GRAND ROUNDSAlyssa Morris , R4

May 12, 2011

CASE

• 63F says she has felt unwell and like her heart is racing since yesterday morning.

OBJECTIVES

• Guidelines • Risk of stroke scores– CHA2DS2-VASc

• Risk of bleeding score– HAS-BLED

• Anticoagulation– Dabigatran

• New drugs– Vernakalant– Dronedarone

CHADS2

ISSUES

• ASA Or Warfarin

• BAFTA trial

• Known risks not in score

CHA2DS2-VASc

ANTICOAGULATION

• Warfarin– Narrow therapeutic window– Many drug interactions– Many food interactions – Inter-individual variable response– Slow onset of action – Constant monitoring

CONTRAINDICATIONS

• Renal failure– CrCl 30-50 mL/min reduced dose

– CrCl <30mL/min can’t use

• Severe hepatic impairment

• Bleeding tendency

• Quinidine

Cost

• 4-8$/day

• 120-240$/month

• Blue Cross doesn’t cover

• Non-formulary in hospital

BLEEDING EMERGENCY

• Can measure PTT/TT

• No antidote

• TRY FFP and packed cells

• ? Activated Factor VII

• Can be dialyzed

PETRO STUDY

RE-LY

• Rates of stroke– Less with 150mg BID– No difference with 110mg BID

• Rates of major bleeding – No difference with 150mg BID– Less with 110mg BID

• Rates of hemorrhagic stroke– Less with both 110mg and 150mg BID

• Mortality – No difference

ADVERSE EVENTS

• Dyspepsia

• Stopping drug early

• MI

• GIB

• Not hepatotoxic

CONCLUSIONS FROM RE-LY

• 110mg– rates of stroke and systemic embolism similar to

coumadin– lower rates major bleeding

• 150mg– lower rates of stroke and systemic embolism– similar rates of major hemorrhage

• AE: dyspepsia, MIs

ISSUES

• No antidote

• Dyspepsia

• No way to objectively know compliance

• Unknown dosing at extremes of weight

What do the stroke and cardiology services think?

CCS GUIDELINES

• “Most patients should receive dabigatran in preference to warfarin”– Dyspepsia– GIB– High risk for CAD

BACK TO CASE

• Q: Who would give her UFH before cardioversion?

• Q: Who would give her LMWH before cardioversion?

CCS GUIDELINES

• No prior anticoagulation, except:– High risk patient– AF onset unknown– AF onset >48

VERNAKALANT

• Atrial selective

• Multiple ion channel blocker

• Rapidly and extensively distributed

• Oral and IV forms

• 3mg/kg over 10m, wait 15m, then 2mg/kg over 10m

• 59.4% converted in 90m

• Median conversion was 12m

• 51.7% vs 5.2% converted in 90m

• Median conversion time 11min

• 53.4% vs 32.8% symptom relief at 90m

• No TDP, VF, sustained VT

RHYTHM CONTROL

DRONEDARONE

• De-iodinated amiodarone

• Long term antiarrhythmic– Normal VF

• ATHENA trial

SUMMARY

• CHADS2 vs CHA2DS2-VASc

• Dabigatran

• HAS-BLED

• Vernakalant