HEARTBEATA Publication of South Jersey Heart Group
March 2019
What's Changed?
Important changes include the preference of DOACs(dabigatran [a direct thrombin inhibitor] and rivaroxaban, apixiban and edoxaban [factor Xa inhibitors]) to warfarin; the dropping of female sex as a risk factor in CHA2DS2-VASc scores; clarifications to triple therapy in patients undergoingpercutaneous coronary intervention (PCI); and recommendations for left atrial appendage (LAA) occlusion devices and catheter ablation in patientswith heart failure with reduced ejection fraction (HFrEF).
CHA2DS2-VASc Score Congestive heart failure: 1 point
Hypertension: 1 point
Age: 65-74 =1 point; >75=2 points
Diabetes: 1 point
Stroke or TIA: 2 points
VAScular disease: 1 point (PAD, previous MI or aortic plaque)
Female sex: 1 point (ONLY if other risk factors are present)
A Disease of Privilege
As we age, the incidence of atrial fibrillation (AF) continues to increase—from one in 20,000 in our 20s toone in eight in our mid-60s. With our aging society andthe association of AF with morbidity and mortality, wemust continue to optimize our treatment plan. Numerouslandmark studies relevant to AF management have been published since the comprehensive 2014 AmericanHeart Association/American College of Cardiology/HeartRhythm Society guidelines were released.1
New Update to the Atrial Fibrillation Guideline:A Focus on Anticoagulation Strategies
The guideline task force has updated key aspects, especially with regards to new data on direct-actingoral anticoagulants (DOACs)—also known as non-vitamin K oral anticoagulants (NOACs).2 Several randomized, controlled trials published since the2014 guidelines serve as the basis for this importantupdate, which primarily changes recommendationsregarding DOACs. These changes will potentially affect our informed shared-decision discussions with many of our patients—to improve outcomes.
Key Points
� The decision to use an anticoagulant for stroke
prevention should be determined by the
CHA2DS2-VASc risk score—and not be influenced
by whether the AF is paroxysmal or persistent—
or resolved post-ablation.
� Female sex, if the only risk factor, does not confer
a CHA2DS2-VASc score of 1. Female sex adds to the
score only when another risk factor is present. Oral
anticoagulants (OACs) are recommended for
patients with AF and elevated CHA2DS2-VASc
scores — ≥2 in men and ≥3 in women.
� For patients with low CHA2DS2-VASc scores,
aspirin is no longer recommended. OACs might
be reasonable for men with CHA2DS2-VASc score
of 1 and women with CHA2DS2-VASc score of 2.
This is an individualized shared decision-making process
with the patient—as always—but I push harder to
anti-coagulate in obese patients, those with obstructive
sleep apnea and those with chronic kidney disease (CKD)
as these factors increase stroke risk but are not included
in the risk score. Many patients choose anticoagulation
because they do not want to have a debilitating stroke
and will tolerate the increased risk of bleeding.
� DOACs are the preferred OAC over warfarin,
although this has been the standard practice for most
cardiologists for several years, except in certain cases
such as valvular heart disease (VHD). Hepatic
and renal function should be evaluated before
initiation and checked yearly.
� VHD is now defined more narrowly as moderate-
to-severe mitral stenosis (MS) or a mechanical
heart valve. For patients with AF who have
mechanical heart valves or moderate-to-severe MS,
warfarin, not DOACs, is recommended. Optimal
therapy for bio-prosthetic heart valves is uncertain,
although limited data suggest apixiban and edoxaban
are non-inferior to warfarin in that population (we use
apixiban). In patients with hypertrophic obstructive
cardiomyopathy and AF, we lean toward warfarin
because there isn’t enough data to use DOACs.
� In end-stage renal disease, apixaban is a reasonable
alternative to warfarin. Apixaban has a lower risk of
bleeding and is easier to use. The appropriate dose is 5 mg
Bid unless the patient meets one or more of the following
exclusion criteria (age 80 or greater and weight less than
132 pounds). They obviously have a creatinine greater
than 1.5 mg/dL. There is a lot of under-dosing of apixiban.
The lower 2.5 mg dose Bid is not as effective.3 The lower
dose should only be used if two of the following criteria are
met: 80 years of age or greater, weight less than 132
pounds and creatinine greater than 1.5 mg/dL.
