction, TTR=Time in therapeutic range 28 Connolly SJ et al. N Engl J Med 2009;361: , Connolly SJ et al. N Engl J Med 2011;363: ROCKET-AF Stroke/Systemic Embolism 6-5- Warfarin Rivaroxaban 20 mg QD 2.2%/yr % Events/ yr Days 1.7%/yr RR = 0.79 Noninferiority p < 0.00l Patel MR, et al N Engl J Med 2011;365(10): ROCKET-AF Major Endpoints N=14,264 patients TTR 55% HR 0.88 (95% CI 0.75, 1.03) N.I.: P<0.001 S: p=0.12 P=0.58 HR 1.03 (95% CI 0.96, 1.11) S: P=0.44 P<.0001 P=0.07 P<0.024 Efficacy p values are either non-inferiority (N.I.) or superiority (S) of rivaroxaban AF=Atrial fibrillation, GI=Gastrointestinal, Relev = Clinically relevant, TTR=Time in therapeutic range Patel MR, et al. N Engl J Med 2011; 365: Safety 30 Care: 2015 Atrial Fibrillation - 10

11 ARISTOTLE Stroke/Systemic Embolism 6-5- Warfarin Apixaban QD 2.2%/yr % Events/ yr Days 1.7%/yr RR = 0.79 Noninferiority p < 0.00l Superiority p = 0.01 Granger CB, et al N Engl J Med 2011;365(11): ARISTOLE Major Endpoints N=18,113 patients TTR 62% HR 0.69 (95% CI 0.60, 0.80) P<0.001 P=0.47 HR 0.79 (95% CI 0.66, 0.95) P<0.01 P<.001 P=0.42 P=0.37 Efficacy All p values are superiority of apixaban AF=Atrial fibrillation, GI=Gastrointestinal, TTR=Time in therapeutic range Granger CB, et al. NEJM 2011;365: Safety 32 ENGAGE AF Study Design 21,105 patients with non-valvular AF; CHADS 2-3, 4-6 Edoxaban 30 mg QD Edoxaban 60 mg QD Warfarin INR target 2-3 Duration: 2.8 years (median) mitt, non-inferiority Primary Endpoint: Stroke (thrombotic or hemorrhagic), systemic embolism Safety Endpoint: Major bleeding Ruff CR et al. Am Heart J 2010; 160:635-41; Giugliano R, et al, NEJM 2013;369: Care: 2015 Atrial Fibrillation - 11

12 ENGAGE AF Major Endpoints N=21,105 patients TTR 68.4% mitt HR 0.79 (95% CI 0.63, 0.99) N.I.: P< S: p=0.017 ITT: HR 0.87 (p=0.08) HR 0.80 (95% CI 0.71, 0.91) S: P<0.001 P=0.08 P=0.97 P=.0.03 P<.0001 Efficacy Safety p values are either non-inferiority (N.I.) or superiority (S) of rivaroxaban AF=Atrial fibrillation, GI=Gastrointestinal, Relev = Clinically relevant, TTR=Time in therapeutic range Ruff CR et al. Am Heart J 2010; 160:635-41; Giugliano R, et al, NEJM 2013;369: Recommended Dosing Dabigatran 150mg twice daily : CrCl > 30 ml/min 75mg twice daily : CrCl Rivaroxiban 20mg once daily: CrCl > 50 15mg once daily: CrCl Edoxaban 60 mg once daily: CrCl > mg once daily: CrCl mg once daily Apixaban 5mg twice daily 2.5mg twice daily if 2 of following 3: Age 80 Body weight Κ 60kg Creat 1.5mg/dL 35 Heidbuchel H, et al Europace ; Care: 2015 Atrial Fibrillation - 12

13 Drug interactions 37 Heart.org/Medscape Sept 2014 DOACs in NVAF: Clinical Trials Stroke or systemic embolism Ischemic stroke ICH Worse than warfarin Non-inferior to warfarin Superior to warfarin Dabigatran 150mg Rivaroxaban Apixaban Edoxaban 60mg Death Major bleeding Bleeding Complica5ons GI bleeding RELY Connolly NEJM 2009; 361: ; ROCKET-AF Patel NEJM 2011; 365: ARISTOTLE Granger NEJM 2011; 365:981-92; ENGAGE AF Giugliano NEJM 2013;369: Novel Anticoagulant and AF Meta-Analysis 12 Phase II & III studies compared to warfarin, 54,875 patients Stroke, embolism RR 0.77 (95%CI: 0.7, 0.86) ARR 0.74% NNT 135 Major Bleeding RR 0.86 (95%CI: 0.8, 0.93) ARR 0.64% NNT 156 Total Mortality RR 0.89 (95%CI: 0.83, 0.96) ARR 0.41% NNT 244 Dentali F, et al. Circ 2012;126: Care: 2015 Atrial Fibrillation - 13

