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AFib in Special Populations
CME Multimedia Activity 1 in 4 patients are adequately anticoagulated with warfarin, and thus there is a large unmet need for achieving better anticoagulation in these patients. Although physicians have sometimes tried to use antiplatelet therapy (aspirin, plus or minus clopidogrel) for anticoagulation, this may result in as much as a doubling of the risk of thromboembolic events. Recently 2 new classes of oral anticoagulant agents have appeared: direct thrombin inhibitors (DTIs) and factor Xa inhibitors. This review sequentially examines the recent clinical trial evidence for the 3 approved NOACs in the 2 classes, highlighting that all 3 share a class effect of being noninferior to warfarin for reducing risk of stroke and systemic embolization and reducing risk of bleeding, with a relative risk of mortality consistently reduced by 10% per year. In addition, all of the NOACs have a significantly lower risk of intracranial/intracerebral bleeding than warfarin, an important clinical consideration, since that is the most feared bleeding risk and may be sufficient reason to consider switching patients from warfarin to a NOAC, even if they seem to be doing well on warfarin. Finally in addition to reviewing the overall benefits of these NOACs over traditional therapy, the clinical application differences between the classes and between the agents are reviewed. Ó 2014 Published by Elsevier Inc. The American Journal of Medicine (2014) 127, e16-e17
AUTHOR DISCLOSURES James A. Reiffel, MD, has disclosed the following relevant financial relationships: Served as an advisor or consultant for: sanofi-aventis; Gilead Sciences, Inc.; CV Therapeutics; GlaxoSmithKline; Merck & Co., Inc.; Cardiome Pharma Corp.; Boehringer Ingelheim Pharmaceuticals, Inc.; Medtronic, Inc. Served as a speaker or a member of a speakers bureau for: sanofiaventis; Boehringer Ingelheim Pharmaceuticals, Inc. Received grants for clinical research from: Boehringer Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline. Dr. Reiffel does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.
AFib in Special Populations William J. French, MD
Cardiac Catheterization Laboratory, Anticoagulation Clinic, Harbor-UCLA Medical Center, Torrance, California.
ABSTRACT For physicians who see and treat patients who present with AFib in routine clinical practice there are 4 important factors to understand and bear in mind when diagnosing and
e17 planning treatment strategies: age, gender, prior or incident heart failure, and underlying coronary artery disease (CAD) and acute coronary syndrome (ACS). (online video available at: http://education.amjmed.com/video.php?event_id¼445& stage_id¼5&vcs¼1). This review addresses the clinical characteristics of each of these presentations in order. For all patients with AFib, of either gender or any age, the greatest risk is failure to prescribe anticoagulation therapy, with currently only about half of these patients are being prescribed anticoagulation therapy, a percentage that is often much lower in the elderly, where only about 1 in 3 eligible patients receive anticoagulation. This highlights the most important clinical point for physicians: first, diagnose! This means ensuring the simple procedure of taking the pulse; if that is irregular, then record the ECG and look for AFib. After these 2 simple steps, physicians should be aware of the 2 most important risk scoring systems at present, CHADS2, which has been updated as the CHAD2DS2 vascular score (CHA2DS2-VASc); the latter takes gender into account and is a more sensitive scoring system for differentiating truly lowrisk patients from those who may appear to be low risk, but actually are at significant risk. As discussed, while the 2012 ESC guidelines recommend a shift toward a greater emphasis on identifying patients who are truly low-risk (vs those who are only apparently low risk), the US emphasis is on identifying the high-risk patients, and how use of the CHADS2 versus CHA2DS2-VASc to accomplish these 2 goals is outlined. Two further important subpopulations of AFib patients are those with congestive heart failure (CHF) and those with acute coronary syndromes (ACS). As discussed, the real progress that has been seen in the prognosis of CHF has not been seen for patients with CHF and concomitant AFib, meaning that even with optimal therapy, the patient with AFib who develops CHF is at higher risk of mortality. The challenge for patients with ACS and AFib is that their ACS will probably require antiplatelet therapy, and addition of anticoagulation therapy as prophylaxis against stroke and systemic embolism because of the AFib creates the problem of so-called “triple therapy.” This review includes a clinical decision algorithm for balancing the lowest risk of thromboembolic events against the highest risk of bleeding in patients who must receive triple therapy. Finally, this review concludes with a brief overview of the possible benefits of the NOACs in these populations, while also emphasizing that all clinicians—especially primary care physicians, who may become the principal caregivers for these patients with AFib in the era of NOACs—should be familiar with one of current bleeding scores, perhaps the best of which is the HAS-BLED score, which includes patients who have hypertension, abnormal renal or liver function, bleeding history, predisposition or labile INR, elderly patients who are frail or >65 years, or with a history of drugs/alcohol concomitantly. Ó 2014 Published by Elsevier Inc. The American Journal of Medicine (2014) 127, e17-e18
e18
ACKNOWLEDGMENT
This program of clinical reviews has been published as part of the Anticoagulation Resource Center, supported in part from a grant from Janssen Pharmaceuticals. Logistic and
The American Journal of Medicine, Vol 127, No 4, April 2014 editorial support for the publication was provided by Independent Publishing Solutions, LLC, with support provided by Elsevier from the grant.
