Anticoagulation in atrial fibrillation - oeige.it209:slide-7-anticoagulation-in-atrial-fibrillation.pdf · Delirium Cordis “In questa forma di aritmia i battiti cardiaci si susseguono

Anticoagulation in atrial fibrillation Fibrillazione atriale

Delirium Cordis “In questa forma di aritmia i battiti cardiaci si susseguono in completa irregolarità. Contemporaneamente, l’ampiezza e la tensione di ogni onda di polso cambiano in continuazione”

Nothnagel H. Deutsches Archiv fur Klinische Medizin. 1876;17:190

Am J Med 2002

Delirium Cordis

“In questa forma di aritmia i battiti cardiaci si susseguono in completa irregolarità. Contemporaneamente, l’ampiezza e la tensione di ogni onda di polso cambiano in continuazione”

Nothnagel H. Deutsches Archiv fur Klinische Medizin. 1876;17:190

Trigger

Incidence of AF per 1000 person-years stratified by age

Yoko Miyasaka, Circulation. 2006;114(11):e498.

Ictus: complicanza frequente della FA • La FA si associa a un rischio globale di ictus 5 volte

maggiore

•Senza trattamento preventivo, ogni anno circa

1 paziente su 20 (5%) con FA avrà un ictus

•La FA è responsabile da 1/5 a 1/4 di tutti gli ictus ed è la causa

principale degli ictus embolici

•Il rischio di ictus in pazienti con FA è lo stesso, indipendentemente dalla natura parossistica, persistente o permanente di questa

Se si considerano i TIA e gli ictus clinicamente “silenti”, il tasso di ischemie cerebrali associate a FA non valvolare supera il 7% annuo4

1. Rosamond W et al. Circulation. 2008;117:e25–146; 2. ACC/AHA/ESC guidelines: Fuster V et al. Circulation 2006;114:e257–354 & Eur Heart J 2006;27:1979–2030; 3. Atrial Fibrillation Investigators. Arch Intern Med 1994;154:1449–57; 4. Carlson M. Medscape Cardiology. 2004;8; available at http://cme.medscape.com; accessed Feb 2010

Lip GY : Lancet Neurol 2007; 6: 981–93

TAO confrontata con placebo o nessuna terapia

RR –64% con Warfarin

Aspirina confrontata con placebo o nessuna terapia

Lip GY : Lancet Neurol 2007; 6: 981–93 RR –19% con ASA

Score Risk Anticoagulation Therapy Consideration

0 Low No antithrombotic th or Aspirin No antithrombotic therapy (or Aspirin 75–325 mg daily)

1 Moderate Oral anti-coagulant or Aspirin Oral anticoagulant, either new oral anticoagulant drug e.g. rivaroxaban or dabigatran or well controlled warfarin at INR 2.0-3.0 (or Aspirin 75–325 mg daily, depending on factors such as patient preference)

2 or greater High Oral anti-coagulant Oral anticoagulant, using either a new oral anticoagulant drug (apixaban, rivaroxaban or dabigatran) or well controlled warfarin at INR 2.0-3.0

Hagerty T : CCJM 2017; 84 :35

Score > 3 : high risk

• In practice up to 50% of older patients do not receive maintenance anticoagulation therapy.

• The most common reason physicians cite for withholding anticoagulation in older patients with atrial fi brillation is a – perception of a high risk of falling – and associated bleeding,especially intracranial

hemorrhage.

Hagerty T : CCJM 2017; 84 :35

Trends in anticoagulant prescriptions according to CHADS2, HAS-BLED, and Clinical Frailty Scale (CFS) scores. CHADS: Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack; HAS-BLED: Hypertension, Renal/Liver Failure, Stroke, Bleeding History or Predisposition, Labile IINR, Age >65 years, Drugs/Alcohol Use CFS: functional autonomy, mobility, assistance in ADL, cognitive status, nutrition, polypharmacy, multimorbidity

The Effect of Bleeding Risk and Frailty Status on Anticoagulation Patterns in Octuagenarians With Atrial Fibrillation: The FRAIL-AF Study

