Transcript Corso TAO ASL

ASL PROVINCIA DI BERGAMO
La gestione del paziente in
Terapia Anticoagulante Orale (TAO)
Fibrillazione atriale
Antithrombotic therapy in atrial fibrillation:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):
•
For patients with AF of > or =48 h or of unknown duration for whom
pharmacologic or electrical cardioversion is planned, anticoagulation for 3 weeks
before elective cardioversion and for at least 4 weeks after sinus rhythm has been
maintained (Grade 1C).
•
For patients with AF of > or = 48 h or of unknown duration undergoing
pharmacological or electrical cardioversion, either immediate anticoagulation with
unfractionated IV heparin, or low-molecular-weight heparin (LMWH), or at least 5
days of warfarin by the time of cardioversion (achieving an INR of 2.0-3.0) as well
as a screening multiplane transesophageal echocardiography (TEE).
– If no thrombus is seen, cardioversion is successful, and sinus rhythm is maintained,
anticoagulation for at least 4 weeks.
– If a thrombus is seen on TEE, then cardioversion should be postponed and anticoagulation
should be continued indefinitely.
– We recommend obtaining a repeat TEE before attempting later cardioversion (Grade 1B
addressing the equivalence of TEE-guided vs non-TEE-guided cardioversion).
•
For patients with AF of known duration <48 h, we suggest cardioversion without
prolonged anticoagulation (Grade 2C). However, in patients without
contraindications to anticoagulation, we suggest beginning IV heparin or LMWH at
presentation (Grade 2C).
Antithrombotic Therapy For Paroxysmal AF
National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and secondary
care. London (UK): Royal College of Physicians; 2006
• B - Decisions on the need for antithrombotic
therapy in patients with paroxysmal AF should
not be based on the frequency or duration of
paroxysms (symptomatic or asymptomatic)
but on appropriate risk stratification, as for
permanent AF.
Follow-Up Post Cardioversion
National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and secondary
care. London (UK): Royal College of Physicians; 2006
• D - Following successful cardioversion of AF routine follow-up to assess
the maintenance of sinus rhythm should take place at 1 month and 6
months.
• D - At the 1-month follow-up the frequency of subsequent reviews should
be tailored to the individual patient taking into account comorbidities and
concomitant drug therapies.
• D (GPP) - At each review the clinician should take the opportunity to reassess the need for, and the risks and benefits of, continued
anticoagulation.
• D - At 6 months, if patients remain in sinus rhythm and have no other
need for hospital follow-up, they should be discharged from secondary
care with an appropriate management plan agreed with their GP.
• D (GPP) - Patients should be advised to seek medical attention if
symptoms recur.
• D (GPP) - Any patient found at follow-up to have relapsed into AF should
be fully re-evaluated for a rate-control or rhythm-control strategy
Antithrombotic Therapy For Permanent AF
National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and secondary
care. London (UK): Royal College of Physicians; 2006
• D (GPP) - In patients with permanent AF a risk–benefit assessment
should be performed and discussed with the patient to inform the
decision whether or not to give antithrombotic therapy.
• In patients with permanent AF where antithrombotic therapy is
given to prevent strokes and/or thromboembolism :
• A - adjusted-dose warfarin should be given as the most effective
treatment
• A - adjusted-dose warfarin should reach a target INR of 2.5 (range
2.0 to 3.0)
• B - where warfarin is not appropriate, aspirin should be given at 75
to 300 mg/day
• B - where warfarin is appropriate, aspirin should not be coadministered with warfarin purely as thromboprophylaxis, as it
provides no additional benefit.
Antithrombotic Therapy For
Asymptomatic AF
National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and secondary
care. London (UK): Royal College of Physicians; 2006
• D (GPP) - Patients with asymptomatic AF
should receive thromboprophylaxis as for
symptomatic AF
Risks of Long-Term Anticoagulation
National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and secondary
care. London (UK): Royal College of Physicians; 2006
• D (GPP) - Both the antithrombotic benefits and the potential bleeding
risks of long-term anticoagulation should be explained to and discussed
with the patient.
