Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial
|
|
- Cory Whitehead
- 8 years ago
- Views:
Transcription
1 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 Azienda Ospedaliera Sant Andrea
2 Disclosures: none
3 AF: The Most Common Arrhythmia It has been estimated that 2.2 million people in America and 4.5 million in the European Union have paroxysmal or persistent AF The estimated prevalence of AF is 0.4% to 1% in the general population, increasing with age Accounts for approximately 1/3 of hospitalizations for cardiac rhythm disturbances
4 Prevalence (%) AF Prevalence: Age and Gender Prevalence of atrial fibrillation with age Age, years JAMA 2001; 285: 2370
5 Patient characteristcs Data from Euro Heart Survey on Atrial Fibrillation First detected Paroxymal Persistent Permanent Age (years) Female gender (%) Hypertension (%) CAD (%) Heart failure (%) Valvular heart disease (%) Diabetes (%) Previous tromboembolism (%) Stroke (%) European Heart Journal (2005) 26,
6 Consequences of atrial fibrillation Thromboembolism Risk of stroke 5-fold Mortality Risk 2 fold in CV disease Reduction of quality of life Impaired hemodynamics Heart failure Hospitalization Risk 2-3-fold
7 Hemodynamic stabilization Rate Rhythm control Management of atrial fibrillation Thromboembolism prevention Antithrombotic Therapy
8 Risk stratification
9 Stroke Rate (% per year) Stroke Risk in Atrial Fibrillation Data from Framingham Heart Study Age (years) Stroke 1991;22;
10 Risk Stratification in AF Stroke Risk Factors High-Risk Factors Mitral stenosis Prosthetic heart valve History of stroke or TIA Moderate-Risk Factors Age >75 years Hypertension Diabetes mellitus Heart failure or LV function Less Validated Risk Factors Age years Coronary artery disease Female gender Thyrotoxicosis Dubious Factors Duration of AF Pattern of AF Left atrial diameter AHA/ACC/ESC guidelines on atrial fibrillation 2006
11 Nonvalvular Atrial Fibrillation Stroke Rates Without Anticoagulation According to Isolated Risk Factors 15 12,5 10 7,5 5 2,5 0 Prior Stroke/TIA Age > 75 years Hypertension Diabetes Heart Failure LVEF Hart RG et al. Neurology 2007; 69: 546.
12 The CHADS 2 Index Stroke Risk Score for Atrial Fibrillation Score (points) Prevalence (%) Congestive Heart failure 1 32 Hypertension 1 65 Age >75 years 1 28 Diabetes mellitus 1 18 Stroke or TIA 2 10 Moderate-High risk > Low risk VanWalraven C, et al. Arch Intern Med 2003; 163:936.
13 The CHADS 2 Index Stroke Risk Score for 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: 2287.
14 Antithrombotic therapy in atrial fibrillation ASA Warfarin ASA Clopidogrel New antithrombotic drugs
15 Antiplatelet therapy vs placebo N Patientevents Year AFASAK ASA Risk Reduction (%) SPAF Relative RR vs. placebo 19% EAFT Absolute risk 130 reduction 838 primary 0.8%/yr Absolute risk reduction secondary 2.5%/yr Combined NNT primary prevention 125 NNT secondary prevention ASA better ASA worse -100 Hart RG et al. Ann Intern Med 2007; 146:
16 Warfarin therapy vs placebo N Patientevents Year AFASAK BAATAF CAFA SPAF SPINAF Combined Warfarin Risk Reduction (%) Relative RR vs. placebo 64% Absolute risk reduction primary 2.7%/yr Absolute risk reduction secondary 8.4%/yr NNT primary prevention 37 NNT secondary prevention Warfarin better Warfarin worse -100 Hart RG et al. Ann Intern Med 2007; 146:
17 ASA + Clopidogrel Documented AF + 1 risk factor for Stroke ACTIVE W ASA + Clopidogrel versus VKA
18 ACTIVE W Failure of clopidogrel/asa to prevent stroke, embolism, MI or vascular death compared to anticoagulant therapy Lancet 2006; 367:
19 Antithrombotic Therapy for Atrial Fibrillation ACC/AHA/ESC Guidelines 2006 No risk factors CHADS 2 = 0 Risk Factor One moderate risk factor CHADS 2 = 1 Any high risk factor or >1 moderate risk factor CHADS 2 >2 or Mitral stenosis Prosthetic valve Recommended Therapy Aspirin, mg qd Aspirin, mg/d or Warfarin (INR , target 2.5) Warfarin (INR , target 2.5) Warfarin (INR , target 3.0)
20 Limitations of Warfarin Limitation Slow onset of action Genetic variation in metabolism Multiple food and drug interactions Narrow therapeutic index Consequence Overlap with a parenteral anticoagulant Variable dose requirements Frequent coagulation monitoring Frequent coagulation monitoring Risk of fatal bleeding (1,5% per year)
21 Adequacy of Anticoagulation in Patients with AF in Primary Care Practice Warfarin 50% Contraindication 25% No compliance 25% Therapeutic range 50% Higher 20% Lower 30% Samsa GP, et al. Arch Intern Med 2000;160:967.
