ESC Congress FA eBook 2016 - 5

ESC CONGRESS 2016

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IN REVIEW

FOCUS ON ARRHYTHMIAS

Before instituting anticoagulation therapy, modifiable
bleeding risk factors should be identified and corrected
if possible. Modifiable risk factors include hypertension,
labile INR or time in therapeutic range < 60% in patients
on VKAs, medications such as antiplatelet drugs and nonsteroidal anti-inflammatory drugs, and excess alcohol use.
Potentially modifiable bleeding risk factors include anemia,
impaired renal or liver function, and reduced platelet count
or function. Nonmodifiable bleeding risk factors include
age > 65 years, history of major bleeding, previous stroke,
dialysis-dependent kidney disease or kidney transplant, cirrhotic liver disease, malignancy, and genetic factors.
Several bleeding risk scores are available to identify
modifiable risk factors for major bleeding. Biomarkers such
as high-sensitivity troponin and natriuretic peptide may be
considered to further refine stroke and bleeding risk.
The recommendations for stroke prevention in
patients with AF are shown in Table 4.
In general, the combination of OAC with antiplatelets is not necessary (eg, in patients with stable coronary
artery disease [CAD]). However, combination therapy is
recommended in patients with AF at risk for stroke after
elective percutaneous coronary intervention with stent
(PCI) or after an acute coronary syndrome (ACS): For
PCI, triple therapy with OAC, aspirin and clopidogrel,
for 1 month after PCI followed by dual therapy with OAC
plus aspirin or clopidogrel up to 6 or 12 months; For ACS
with stent, triple therapy for 1-6 months followed by dual
therapy up to 12 months after ACS. For ACS without

stent implantation, dual treatment with OACs and aspirin or clopidogrel for up to 12 months. The duration of
combination therapy should be limited, balancing the
estimated risk of stroke, coronary events and bleeding.
Dual therapy with any OAC plus aspirin or clopidogrel
75 mg/d may be considered as an alternative to initial
triple therapy in selected patients.
The most common complications in patients with AF
are bleeding and stroke. Hans-Christoph Diener, MD,
University Hospital Essen, Essen, Germany, discussed
the ESC recommendations for managing these complications. Some causes of major bleeding can be treated
or eliminated, including hypertension, gastrointestinal ulcers, and intracranial aneurysms. Management
includes treatment of the triggering condition, interruption of OAC therapy, and reduction of OAC dose where
appropriate. Re-initiation of OAC therapy after a bleeding event should be considered in all eligible patients by
a multidisciplinary AF team, considering different anticoagulants and stroke prevention interventions, improved
management of bleeding risk factors, and stroke risk. In
patients with severe bleeding, OAC therapy should be
interrupted until the cause of bleeding is resolved.
The ESC algorithm for management of bleeding in
anticoagulated patients is shown in Figure 3. For patients
on dabigatran with severe or life-threatening bleeding, the antidote idarucizumab was approved by the
US FDA and the European Medicines Agency in 2015.
Idarucizumab is a humanized antibody fragment that

Figure 3. Management of Bleeding in Anticoagulated Patients
Patient with active bleeding
Compress bleeding sites mechanically
Assess hemodynamic status blood pressure, basic
coagulation parameters, blood count, and kidney function
Obtain anticoagulation history (last NOAC / VKA dose)

VKA
Delay VKA until INR < 2
Ad symptomatic treatment:
Fluid replacement
Blood transfusion
Treat bleeding cause
(eg, gastroscopy)

NOAC
Delay NOAC for 1 dose or 1 day

Minor

Moderate - Severe

Consider adding oral charcoal
if recently ingested NOAC

Consider adding
vitamin K (1-10 mg) IV
Consider PCC and FFP
Consider replacement of
platelets where appropriate

Ad symptomatic treatment:
Fluid replacement
Blood transfusion
Treat bleeding cause
(eg, gastroscopy)

Severe or
life-threatening

Consider specific antidote, or
PCC if no antidote available
Concider replacement of
platelets where appropriate

FPP, fresh frozen plasma; INR, international normalized ratio; NOAC, non-vitamin K antagonist oral anticoagulant; PCC, prothrombin complex concentrates; VKA, vitamin K antagonist.
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. By
permission of Oxford University Press on behalf of the European Society of Cardiology.

Official Peer-Reviewed Highlights From ESC Congress 2016

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