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Afib: Prevention of Stroke in AFib and Atrial Flutter

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The focus of this video will be on the use of oral anticoagulation therapy for the prevention of stroke in patients with non-valvular atrial fibrillation – or N.V.A.F.

When considering the management of af it’s important to remember that it’s a symptom not a disease in and of itself broadly speaking af is an irregular heartbeat or arrhythmia that can lead to serious complications including stroke heart failure chronic fatigue and other cardiac complications the risk of af increases with advancing age and also with other risk

Factors including male sex hypertension underlying heart disease such as heart failure tyroid disease and obstructive sleep apnea in some cases the cause of af is unknown genes have been identified that predisposed to af but it’s also possible for people with no family history of af to develop it af is associated with substantial morbidity and mortality it is the

Leading cardiac cause of stroke in fact diagnosed af accounts for more than 1 in 6 ischemic strokes and people with af have 3 to 6 times higher risk for ischemic stroke it is estimated that one-third of all strokes after age 60 are caused by af however the true proportion of af related strokes is probably higher considering that embolic stroke scan result from

Subclinical af which is thought to be one of the most commonly under-diagnosed and undertreated risk factors for recurrent strokes a major goal of arrhythmia management is therefore to reduce af related tachycardia and cardiomyopathy and to reduce or prevent emergency visits or hospitalizations other goals of therapy include the identification and treatment of

Underlying structural heart disease and other predisposing conditions symptomatic relief improvement in patients functional capacity and quality of life and the prevention of stroke and system thromboembolism will focus on the last goal in the remainder of this video the 2018 atrial fibrillation guidelines were published in the november 2018 issue of the canadian

Journal of cardiology and are an update to the 2016 af guidelines this video will focus on the ccs algorithm otherwise known as the chad’s 65 algorithm for oral anticoagulation therapy in af this algorithm depicts the key steps in the management of af once af is detected the first step is to identify and treat precipitating factors such as underlying structural

Heart disease and other predisposing factors next is the assessment of the patient’s risk of stroke and systemic thromboembolism to determine whether antithrombotic therapy is needed the ccs has a stroke risk stratification for patients with non valvular atrial fibrillation it’s nicknamed the chad’s 65 algorithm this algorithm borrows from the strengths of both

The chads2 and the chad’s vasc scoring systems in the first step of the ccs algorithm patients aged 65 years or older should be started on oral anticoagulation therapy usually a non vitamin k oral anticoagulant or noack the ccs recommends that when ose therapy is indicated for patients with non valvular af most patients should receive dabigatran rivaroxaban apixaban

Or a doc seban in preference to warfarin no acts are the preferred agents for stroke prevention in nvaf patients who merit anticoagulation although there was less life-threatening bleeding with no acts than with warfarin in the randomized controlled trials bleeding remains an important risk the availability of specific reversal agents has the potential to mitigate

The risks associated with major bleeding events and with it patient and physician acceptance of oac therapy one of the key differences between warfarin and the no acts is the need for inr monitoring and dosage with warfarin in contrast while the no acts do not require inr monitoring they are largely eliminated via the kidneys and therefore dosage adjustments

Are recommended in the setting of renal dysfunction consult the ccss guidelines site for information about recommended dose adjustments of individual no acts based on renal function in situations where noack effects must be rapidly reversed for example in situations of acute bleeding episodes the only antidote currently available in canada is ida ruse is a map

A dabigatran specific reversal agent there are also other agents currently being evaluated in clinical trials one of these is a dexa net alpha which is a factor 10 a reversal agent that works on a picc seban rivaroxaban and a doc seban some of the older anticoagulants like an ox oparin and fonda paradox are also being evaluated the second agent in development

Is seer apparent egg termed the universal reversal agent since it works on both direct thrombin inhibitors as well as factor 10a the results of the reverse ad trial underpin the ccss recommendation that ida ruses umma be administered for emergency reversal of dabigatran anticoagulant effect in patients with uncontrollable or potentially life-threatening bleeding

And in patients who require urgent surgery for which normal hemostasis is necessary this recommendation places relatively greater value on the ability of ida russa zmapp to reverse coagulation parameters indicative of d’vega trans effect it’s potential to decrease bleeding related outcomes and risks of urgent surgery and its safety and tolerability profile it

