Transcript Document

Stroke
Prophylaxis
Oral anticoagulation
Lauren Butler
Dr Pervez Muzaffar
symptoms
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AF – most common arrhythmia
Asymptomatic/exercise intolerance
chest pain/palpitation/fainting
CCF/TIA
weight loss/diarrhoea
Light-headedness
Diagnosis
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History
Examination (inc manual pulse check)
ECG (essential for diagnosis)
Case specific bloods
Echocardiogram
Cxr
Classification
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Timing and termination based classification
1st detected only one diagnosed episode
Paroxysmal recurrent self terminates < 7 days
Persistent - recurrent lasts for > 7 days
Permanent - on-going long term
Other categories:
Lone AF – age under 60 no h/o CVD/HT/Pulmonary disease
Non-valvular AF – absence of Rheumatic MVD/prosthetic valve or
MV repair
• Secondary AF – MI/cardiac
surgery/pericarditis/myocarditis/hyperthyroidism/PE/Pneumonia
We need to improve
• Our prevalence of AF is below national
average
– 1.12% BwD
– 1.74% England
• In BwD we only anticoagulate 42% of High
risk AF cases, England 56%, we should
aim for 85%!
Stroke in AF
• 14% of all strokes are due to AF
• AF increases risk of stroke five-fold
• 16 000 strokes per year occur in AF patients,
12 500 of these are directly attributable to the AF
• AF strokes tend to be bigger and more disabling
• Warfarin reduces stroke risk by around 2/3
Atrial fibrillation (AF)
Points
AF1. The practice can produce a register of patients with atrial
fibrillation
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AF5. The percentage of patients with atrial fibrillation in whom
stroke risk has been assessed using the CHADS2 risk
stratification scoring system in the preceding 15 months
(excluding those whose previous CHADS2 score is greater than 1)
AF6. In those patients with atrial fibrillation in whom there is a
record of a CHADS2 score of 1(latest in the preceding 15
months), the percentage of patients who are currently treated
with anti-coagulation drug therapy or anti-platelet therapy
AF7. In those patients with atrial fibrillation whose latest record
of a CHADS2 score is greater than 1, the percentage of patients
who are currently treated with anti-coagulation therapy
Pay
stage
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40–90 %
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50-90%
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40-70%
Capturing information
• Grasp tool- how does it work?
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Works on all GP software
Set of MIQUEST queries on AF patients
Calculates stroke risk using CHADS2
With option to use latest CHA2DS2-VASc scoring tool
Highlights those who would benefit from a medication review
Does not assess C/I to warfarin
Results in spread sheet/dashboard format
• www.improvement.nhs.uk
Classic Grasp-AF tool view
CHADS2 Score
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Congestive Heart failure
Hypertension
Age ≥ 75
Diabetes
Previous Stroke or TIA
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2
• Consider anticoagulation if
≥2
• Use CHA2DS2VASc
assessment tool if < 2
Yet under prescribed
NICE estimate that approximately 40% of
patients in whom warfarin is indicated are not
receiving it.
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RCPE - 91.6% of people with AF should be
considered for this treatment
Aspirin vs. Warfarin
• Warfarin represents a 64% reduced stroke risk
• BAFTA - Warfarin did not increase haemorrhage risk in
comparison with aspirin (Warfarin 1.4% Aspirin 1.6%)
• Falls - Older patients taking warfarin must fall about 295
times in one year for warfarin not to be optimal therapy
and the propensity to fall is not a contraindication to the
use of antithrombotic agents (especially warfarin) in
elderly persons with AF.
