MA Akbarzadeh MD Assistant professor of Electrophysiology Shahid Beheshti university of medical sciences Modarres Hospital Aug 2016 New Oral Anticoagulants Practical Approach Case 1 ID: 930484
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Slide1
Atrial Fibrilation(Anticoagulation)
M.A Akbarzadeh MDAssistant professor of Electrophysiology Shahid Beheshti university of medical sciences
Modarres
Hospital
Aug 2016
Slide2Slide3Slide4Slide5Slide6Slide7Slide8New Oral Anticoagulants
Slide9Practical Approach
Slide10Case 1A 28 year-old come to the emergency room due to one palpitation started 1 hour ago. His past medical history was unremarkable.
Echocardiography 1 years ago was normal.BP=105/75Heart tachycardia, Irregular S1, S2Lung clear
Slide11Slide12What is your plan?
1- immediate electrical cardioversion without TEE, No antithromotic drug post cardioversion2- immediate pharmacological cardioversion (amiodarone) without TEE, No
antithromotic
drug post cardioversion
3-
immediate
electrical
cardioversion,
raviroxaban
for 4 weeks post cardioversion
4- TEE if no clot,
electrical
cardioversion, No
antithromotic
drug post cardioversion.
5- TEE
if no clot, electrical cardioversion, Bridging therapy with
LMWH and change to warfarin
post
cardioversion
Slide13Slide14CHADS2Vasc
= 0shortest preexcited R-R interval (SPERRI) ≤250 ms in atrial fibrillation
Slide15Slide16What is your plan?
1- immediate electrical cardioversion without TEE, No antithromotic drug post cardioversion2- immediate pharmacological cardioversion (amiodarone) without TEE, No
antithromotic
drug post cardioversion
3-
immediate
electrical
cardioversion,
raviroxaban
for 4 weeks post cardioversion
4- TEE if no clot,
electrical
cardioversion, No
antithromotic
drug post cardioversion.
5- TEE
if no clot, electrical cardioversion, Bridging therapy with
LMWH and change to warfarin
post
cardioversion
Slide17Case 2A
41 year-old man with palpitation started 3 days ago. His past medical history was unremarkable.BP=130/75Heart tachycardia, Irregular S1, S2Lung
clear
ECG: AF rhythm
The echocardiography showed:
EF=60%, No LVH, Mod MR, Mild AI, LAD 3.8cm
Slide18What is your strategy?1- electrical/pharmacological cardioversion
without TEE, No antithromotic drug post cardioversion2- TEE if no clot, electrical/pharmacological cardioversion, No antithromotic drug post cardioversion. 3- TEE if no clot, electrical/pharmacological cardioversion, Rivaroxaban for 4 week post cardioversion
4-
TEE if no clot, electrical/pharmacological cardioversion,
warfarin( bridge with LMWH) for 4 weeks
5-
rate control with
metoral
, Rivaroxaban for life long
6-
rate control with
metoral
,
ASA for
life long
Slide19AF>48hr
CHA2DS2-VASc = 0Mod MR, Mild AILAD 3.8cm (Normal)
Slide20Rhythm or rate control?
Although an initial rate-control strategy is reasonable for many patients, several considerations favor pursuing a rhythm-control strategy. Successful sinus rhythm maintenance is associated with improvements in symptoms
and
quality of life
for some
patients.
Other
factors that may favor attempts at
rhythm control
include difficulty in achieving adequate rate control,
younger patient age
,
tachycardia-mediated cardiomyopathy
,
first episode
of AF, AF that is precipitated by an acute illness, and patient preference
.
Younge
patients (<65 years old) and LAD < 5cm, at least one time try cardioversion
Slide21Slide222014 AHA/ACC/HRS Guideline
Slide23Slide24What is your strategy?1- electrical/pharmacological cardioversion
without TEE, No antithromotic drug post cardioversion2- TEE if no clot, electrical/pharmacological cardioversion, No antithromotic drug post cardioversion. 3- TEE if no clot, electrical/pharmacological cardioversion, Rivaroxaban for 4 week post cardioversion
4-
TEE if no clot, electrical/pharmacological cardioversion,
warfarin( bridge with LMWH) for 4 weeks
5-
rate control with
metoral
, Rivaroxaban for life long
6-
rate control with
metoral
,
ASA for
life long
Slide25Case 3
A 74 years old man, a case of HTN, come due to dyspnea from 3 months ago. Patient is on Diclofenac due to sever rheumatoid arthritis. PMH : Ischemic stroke 5 years ago (mildly decreased right upper arm forced)ECG AF (HR=100bpm)
Echocardigraphy
:
EF= 55%, mild MR, LAD =5.8cm, PAP=40
GFR=40
Slide26What is you strategy for this patient?1- Rivaroxaban 15 mg BID
2- ASA + Clopidegrel3- Warfarin with 1.5<INR<2.54- Watchman Device (mechanical LAA closure)
Slide27Slide28HAS-BLED=5
CHA2DS2-VASC=5High Risk for StrokeHigh risk for bleeding
Slide29GuidelineAlthough
these (HAS-BLED, …) scores may be helpful in defining patients at elevated bleeding risk, their clinical utility is insufficient for use as evidence for the recommendations in this guideline.A score of ≥3 indicates potentially “high risk” for bleeding and may require closer observation of a patient for adverse risks, closer monitoring of
INRs.
Slide30Slide31Slide32Case 4
A 65 year-old lady, a case of HTN, DM, is on rivaoxaban 20 mg daily. She take her drug at 8 pm, with evening meal. At the time of lunch(12 MD) she remembers that she forgot to take her medication last night. What should she do?1- Take her drug at 12MD, and continue with her scheduled.2- take ½ tab of her drug and continue her scheduled
.
3-
the dose should
be skipped
and the next scheduled dose should be
taken
4- the dose should be skipped and the next scheduled dose should be
taken doubled
Slide33In case of a missed
dose, no double dose should be taken to make up for missed individual doses. The forgotten dose may, however, be taken until halfway the dosing interval (e.g. up to 12 h for a once daily dosing). If that is not possible anymore, the dose should be skipped and the next scheduled dose should be taken.
Slide34Case 5A 67 year-old lady, a case of AF on Rivaroxaban 20 mg daily, come with car accident and confusion, brain CT scan revealed ICH,
condidate for operation. What is your plan for this patient?1- hemodialysis2- FFP infusion 4 Unit3- Platelet substitution4- Activated Prothrombin complex concentrate
50 IE/kg
Slide35Slide36EHRA Practical Guide on the use of new oralanticoagulants in patients with non-valvular atrial
fibrillation
Slide37For the primary outcomes, dabigatran 150 mg twice daily was superior to warfarin,
and dabigatran 110 mg twice daily was noninferior to warfarin. Compared with warfarin, the risk of hemorrhagic strokes was also significantly lower (74% lower) with both the 110 mg and 150 mg doses. Major bleeding was significantly decreased with the 110 mg dose but not with the 150 mg dose. Both doses had lower rates of intracranial
bleeding and life-threatening bleeding, whereas gastrointestinal bleeding was higher in the 150
mg dose
(1.6% versus 1.0% per year) group. Dyspepsia was more frequent for both doses. For secondary
prevention of
stroke, the results were similar to the primary analysis but statistically weaker because of smaller sample
size.