22 New Oral Anticoagulants for Stroke Prevention in AF
23 Factor X Otamixaban Rivaroxaban Apixaban Factor Xa AT III Fondaparinux AT III LMWH Heparin Pro-thrombin Thrombin Bivalirudina (ev) Ximelagatran (os) Dabigatran (os)
24 PHASE III TRIALS IN PATIENTS WITH AF Direct inhibitors of Xa Direct inhibitors of thrombin Rivaroxaban ROCKET-AF (ongoing) Apixaban ARISTOTLE (ongoing) Dabigatran RE-LY Ximelagatran SPORTIF
25 Dabigatran etexilate is approved as Pradaxa in over 28 countries for the primary prevention of venous thromboembolic events (blood clots) in adults who have undergone elective total hip or elective total knee replacement surgery. Dabigatran etexilate (Boeringher Ingelheim) is not approved by the FDA.
26
27 Comparison of Features of Dabigatran With Those of Warfarin Features Warfarin Dabigatran Onset Slow Rapid Dosing Variable Fixed Food effect Yes No Drug interactions Many Few Monitoring Yes No Half-life Long Short Antidote Yes No
28 New treatment superior Standard treatment superior SUPERIORITY NON INFERIORITY EQUIVALENCE - % 1 + %
29 Dabigatran versus Warfarin in Patients with Atrial Fibrillation Follow up (median): 2 years Dabigatran 110 mg patients with atrial fibrillation and a risk for stroke Dabigatran 150 mg Warfarin sec INR NEJM 2009; 12(361):139
30 RE-LY: Baseline Characteristics Characteristic Dabigatran 110 mg Dabigatran 150 mg Warfarin Randomized Mean age (years) Male (%) CHADS2 score (mean) 0-1 (%) 2 (%) 3+ (%) Prior stroke/tia (%) Prior MI (%) CHF (%) Baseline ASA (%) Warfarin Naïve (%) Connolly et al., NEJM, 2009
31 Time in Therapeutic Range (TTR) with Warfarin in the RE-LY Trial 64% As in other trials...
32 % event/year Dabigatran versus Warfarin in Patients with AF PRIMARY OUTCOME 1,8 Efficacy end-point 1,5 1,2 0,9 0,6 0,3 0 Systemic embolism Stroke or stroke Warfarin - adjusted dose 1,69 1,2 Dabigatran mg 1,53 1,34 Dabigatran mg 1,11 0,92
33 RE-LY: Systemic embolism or stroke Dabigatran 110 vs. Warfarin HR 0.91 Non-inf p-value <0.001 Sup p-value 0.34 Dabigatran 150 vs. Warfarin HR 0.66 <0.001 <0.001 Margin = 1.46 Connolly et al., NEJM, 2009 Dabigatran better HR (95% CI) Warfarin better
34 RELY: results by CHADS2 Score Dabigatran 110 vs. Warfarin Dabigatran 150 vs. Warfarin CHADS2 1 CHADS2 2 CHADS2 3+ p=0.41 p= HR (95% CI) Dabigatran better Warfarin better HR (95% CI) Dabigatran better Warfarin better
35 RE-LY: Secondary Efficacy Outcomes According to Treatment Group Event (% per year) Warfarin Dabigatran 110 mg Dabigatran 150 mg All-cause mortality Vascular death Myocardial infarction Connolly, et al. N Engl J Med 2009;361: Increased myocardial infarction: Dabigatran harmful or Warfarin protective?
