Atrial Fibrillation and Anticoagulation Dr Mark Merrick GP

Atrial Fibrillation and Anticoagulation Dr Mark Merrick GP

Atrial Fibrillation and Anticoagulation Dr Mark Merrick GP Hannage Brook Medical Centre Wirksworth Meeting funded by Bayer HealthCare L.GB.MKT.07.2015.11874 July 2015 X-Impact is organised and funded by Bayer HealthCare. This meeting contains promotional content. This meeting has been organised and funded by Bayer. Xarelto (rivaroxaban) prescribing information is available on request at this meeting Adverse events should be reported. Reporting forms and information can be found at

www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Bayer plc. Tel : 01635 563500 Fax : 01635 563703 Email : [email protected] X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Prevalence of AF X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Stroke in AF Patients with AF have a five-fold higher stroke risk than those without AF

AF doubles the risk of stroke when adjusted for other risk factors Without preventive treatment, each year approximately 1 in 20 patients (5%) with AF will have a stroke It is estimated that 15% of all strokes are caused by AF and that 12,500 strokes per year in England are directly attributable to AF X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content

X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content AF strokes are severe strokes 20% are fatal 60% are disabling Compared to non AF strokes:70% increased hospital mortality 40% decrease in chance of discharge home 20% increase length of hospital stay X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Risk reduction with warfarin Reduces relative risk of stroke by approx 65 % Absolute risk reduction: Primary stroke 2.7 %

Secondary stroke 8.4 % Numbers needed to treat for 1 year to prevent 1 stroke: Primary stroke 37 Secondary stroke 12 Overall 25 (approx) X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content NOACS Studies show to be at least as effective and probably more effective than Warfarin at stroke reduction in AF X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content

ROCKET AF Primary efficacy endpoint Stroke or systemic embolism Cumulative event rate (%) 6 Warfari n 5 4 3

Rivaroxaba n 2 1 0 0 120 240 360

480 600 720 840 Days since randomization Number of subjects at risk Rivaroxaban 6958 Warfarin 7004 X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content

ASPIRIN There is no role for aspirin in the treatment of AF It may be used in conjunction with an anticoagulant if there is coexisting vascular disease eg MI, PAD X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content CHA2D2S2 VASC ITEM SCORE Congestive Heart Failure or Left Ventricular Dysfunction Hypertension 1

1 Age >/= 75 Diabetes Stroke/TIA 2 1 2 Vascular disease (MI, PAD) 1 Age (65-74) 1

Sex category (female) 1 X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content CHA2D2S2 VASC Score Annual Stroke Rate 0 0.8% 1 2% 3 3.7% 4 5.9%

5 9.3% 6 15.3% 7 19.7% 8 21.5% 9 23.6% X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content HAS-BLED SCORE

X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content NICE June 2014 Anticoagulation may be with apixaban, dabigatran, rivaroxaban or a vitamin K antagonist Discuss the options for anticoagulation with each patient and base the choice on their clinical features and preferences X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Which Anticoagulant?

X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Warfarin- Pros Warfarin has been prescribed for more than 50 years. Warfarin remains an established and cost effective option for anticoagulation in patients. Can be used in valve disease including valve replacement. INR gives clinicians a guide to patient compliance.

Effective and familiar use of antidote with vitamin K should a severe bleed occur whilst being treated. Clearance of warfarin is not affected by renal function. For patients with poor adherence, long half life may be advantageous X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Warfarin - Cons

Warfarin - time to peak effect ranges from 3-5 days and a half-life averaging 40 hours. Warfarin is known to interact with many food and drugs Patients may have difficulty around complying with or accessing INR monitoring Narrow therapeutic range

Poor INR control associated with increased morbidity and mortality X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content NICE Guideline for AF (June 2014) Review TTR at each visit (exclude 1 6/12): st 6 weeks and must be over a period of Reassess if over the past 6 months: x2 INRs > 5 or x1 INR > 8 or x2 INRs < 1.5 TTR < 65%

Try to correct and take into account reasons for poor control: Cognitive function Adherence Illness Interacting drug Rx Lifestyle inc.diet and EtOH If cannot be improved consider other strategies X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content NOACS - PROS As well tolerated as warfarin No

food and minimal drug interactions Predictable Fixed As anticoagulant response (no A/C monitoring) dosing or more effective than warfarin Rapid onset and offset of action X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content

NOAC - CONS Short half life missed does means inadequate anticoagulation Cost Renal function determines dose. Not suitable for severe renal impairment.

Does require baseline tests and ongoing monitorring Not suitable for valvular AF No known antidote X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Bleed risks of NOACs NOACS all have lower risk of Intracranial Bleeds

Warfarin has slightly lower GI bleed risk than Rivaroxaban and Dabigatran (trials use different criteria so no head to head data) GI bleeds on NOACS seem less severe X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Renal Function and NOACS All NOACs are a reasonable choice in mild to moderate CKD Estimated Creatinine Clearance should be calculated to determine dose.