14 Thomas Thomas is a 62 yo male with AF who is currently on warfarin. He does not want to get repeated lab work and would like to consider switching to a DOAC. You plan to start rivaroxaban. What should you do to transition from warfarin to rivaroxaban? 1. Start rivaroxaban 20 mg QD the day you stop warfarin 2. Start rivaroxaban 15 mg QD, when INR < 2.0 increase rivaroxaban to 20mg QD 3. Check renal function, stop warfarin, when INR < 2.0 start rivaroxaban 20mg QD 4. Check renal function, stop warfarin, when INR < 3.0 start rivaroxaban 20mg QD 40 Transitioning General Tips Warfarin to NOAC/DOAC Stop warfarin Start dabigatran, apixaban when the INR < 2.0 Start rivaroxaban when INR < 3.0. Start edoxaban when INR 2.5 Parenteral Anticoagulant to NOAC/DOAC Intermittently administered parenteral anticoagulant: Start dabigatran, rivaroxaban or apixaban 0-2 hrs before time of next dose Continuously administered parenteral anticoagulant: Start dabigatran or rivaroxaban at the time of discontinuation. Stop anticoagulant and start edoxaban after 4 hours. Food and Drug Administration. Rivaroxaban or Dabigatran. Available at: 41 Transitioning General Tips, cont. DOAC to Warfarin: Stop apixaban or rivaroxaban, start warfarin and bridging agent at time next DOAC dose due Patients with lower CrCl may have lingering DOAC effect DOAC to DOAC or bridging agent: Start new one at time of next expected dose Kovacs R, et al JACC Care: 2015 Atrial Fibrillation - 14

15 NOAC Dosing by Renal Function Dabigatran 150 mg BID 75 mg BID X Rivaroxaban 20 mg QD 15 mg QD X Edoxaban X 60 mg QD 30 mg QD X Apixaban Creatinine Clearance (ml/min) 5 mg BID 2.5 mg BID* 1.5 Creatinine (ml/min) * Creatinine 1.5 mg/dl, weight 60 kg, age 80 years Patient Provider Communication: Improving Adherence 44 JANE Jane is a 78 yo with AF who was recently started on anticoagulation. When she comes in for visits what are factors related to her adherence for this treatment strategy? 1. Ask the patient if she misses any doses of medications. 2. Ask about any concerns she may have about her medications at every visit? 3. Stress the importance of adherence to her medication at every visit. 4. Provide education as to why anticoagulation is important for reducing her risk of stroke in the setting of Atrial Fibrillation. 5. All of the above 45 Care: 2015 Atrial Fibrillation - 15

16 Importance of Adherence and Persistence Persistence Stopping an anticoagulant (warfarin or DOACS) 16.6% to 27.5% discontinue < 2 years (from trial data) Adherence Poor Time in Therapeutic Range (TTR) Increased risk of Stroke, Intracranial Hemorrhage, and Death Direct Oral Anticoagulants (DOACs) Short half-life Chest Feb;137(2): Circulation CVQO. 2011;4: DOAC Direct Oral Anticoagulant J Thromb Haemost Apr 16. doi: /jth Thromb Res 133 (2014) Persistence: Real World Data Warfarin and Rivaroxaban Persistence: CMRO 2014:1-9 Non-persistence = >60 days without medication refill 47 Tools to Enhance Communication ACC/AHA many only resource and apps Anticoagulation Clinic - source of information Patient Selection Decision aids & online resources Patient Education Education on administration, review of side effects and the importance of adherence Ongoing Monitoring JAMA 2015; 313(14): Re-assess adherence, side effects, renal function Peri-procedural management 48 Care: 2015 Atrial Fibrillation - 16

