ESC Congress FA eBook 2016 - 11C

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Figure
Figure 1. Treatment Algorithm for Stroke Prevention
Figure1.
1. CHA
CHA DS
DS -VASc
-VAScScore
ScoreBetter
BetterThan
ThanCHADS
CHADS Score
Score
The
The Changing
Changing Landscape
Landscape of
of Stroke
Stroke
for
forRisk
RiskStratification
Stratificationof
ofThromboembolism
Thromboembolism
Prevention
in
Prevention and
and Bleeding
Bleeding
in AF
AF
Yes
Mechanical heart valves or moderate or severe mitral
22

CHA
CHA2DS
DS2-VASc
-VASc==00
2
2
CHA
CHA2DS
DS2-VASc
-VASc==22

CHA
CHA2DS
DS2-VASc
-VASc==11
2
2
CHA
CHA2DS
DS2-VASc
-VASc==33

stenosis
In
In the
the past
past decade,
decade, the
the landscape
landscape for
for management
management
CHADS
CHADS ==00
No
of
of patients
patients with
with atrial
atrial fibrillation
fibrillation (AF)
(AF) has
has changed
changed
100%
Estimate
stroke risk basedofon number of 100%
dramatically,
dramatically, particularly
particularly due
due to
to the
the emergence
emergence of
CHA 2DS 2-VASc risk factors
improved
and
98%
improved risk
risk stratification
stratification tools
tools for
for stroke
stroke
and bleedbleed98%
ing,
ing,and
andnovel
novelantithrombotic
antithromboticagents.
agents.
96%
96%
Gregory
of
Gregory Y.H.
Y.H. Lip,
Lip, MD,
MD, University
University
of Birmingham,
Birmingham,
0a
1
≥ 2b
Birmingham,
Birmingham, United
United Kingdom,
Kingdom, addressed
addressed the
the use
use of
of risk
risk
94%
94%
stratification
stratificationtools
toolsfor
forthe
theprevention
preventionof
ofstroke
strokeand
andbleeding.
bleeding.
Oral anticoagulation indicated
No antiplatelet
He
of
Healso
alsoemphasized
emphasizedthe
theimportance
importance
ofbalancing
balancingthe
therisk
riskof
of
92%
or anticoagulant
Assess92%
for contra-indications
OAC AF.
should
treatment (IIIB)
stroke
of
Correct reversible bleeding
strokeand
andbleeding
bleedingin
inthe
thetreatment
treatment
ofpatients
patientswith
with
AF. be
considered (IIaB)
0%
0%
risk factors
The
The stroke
stroke risk
risk assessment
assessment tool
tool used
used most
most commonly
commonly
00
100
200
300
100
200
300
isis the
Days
the CHADS
CHADS22 score,
score, which
which was
was initially
initially developed
developed as
as aa
DaysFrom
FromDischarge
Discharge
stroke
stroke risk
risk assessment
assessment index
index to
to predict
predict the
the risk
risk of
of stroke
stroke
LAA occluding
deviceset al. The value of the CHA2DS2-VASc score for refining stroke risk stratification in
1
Olesen
OlesenJB
JB et al. The value of the CHA2DS2-VASc score for refining stroke risk stratification in
in
isisconsidered
in patients
patients with
with nonvalvular
nonvalvular AF.
AF.1 However,
However, this
this score
score
may be
patients
with
patientsin
withatrial
atrialfibrillation
fibrillationwith
withaaCHADS2
CHADS2score
score0-1:
0-1:AAnationwide
nationwidecohort
cohortstudy.
study.Thromb
Thromb
Haemost.
2012;107:
largely
from
patients
with clear
contraHaemost.
2012;107:1172-1179.
1172-1179.With
Withpermission
permissionfrom
fromSchattauer.
Schattauer.
largely based
based on
on risk
risk factors
factors for
for stroke
stroke identified
identified
from
c
VKA (IA)
NOAC (IA)
indications for OAC (IIbC)
the
the non-warfarin
non-warfarin arms
arms of
of historical
historical clinical
clinical trial
trial cohorts.
cohorts.
a
The
has
limitations,
Includes
women
without
other stroke riskincluding
factors
andlone
loneAF
AF[including
[includingfemales],
females],or
oraaCHA
CHA22DS
DS22-VASc
-VAScscore
score
The CHADS
CHADS22 score
score
has many
many
limitations,
including the
the and
b IIaB for women with only one additional stroke risk factor
of
0
[males]
or
1
[females])
with
AF
who
do
not
require
fact
for
many
other
common
risk
of
0
[males]
or
1
[females])
with
AF
who
do
not
require
