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Implementazione del percorso stroke      All’interno dello SPOKE S.Eugenio:       Dalla gestione intra-ospedaliera        ...
ESC 2012 guidelines: selection of patientsfor OACs       Non-valvular atrial fibrillation                                 ...
CHA2DS2-VASc Score                                               Lip, Chest, 2010Stroke Risk Factor                       ...
ESC 2012 guidelines: eligibility criteria for use ofantithrombotic therapy includes CHA2DS2-VAScCamm AJ et al. Eur Heart J...
ESC 2012 guidelines: all NOACs preferred over VKAsbased on net clinical benefitCamm AJ et al. Eur Heart J 2012 *Class of r...
ESC 2012 guidelines: specific recommendations fornew OACsCamm AJ et al. Eur Heart J 2012 *Class of recommendation; #Level ...
ESC 2012 guidelines: bleedingCamm AJ et al. Eur Heart J 2012 *Class of recommendation; #Level of evidence
HAS-BLED for evaluation of bleeding riskPisters R et al. Chest 2010;138:1093–1100
ESC 2012 guidelines: recommendations forcardioversion and AF/ACS patients**Rivaroxaban and apixaban not recommended due to...
ESC 2012 guidelines: recommendations fornew OACS   All NOACs are recommended for SPAF in patients at risk of stroke (CHA2D...
ESC 2012 guidelines: management ofbleeding with NOACs                  Patient on a NOAC presenting                       ...
Beneficio clinico netto* di warfarin per gruppi di età                                           The ATRIA AF Cohort: N=13...
Microemorragie e rischio di emorragie                Il rischio di emorragia cerebrale in soggetti                con leuc...
Emorragia cerebrale in pz. in terapiaanticoagulante: che fare in fase acuta ora?Nei pz con emorragia cerebrale in trattame...
Emorragia cerebrale in pz. in terapia connuovi ACO: che fare in fase acuta in futuro?In caso di emorragia cerebrale in paz...
Emorragia cerebrale in pz. in terapia ACO    con aVK: quando riprendere la terapia?•   Rivalutare l’indicazione alla terap...
Emorragia cerebrale in pz. in terapia con    nuovi ACO: quando riprendere la terapia?•   Rivalutare l’indicazione alla ter...
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Toni D. Nuove prospettive terapeutiche. I nuovi anticoagulanti An Up to Date. ASMaD 2012

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  • Camm et al, 2012 focused update of the ESC: Guidelines for the management of atrial fibrillation. European Heart Journal doi:10.1093/eurheartj/ehs253 ESC 2012 Guidelines
  • Reference Camm et al, European Heart Journal doi:10.1093/eurheartj/ehs253 ESC 2012 Guidelines
  • Reference Camm et al, European Heart Journal doi:10.1093/eurheartj/ehs253 ESC 2012 Guidelines
  • Reference Camm et al, European Heart Journal doi:10.1093/eurheartj/ehs253 ESC 2012 Guidelines
  • Reference Camm et al, European Heart Journal doi:10.1093/eurheartj/ehs253 ESC 2012 Guidelines
  • Reference Camm et al, European Heart Journal doi:10.1093/eurheartj/ehs253 ESC 2012 Guidelines
  • ESC 2010 guidelines: HAS-BLED for evaluation of bleeding risk 2 Optimum selection of patients with AF for anticoagulation therapy depends not only on assessment of their risk of stroke but also on identification of those at increased risk of developing bleeding complications Using a ‘real-world’ cohort of 3,978 European subjects with AF from the Euro Heart Survey, 1 a new simple bleeding risk score, HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol concomitantly), has been derived 2 The maximum possible score is 9, with 1 point for each of the components: ‘ Hypertension ’: systolic BP >160 mm Hg ‘ Abnormal kidney function ’: the presence of chronic dialysis or renal transplantation or serum creatinine ≥200 mmol/l. ‘ Abnormal liver function ’: chronic hepatic disease (e.g. cirrhosis) or biochemical evidence of significant hepatic derangement ‘ Bleeding ’: previous bleeding history and/or predisposition to bleeding (e.g. bleeding diathesis, anaemia, etc.) ‘ Labile INRs ’: unstable/high INRs or poor time in therapeutic range (e.g. 60%) ‘ Elderly’: patients aged >65 years ‘ Drugs/alcohol’: concomitant use of drugs, such as antiplatelet agents, non-steroidal anti­inflammatory drugs or alcohol abuse, etc. A score of more than 3 indicates ‘high risk’, and some caution and regular review of the patient is needed following the initiation of antithrombotic therapy, whether with VKA or ASA 2 Abbreviations BP, blood pressure; HAS-BLED, hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol concomitantly References Pisters R et al. Chest 2010;138:1093–1100 Camm AJ et al. Eur Heart J  2010;31:2369–2429 Treatment guidelines
  • Reference Camm et al, European Heart Journal doi:10.1093/eurheartj/ehs253 ESC 2012 Guidelines
  • Reference Camm et al, European Heart Journal doi:10.1093/eurheartj/ehs253 ESC 2012 Guidelines
  • Reference Camm et al, European Heart Journal doi:10.1093/eurheartj/ehs253 ESC 2012 Guidelines
  • Transcript of "Toni D. Nuove prospettive terapeutiche. I nuovi anticoagulanti An Up to Date. ASMaD 2012"

    1. 1. Implementazione del percorso stroke All’interno dello SPOKE S.Eugenio: Dalla gestione intra-ospedaliera alla dimissione Roma 23 Novembre 2012Nuove prospettive terapeutiche I nuovi anticoagulanti An Up to Date Danilo Toni Unità di Trattamento Neurovascolare Policlinico Umberto I Sapienza Università di Roma
    2. 2. ESC 2012 guidelines: selection of patientsfor OACs Non-valvular atrial fibrillation Valvular atrial fibrillation Yes < 65 years and lone AF including women Stroke risk assessment using CHA2DS2-VASc 0 1 ≥2 Oral anticoagulant Assess bleeding risk (HAS-BLED score); consider patient values/preferences New oral anticoagulant;No antithrombotic therapy rivaroxaban, dabigatran Vitamin K antagonist apixabanCamm AJ et al. Eur Heart J 2012 Slide line preferred; dotted line alternative
    3. 3. CHA2DS2-VASc Score Lip, Chest, 2010Stroke Risk Factor ScoreCongestive Heart Failure / LV Dysfunction 1Hypertension 1Age >75 years 2Diabetes mellitus 1Stroke / TIA / TE 2Vascular Disease (MI, PAD, aortic plaque) 1Age 65-74 years 1Sex category (female) 1Maximum score = 9; Score >1 – OAC; Score = 1 – ASA (75-325 mg) or OAC (preferred);Score = 0 - ASA (75-325 mg) or None (preferred)
    4. 4. ESC 2012 guidelines: eligibility criteria for use ofantithrombotic therapy includes CHA2DS2-VAScCamm AJ et al. Eur Heart J 2012 *Class of recommendation; #Level of evidence
    5. 5. ESC 2012 guidelines: all NOACs preferred over VKAsbased on net clinical benefitCamm AJ et al. Eur Heart J 2012 *Class of recommendation; #Level of evidence; AE=adverse events
    6. 6. ESC 2012 guidelines: specific recommendations fornew OACsCamm AJ et al. Eur Heart J 2012 *Class of recommendation; #Level of evidence
    7. 7. ESC 2012 guidelines: bleedingCamm AJ et al. Eur Heart J 2012 *Class of recommendation; #Level of evidence
    8. 8. HAS-BLED for evaluation of bleeding riskPisters R et al. Chest 2010;138:1093–1100
    9. 9. ESC 2012 guidelines: recommendations forcardioversion and AF/ACS patients**Rivaroxaban and apixaban not recommended due to lack of published dataCamm AJ et al. Eur Heart J 2012 *Class of recommendation; #Level of evidence
    10. 10. ESC 2012 guidelines: recommendations fornew OACS All NOACs are recommended for SPAF in patients at risk of stroke (CHA2DS2- VASc≥2) in preference over a VKA • Rivaroxaban 20 mg od • Dabigatran 150 mg bid • Apixaban • Rivaroxaban 15 mg od • Dabigatran 110 mg bid in: • No recommendation in with: • ≥ 80 years severe renal impairment • HAS-BLED ≥3 • Concomitant use of CrCl <30 mL/min • CrCl 30-49 mL/min interacting drugs • HAS-BLED ≥ 3 • No recommendation for • No recommendation in • CrCl 30-49 mL/min cardioversion * severe renal impairment CrCl < 30 mL/min • Peri-cardioversion • No specific recommendations due to • No recommendation for • No recommendation in regulatory approval cardioversion* severe renal impairment status CrCl < 30 mL/minCamm AJ et al. Eur Heart J 2012; od=once daily; bid=twice daily*based on lack of published data