� Idarucizumab is recommended for the reversal of
dabigatran in the event of a life-threatening
bleed or urgent surgical procedure. Andexanet alfa
(re combinant factor Xa) is recommended for the
reversal of rivaroxaban and apixaban in the same
situations. One of the biggest advantages of DOACs
is their average short half-life of about 10 hours, working
in our favor. With good renal function, we should not get
into trouble that often and will not need to use these very
expensive reversal agents.
� Percutaneous LAA may be considered in patients
with AF who have heightened risks for stroke and
contraindications to long-term anticoagulation. It is
not an equal option to OAC therapy, as it is not as effective
for stroke reduction and carries an up-front surgical risk.
� In specific patients with symptomatic AF and
HFrEF, catheter ablation may be reasonable as it
could lower mortality and HF hospitalizations. The
focused update only assigns a “soft” indication for catheter
ablation in patients with AF and HF, suggesting that the
task force believed some or all these studies provided only
moderate-quality evidence, as there were limitations to
each study. Nevertheless, referral of patients with reduced
LVEF, HF symptoms and paroxysmal or persistent AF for
catheter ablation should be considered early—certainly
prior to committing patients to long-term amiodarone
or if a potentially recoverable cardiomyopathy if AF
is eliminated.
� The update clarifies the use of anticoagulants in
AF patients undergoing percutaneous coronary
intervention (PCI) with stenting.
• For triple therapy, choosing clopidogrel over
prasugrel for the P2Y12 inhibitor is reasonable for
the anti-platelet component of therapy along with
aspirin 81mg.
• The guideline strengthens its preference for dual
therapy with warfarin and clopidogrel (i.e., “it is
reasonable to choose” it) over triple therapy—to reduce the
risk of bleeding.
Dual therapy can involve rivaroxaban (15 mg daily) or
dabigatran (150 mg twice daily). Our usual protocol is to
use triple therapy for the first month and add a proton-pump
inhibitor, then switch to clopidogrel and a DOAC. Obviously,
NSAIDs are always contraindicated in all patients on OACs
and/or antiplatelet treatment. Results of the AUGUSTUS trial
presented at the American College of Cardiology meeting on
March 17 concluded that “less is more.” In patients with
atrial fibrillation and a recent acute coronary syndrome or PCI
treated with a P2Y12 inhibitor, an antithrombotic regimen
that included apixaban, without aspirin, resulted in less
bleeding and fewer hospitalizations without significant
differences in the incidence of ischemic events than regimens
that included a vitamin K antagonist, aspirin, or both.4
� Weight loss combined with risk factor modification
is recommended for overweight and obese patients
with AF. Obesity is associated with atrial remodeling and
is recognized as both a risk factor for AF and a barrier to
maintenance of sinus rhythm. Modification of key risk
factors (including, but not limited to, sleep apnea,
hypertension, alcohol and smoking) and exercise are all
recommended.
� In patients with cryptogenic stroke in whom
external ambulatory monitoring is inconclusive,
implantation of a cardiac monitor (loop recorder)
is reasonable for detection of subclinical AF—not
surprising, considering both the ease of implant and the
growing evidence to suggest sensitivity increases
dramatically beyond several weeks of monitoring.
� Perioperative bridging is only indicated for patients
with mechanical valves and those with very high-
risk CHA2DS2-VASc scores (greater than 6) or
history of stroke. Holding DOACS for 24 hours is
sufficient for minor surgery and 48 hours for more
complicated surgeries unless renal function is
significantly compromised. We usually hold
warfarin five days.
Special Guest Editor: Rohan Penmetcha, DO, Cardiology Fellow PGY V
Mario L. Maiese, DO, FACC, FACOI Clinical Associate Professor of Medicine, Rowan SOM
Email: [email protected]
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References
1 January CT, Wann LS et al. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol December 2 2014; 64: e1-16.
2 January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol January 21 2019; pii: S0735-1097(19)30209-8. doi: 10.1016/j.jacc.2019.01.011.
3 Siontis KC et al. Outcomes associated with apixiban use in end stage kidney disease patients with atrial fibrillation in the US. Originally published 24 Jul 2018 Circulation 2019; 0:CIRCULATIONAHA.118.035418.
4 Lopes RD, et al for the AUGUSTUS Investigators. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med Online March 17 2019; DOI: 10.1056/NEJMoa1817083.