GIANCARLO PIOVACCARIGiancarloPiovaccariDipartimentoMalattieCardiovascolari

Rimini

Rimini, 9 aprile 2016

Happy 6th Birthday:How Has AF Stroke Prevention Changed?

Rimini, 9 aprile 2016

AVERROES (Apixaban Versus ASA to Prevent Stroke In AF Patients Who Have Failed

or Are Unsuitable for Vitamin K Antagonist Treatment) trial (n = 5,599) included

1,898 patients ≥75 years and 366 patients ≥85 years.

Results: Apixaban was more efficacious for preventing strokes and systemic

embolism in patients ≥85 years (absolute rate [AR] 1%/year on Apixaban versus

7.5%/year on Aspirin; hazard ratio [HR] 0.14);

compared with younger patients (AR 1.7%/year on Apixaban versus 3.4%/year on

Aspirin; HR 0.50) (P-value for interaction = 0.05).

Age and Ageing 2016; 45: 77–83

AVERROES (Apixaban Versus ASA to Prevent Stroke In AF Patients Who Have Failed

or Are Unsuitable for Vitamin K Antagonist Treatment) trial (n = 5,599) included

1,898 patients ≥75 years and 366 patients ≥85 years.

Age and Ageing 2016; 45: 77–83

•Conclusions:• older patients with AF are at particularly high risk of stroke •if given aspirin and have substantially greater relative•and absolute benefits from apixaban compared with younger patients with no greater risk of haemorrhage.

64 661 pts with atrial fibrillation who initiated warfarin, dabigatran, rivaroxaban, or apixaban treatment between November 1, 2010, and December 31, 2014.

During a median of 1.1 y of follow-up, 47.5% of NOAC ptshad a proportion of days covered of ≥80%, compared with

40.2% in warfarin pts (P<0.001).

J Am Heart Assoc. 2016;5:e003074

*Unadjusted adherence was the percentage of patients with PDC ≥80%.†Adjusted adherence was the predicted probability of PDC ≥80% based on multivariable logistic regression.

Adherence to OACs (PDC ≥80%) Within First 6 Months of Follow-up, Stratified by Index Medication (N=64 661)

J Am Heart Assoc. 2016;5:e003074

J Am Heart Assoc. 2016;5:e003074

ConclusionsAdherence to anticoagulation is poor in practice and may be modestly improved with NOACs.Adherence to therapy appears to be most important in pts with CHA2DS2-VASc score ≥2, whereas the benefits of anticoagulation may not outweigh the harms in pts with CHA2DS2-VASc score 0 or 1.

Our results suggest clinicians may need to provide regular follow-up with pts at elevated risk of stroke to assess and minimize nonadherence after initiating oral anticoagulation therapy.

I Nuovi Anticoagulanti Orali nel Trattamento della TROMBOSI VENOSA ED EMBOLIA POLMONARE

RaccomandazioniperiltrattamentoinfaseacutadellaEPsenzashockeipotensione

Raccomandazioni Classe Livello

EPsenzashockoipotensione(rischiointermedioobasso)

InalternativaallacombinazionedeglianticoagulantiparenteraliconAVK, siraccomandaunaterapiaanticoagulanteconrivaroxaban(15mgduevoltealgiornoper3settimane,seguitoda20mgunavoltaalgiorno)

I B

InalternativaallacombinazionedeglianticoagulantiparenteraliconAVK, siraccomandaunaterapiaanticoagulanteconapixaban(10mgduevoltealgiornoper7giorni,seguitoda5mgduevoltealgiorno)

I B

InalternativaallacombinazionedeglianticoagulantiparenteraliconAVK, siraccomandalasomministrazionedidabigatran(150mgduevoltealgiornoo110mgduevoltealgiornoneipazienti≥80anniointerapiaconcomitanteconverapamil)aseguitodiunaterapiaanticoagulanteparenteraleinfaseacuta

I B

InalternativaallaterapiaconAVK,siraccomandalasomministrazionediedoxabanaaseguitodiunaterapiaanticoagulanteparenteraleinfaseacuta I B

®iNAOsonopossibilialternativeallaterapiastandard

- raccomandazioneIB

Konstantinides S., et al. Eur Heart J. 2014 Nov 14;35(43):3033-69, 3069a-

3069k

AVK,antagonistidellavitaminaK;EP,emboliapolmonare;NAO,nuovi anticoagulantiorali.