Places less value on the absence of a control group in the reverse ad trial and on the cost of the drug in acute life-threatening bleeding situations in which standard resuscitation is anticipated to be insufficient or in situations in which standard resuscitation has not stabilized the patient 5 grams of iv ida ruk suzy mab should be administered as soon as

Possible activated partial thromboplastin and thrombin tie may be used to qualitatively identify the presence of active dabigatran at baseline in a patient although they are less sensitive than dtt and ect nevertheless obtaining these measures should not delay the administration of ida russa zmapp in many instances of life-threatening bleeding clinicians have

To make a treatment decision on the basis of a history of dabigatran use rather than laboratory evidence renal function and timing of the last dose of dabigatran provide key information regarding the likely extent of remaining dabigatran affect urgent surgery is defined in the reverse ad trial is surgery that cannot be delayed beyond eight hours amended from

Four hours in the initial version of the protocol the timing of surgery should be on the basis of the clinical indication and stability of the patient in instances in which delayed surgery is appropriate clinicians may obtain coagulation parameters to identify patients who would be unlikely to benefit from ida russa zmapp reversing dabigatran therapy exposes

Patients to the thrombotic risk of their underlying disease oral anticoagulation should be reintroduced as soon as medically appropriate for patients under the age of 65 consider the traditional chads2 risk factors which include prior stroke or transient ischemic attack or hypertension or heart failure or diabetes in the presence of any one of these risk factors

Oral anticoagulation therapy is indicated if a patient has none of the aged or traditional chads2 risk factors or vascular disease then it is entirely appropriate to forego antithrombotic therapy the ccs suggests no antithrombotic therapy for stroke prevention for patients less than 65 and no chads2 risk factors if a patient has none of the aged or traditional

Chads2 criteria and their sole risk factor is vascular disease either coronary disease or peripheral arterial disease the only antiplatelet therapy is needed with management of their coronary or arterial vascular disease as directed by the 2018 ccs and c aic antiplatelet therapy guidelines for patients with non valvular af or flutter aged less than 65 years

With no chads2 risk factors the risk of stroke associated with af is not sufficiently elevated to justify oac therapy for this group treatment should be directed at the underlying coronary artery disease therapeutic options include a si 81 to 100 milligrams daily alone or a si plus either clopidogrel 75 milligrams daily ty carol or 60 milligrams twice daily or

Rivaroxaban 2.5 milligrams twice daily now that we’ve covered appropriate antithrombotic therapy for patients at risk of af related stroke let’s go back to the af management overview once the patient’s thromboembolic risk has been assessed and managed the next step is to manage the arrhythmia there are two general strategies for management of af rate control and

Rhythm control choice of rhythm control drug depends on the presence or absence of cardiac comorbidities consult the ccss each guideline site for information about recommended doses of individual rate control medications choice of rhythm control strategy depends on the patient’s history of heart failure and their systolic function consult the ccss each guideline

Site for information about recommended doses of individual rhythm control medications and for a risk benefit analysis for ablation let’s recap the steps in the full algorithm in patients with af the decision to use oral anticoagulation therapy for stroke prevention is based on the patient’s age in the presence of traditional chads2 risk factors as well as vascular

Disease patients with af who are 65 and older should receive oral anticoagulation therapy preferably a noack instead warfarin patients who are younger than 65 should be assessed for traditional chads2 risk factors the presence of one or more chad’s risk factor constitutes an indication for oral anticoagulation therapy patients who do not meet the age or chads2

Criteria but who have coronary or peripheral arterial disease can be treated with antiplatelet therapy patients who do not meet the age or chads2 criteria and who do not have vascular disease are not at sufficiently elevated stroke risk to justify anticoagulant therapy the full atrial fibrillation guidelines cover several additional topics beyond the prevention

Of stroke in af including those listed here and many more for more information and other topics related to the management of af visit the ccs a–‘s eat guidelines website the e guidelines site allows users to quickly browse search and filter the ccss most sought after guidelines thank you to the many volunteer experts who’ve contributed countless hours to atrial

Fibrillation guideline development and dissemination you

Transcribed from video
Afib: Prevention of Stroke in AFib and Atrial Flutter By Canadian Cardiovascular Society