Cockroft-Gault equation uses age ,weight and serum creatinine) CrCl> 50 ml/min: No dosing adjustments required CrCl30-50 ml/min: use lower dose CrCl15-30 ml/min: do not use dabigatran X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content

Safe Prescribing of NOACs Counselling the importance of strict adherence to therapy is the most crucial aspect of NOAC Rx (reinforce at every FU) Routine monitoring: Hb and liver function (annually) Renal function: Annually for CKD stage III (CrCl60 ml/min) 6 monthly for CKD stage III (CrCl3060 ml/min) 3 monthly for CKD stage IV (CrCl30 ml/min) Regular (3 monthly) follow up: Counselling Side effects Medication review (interactions) X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content

Drug Interactions Verapamil (use lower dose dabigatran) Amiodarone Dronedarone Azole antifungals HIV protease inhibitors Rifampicin, St Johns wort and phenytoin (drugs that affect CYP and P450) X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Switching Warfarin to a NOAC: INR < 2.0: start NOAC immediately INR 2.0-2.5: start NOAC the next day

NOAC to warfarin: Initiate warfarin with NOAC concomitantly until INR 2 Re-test INR 24hrs after NOAC discontinuation Missed doses: pt should take forgotten dose up till 6h (if bd NOAC) or 12h (if od NOAC) after scheduled intake otherwise skip dose and take next dose as scheduled X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Hannage Brook AF Audit 11/14

- Practice size 8500 - Number on AF register 207 - Score of 2 or more but no anticoagulation 63 Score of 1 (no anticoag) 8 Score 2 or more on aspirin 40 Score 1 on aspirin 4 X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content

Nottingham City CCG: The Huge opportunity in Af 750 AF patients undiagnosed In addition, use of CHA2DS2-Vasc instead of CHADS2and reducing exception reporting for anticoagulation to less than 15%, a further 2000high risk AF patients could be anticoagulated This will likely result in: 56 fewer strokes per year 19 fewer deaths per year 660,000 reduction in AF stroke related hospital admission costs per year X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content Discussion Choosing

which anticoagulant Fear of new drugs Patients worried re change (esp if on aspirin) Worried not having INR Compliance Medidose Domiciliary patients GP-Pharmacy communication X-Impact is organised and funded by Bayer HealthCare. This meeting includes promotional content

Recently Viewed Presentations

  • 1 . What body of water does the

    1 . What body of water does the

    India 1.Ganges - 1557 miles long, flows through India and Bangladesh, from the Himalayas eastward and empties into the Bay of Bengal, considered holy to the Hindus of India, very polluted 2.Indus - 1975 miles long, flows through China, Pakistan,...
  • Real-time Communication WeeSan Lee weesan@cs.ucr.edu Async. vs Sync.

    Real-time Communication WeeSan Lee [email protected] Async. vs Sync.

    Homework 8 In general, is it ethical for a CEO of a company to blog or post comments, especially the bad ones, about its rivals on a public forum anonymously? Or, is it perfectly fine because the CEO is exercising...
  • Effectiveness and Clinical Usefulness of Electronic Agenda Setting

    Effectiveness and Clinical Usefulness of Electronic Agenda Setting

    To facilitate shared decision making between psychiatrist and patient via pre-visit patient agenda setting. To investigate the usefulness and feasibility of using an electronic tablet to assist the patient in setting the agenda for the psychiatric clinical visit. Methods
  •  TIP: Use only this front page for simple

    TIP: Use only this front page for simple

    Opportunity or problem this idea will address & rationale. ... to track project performance, the best business cases define and monitor leading indicators to allow time for mid-course correction and improve project benefit realisation. ... Identify key stakeholders inside and...
  • WELCOME Annual Spring Dinner 2011 WFSOM Women Faculty

    WELCOME Annual Spring Dinner 2011 WFSOM Women Faculty

    WELCOME Annual Spring Dinner 2011 Renewed Bylaws The mission of the Women Faculty School of Medicine organization at Case Western Reserve University is to provide: 1) Professional Development opportunities for women faculty in the School of Medicine.
  • ENGINEERING TIME! With Emmanuel and Matt Last Week:

    ENGINEERING TIME! With Emmanuel and Matt Last Week:

    MATERIALS. Parachutes have to be very light in order to work. We have to choose a . light. material to make the parachute out of.
  • 10:1-20 10:1-20 SUBURBAN JUNGLE 10:1-20  10:1-20 NLT, NIV

    10:1-20 10:1-20 SUBURBAN JUNGLE 10:1-20 10:1-20 NLT, NIV

    10:1-20. Heb. 12:1 ~ Therefore we also, since we are surrounded by so great a cloud of witnesses, let us lay aside every weight, and the sin which so easily ensnares us, and let us run with endurance the race...
  • Cooperative Multiple Input Multiple Output Communication in ...

    Cooperative Multiple Input Multiple Output Communication in ...

    Low Density Parity Check Codes(LDPC) LDPC codes are specified by a matrix containing mostly 0's & relatively few 1's. LDPC codes are decoded by means of iterative belief propagation using the Sum-Product (SP) algorithm. The code length is designed by...