Thrombosis Canada Clinical Tools Perioperative Management of Anticoagulants Antithrombotic Use in Atrial Fibrillation Dr. Benjamin Bell, MD FRCPC Staff General Internist North York General Hospital Lecturer, University of Toronto Executive Member, Thrombosis Canada Dr. Pascal Bastien, MD FRCPC Head, Division of General Internal Medicine North York General Hospital Lecturer, University of Toronto Member, Thrombosis Canada
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Thrombosis Canada Clinical Tools
Perioperative Management of AnticoagulantsAntithrombotic Use in Atrial Fibrillation
Dr. Benjamin Bell, MD FRCPCStaff General Internist
North York General HospitalLecturer, University of TorontoExecutive Member, Thrombosis Canada
Dr. Pascal Bastien, MD FRCPCHead, Division of General Internal Medicine
North York General HospitalLecturer, University of TorontoMember, Thrombosis Canada
Faculty/Presenter Disclosure
• Faculty: Dr. Benjamin Bell• Relationships with commercial interests:*
Disclosure of Commercial Support• This program has received financial support from Alexion Canada, Leo
Pharma, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Covidien, Novartis, Octapharma, BMS/Pfizer Alliance, Pfizer Canada Injectables, Aspen Pharmacare and Sanofi in the form of an Unrestricted Educational Grant
• This program has not received in-kind support from any commercial organization
• Potential for conflict(s) of interest:– Thrombosis Canada developed a free clinical app that will be discussed
in this program
Mitigating Potential Bias
• No commercial or other non-commercial organization have had any input to the content of this program
• No commercial or other non-commercial organization have been present at or privy to any discussions, meetings, or other activities related to the content of this program
Stroke Prevention in Atrial Fibrillation
Dr. Pascal Bastien, MD FRCPCHead, Division of General
Internal MedicineNorth York General Hospital
Lecturer, University of TorontoMember, Thrombosis Canada
Objectives
• Review updated CCS algorithm from 2014 Atrial Fibrillation guidelines
• Describe the complementary roles of NOACs and warfarin in stroke prevention in atrial fibrillation
• Showcase a safe, effective and prompt strategy to assist in the choice and dosing of antithrombotics for atrial fibrillation
Atrial Fibrillation Scope of Problem
• AF is responsible for a 5‐ to 7‐fold increase in stroke risk
• 350,000 Canadians have AF• Prevalence of AF increases with age
– 0.5% in patients 55‐59 yo– 10% in patients ≥ 80 yo
• Almost all patients with AF should be anticoagulated
Projected Number of Adults with AF in USA between 1995 and 2050
Go AS, et al. JAMA. 2001;285(18):2370–2375.
CCS Guidelines for AF Stroke Prevention
CHADS2 CHA2DS2‐VASc CCS algorithm
Case 1
• 36 yo woman, otherwise healthy, complaining of palpitations
• She undergoes a 48h Holter and is found to have symptomatic paroxysms of AF
• Rate vs. rhythm control• Stroke prophylaxis
Rate vs. Rhythm Control
Audience Poll: What antithrombotic agent would you recommend for this woman?A. WarfarinB. DabigatranC. AspirinD. None
A. B. C. D.
0% 0%0%0%
10
Stroke Prophylaxis
Is there an app for that?
Take Home Point 1
• Not all patients with AF need to receive antithrombotic therapy
• Female sex alone is not sufficient to justify antithrombotic therapy in AF
Case 2
• 54 yo man, current smoker, with history CAD but no CHADS risk factors
• A routine ECG incidentally shows AF at 94 bpm
• Rate vs. rhythm control• Stroke prophylaxis
Is there an app for that?
Take Home Point 2
• Aspirin is an appropriate antithrombotic agent in a select group of patients.
• Vascular disease alone is not sufficient to justify OAC in AF (in contrast to ESC guidelines)
Case 3
• 75 year old man with diabetic nephropathy and ESRD on dialysis (guidelines suggest that warfarin is favored if GFR<30).
Is there an app for that?
Take Home Point 3
• Warfarin remains the agent of choice for AF in a number of circumstances– CrCl < 30cc/min *– AF with rheumatic mitral stenosis– Poor medication adherence (although failure to undergo blood testing favors NOAC)
– In association with another indication for warfarin• eg. mechanical valve, LV thrombus
Case 4
• 85 yo man with hypertension, diabetes, CKD (CrCl 55) and atrial fibrillation. His weight is 60kg.