factthat
thatititdoes
doesnot
notc IBaccount
account
for
many
other
common
risk
for patients with mechanical heart valves or mitral stenosis
factors
antithrombotic therapy.
therapy. This
This isis aa shift
shift from
from prior
prior practice
practice
factorsfor
forstroke
strokethat
thathave
havebeen
beenidentified
identifiedin
inlarge
largeobserobser- antithrombotic
22
guidelines,
which
focused
on
identifying
high-risk
patients.
vational
cohort
studies.
Consequently,
the
CHA
DS
2
2
guidelines,
which
focused
on
identifying
high-risk
patients.
vational
cohort
studies.
Consequently,
the
CHA
DS
2 anticoagulant;
2
AF, atrial fibrillation; LAA, left atrial appendage; NOAC, non-vitamin K antagonist oral
OAC, oral anticoagulant; VKA, vitamin K antagonist.
VASc
Patients with
with ≥≥11 additional
additional stroke
stroke risk
risk factors
factors should
should be
be
VASc score
score was
was developed
developed to
to account
account for
for factors
factors such
such as
as Patients
Reprinted from Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016. doi:10.1093/eurheartj/ehw210.
8
female
sex,
age
65
74
and
coronary
disBy
permission
of Oxford
on
behalf of
the European
Societyartery
of
Cardiology.
offeredoral
oralanticoagulation
anticoagulationto
toprevent
preventstroke.
stroke.8
female
sex,
ageUniversity
65 to
to Press
74 years,
years,
and
coronary
artery
dis- offered
Raffaele
De
MD, PhD,
G.
d'Annunzio
University,
ease.
risk
identifies subjects
Raffaele
DeCaterina,
Caterina,
PhD,Ia
G.recom
d'Annunzio
University,
ease. This
This
risk score
score
subjects at
at high
high risk
risk for
for (Class
factors
including
age,identifies
renal function,
comorbidities,
IIa), while
there isMD,
a Class
mendation
for
Chieti,
and
G.
Monasterio
Foundation,
Pisa,
Italy,
provided
thromboembolism,
as
well
as
those
who
are
at
low
risk,
Chieti,
and
G.
Monasterio
Foundation,
Pisa,
Italy,
provided
thromboembolism,
as
well
as
those
who
are
at
low
risk,
and relative risk of stroke and bleeding. In a summary
patients
with
a
higher
level
of
risk.
3,4
further
more
than
the
1).
22score
furtherinsight
insightinto
intohow
howthe
thetreatment
treatmentguidelines
guidelinesare
arebeing
being
moreaccurately
accurately
than
theCHADS
CHADS
score(Figure
(Figure
1).3,4enanalysis
of several
high-risk
subgroups
of patients
Aspirin is not clinical
recommended for
use to prevent
stroke
There
implementedin
in clinicalpractice,
practice,focusing
focusingon
ondata
datafrom
fromthe
the
There isis considerable
considerable overlap
overlap of
of risk
risk factors
factors that
that prepre- implemented
rolled
in ENGAGE
AF-TIMI 48, Dr.therapies
Giugliano noted thatto in
patients with
AF.
dict
Preventionof
ofthromboembolic
thromboembolicevents
events--European
EuropeanRegistry
Registry
dict stroke
stroke and
and bleeding.
bleeding. Thus,
Thus, therapies designed
designed to Prevention
both efficacy
and safety
outcomes
were more
favorable
9
Kidney
function must
be evaluated
[PREFER
in
reduce
inAtrial
AtrialFibrillation
Fibrillation
[PREFER
inAF].
AF].9 in every patient
reduce the
the risk
risk of
of stroke
stroke (eg,
(eg, novel
novel oral
oral anticoagulants)
anticoagulants) in
with
edoxaban
than
warfarin
in
these
most
vulnerable
before
starting
an
OAC
and
at
least
once
every
year
Given
patients
with
AF,
need
Given the
the high
high incidence
incidence of
of stroke
stroke in
in
patients
with
AF,
need to
to balance
balance the
the benefit
benefit from
from stroke
stroke prevention
prevention
patients.
(more
often
the
worse
the
renal
function),
to
determine
against
current ESC
ESC guidelines
guidelines recommend
recommend anticoagulant
anticoagulant therapy
therapy
against the
the risk
risk of
of bleeding.
bleeding. The
The HAS-BLED
HAS-BLED score
score has
has current
8,10 reafneed
for dose
adjustment.
ESC
guideline
