Management of medications pre and post procedure€¦ · Management of medications pre and post...
Transcript of Management of medications pre and post procedure€¦ · Management of medications pre and post...
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Management of medications pre and
post procedure
Dhiraj Gupta MD DM FRCP
Consultant Cardiologist
Liverpool Heart and Chest Hospital
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• Largest Cardiothoracic Centre in the UK
• 1400 EP procedures (500 AF ablations)
• 1200 device cases
• 3000 PCI cases
• Commissioning through Evaluation selected site for LAAO/ PFO work
Liverpool Heart and Chest Hospital
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Liverpool Heart and Chest Hospital
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Drugs
• Anticoagulants: Warfarin and NOACs
• Antiarrhythmic drugs
• Diabetic medications and Insulin
• Others: Antihypertensives
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Drugs
• Anticoagulants: Warfarin and NOACs
• Antiarrhythmic drugs
• Diabetic medications and Insulin
• Others: Antihypertensives
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PVI Complications Author/year
Design Size (Patients) Stroke (%) Tamponade (%)
Stabile (CACAF)
2006 RCT 68 1.5 1.5
Oral
2006
RCT 130 0 0
Pappone
2006
RCT 99 0 0
Jais (A4)
2008
RCT 155 1 0
Wilber (Thermocool-AF)
2010
RCT 106 0 1.2
Nielsen (MANTRA PAF)
2012
RCT 146 0 0.9
Packer (STOP AF)
2013
RCT 163 1.3 2.1
Cappato
2010
Survey 16309 2.2 0.6
Deshmukh
2013
Survey 93801 0.9 1.3
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Groin Complications
• Most common complications
• 2-5%, including Femoral pseudoaneurysm and AV fistulae
• Use of Vascular Ultrasound hugely decreases risk*
G Wynn et al J Cardiovasc Electrophysiol 2014;25:680-5
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Complications in Current Practice
• LHCH Audit of AF procedures in 2012-2015
• 1358 cases
• Significant Complications:14 (1%)
• Cardiac Tamponade 4
• Phrenic Nerve Palsy 4
• TIA 1
• Groin Hematoma delaying discharge 5
• No death/stroke/requirement for surgery
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Position Paper Recommendations
• All patients undergoing AF catheter ablation who present for the
procedure in AF should
• Be anticoagulated with a NOAC, or a VKA with a therapeutic
INR of 2.0 – 3.0 for 3 weeks prior to the procedure; or
• undergo a TEE to screen for thrombi prior to the procedure
• Post procedure, patients should receive anticoagulation for at
least 2 months
• In patients receiving a VKA, the ablation should be performed
without interruption of VKA therapy
• The VKA should not be stopped and no bridging with a low
molecular weight should be instituted
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• In patients receiving a NOAC and with normal renal
function, it is reasonable to give the last dose 24 h
before the ablation. For patients on dabigatran and
renal impairment, this period of interruption is longer
• Uninterrupted NOAC therapy may be considered in
some patients undergoing ablation
• For patients in sinus rhythm and a CHA2DS2-VASc
score of 0 (males) or 1 (females), it may be considered
starting a NOAC on the day of the procedure, post-
ablation
Position Paper Recommendations
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What about device implants?
In the following patient groups with AF, it is recommended
to perform device surgery without interruption of VKA
• Patients with non-valvular AF and a CHA2DS2-VASc
score of ≥3
• Patients with a CHA2DS2-VASc score of 2 due to
stroke or TIA within 3 months
• Patients with AF planned for cardioversion or
defibrillation testing at device implantation
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What about Valvular AF?
In the following patient groups with prosthetic heart
valves, it is recommended to perform device surgery
without interruption of VKA
• Prosthetic mitral valve
• Caged ball or tilting disc aortic valve
• Bileaflet aortic valve prosthesis and AF and a
CHA2DS2-VASc score of ≥2
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NOACs and device surgery
• Non-vitamin K oral anticoagulants should probably
be temporarily discontinued for all device surgery
• The period of discontinuation should be based on
product characteristics
• It is suggested that the first dose of NAOC should
be ≥24 – 48 h after surgery. The timing of the
resumption should be based on individual
assessment of the competing risks of stroke risk
and pocket haematoma.
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AF ablation on NOAC agents
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NOAC Reversal Agents
• Idarucizumab for Dabigatran reversal
• N Engl J Med 2015;373:511-20
• REVERSE-AD study: 90 patients, reversal within minutes
• EMA approved
• FDA priority review: ?approval before Xmas
• Andexanet Alfa for Xabans reversal
• currently in phase 3 clinical trials
• (ANNEXA-A [apixaban]
• ANNEXA-R [rivaroxaban]
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To Bridge or Not to Bridge? Author/year Design Size
(Patients)
Continued
Warfarin
Bridging with
heparin
Tolosana et al
2009
RCT 101 Hematoma in
4/50
Hematoma in 4/51
Cheng et al
2011
RCT 100 0 2 pocket
hematomas
1 pericardial
tamponade
Birnie et al
2013
RCT 681 Hematoma
12/343(3.5%)
Hematoma
54/338 (16%)
Douketis et al
(BRIDGE)
2015
D/B
RCT
1884 Major bleeding
1.3%
Major bleeding 3.2%
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Summary
• Ablation procedures are becoming safer
• Increasing data on safety of continued oral anticoagulation
• Bridging heparin to be avoided as far as possible
• Arrival of NOAC reversal agents imminent