Raccomandazionesulladimissioneprecoce nellaEPacutasenzashockoipotensione

Raccomandazioni Classe Livello

Dimissioneprecoceetrattamentodomiciliare

NeipazienticonEPacutoabassorischiosidovrebbeconsiderareladimissioneprecoce

eilproseguoconuntrattamento

domiciliareseèpossibilefornireun’assistenzaalpazienteeunaterapia

anticoagulanteadeguati

IIa B

Konstantinides S., et al. Eur Heart J. 2014 Nov 14;35(43):3033-69, 3069a-3069k

EP,emboliapolmonare;PESI,pulmonary embolism severity index;sPESI,simplified pulmonary embolismseverity index.

Guideline Recommendations

2016 InpatientswithDVTofthelegorPEandNOCANCER,aslong-term(first3months)anticoagulant therapy,wesuggestDABIGATRAN,RIVAROXABAN,APIXABANOREDOXABANoverVKAtherapy(allGrade2B)*.ForpatientswithDVTofthelegorPEandnocancerwhoarenottreatedwithNAO,wesuggestVKAtherapyoverLMWH(Grade2C).

2012 InpatientswithDVTofthelegandNOCANCER,wesuggestVKATHERAPYoverLMWHforlong-termtherapy(Grade2C).ForpatientswithDVTandnocancerwhoarenottreatedwithVKAtherapy,wesuggestLMWHoverDABIGATRANORRIVAROXABAN forlong-termtherapy(Grade2C).

ChoiceofLong-Term(First3Months)Anticoagulant

PAZIENTISENZACANCRO:

*StessogradodiraccomandazioneperidiversiNAO

CliveKearon,etal.Chest2016CliveKearon,etal.Chest2012

Guideline Recommendations

2016 InpatientswithDVTofthelegorPEandCANCER ("cancer-associatedthrombosis"),aslong-term(first3months)anticoagulant therapy,wesuggestLMWHoverVKA therapy(Grade2C),dabigatran (Grade2C),rivaroxaban(Grade2C),apixaban(Grade2C)oredoxaban(Grade2C).*

2012 InpatientswithDVTofthelegandCANCER,wesuggestLMWHoverVKAtherapy(Grade2B).InpatientswithDVTandcancerwhoarenottreatedwithLMWH,wesuggestVKAoverDABIGATRANORRIVAROXABANforlongtermtherapy(Grade2B)

ChoiceofLong-Term(First3Months)Anticoagulant

PAZIENTICONCANCRO:

*StessogradodiraccomandazioneperVKAeNAOcomealternativaaLMWH

CliveKearon,etal.Chest2016CliveKearon,etal.Chest2012

Guideline Recommendations

2016 Inpatientswithlow-riskPEandwhosehomecircumstancesareadequate,wesuggestTREATMENTATHOMEorEARLYDISCHARGEoverSTANDARDDISCHARGE(e.g.afterfirst5daysoftreatment)(Grade2B).