682 hospitalized patients aged 80 years and older with AF or atrial flutter in Montreal 70% of octegenarians with AF received anticoagulation

Lefebvre MCD et al, Can J Cardiol 2016; 32:169

Two large community-based AF cohorts: 1405 individuals with ischemic stroke mean age=79.0±7.4 years; median CHA2DS2-VASc score = 5

44% were not prescribed an OAC REASONS (%):

Fall Risk 26.7 Poor Prognosis 19.3 Bleeding history 17.1 Family refusal 14.9 Older Age 11.0 Dementia 9.4

%

0

50

100

NO OAC OAC

% 42.5% 19.1%

p<0.001

Use of Oral Anticoagulant Therapy in Older Adults with Atrial Fibrillation After Acute Ischemic Stroke

McGrath ER et al, JAGS 2016 Dec 30. doi: 10.1111/jgs.14688

One-year Mortality

CONCLUSION: To improve anticoagulant decisions and outcomes future research should focus on strategies to mitigate fall risk, improve assessment risks and benefits of OAC and determine whether newer anticoagulants are safer in complex elderly and frail individuals.

- Activities of Daily Living (ADL) 6 items - Instrumental Activities of Daily Living (IADL) 8 items - Short Portable Mental Status Questionnaire (SPMSQ) 10 items - Mini-Nutritional Assessment (MNA) 18 items - Exton-Smith Scale 5 items - Cumulative Illness Rating Scale_comorbility (CIRS) 14 items - Number of drugs 1 - Social index 1

TOTAL 63 items

Mild Moderate Severe SCORE 0.18±0.09 0.48±0.09 0.77±0.08 RANGE 0.00-0.33 0.34-0.66 0.67-1.0

M. P. I.

Pilotto & Ferrucci, Rejuvenation Res 2008;11:151-61

Development and Validation Of a Multidimensional Prognostic Index for

One-Year Mortality from Comprehensive Geriatric Assessment in Hospitalized Older Patients

MPI grade 1-Year

Mortality(*) HR

[95% CI] p

ALL Patients

0.5 0.4-0.6 <0.001

MPI 1 Low risk

0.5 0.4-0.7 <0.001

MPI 2 Moderate risk

0.5 0.4-0.7 <0.001

MPI 3 Severe risk

0.4 0.3-0.5 <0.001

•Adjusted for age, sex, main diagnosis, all MPI-SVaMA domains and past prescription rate (tertiles)

MPI grade 3-Year

Mortality(*) HR

[95% CI] p

ALL Patients

0.6 0.6-0.7 <0.001

MPI 1 Low risk

0.6 0.5-0.8 <0.001

MPI 2 Moderate risk

0.7 0.6-0.9 <0.001

MPI 3 Severe risk

0.6 0.4-0.7 <0.001

CONCLUSION: Community-dwelling older patients with AF can benefit from anticoagulation in terms of reduced all-cause mortality, regardless of poor health and functional conditions.

Warfarin Treatment and All-cause Mortality in Community-dwelling Older Patients with Atrial

Fibrillation: A Retrospective Observational Study

Pilotto et al, JAGS 2016 Jul;64(7):1416-24

FALLS AND ANTICOAGULATION

• the incidence and prevalence of falls increase with age • the rate of falls in the preceding year increases with age and

exceeds 50% in nursing home residents (1) • history of falls or documented high risk of falling is associated

with a risk of intracranial hemorrhage during follow-up that was 1.9 times higher (2)

• it was estimated that an individual would have to fall 295 times in 1 year for the risk of fall-related major bleeding to outweigh the benefit of warfarin in reducing the risk of stroke (3)

Hagerty T : CCJM 2017; 84 :35

Fear the clot, not the bleed

Warfarin reduces the risk of stroke by about 2/3 in atrial fibrillation

The oldest patients derive the greatest

net benefit from anticoagulation

Lip GY: Stroke 2015; 46:143–150.

“The benefit of anticoagulation in atrial fibrillation does not appear to have an

upper age limit “

Hagerty T : CCJM 2017; 84 :35