for
of
with
AF,
those
at
risk.
been
forall
all
ofpatients
patients
with
AF,except
exceptThe
those
atlow
low
risk.8,10In
Inparparbeen developed
developed as
as aa bleeding
bleeding risk
risk assessment
assessment tool
tool to
to the
5
2016
ESC
Guidelines
for the Management
ofwith
AF AF.
firms
allwhen
the dose
reduction vitamin
algorithms
for NOACs(VKAs;
used
ticular,
adjusted-dose
support
clinical
decision-making
for
ticular,
when
adjusted-dose
vitamin KK antagonists
antagonists
(VKAs;
support
clinical
decision-making
forpatients
patients
with
AF.5
A NOAC
(apixaban,
edoxaban,
or rivaroxaINR
2-3)
cannot
in
with
AF
OAC
their
trials,
Prof
Heidbuchel,
According
to
Lip,
score
has
INR
2-3)respective
cannotbe
beused
used
inastated
apatient
patient
with
AFwhere
wherean
anand
OAC
According
to Prof
Profdabigatran,
Lip, the
the HAS-BLED
HAS-BLED
score
has been
been in
ban)
was
preferentially
over
a VKAand
antagisis recommended,
of
of
the
shown
to
outperform
bleeding
scores
the
are providedthe
in ause
table
in
the
recommended,
the
use
of one
one
ofdocument.
the non-VKA
non-VKA oral
oral antiantishown
torecommended
outperform older
older
bleeding
scores
and
the these
coagulants
(NOACs)
isis advised.
Furthermore,
where
Anticoagulation
and
Risk
in
Fibrillation
onist
in patients with
whoFactors
are eligible
for both
(Class I,
The current
guideline
reaffirmed
its prior recommencoagulants
(NOACs)
advised.
Furthermore,
where OAC
OAC
Anticoagulation
andAF
Risk
Factors
in Atrial
Atrial
Fibrillation
therapy
isisrecommended,
of
the
NOACs
should
be
conscore
to
the
serious
bleeding.
Level
A)
in the new
ESC guidelines
forof
AF
(Figure
1). The dation
DS
-VASc
score
to
predict
the
using the CHAone
therapyfor
recommended,
one
of
the
NOACs
should
be
conscorein
inrelation
relation
topredicting
predicting
therisk
risk
of
serious
bleeding.
2
2
sidered
instead
of
VKA
2-3)
for
most
The
isiscurrently
the
prediction
data
available forscore
all four
NOACs
provide
therisk
scientific
ba- risk
sidered
instead
of adjusted-dose
adjusted-dose
VKA (INR
(INR
2-3)not
forrecmost
of stroke
(Class
I, Level A). However,
it did
TheHAS-BLED
HAS-BLED
score
currently
theonly
only
risk
prediction
patients
AF,
on
clinical
model
that
reliably
hemorrhage
patientswith
with
nonvalvular
AF,based
basedrisk
onnet
net
clinical
benefit.
model
thatrecommendation,
reliably predicts
predictsanintracranial
intracranial
hemorrhage
sis
for this
upgrade from
a Class II ommend
anynonvalvular
particular bleeding
score,
but benefit.
states
6,7
6,7 While this risk score can be used to identify
As
a
result
of
these
guidelines,
the
purpose
of
PREFER
in
(ICH).
As
a
result
of
these
guidelines,
the
purpose
of
PREFER
inAF
AF
(ICH).
While
this
risk
score
can
be
used
to
identify
that patients should be stratified for bleeding risk. A table
recommendation in the previous guideline, stated Hein
was
to
describe
how
patients
with
AF
are
currently
being
subjects
at
risk
for
bleeding
and
to
identify
modifiable
was
to
describe
how
patients
with
AF
are
currently
being
subjects
at
risk
for
bleeding
and
to
identify
modifiable
of non-modifiable and modifiable risk factors for major
Heidbuchel, MD, PhD, Antwerp University, Antwerp, Bel99
managed
in
risk
for
noted
that
aa high
HASmanagedthat
inEurope.
Europe.
risk factors
factors
for bleeding,
bleeding,
Prof
Lip
noted
thatcan
high
HAS- bleeding
should be assessed and addressed in all
gium.
For patients
alreadyProf
on aLip
VKA,
a NOAC
be conPREFER
in
AF
aa prospective,
mulBLED
not
as
to
PREFER
inbeing
AF was
was
prospective,
observational,
mulBLED score
score
should
not be
be used
used
as aa reason
reason
to withhold
withhold
patients
on or
considered
for an observational,
oral
anticoagulant
sidered
if theshould
TTR indicates
suboptimal
control
(ie,
TTR
ticenter
center
conducted
in
461
sites