36 % event/ year Dabigatran versus Warfarin in Patients with AF BLEEDINGS Safety end-point 3,5 3 2,5 Dabigatran 150 mg increased G-I bleeding RR = ,5 1 0,5 0 Major bleeding Hemorrhagic Gastrointestinal stroke Warfarin - adjusted dose 3,36 0,38 1,02 Dabigatran mg 2,71 0,1 1,12 Dabigatran mg 3,11 0,12 1,51
37 % event/year Net clinical benefit 7,8 7,64 7,6 Major vascular events Major bleeding 7,4 7,2 7 7,09 6,91 Warfarin - adjusted dose Dabigatran mg Death 6,8 6,6 Dabigatran mg 6,4 Net clinical benefit
38 Concerns with dabigatran Dyspepsia: 12% in dabigatran group Renal function Elderly Low weight Drug interaction: P-glycoprotein inhibitors Amiodarone Verapamil Quinidine Hepatotossicity: 2% in dabigatran group
39 Differences in price Warfarin (1 month): $ 35 (including cost of monitoring) Dabigatran 110 mg (1 month): $ 339 Can we afford RE-LY? N Engl J Med 2009;361:2674-5
40 Possible dabigatran scenarios in AF Lower-dose regimen Elderly Renal insufficiency Lower stroke risk (CHADS 2 score of 1) Higher-dose regimen Higher stroke risk (CHADS 2 score 2)
41 Conclusions The past twenty years have led to a considerable improvement in the antithrombotic prophylaxis of AF Warfarin has demonstrated his superiority compared with treatment with both ASA alone and ASA plus clopidogrel
42 Conclusions Dabigatran (as other new drugs) may represent a therapeutic revolution that will likely overcome conventional therapy offering both patients and clinicians a better tolerability and manageability. In this way, we hope this new drug(s) will bring effective anticoagulation to a wider segment of the population at risk and help to prevent strokes.
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 informationSTROKE 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 informationNew 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 informationAnticoagulation 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 informationNew 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 informationSTROKE 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 informationRR 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 information4/9/2015. 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 informationThe 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 informationAntiplatelet 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 information3/25/14. 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 information1/7/2012. 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 informationKevin 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 informationAntiplatelet 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 informationAnalyzing 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 informationNOAC 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 informationAF, 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 information22-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 informationNovel 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 informationAHA/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 information9/5/14. Objectives. Atrial Fibrillation (AF)
Novel Anticoagulation for Prevention of Stroke in Patients with Atrial Fibrillation Objectives 1. Review current evidence on use of warfarin in individuals with atrial fibrillation 2. Compare the three
More informationCurrent 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 informationCardiology 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 informationDevang 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 informationNew 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 informationAnticoagulation: 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 informationThe 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 informationTime 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 informationGoals 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 informationHow 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 informationCommittee Approval Date: September 12, 2014 Next Review Date: September 2015
Medication Policy Manual Policy No: dru361 Topic: Pradaxa, dabigatran Date of Origin: September 12, 2014 Committee Approval Date: September 12, 2014 Next Review Date: September 2015 Effective Date: November
More informationThe 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 informationDERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF)
DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) Key priorities Identification and diagnosis Treatment for persistent AF Treatment for permanent AF Antithrombotic
More information3/3/2015. Patrick Cobb, MD, FACP March 2015
Patrick Cobb, MD, FACP March 2015 I, Patrick Cobb, MD, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict
More informationAnticoagulation 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 informationPHARMACOLOGICAL 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 informationAnticoagulants 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 informationThree new/novel oral anticoagulants (NOAC) have been licensed in Ireland since 2008:
Key Points to consider when prescribing NOACs Introduction Three new/novel oral anticoagulants (NOAC) have been licensed in Ireland since 2008: Dabigatran Etexilate (Pradaxa ) 75mg, 110mg, 150mg. Rivaroxaban
More informationThe 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 informationTreating AF: The Newest Recommendations. CardioCase presentation. Ethel s Case. Wayne Warnica, MD, FACC, FACP, FRCPC
Treating AF: The Newest Recommendations Wayne Warnica, MD, FACC, FACP, FRCPC CardioCase presentation Ethel s Case Ethel, 73, presents with rapid heart beating and mild chest discomfort. In the ED, ECG
More informationXarelto (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 informationAtrial 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 informationAnticoagulation 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 informationFDA 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 informationManagement 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 informationNew 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 informationPrevention 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 informationFinancial 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 informationManagement 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 informationNon- 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 informationNORTH WEST LONDON GUIDANCE ANTITHROMBOTIC MANAGEMENT OF ATRIAL FIBRILLATION
North West London CardioVascular & Stroke Network NORTH WEST LONDON GUIDANCE ON ANTITHROMBOTIC MANAGEMENT OF ATRIAL FIBRILLATION Key Messages 1. Efforts should be made to identify patients with Atrial
More informationNew Oral Anticoagulants. How safe are they outside the trials?