• NB current guidance suggests that Aspirin should not
be used for stroke prevention in AF. (RCPE UK 2012)
CHA2DS2-VASc Score
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Congestive Heart Failure/ LVD
Hypertension
Age ≥ 75 years
Diabetes mellitus
Stroke/TIA/TE
Vascular disease (MI, PAD or aortic
plaque)
• Age between 65 and 74 year
• Sc - Sex category - Female
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2
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• Score of ≥ 2 anticoagulation therapy
• Score of 1 consider risk/benefit and HASBLED score to aid decision for
anticoagulation or antiplatelet therapy
HAS-BLED Score
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Annual Hypertension, Uncontrolled Sys >160mmHg
Abnormal Kidney (Cr > 200) and/or liver function
Stroke
Bleeding, previous history, anaemia or predisposition
Labile INR, high INR or poor time in Therapeutic range
Elderly, age ≥ 65yrs
Drugs and/or alcohol, antiplatelets, more than
8 drinks per week
1pt
1pt each
1pt
1pt
1pt
1pt
1pt each
• A score of 3 or more is not a contraindication to oral anticoagulation
but these patients require extra care
CHADS 2
Risk score
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0
1
2
3
4
5
6
1.9%
2.8%
4.0%
5.9%
8.5%
12.5%
18.2%
HAS – BLED
Risk score
vs
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0
1
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5
1.1%
1.0%
1.9%
3.7%
8.7%
12.5%
Using both….. Lancashire & Cumbria Guidelines
Calculate CHADS2 score ………
CHADS2 > 1 anti-coagulate
CHADS2 ≤ 1 calculate CHA2DS2-VASC
CHA2DS2-VASC >1 anti-coagulate
CHA2DS2-VASC ≤1no treatment (or aspirin)
Consider a risk of bleeding assessment such as the
HAS-BLED score before anticoagulation
New oral
anticoagulant drugs
• Dabigatran, RivaroXaban, ApiXaban
Dabigatrin (Pradaxa ) 150mg bd or 110 mg bd
Rivaroxaban (Xarelto ) 20mg od
Apixaban 5mg bd (not yet licensed for stroke prevention in AF)
• NOACs are recommended as an treatment option where warfarin is
either contraindicated or where the patient has a documented
hypersensitivity to or intolerance of coumarin anticoagulants
severe enough to cause treatment withdrawal
• Studies show similar or better efficacy than warfarin with
less risk of bleeding
• No monitoring required
• Few drug and diet interactions
• Very expensive (but savings on monitoring)
New oral
anticoagulant drugs (2)
• Still black triangle drugs – Amber rating in BwD
• No simple antidote (but short half life)
• In RE-LY trial, Dabigatran higher drop out rate than
warfarin
• Higher rate of GI bleeding, lower rate of ICH
• Warfarin is still likely to remain drug of choice for those
who are well controlled (TTR 65%)
• However NOACs do have advantages, and will benefit a
proportion of the population
Warfarin or NOAC ?
Where to refer ?
• Warfarin
• NOAC
Anticoag clinic
Community
cardiology (Mammen)
• Remember – NOACs still carry bleeding
risk, black triangle drugs with no
antidote
Key points
• Aspirin is ineffective in stroke prevention for AF
• If warfarin can not be controlled and compliance
is not the issue then a NOAC should be
commenced
• Where compliance is the issue, then is it
preferable to at least be able to monitor this?
• Watch NOACs in the elderly and those with poor
renal function
• Remember – BwD anticoag service has
domiciliary service for patients unable to attend
clinic
case
66 years old female presented with
sob/tiredness feels skipping beat
occasionally when playing golf
no cough no chest pain no fainting no other
symptoms
PMH: nil
No allergy
Examination/tests
BP 132/70 pulse 104/min irregular no murmur no
ankle oedema no carotid bruits
CNS- normal
Chest- sats 98% RR 20/min no wheeze mild basal
crepts
apyrexial
ECG AF 112/min
Requested bloods
Diagnosis?
• CHADS2 Score??
• What would you next?
Anticoagulate?
• CHA2DS2-VASc Score ??
• What is next?
NOAC
• After discussion she decides to be referred to
anticoagulation clinic
• She comes back in a week time with her consultant
surgeon son who says he does not want her to go on
warfarin – but like her to go on Dabigatran (NOAC)
• Your response to his request?
• He wishes to pay for private prescription?