in
7
European
oral
anticoagulant
(OAC)
therapy
since
the
bleeding
risk
ticenter
center
conducted
in
461
sites
in
7
European
oral
anticoagulant
(OAC)
therapy
since
the
bleeding
risk
(OAC) is provided.
Biomarkers, such as high-sensitivity
< 70%), despite good adherence with VKA. Even among
11
11 From January 2012 to January 2013, 7243 concountries.
may
the
of
therapy. troponin
countries.and
From
January 2012
to January
2013,
7243 conmaynot
notoutweigh
outweigh
thebenefit
benefitVKA,
ofanticoagulation
anticoagulation
natriuretic
peptide
may be
considered
patients
with
well-controlled
switching to a therapy.
NOAC
secutive
participants
(age
≥
18
years;
mean
age
=
72
Prof
Lip
discussed
how
clinical
guidelines
have
also
secutive
participants
(age
≥
18
years;
mean
age
=
72 years;
years;
Prof
Lip
discussed
how
clinical
guidelines
have
also
to further refine stroke and bleeding risk (Class
IIb,
may be considered based on patient preference, since
male
==60%)
with
aa history
of
AF
were
enrolled.
Of
the
evolved
in
the
past
decade
to
reflect
these
changes.
The
male
60%)
with
history
of
AF
were
enrolled.
Of
the
evolved
in
the
past
decade
to
reflect
these
changes.
The
Level
B).
routine blood tests and continual dose titration are not
30%
had
paroxysmal
AF,
24%
had
persisEuropean
participants,
30%
had
paroxysmal
AF,
24%
had
persisEuropeanSociety
Societyof
ofCardiology
Cardiology(ESC)
(ESC)guidelines
guidelinesnow
nowrecrec- participants,
The modified European Heart Rhythm Association
required with
NOACs.
tent
ommend
tent AF,
AF, 7%
7% had
had long-standing
long-standing persistent
persistent AF,
AF, and
and 39%
39% had
had
ommendidentifying
identifying"truly
"trulylow
lowrisk"
risk"patients
patients(age
(age<<65
65years
years symptom
scale was recommended (Class I, Level C)
A VKA was still recommended for patients with modas an important tool to communicate about symptom
erate to severe mitral stenosis or with mechanical heart
status with patients. Patient-centered, integrated AF
valves (Class I, Level B).
This
Thispeer-reviewed
peer-reviewedarticle
articlewas
wasbased
basedon
onscientific-clinical
scientific-clinicalcontent
contentpresented
presentedatatthe
theESC
ESC(European
(EuropeanSociety
Societyof
ofCardiology)
Cardiology)Congress
Congress2014.
2014.The
Thecontent
contentof
ofthis
thisarticle
article
promoted,
including
the
patient,
mulAn
OAC
should
be
considered
for
men
with
a
was
entirely
developed
by
MD
Conference
Express
and
SAGE
Publications,
and
the
opinions
herein
do
represent
those
of
was entirely developed by MD Conference Express and SAGE Publications, and themanagement
opinionsexpressed
expressedis
herein
donot
notnecessarily
necessarily
represent
those
ofthe
theEuropean
European
Society
of
Cardiology,
nor
of
Daiichi
Sankyo.
The
development
of
this
article
was
supported
by
Daiichi
Sankyo.
This
material
is
intended
for
educational
purposes.
Society DS
of Cardiology,
nor of Daiichi Sankyo. The development of this article was supported
by Daiichi Sankyo.
material is intended
educational
tidisciplinary
teams,This
technology
tools,forand
accesspurposes.
to all
CHA
2
2 -VASc score of 1 or for women with a score of 2
2

Proportionof
ofPatients
PatientsFree
Freeof
of
Proportion
Stroke/Thromboembolism
Stroke/Thromboembolism

This peer-reviewed article was based on scientific-clinical content presented at the ESC (European Society of Cardiology) Congress 2016. The content of this article was entirely developed
by Content Ed Net Medicom, and the opinions expressed herein do not necessarily represent those of the European Society of Cardiology, nor of Daiichi-Sankyo Europe GmbH. The
development of this article was supported by Daiichi-Sankyo Europe GmbH. This material is intended for educational purposes.

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