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Prof. Gregory Y. H. Lip
This Meet the Expert session provoked great discussion and debate based around 2 challenging cases presented by A Rubboli (Bolognia, Italy) and L Fauchier (Tours, France), with the expert panel which also consisted of L Rasmussen (Alborg, Denmark) and as session moderators, E Hylek (Boston, USA) and myself.
The first case was presented by A Rubboli on stroke and bleeding risk assessment in a high risk atrial fibrillation (AF) patient who needs a coronary stent. This scenario is a complex one, and requires balance between stroke prevention and the risk of stent thrombosis and/or recurrent cardiac ischaemia (in an acute coronary syndrome setting) and potential bleeding risk (with the need for combination antiplatelet and anticoagulant therapy). There are no randomised trials to guide us, and only case series or cohort studies have been published, and consensus recommendations have been published by the ESC Working Group on Thrombosis, endorsed by EHRA and the EAPCI (the consensus document also includes a systematic review – see Thrombosis & Haemostasis January 2010). This document also provides some of the evidence that informed the ESC guidelines on AF management (2010). Of interest, a similar consensus document providing the North American perspective has just been published (Faxon et al Thrombosis and Haemostasis October 2011, already available online), with many reassuring similarities in the clinical approach between Europe and North America.
The second case was presented by L Fauchier, on the identification of the ‘truly low risk’ patients with AF, and what to do post-ablation. Until recently, the focus was trying to risk stratify to identify high risk categories of patients, who would be subjected to an inconvenient drug, warfarin. With the availability of new oral anticoagulant drugs that overcome the limitations of warfarin, the focus has shifted to identifying the ‘truly low risk’ patients who do not even need any antithrombotic therapy, and those with one or more stroke risk factors can be considered for oral anticoagulation, whether with well controlled warfarin or one of the new oral anticoagulants. The CHA2DS2-VASc score used within the ESC guidelines on AF has consistently been shown to be very good (and outperforms the older simple CHADS2 score) in identifying low risk patients by being more inclusive of common stroke risk factors. Post ablation, the development of stroke risk factors and recurrence of AF should be ‘flags’ for oral anticoagulation, and the current guidelines recommend the such treatment is required post-ablation in AF patients with a CHA2SDS2-VASc score of ≥2. The session ended by a presentation from myself (GYH Lip, Birmingham, UK) on ‘What the Guidelines say’. Clearly, the ESC guidelines on AF evolved to deemphasise the artificial low/moderate/high risk strata (as they were not very predictive of events, anyway) and stressed a risk factor based approach (within the CHA2DS2-VASc score) given that stroke risk is a continuum. In patients with a CHA2DS2-VASc score=0, no antithrombotic therapy is preferred, whilst in those with a CHA2DS2-VASc score of 1 or more, oral anticoagulation is recommended or preferred. Given that guidelines should be applicable for >80% of the time, for >80% of the patients, the stroke risk assessment approach covers the most of the patients we commonly seen in everyday clinical practice, and considers the common stroke risk factors in such patients. The guidelines do stress that antithrombotic therapy is necessary in all patients with AF unless they are age <65 and truly low risk. Indeed, some patients with ‘female gender’ only as a single risk factor (thus, still CHA2DS2-VASc score of 1) do not need anticoagulation, especially if they fulfil the ‘age <65 and lone AF, so very low risk’ criterion.
Anti-thrombotic therapy in atrial fibrillation - difficult management scenarios
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