2012 Inpatientswithlow-riskPEandwhosehomecircumstancesareadequate,wesuggestEARLYDISCHARGEoverSTANDARDDISCHARGE(eg,afterthefirst5daysoftreatment)(Grade2B)

CliveKearon,etal.Chest2016CliveKearon,etal.Chest2012

Treatmentofacutepulmonaryembolismoutofhospital

® NAO:primaopzioneterapeuticaperiltrattamentoinizialeealungoterminedeltromboembolismovenosoneipazientinonaffettidaneoplasie

® Stesso grado diraccomandazione peri diversi NAO® TRATTAMENTODOMICILIARE ,oltre adimissioneprecoce,per

EPinpazienti abassorischio

CliveKearon,etal.Chest2016

Laprevenzionedell’IctusrecidivanteL’importanzadellaricercadellaFibrillazioneAtriale

FibrillazioneAtrialeeStrokeCardioembolico

• LaFAèl’aritmiapiùfrequente

• Circail25%degliStrokessonocardioembolici

-- LaFaèunafonteadaltorischiodicardioembolismo

• IpazienticonStrokeeFAhanno:

-- disabilitàpiùgrave,infartocerebralepiùesteso

-- rischiopiùelevatodirecidiva

43

CT and MRI Scans of a Chicken Wing LAA Morphology

44

CT and MRI Scans of a Windsock LAA Morphology

45

CT and MRI Scans of a Cactus LAA Morphology

46

CT and MRI Scans of a Cauliflower LAA Morphology

STROKECRIPTOGENETICODefinizione

• InfartoCerebraledacausaindeterminata

-- Nessunacausaèidentificataall’esameclinicostrumentalecompleto-- Nonètrovataalcunaetiologiaprobabile

• Rappresentail30-40%degliStrokes

• DefinizionicorrelatealloStrokeEmbolicodiNatura

indeterminata:

-- Strokenonlacunare(allaTAC>=1,5cmoallaRMN>=2,0cm-- Assenzadistenosicarotideeextraedintracraniche-- NoFibrillazioneAtriale-- assenzadialtrecausecomearteriti,dissezioniarteriose,vasospasmo,abusodidroghe

STROKECRIPTOGENETICODiagnosticainOspedale

• ECG

• TelemetriaCardiaca

• HOLTER24H,7giorni

• Registratoresottocutaneo(looprecorder)

• Prevenzionesecondaria,selaFAnonèregistrataduranteil

ricovero

-- terapiaantitromboticadopoladimissione>>>aspirinaoaltri

antiaggregantipiastrinici(TAC>=1,5cmoallaRMN>=2,0cm)

-- Assenzadistenosicarotideeextraedintracraniche

-- NoFibrillazioneAtriale

-- l’impiegodeiNOAdovràessereavvallatodatrialsincorso

CasoClinicoPresentazione

• Donnadi69anni

-- Ipertensionearteriosadaanni

-- Ipercolesterolemia

-- nonaltrodirilevante

° Presentazioneclinica

-- perditaimpèrovvisaforzabracciosinistrocherecupera

dopo1ora,rimaneformicolioallamano

-- Nopalpitazioni

° StudioArterieCarotidiconultrasuoni:

-- negativo

° EcoTransesofageo(TEE)

-- noForameOvalePervio(PFO)

-- atriosinistronondilatato

-- visualizzatal’auricolasinistracheènormale

-- lievesclerosivalvolareaortica

RicercaAritmie

• ECG:ritmosinusale

• Telemetria24H:noaritmie

• Holter24H:noFA;Extrasistoliatriali

isolate

• Holter7giorni:noFA;rarebrevifasidi

Extrasistoliatriali

GestioneinterdisciplinaredelloStrokefra

CardiologoeNeurologo

• Cardiologo

-- impiantosottocutaneodelmonitorcontinuo

-- raccoltaedinterpretazionedati

-- managementdell’aritmia

• Neurologo

-- follow-upperl’evoluzioneneurologica

-- prevenzionesecondariadellostroke

Conclusioni

• LarecidivadiStrokeèassociataspessoaprognosi

negativaeacostieconomico-socialimoltoalti.

• Diffonderelaculturadimonitorareilpzalungo

termineperlaricercadiFA

• IlriscontrodiFAdovrebbeguidareallaterapia

appropriata(aggiuntaTAOoNAO)

• LaterapiaanticoagulantebencondottaconAnti

VitaminaKoNAOriducesensibilmenteilrischiodi

Strokeembolico.