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    5-Min Atrial Fibrillation

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    Asim Kumar Biswas
    This document discusses antithrombotic therapy options for patients with atrial fibrillation. It outlines several risk stratification schemes for assessing stroke and bleeding risk, such as CHA2DS2-VASc and HAS-BLED. For patients with nonvalvular AF and a CHA2DS2-VASc score of 2 or higher, options for anticoagulation include warfarin, direct oral anticoagulants like dabigatran and rivaroxaban, and percutaneous or surgical closure of the left atrial appendage. Interrupting warfarin therapy requires bridging with heparin for higher risk patients, while NOACs have the

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    5-Min Atrial Fibrillation

    Uploaded by

    Asim Kumar Biswas
    10 views17 pages
    This document discusses antithrombotic therapy options for patients with atrial fibrillation. It outlines several risk stratification schemes for assessing stroke and bleeding risk, such as CHA2DS2-VASc and HAS-BLED. For patients with nonvalvular AF and a CHA2DS2-VASc score of 2 or higher, options for anticoagulation include warfarin, direct oral anticoagulants like dabigatran and rivaroxaban, and percutaneous or surgical closure of the left atrial appendage. Interrupting warfarin therapy requires bridging with heparin for higher risk patients, while NOACs have the

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    5-min Atrial fibrillation

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    This document discusses antithrombotic therapy options for patients with atrial fibrillation. It outlines several risk stratification schemes for assessing stroke and bleeding risk, such as CHA2DS2-VASc and HAS-BLED. For patients with nonvalvular AF and a CHA2DS2-VASc score of 2 or higher, options for anticoagulation include warfarin, direct oral anticoagulants like dabigatran and rivaroxaban, and percutaneous or surgical closure of the left atrial appendage. Interrupting warfarin therapy requires bridging with heparin for higher risk patients, while NOACs have the

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    10 views17 pages

    5-Min Atrial Fibrillation

    Uploaded by

    Asim Kumar Biswas
    This document discusses antithrombotic therapy options for patients with atrial fibrillation. It outlines several risk stratification schemes for assessing stroke and bleeding risk, such as CHA2DS2-VASc and HAS-BLED. For patients with nonvalvular AF and a CHA2DS2-VASc score of 2 or higher, options for anticoagulation include warfarin, direct oral anticoagulants like dabigatran and rivaroxaban, and percutaneous or surgical closure of the left atrial appendage. Interrupting warfarin therapy requires bridging with heparin for higher risk patients, while NOACs have the

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 17

    Antithrombotic therapy in Atrial

    Fibrillation

    Dr. Asim Biswas


    MD Final Part Student
    NHFH&RI
    • Atrial Fibillation(AF), whether paroxysmal, persistent, or permanent
    and whether symptomatic or silent, significantly increases the risk of
    thromboembolic ischemic stroke.

    • Nonvalvular AF increases the risk of stroke 5 times, and AF in the


    setting of mitral stenosis increases the risk of stroke 20 times over
    that of patients in sinus rhythm.
    Risk Stratification Schemes
    Stroke risk
    • CHA2DS2-VASc
    Bleeding risk
    • HAS-BLED
    • RIETE
    • HEMORR2HAGES
    • ATRIA

    Evaluated for nonvalvular AF


    CHA2DS2-VASc Scoring
    • increase in stroke rate of approximately
    2.0% for each 1-point increase in score
    (from 1.9% with a score of 0 to 18.2% with
    a score of 6)

    Score 0: no anticoagulant
    Score 1: Aspirin or Warfarin
    Score ≥ 2: Warfarin
    HAS-BLED
    HAS-BLED is a score based on the presence of
    • Hypertension (systolic blood pressure >160 mmHg),
    • Abnormal liver or renal function,
    • history of Stroke or Bleeding,
    • Labile INRs,
    • Elderly age (>65 years),
    • use of Drugs that promote bleeding, or alcohol excess .

    A score >3 indicates potentially “high risk” for bleeding


    Therapeutic options
    Pharmacological
    • warfarin
    • NOAC: direct thrombin and factor Xa inhibitors
    • antiplatelet drugs (aspirin and clopidogrel)
    • UFH and LMWH
    Nonpharmacological
    • Percutaneous Approaches to Occlude the LAA
    • Cardiac Surgery—LAA Occlusion/Excision
    Valvular AF: Warfarin
    • all patients with rheumatic valvular heart disease and AF require
    anticoagulation with warfarin unless there is an absolute
    contraindication.
    Nonvalvular AF:
    • 1st line:
    • Warfarin
    • 2nd line:
    • Thrombin inhibitor: Dabigatran
    • Factor Xa inhibitor: Rivaroxaban, or Apixaban
    • Percutaneous closing device
    • Surgical closure of LAA
    Warfarin
    • Target INR for warfarin: 2-3 (2.5)
    • With warfarin, determine INR at least weekly during initiation of
    therapy and monthly when stable: I A
    NOAC
    Benefits:
    • more predictable pharmacological profiles
    • fewer drug–drug interactions
    • an absence of major dietary effects
    • less risk of intracranial bleeding than warfarin
    • do not require regular monitoring of INR or activated partial thromboplastin time
    • rapid onset and offset of action so that bridging with parenteral anticoagulant therapy is not
    needed during initiation, and bridging may not be needed in patients on chronic therapy
    requiring brief interruption of anticoagulation for invasive procedures.

    Disadvantages
    • However, strict compliance with these new oral anticoagulants is critical. Missing even 1
    dose could result in a period without protection from thromboembolism.
    • reversal agents are not available, although the short half-lives lessen the need for an
    antidote
    Interruption and Bridging Anticoagulation
    • For patients who are treated with warfarin and who are at low risk of
    thromboembolism or those who are back in normal sinus rhythm and
    are undergoing surgical or diagnostic procedures that carry a risk of
    bleeding, stopping warfarin for up to 1 week and allowing the INR to
    normalize without substituting UFH is a recognized approach. Warfarin
    is then resumed after adequate hemostasis has been achieved.

    • For patients at higher risk of thromboembolism (mechanical valves,


    prior stroke, CHA2DS2-VASc score >2), bridging with UFH or LMWH is a
    common practice.
    Percutaneous Approaches to Occlude the
    LAA
    First Strategy: Implantable devices for occluding or plugging the LAA.
    Devices for LAA occlusion include the
    • WATCHMAN device (Boston Scientific, Natick, MA) and
    • The Amplatzer cardiac plug (St. Jude Medical, Plymouth, MN).

    Second strategy: to tie off the LAA using an epicardial snare, referred to
    as the LARIAT device (SentreHEART, Redwood City, CA).
    WATCHMAN device
    Cardiac Surgery—LAA Occlusion/Excision
    • Surgical excision of the LAA may be considered in patients undergoing
    cardiac surgery.
    Thank You

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