Atrial Fibrillation: When and How To Anti-Coagulate Plus LAAO Simon James Consultant Cardiologist James Cook University Hospital Outline • Establishing risk of stroke • Overview of options for stroke prevention – Traditional oral anticoagulation – Newer alternatives – Mechanical alternative to anticoagulation Doesn’t encompass every possible complex clinical scenario Atrial Fibrillation • Common arrhythmia • 1.2 million sufferers in UK • Incidence increases with age – 0.1% at 55yrs – 3.8% at 60 years – 10% at 80yr Clinical Features: Symptoms • • • • • • Palpitations Breathlessness Chest pain Heart failure Lethargy / reduced exercise capacity Non-specific AF: Morbidity / Mortality • Stroke 5% per year (7 times baseline risk) • 1.5 to 2 x mortality rate per year • CCF increased 2x or more Myths and Legends • Which of these are true? X X X  – Aspirin is effective at stroke prevention in AF – Paroxysmal AF and persistent AF have different stroke risks – Ablation and pacemakers reduce stroke risk – Aston Villa 6 – Sunderland 1 Stroke Prevention • Anticoagulation – Warfarin – Alternative anticoagulants • Exclusion of left atrial appendage • Catheter ablation, anti-arrhythmic drugs and pacing treat symptoms only Anticoagulation: for whom? Anticoagulation: for whom? • Patients at risk of stroke • Providing it is safe / feasible Who is at risk of stroke? • Obvious examples – Mitral stenosis – Hyperthyroidism • Spectrum of risk • Scoring systems… Stroke Risk • CHADS2 → CHAD VASc • CHADS2 score 1 risk = from 2 to 4 % CHADS2-VASc CHADS2-VASc • Originally to subdivide the CHADS2 intermediate risk (1) • Now used to stratify all • CHADS2VASC 0 = low risk • CHADS2VASC 1 = pt value / preference • CHADS2VASC ≥ 2 high risk – anticoagulate How Safe is anticoagulation? • Risk score • Same Features that predict stroke risk! HASBLED risk per year “caution if ≥ 3” All anticoagulation? • Wafarin specific? • All anticoagulants? • Some relevant to dose / effect variation HASBLED and risk • Labile INR • Liver function • Drug interaction • Concerns with wafarin use • Other anticoagulant may be preferable… Stroke prevention: the options • Traditional anticoagulants – Warfarin, Nicoumalone – Heparins • Novel anticoagulants – Dabigatran, Rivaroxaban, Apixaban • Exclusion of the appendage Novel Oral Anti-Coagulants • “NOACs” – Dabigatran – Rivaroxaban – Apixaban • Act on specific targets in the clotting cascade Anticoagulation Target Are they better than warfarin? NOACs • Trials suggest at least as effective at stroke prevention (in non-valvular AF) – RE-LY* – dabigatran – ROCKET-AF* – rivaroxaban – ARISTOTLE – apixaban • May be more effective by means of reduction in haemorrhagic stroke * Patients with bleeding history or risk of bleeding were excluded from 2 trials Safe in bleeders? • Not proven • Excluded from 2 trials • Newly declared bleeders highest rebleed rate in NOAC groups • Where are they the most use? Contraindications to Warfain? • Warfarin allergy / hair loss…. Warfarin contraindications • • • • • • • • • • • • • Bleeding disorder Almost all are a Recent CVA or TIA contraindication to Uncontrolled BP anti-coagulation, not specifically warfarin Active bleeding Haemorrhagic retinopathy All excluded Intracranial haemorrhage from trial Use of NSAID Chronic alcohol abuse Newly declared Risk of GI bleed may actually do Planned surgery worse – who Pregnancy knows? Psychiatric disorder or dementia Poor compliance / access to service Warfarin contraindications? • • • • • • • • • • • • • Bleeding disorder Recent CVA or TIA Uncontrolled BP ? Fall, bleed or to Active bleeding chaotic to take tablets ? Haemorrhagic retinopathy Intracranial haemorrhage Use of NSAID Chronic alcohol abuse Risk of GI Unable to manage? Planned surgery Pregnancy Psychiatric disorder or dementia Poor compliance / access to service Unable v unwilling? NOACS – for whom? • Stroke prevention for Non-valvular AF • NICE – “suitable alternative to warfarin” – In theory anyone • Practically – INR control – Logistics of monitoring / dosing – Drug interaction – Rapid anticoagulation (eg for DCCV) What about the bleeders? • History / risk of bleeding- Eg.GI / ICH • Concern lack of data for NOACs / reversibility • Concept of perfect anticoagulant that only stops bad clotting? – differing contribution of clotting factors / endothelial factors for inter-cranial vs systemic • Exclusion of left atrial appendage may be better option… Left Atrial Appendage Occlusion LAA occlusion • 90 % of AF related embolic events due to intra-cardiac thrombus located in LAA • Reduced emptying velocities in AF patients • Stagnant blood pools – Surgical excision – Catheter occlusion Catheter delivered Left atrial appendage occlusion LAA Exclusion / Occlusion • Remove site for thrombus formation • Provides similar reduction in stroke to anticoagulation (with warfarin) • Avoids use of anticoagulation • Downside is delays in commisioning agreement… Summary Summary: For Whom ? • Traditional risk factors for stroke – Valve disease • Scoring systems for non valvular AF – CHADS2 – CHADS-VASc • Risk of anticoagulation How? Wafarin • First line Rx • Positive – Cheap – Vast experience – Effective if good control • Negative – Monitoring / titration / Inconvenient – Doesn’t completely remove risk – Bleeding – Stigma How ? NOACs • INR control poor • Logistics of monitoring / dosing • Drug interaction / true warfarin allergy • Rapid anticoagulation (eg for DCCV) (not bleeders) How (3) LAAO exclusion • Contraindication to anticoagulation • Bleeders or high risk • (concomittant other cardiac surgery) Questions?