Pennine VTS
Atrial Fibrillation 2019
AF increases stroke risk 5 fold compared to people without AF.
Anticoagulation reduced risk of stroke by 66%.
2 key issues – under detection (1 in 3 cases estimated as undiagnosed) and under treatment (especially for patients on warfarin where at any one time 40% are not in the therapeutic range).
ESC-AF guidance 2016 and BMJ 2017 and BJGP 2018 advises several changes, including:
- Anticoagulation needs to be used to reduce stroke risk.
- DOACs are 1st line choice of anticoagulation for most patients unless they have mechanical heart valves, moderate to severe mitral stenosis or significant CKD.
- Rate control should be offered for the majority (1st line).
- CHA2DS2Vasc score still used to assess stroke risk.
- HASBLED is no longer considered a valuable tool as it often excludes those patents who benefit most.
- Stratify stroke risk for paroxysmal AF and Atrial flutter in the same way as for permanent AF.
- Increased use of left atrial appendage ablation (see later) for those who don’t respond to conventional therapies.
Which anticoagulant? – BMJ 2017
• All-cause mortality lower with DOACs than warfarin.
• Lower risk of stroke with DOACs vs warfarin.
• Lower risk of major bleeding with DOACs vs warfarin.
• Lower risk of intracranial bleeding with DOACs vs warfarin.
• Apixiban 5mg bd was the most effective DOAC for reducing stroke and all-cause mortality and also one of the safest with the lowest incidence of major bleeds and GI bleeds. Next in terms of effectiveness and safety was Rivaroxaban.
Switching from Warfarin to a DOAC
|Dabigatran |Rivaroxaban |Apixaban |
|Stop warfarin. |Stop warfarin. |Stop warfarin. |
|Start dabigatran as soon as INR is ................
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