New Oral Anticoagulants How safe are they outside the trials? Objectives The need for anticoagulant therapy Indications for anticoagulation Traditional anticoagulant therapies Properties of new oral anticoagulants
More informationAppendix C Factors to consider when choosing between anticoagulant options and FAQs
Appendix C Factors to consider when choosing between anticoagulant options and FAQs Choice of anticoagulant for non-valvular* atrial fibrillation: Clinical decision aid Patients should already be screened
More informationDabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism ERRATUM
Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism ERRATUM This report was commissioned by the NIHR HTA Programme as project number 12/78
More informationHow 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 informationBreadth 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 informationApixaban Plus Mono vs. Dual Antiplatelet Therapy in Acute Coronary Syndromes: Insights from the APPRAISE-2 Trial
Apixaban Plus Mono vs. Dual Antiplatelet Therapy in Acute Coronary Syndromes: Insights from the APPRAISE-2 Trial Connie N. Hess, MD, MHS, Stefan James, MD, PhD, Renato D. Lopes, MD, PhD, Daniel M. Wojdyla,
More informationHow 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 informationNone. 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 informationTHE INTERNET STROKE CENTER PRESENTATIONS AND DISCUSSIONS ON STROKE MANAGEMENT
THE INTERNET STROKE CENTER PRESENTATIONS AND DISCUSSIONS ON STROKE MANAGEMENT Stroke Prevention in Atrial Fibrillation Gregory Albers, M.D. Director Stanford Stroke Center Professor of Neurology and Neurological
More informationΠΟΙΟ 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 informationAnticoagulation 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 informationFailure 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 informationNovel 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 informationAtrial 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 informationThe Anti coagulated Patient: The Cardiologist s View. February 28, 2015
The Anti coagulated Patient: The Cardiologist s View February 28, 2015 Conflicts Dr. McMurtry has no conflicts to disclose. CanMeds Medical Expert (as Medical Experts, physicians integrate all of the CanMEDS
More informationPrevention of stroke in patients with atrial fibrillation
www.sign.ac.uk Prevention of stroke in patients with atrial fibrillation A guide for primary care January 2014 Evidence Contents 1 Introduction... 1 2 Detection...2 3 Risk stratification... 3 4 Treatment
More informationNIL. 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 informationTA 256: Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation
Service Notification in response to DHSSPS endorsed NICE Technology Appraisals TA 256: Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation 1 Name of Commissioning
More informationWhat 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 informationFOR THE PREVENTION OF ATRIAL FIBRILLATION RELATED STROKE
www.bpac.org.nz keyword: warfarinaspirin FOR THE PREVENTION OF ATRIAL FIBRILLATION RELATED STROKE Key Concepts In atrial fibrillation (AF) warfarin is more effective than aspirin for stroke prevention.
More informationThe 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 informationDorset Cardiac Centre
P a g e 1 Dorset Cardiac Centre Patients with Atrial Fibrillation/Flutter undergoing DC Cardioversion or Ablation procedures- Guidelines for Novel Oral Anti-coagulants (NOACS) licensed for this use February
More informationNew Oral Anticoagulants
New Oral Anticoagulants Tracy Minichiello, MD Associate Professor of Medicine Chief, San FranciscoVA Anticoagulation and Thrombosis Service Ansell, J. Hematology Copyright 2010 American Society of Hematology.