17 How important is this to the patient? Issue Very Important Important Unimportant Size of pill and number of times per day it is taken Risk of Stroke on/off the medication Risk of major bleeding Other side effects Need for regular lab work Adapted from How important is this to the patient? Issue Very Important Important Unimportant Need to change my diet Will the medication interact with other meds What do I do if I need urgent surgery Cost Adapted from Management of Bleeding 51 Care: 2015 Atrial Fibrillation - 17

18 Assess Bleeding Risk when Starting Anticoagulant Therapy HASBLEED Provides information on bleeding risk Allows for discussion of bleeding risks compared to stroke risks (using CHADS VASC) Chest Nov;138(5): Atrial Fibrillation Marcucci, AJM epub May 13, 2014 NOAC Management of Bleeding FXa Inhibitors (Apixaban, Rivaroxaban, Endoxaban) Local hemostasis & Fluid Replacement (colloids) Transfusion of RBCs Platelets Fresh frozen plasma (not a reversal therapy, but plasma expander Prothrombin Complex Concentrate (PCC) U/kg Varies between companies and Varies with NOACs Data on outcomes using PCC lacking 4-factor PCC (factors II, VII, IX, X) 3-factor PCC (factors II, IX, X) Activated factor VII 54 Care: 2015 Atrial Fibrillation - 18

19 NOAC Management of Bleeding Direct Thrombin Inhibitors (Dabigatran) Local hemostasis & Fluid Replacement (colloids) Transfusion of RBCs Platelets Fresh frozen plasma (not a reversal therapy, but plasma expander Dialysis (-65% after 4 hours) Prothrombin Complex Concentrate (PCC) U/kg Varies between companies and Varies with NOACs Data on outcomes using PCC lacking 4-factor PCC (factors II, VII, IX, X) 3-factor PCC (factors II, IX, X) Activated factor VII 55 NOAC antidotes Under Investigation Andexanet (PRT064445) For factor Xa inhibitors Modified FXa molecule which binds to FXa inhibitor Allows pt s intrinsic FXa to act in coagulation Aripazine (PER977) For factor Xa inhibitors, Synthetic small molecule directly binds factor X agents (also binds to heparin products) Idarucizumab (BI ) For Dabigatran Humanized antibody fragment REVERSE-AD trial is ongoing Kovacs et al, JACC 2015 Warfarin Management of Bleeding Vitamin K IV does not reduce INR for ~ 6 hours (24 + hours for complete reversal) also potential allergic reaction SC or IM admin of Vitamin K not recommended PO Vitamin K used for minor bleeds with elevated INR Fresh frozen plasma (may need large amount to increase coagulation factors be careful in patients with HF/CAD) Prothrombin Complex Concentrate (PCC) can improve INR within minutes Recombinant factor VIIa Local hemostasis & Fluid Replacement (colloids) Transfusion of RBCs Care: 2015 Atrial Fibrillation - 19

20 Atrial Fibrillation Survival Curves by Bleeding and Stroke Risk Multivariate HR for all ranges of HAS- BLED in favor of anticoagulation Composite endpoint: Death, Stroke, ICH Circ 2012; 125: Perioperative Management of Antithrombotic Therapy Care: 2015 Atrial Fibrillation - 20

21 Warfarin Bridging Key Question: Is bridging necessary? Safe for on-treatment procedures Dental cleaning and extraction Bone marrow biopsy Endoscopy (± mucosal biopsy) Cataract surgery Pacemaker Placement Venography Derm surgery Joint aspiration Circulation 2012;126: Primary Recommendations When Warfarin Must Be Withheld for Surgery Stop VKA 5 days preop (not less) Resume VKA hr postop (not later) assuming adequate hemostasis LOW risk: no bridging HIGH risk: bridging INTERMEDIATE: individualize Douketis JD et al Chest 2012;141;e326-e350S 62 Risk Stratification for Perioperative Thromboembolism: AF Risk High Moderate CHADS 3-4 Low CHADS 0-2 AF CHADS score 5 Stroke/TIA within 3 months Rheumatic heart valve disease Douketis JD et al Chest 2012;141;e326-e350S 63 Care: 2015 Atrial Fibrillation - 21

