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Clinical scenarios with new anticoagulation drugs for stroke prevention in atrial fibrillation

Speakers
  • The patient with poorly controlled INRs and doubts about drug compliance, who is started on a new oral anticoagulant and has a bleeding episode. Presented by E Hylek (Boston, US),
  • The patient at high stroke risk, who subsequently presents with an acute coronary syndrome whilst on a new oral anticoagulant drug. Presented by A Rubboli (Bologna, IT),
  • The patient taking a new oral anticoagulant who undergoes cardioversion and subsequently, an ablation procedure. Presented by L Fauchier (Tours, FR),
  • Panel. Presented by Elaine HYLEK (Boston, US), Andrea RUBBOLI (Bologna, IT), Laurent FAUCHIER (Tours, FR), Leif FRIBERG (Stockholm, SE), Kurt HUBER (Vienna, AT), Tatjana POTPARA (Belgrade, RS) 
Cardiovascular Pharmacology and Pharmacotherapy


This FOCUS session was Chaired by Prof GYH Lip (Birmingham, UK) and Prof HF Tse (Hong Kong), and covered various clinical scenarios with new anticoagulation drugs for stroke prevention in atrial fibrillation (AF).  The format centres on a case presentation, which then included audience interaction with keypad voting, and discussion/debate with a lively panel, as follows: Elaine HYLEK (Boston, US), Andrea RUBBOLI (Bologna, IT), Laurent FAUCHIER (Tours, FR), Leif FRIBERG (Stockholm, SE), Kurt HUBER (Vienna, AT), Tatjana POTPARA (Belgrade, RS).

The first presentation by Dr Hylek dealt with the patient with poorly controlled INRs and doubts about drug compliance, who is started on a new oral anticoagulant (OAC) and has a bleeding episode.  The balance between stroke and bleeding risk was discussed, with reference to the use of the CHA2DS2-VASc and HAS-BLED scores in clinical practice [1].  Also, the HAS-BLED score has recently been shown to outperform other bleeding risk schemes in bleeding risk assessment [2,3]. 
The new OACs offer opportunities to improve stroke prevention in AF, but considered prescribing is necessary.  In the 2012 ESC focused update guidelines on atrial fibrillation[4], there is a Class I Level of Evidence B recommendation for the when adjusted-dose VKA (INR 2–3) cannot be used in a patient with AF where an OAC is recommended, due to difficulties in keeping within therapeutic anticoagulation, experiencing side effects of VKAs, or inability to attend or undertake INR monitoring, one of the new OACs, either a direct thrombin inhibitor (dabigatran); or an oral factor Xa inhibitor (e.g., rivaroxaban, apixaban) is recommended.

Dr Rubboli presented a case on the patient at high stroke risk, who subsequently presents with an acute coronary syndrome whilst on a new OAC drug.  Management was with reference to the European consensus guidelines on this topic, which has many similarities to a similar North American consensus [5].  Clearly, more experience is needed with the new OACs in the acute coronary syndrome patient population, given excess bleeds with the AF dose of apixaban in combination with dual antiplatelet therapy, with no evidence of benefit [6].

Dr Fauchier presented a case on the patient taking a new OAC who undergoes cardioversion and subsequently, an ablation procedure.  Again, more experience is needed with the new OACs in the acute coronary syndrome patient population.  The available data suggest that a protocolised-approach to management is best.  The post-ablation OAC strategy should be based on prevalent risk factors, and OAC should be continued post-ablation in patients with a CHA2DS2-VASc score of ≥2.

REFERENCES
1. Lane DA, Lip GYH. Circulation. 2012 Aug 14;126(7):860-5.
2. Apostolakis et al J Am Coll Cardiol. 2012 Aug 28;60(9):861-7.
3. Roldan V et al Chest Chest. 2012 Jun 21. [Epub ahead of print] PMID: 22722228
4. Camm AJ et al European Heart Journal 2012 - doi:10.1093/eurheart
5. Faxon D et al Thromb Haemost. 2011 Oct;106(4):572-84.
6. Alexander J et al APPRAISE 2 NEJM 2011 Aug 25;365(8):699-708

References


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SessionTitle:

Clinical scenarios with new anticoagulation drugs for stroke prevention in atrial fibrillation

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.