AUTHOR DISCLOSURES James A. Reiffel, MD, has disclosed the following relevant financial relationships: Served as an advisor or consultant for: sanofi-aventis; Gilead Sciences, Inc.; CV Therapeutics; GlaxoSmithKline; Merck & Co., Inc.; Cardiome Pharma Corp.; Boehringer Ingelheim Pharmaceuticals, Inc.; Medtronic, Inc. Served as a speaker or a member of a speakers bureau for: sanofiaventis; Boehringer Ingelheim Pharmaceuticals, Inc. Received grants for clinical research from: Boehringer Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline. Dr. Reiffel does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.
AFib in Special Populations William J. French, MD
Cardiac Catheterization Laboratory, Anticoagulation Clinic, Harbor-UCLA Medical Center, Torrance, California.
ABSTRACT For physicians who see and treat patients who present with AFib in routine clinical practice there are 4 important factors to understand and bear in mind when diagnosing and
e17 planning treatment strategies: age, gender, prior or incident heart failure, and underlying coronary artery disease (CAD) and acute coronary syndrome (ACS). (online video available at: http://education.amjmed.com/video.php?event_id¼445& stage_id¼5&vcs¼1). This review addresses the clinical characteristics of each of these presentations in order. For all patients with AFib, of either gender or any age, the greatest risk is failure to prescribe anticoagulation therapy, with currently only about half of these patients are being prescribed anticoagulation therapy, a percentage that is often much lower in the elderly, where only about 1 in 3 eligible patients receive anticoagulation. This highlights the most important clinical point for physicians: first, diagnose! This means ensuring the simple procedure of taking the pulse; if that is irregular, then record the ECG and look for AFib. After these 2 simple steps, physicians should be aware of the 2 most important risk scoring systems at present, CHADS2, which has been updated as the CHAD2DS2 vascular score (CHA2DS2-VASc); the latter takes gender into account and is a more sensitive scoring system for differentiating truly lowrisk patients from those who may appear to be low risk, but actually are at significant risk. As discussed, while the 2012 ESC guidelines recommend a shift toward a greater emphasis on identifying patients who are truly low-risk (vs those who are only apparently low risk), the US emphasis is on identifying the high-risk patients, and how use of the CHADS2 versus CHA2DS2-VASc to accomplish these 2 goals is outlined. Two further important subpopulations of AFib patients are those with congestive heart failure (CHF) and those with acute coronary syndromes (ACS). As discussed, the real progress that has been seen in the prognosis of CHF has not been seen for patients with CHF and concomitant AFib, meaning that even with optimal therapy, the patient with AFib who develops CHF is at higher risk of mortality. The challenge for patients with ACS and AFib is that their ACS will probably require antiplatelet therapy, and addition of anticoagulation therapy as prophylaxis against stroke and systemic embolism because of the AFib creates the problem of so-called “triple therapy.” This review includes a clinical decision algorithm for balancing the lowest risk of thromboembolic events against the highest risk of bleeding in patients who must receive triple therapy. Finally, this review concludes with a brief overview of the possible benefits of the NOACs in these populations, while also emphasizing that all clinicians—especially primary care physicians, who may become the principal caregivers for these patients with AFib in the era of NOACs—should be familiar with one of current bleeding scores, perhaps the best of which is the HAS-BLED score, which includes patients who have hypertension, abnormal renal or liver function, bleeding history, predisposition or labile INR, elderly patients who are frail or >65 years, or with a history of drugs/alcohol concomitantly. Ó 2014 Published by Elsevier Inc. The American Journal of Medicine (2014) 127, e17-e18
e18
ACKNOWLEDGMENT
This program of clinical reviews has been published as part of the Anticoagulation Resource Center, supported in part from a grant from Janssen Pharmaceuticals. Logistic and
The American Journal of Medicine, Vol 127, No 4, April 2014 editorial support for the publication was provided by Independent Publishing Solutions, LLC, with support provided by Elsevier from the grant.