22 Manageing NOACS in the Perioperative Setting Apixaban (Eliquis) Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Edoxaban (Savaysa) 64 Surgery: Dabigatran (Pradaxa) GFR 50 ml/min: DC 1-2 days pre-op GFR < 50 ml/min: DC 3-5 days pre-op Consider longer for major surgery spinal puncture spinal or epidural catheter/port Need for complete hemostasis Dabigatran Prescribing Information 65 Rivaroxaban (Xarelto) DC 24 hrs pre-op Restart post-op as soon as adequate hemostasis has been established Rivaroxaban Prescribing Information DC 48 hrs pre-op for procedures with mod-high risk of clinically significant bleed DC 24 hrs pre-op for procedures with low risk of bleed (or non critical & easily controlled area) Apixaban Prescribing Information Apixaban (Eliquis) 66 Care: 2015 Atrial Fibrillation - 22

23 AF: Major Teaching Points Stroke reduction with antithrombotic therapy (warfarin, dabigatran, rivaroxaban, apixaban, edoxaban) is SIGNIFICANT (±66% or more) ICH risk with warfarin is VERY LOW (<1%/yr) and EVEN LOWER with NOACS Assess bleeding risk in all patients & discuss benefits/risks of different agents Perioperative regimens for antithrombotic and antiplatelet therapies are specific to individual agents & procedure Antithrombotic therapy continued indefinitely, despite restoration of sinus rhythm in most patients 67 Post-Test Questions 68 Post-test ARS Question 1 Sarah E, a 68 y/o Hispanic female with a history of HTN, was asymptomatic until 2 days ago when she developed intermittent palpitations and presented to your office. EKG: AF at 120 bpm. Sarah s CHA 2 DS 2 -VASc score is: Not sure 69 Care: 2015 Atrial Fibrillation - 23

24 Post-test ARS Question 2 A 62 y/o dermatologist has recently been diagnosed with AF. He has hypertension and type 2 diabetes, both of which are well controlled. Being a physician, he asks "I've read about all the treatments; which is the best treatment for my AF?" You should answer 1. All of the newer agents are statistically superior to warfarin for stroke risk reduction 2. The major reason to provide warfarin is because overall costs with warfarin are much less than other agents 3. In the absence of head-to-head trials, it is not possible to know if any one of the newer agents is superior to another 4. Major bleeding risk with all the newer agents is markedly less than with 70 warfarin Post-test ARS Question 3 Alice is undergoing surgery for hernia repair. She is taking Dabigatran (Pradaxa) for her non-valvular AF. CBC and basic metabolic panel are wnl; Cr is 1.0, GFR is > 50 ml/min. What should be done about her Dabigatran perioperatively? 1. Continue Dabigatran without interruption 2. Discontinue Dabigatran 1-2 days preop, resume as soon as adequate hemostasis has been established 3. Discontinue Dabigatran 3-5 days preop, resume as soon as adequate hemostasis has been established 4. Discontinue Dabigatran on the day of surgery, resume as soon as adequate hemostasis has been established 71 Post-test ARS Question 4 Beth is a 68 y/o with AF on apixaban who is admitted after a MVA. The trauma surgeon needs to operate for probable major internal bleeding. CBC is pending. What do you recommend to reduce her bleeding? 1. Hold further doses of apixaban, RBC transfusion, delay surgery for 2 hours 2. Hold further doses of apixaban, colloids, fresh frozen plasma 3. Hold further doses of apixaban, RBC transfusion, prothrombin complex concentrate 4. Hold further doses of apixaban, colloids, delay surgery for 6 hours 72 Care: 2015 Atrial Fibrillation - 24

25 Post-test ARS Question 5 On a scale of 1 to 5, please rate how confident you would be in managing anticoagulation in patients with atrial fibrillation. 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 73 Post-test ARS Question 6 Which of the statements below describes your approach to anticoagulation of patients with atrial fibrillation: 1. I do not manage anticoagulation of patients with atrial fibrillation, nor do I plan to this year. 2. I did not manage anticoagulation of patients with atrial fibrillation before this course, but as a result of attending this course I m thinking of managing it now. 3. I do manage anticoagulation of patients with atrial fibrillation and this course helped me change my treatment methods. 4. I do manage anticoagulation of patients with atrial fibrillation and this course confirmed that I don t need to change my treatment methods. 74 QUESTIONS 75 Care: 2015 Atrial Fibrillation - 25

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