More informationAtrial 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 informationAre there sufficient indications for switching to new anticoagulant agents
Are there sufficient indications for switching to new anticoagulant agents Meyer Michel Samama et Gregoris Gerotziafas Groupe Hémostase-Thrombose Hôtel-Dieu, Hôpital Tenon, Paris & Biomnis Ivry/seine,
More informationHERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below
Name: generic (trade) Rivaroxaban (Xarelto ) HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below What it is Indications
More informationManaging 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 informationNew 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 informationAtrial Fibrillation 2014 How to Treat How to Anticoagulate. Allan Anderson, MD, FACC, FAHA Division of Cardiology
Atrial Fibrillation 2014 How to Treat How to Anticoagulate Allan Anderson, MD, FACC, FAHA Division of Cardiology Projection for Prevalence of Atrial Fibrillation: 5.6 Million by 2050 Projected number of
More information2/17/2015 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 informationTherapeutic Class Overview Oral Anticoagulants
Therapeutic Class Overview Oral Anticoagulants Therapeutic Class Overview/Summary: The oral anticoagulants, dabigatran etexilate mesylate (Pradaxa ), rivaroxaban (Xarelto ), and warfarin (Coumadin, Jantoven
More informationDabigatran (Pradaxa) for stroke prevention in patients with non-valvular atrial fibrillation (da-big-a-tran)
Dabigatran (Pradaxa) 1 Dabigatran (Pradaxa) for stroke prevention in patients with non-valvular atrial fibrillation (da-big-a-tran) Similar rate of major bleeding to warfarin KEY POINTS Dabigatran is an
More informationNew 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 informationCardiovascular Subcommittee of PTAC Meeting held 27 February 2014. (minutes for web publishing)
Cardiovascular Subcommittee of PTAC Meeting held 27 February 2014 (minutes for web publishing) Cardiovascular Subcommittee minutes are published in accordance with the Terms of Reference for the Pharmacology
More informationPerioperative 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 informationAtrial Fibrillation Peter Santucci, MD Revised May, 2008
Atrial Fibrillation Peter Santucci, MD Revised May, 2008 Atrial fibrillation (AF) is an irregular, disorganized rhythm characterized by a lack of organized mechanical atrial activity. The atrial rate is
More informationWOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION. Van Crisco, MD, FACC, FSCAI First Coast
WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION Van Crisco, MD, FACC, FSCAI First Coast Conflicts of Interest I have been a paid consultant and speaker for AstraZeneca, makers of
More informationOptimizing Anticoagulation Selection for Your Patient. C. Andrew Brian MD, FACC NCVH 2015
Optimizing Anticoagulation Selection for Your Patient C. Andrew Brian MD, FACC NCVH 2015 Who Needs to Be Anticoagulated and What is the Patient s Risk? 1. Atrial Fibrillation ( nonvalvular ) 2. What regimen
More informationElisabetta 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 informationAnticoagulation 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 informationNew 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 information2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
Measure #326 (NQF 1525): Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy National Quality Strategy Domain: Effective Clinical Care 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS,
More informationAtrial 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 informationManaging 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 informationNew 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 informationThe New Anticoagulants: Which one is for You?
The New Anticoagulants: Which one is for You? by Hans R. Larsen Although there is no evidence that otherwise healthy lone afibbers have an increased risk of ischemic stroke, it is clear that atrial fibrillation
More informationrivaroxaban 15 and 20mg film-coated tablets (Xarelto ) SMC No. (756/12) Bayer PLC
rivaroxaban 15 and 20mg film-coated tablets (Xarelto ) SMC No. (756/12) Bayer PLC 13 January 2012 The Scottish Medicines Consortium (SMC) has completed its assessment of the above product and advises NHS
More informationACCIDENT AND EMERGENCY DEPARTMENT/CARDIOLOGY
Care Pathway Triage category ATRIAL FIBRILLATION PATHWAY ACCIDENT AND EMERGENCY DEPARTMENT/CARDIOLOGY AF/ FLUTTER IS PRIMARY REASON FOR PRESENTATION YES NO ONSET SYMPTOMS OF AF./../ TIME DURATION OF AF
More informationBridging the Gap: How to Transition from the NOACs to Warfarin
Bridging the Gap: How to Transition from the NOACs to April 24 th 2015 UAN: 0048-0000-15-034-L01-P Amanda Styer, Pharm.D. Marion General Hospital, OhioHealth Objectives: 1. Review labeling regarding transition
More information