• The assessment of bleeding risk should be part of the clinical assessment
of patients before starting anticoagulation therapy. Particular attention
should be paid to patients who:
• D - are over 75 years of age
• C - are taking antiplatelet drugs (such as aspirin or clopidogrel) or nonsteroidal anti-inflammatory drugs
• C - are on multiple other drug treatments (polypharmacy)
• C - have uncontrolled hypertension
• C - have a history of bleeding (for example, peptic ulcer or cerebral
haemorrhage)
• D (GPP) - have a history of poorly controlled anticoagulation therapy
Anticoagulation Self-Monitoring
National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and secondary
care. London (UK): Royal College of Physicians; 2006
• C - In patients with AF who require long-term
anticoagulation, self-monitoring should be considered if
preferred by the patient and the following criteria are met:
• the patient is both physically and cognitively able to
perform the self-monitoring test, or in those cases where
the patient is not physically or cognitively able to perform
self-monitoring, a designated carer is able to do so
• an adequate supportive educational programme is in place
to train patients and/or carers
• the patient's ability to self-manage is regularly reviewed
• the equipment for self-monitoring is regularly checked via a
quality control programme
Antithrombotic therapy in atrial fibrillation:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):
• For patients with AF and mitral stenosis, we
recommend long-term anticoagulation with
an oral VKA (Grade 1B).
• For patients with AF and prosthetic heart
valves we recommend long-term
anticoagulation with an oral VKA at an
intensity appropriate for the specific type of
prosthesis (Grade 1B).
NICE risk stratification 2004
high
27%
low
8%
mod
65%
Therapy according to NICE 2004
120.00%
100.00%
80.00%
NONE
60.00%
AP
OAC
40.00%
20.00%
0.00%
low
mod
high
Antithrombotic therapy in atrial fibrillation:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):
• AF, including paroxysmal AF, with prior ischemic stroke, transient ischemic
attack (TIA), or systemic embolism, long-term anticoagulation (Grade 1A).
• AF, including paroxysmal AF, with two or more of the risk factors *for
future ischemic stroke long-term anticoagulation (Grade 1A).
• AF, including paroxysmal AF, with only one of the risk factors long-term
antithrombotic therapy (Grade 1A), either as anticoagulation with an oral
VKA, such as warfarin (Grade 1A), or as aspirin, at a dose of 75-325 mg/d
(Grade 1B). In these patients at intermediate risk of ischemic stroke we
suggest a VKA rather than aspirin (Grade 2A).
• AF, including paroxysmal AF, age < or =75 years and with none of the
other risk factors, long-term aspirin therapy at a dose of 75-325 mg/d
(Grade 1B)
• For patients with atrial flutter, we recommend that antithrombotic
therapy decisions follow the same risk-based recommendations as for AF
(Grade 1C)
•
*risk factors : age >75 years, history of hypertension, diabetes mellitus,
moderately or severely impaired left ventricular systolic function and/or heart
failure
CHADS score
• 2 points:
prior ischemic stroke, transient ischemic
attack (TIA), or systemic embolism
• 1 point:
- age >75 years,
- history of hypertension,
- diabetes mellitus,
- moderately or severely impaired left
ventricular systolic function and/or heart
failure
CHADS risk stratification 2004
CHADS>2
44%
CHADS<2
56%
Therapy according to CHADS 2004
120.00%
100.00%
80.00%
NONE
60.00%
AP
OAC
40.00%
20.00%
0.00%
CHADS<2
CHDS>2
Warfarin versus aspirin for stroke prevention in an
elderly community population with atrial fibrillation
Lancet 2007; 370: 493–503
• There were 24 primary events (21 strokes, two other intracranial
haemorrhages, and one systemic embolus) in people assigned to
warfarin and 48 primary events (44 strokes, one other intracranial
haemorrhage, and threesystemic emboli) in people assigned to aspirin
(yearly risk 1·8% vs 3·8%, relative risk 0·48, 95% CI 0·28–0·80,p=0·003;
absolute yearly risk reduction 2%, 95% CI 0·7–3·2).
• Yearly risk of extracranial haemorrhage was 1·4%(warfarin) versus 1·6%
(aspirin) (relative risk 0·87, 0·43–1·73; absolute risk reduction 0·2%, –0·7
to 1·2).
• These data support the use of anticoagulation therapy for
people aged over 75 who have atrial fibrillation, unless there
are contraindications or the patient decides that the benefits
are not worth the inconvenience