    11. 11. ESC 2012 guidelines: management ofbleeding with NOACs Patient on a NOAC presenting with bleeding Check haemodynamic status, basic coagulation tests to assess anticoagulation effect Minor • Delay next dose or discontinue treatment Moderate • Symptomatic/supportive treatment • Mechanical compression • Fluid replacement • Blood transfusion • Oral charcoal if recently ingested Very severe • Consider rFVIIa or PCC • Charcoal filtration • Dabigatran only: haemodialysisCamm AJ et al. Eur Heart J 2012
    12. 12. Beneficio clinico netto* di warfarin per gruppi di età The ATRIA AF Cohort: N=13559; Age 73y Annual Rate Stroke/Embolism Warfarinoff 2.10% vs. Warfarinon 1.27% Annual Rate ICH Warfarinoff 0.32% vs. Warfarinon 0.58% *[annual rate of ischemic strokes/systemic emboli prevented by warfarin] minus [intracranial hemorrhages due to warfarin] Singer DE et al, Ann Intern Med 2009;151:297- 305
    13. 13. Microemorragie e rischio di emorragie Il rischio di emorragia cerebrale in soggetti con leucoaraiosi e microemorragie trattati con vecchi e nuovi ACO, necessita di una valutazione prospettica su numeri elevati di pazienti riportati in un registro nazionaleEvidenziate più frequentemente dopo l’introduzione nella routinediagnostica di sequenze RM GRE o T2*: focolai <5mm da rottura di vasi didiametro <200μm e deposito perivascolare di emosiderina da patologia deipiccoli vasi: lipoialinosi da ipertensione, angiopatia amiloide, CADASILPotenziali fattori di rischio per emorragia cerebrale da TAO Smith EE et al, Neurology 2002;59:193 Lee S-H et al, Neurology 2009;72:171
    14. 14. Emorragia cerebrale in pz. in terapiaanticoagulante: che fare in fase acuta ora?Nei pz con emorragia cerebrale in trattamento anticoagulante è indicata una rapidacorrezione dell’emostasi che si ottiene a seconda della terapia anticoagulante incorso con:• solfato di protamina in pazienti in trattamento con eparina ev o sc• plasma fresco congelato o concentrati di complesso protrombinico associati con vitamina K ev in pazienti in terapia con anticoagulanti orali (aVK)GPP: il gruppo SPREAD raccomanda il complesso protrombinico per lamaggiore rapidità dazione, il minor volume infuso e l’assenza di trasmissione di virus Raccomandazione 10.31 a Grado D
    15. 15. Emorragia cerebrale in pz. in terapia connuovi ACO: che fare in fase acuta in futuro?In caso di emorragia cerebrale in pazienti in trattamento con i nuovi ACOsarà necessario disporre di:• test quantitativi di anticoagulazione, specifici e sensibili• antidoti: complesso protrombinico? Fattore VII?
    16. 16. Emorragia cerebrale in pz. in terapia ACO con aVK: quando riprendere la terapia?• Rivalutare l’indicazione alla terapia (CHADS2; CHA2DS2-VaSc) ed il rischio emorragico (HASBLED)• “Se i pazienti avevano una chiara indicazione alla terapia antitrombotica, il problema immediato, in caso di evoluzione clinica favorevole, è la sua ripresa. In assenza di dati certi in letteratura, è ragionevole attendere una o due settimane, non essendo considerata mandatoria la completa scomparsa del sanguinamento alla TC, che abbisogna di molte settimane”
    17. 17. Emorragia cerebrale in pz. in terapia con nuovi ACO: quando riprendere la terapia?• Rivalutare l’indicazione alla terapia (CHADS2; CHA2DS2-VaSc) ed il rischio emorragico (HASBLED)• Considerato il profilo di maggior sicurezza dei nuovi ACO rispetto a warfarin relativamente al rischio di emorragie intracraniche, dopo un emorragia intracranica da nuovi ACO è ragionevole che il trattamento venga reintrodotto dopo un intervallo di tempo dall’evento emorragico almeno pari a quello previsto dalle linee guida SPREAD per il trattamento con warfarin

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