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GRAND ROUNDS. Alyssa Morris , R4 May 12, 2011. CASE. 63F says she has felt unwell and like her heart is racing since yesterday morning. . OBJECTIVES. Guidelines Risk of stroke scores CHA 2 DS 2 -VASc Risk of bleeding score HAS-BLED Anticoagulation Dabigatran New drugs Vernakalant

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grand rounds

GRAND ROUNDS

Alyssa Morris , R4

May 12, 2011

slide2
CASE
  • 63F says she has felt unwell and like her heart is racing since yesterday morning.
objectives
OBJECTIVES
  • Guidelines
  • Risk of stroke scores
    • CHA2DS2-VASc
  • Risk of bleeding score
    • HAS-BLED
  • Anticoagulation
    • Dabigatran
  • New drugs
    • Vernakalant
    • Dronedarone
issues
ISSUES
  • ASA Or Warfarin
  • BAFTA trial
  • Known risks not in score
anticoagulation
ANTICOAGULATION
  • Warfarin
    • Narrow therapeutic window
    • Many drug interactions
    • Many food interactions
    • Inter-individual variable response
    • Slow onset of action
    • Constant monitoring
contraindications
CONTRAINDICATIONS
  • Renal failure
    • CrCl 30-50 mL/min  reduced dose
    • CrCl <30mL/min  can’t use
  • Severe hepatic impairment
  • Bleeding tendency
  • Quinidine
slide20
Cost
  • 4-8$/day
  • 120-240$/month
  • Blue Cross doesn’t cover
  • Non-formulary in hospital
bleeding emergency
BLEEDING EMERGENCY
  • Can measure PTT/TT
  • No antidote
  • TRY FFP and packed cells
  • ? Activated Factor VII
  • Can be dialyzed
re ly
RE-LY
  • Rates of stroke
    • Less with 150mg BID
    • No difference with 110mg BID
  • Rates of major bleeding
    • No difference with 150mg BID
    • Less with 110mg BID
  • Rates of hemorrhagic stroke
    • Less with both 110mg and 150mg BID
  • Mortality
    • No difference
adverse events
ADVERSE EVENTS
  • Dyspepsia
  • Stopping drug early
  • MI
  • GIB
  • Not hepatotoxic
conclusions from re ly
CONCLUSIONS FROM RE-LY
  • 110mg
    • rates of stroke and systemic embolism similar to coumadin
    • lower rates major bleeding
  • 150mg
    • lower rates of stroke and systemic embolism
    • similar rates of major hemorrhage
  • AE: dyspepsia, MIs
issues1
ISSUES
  • No antidote
  • Dyspepsia
  • No way to objectively know compliance
  • Unknown dosing at extremes of weight
ccs guidelines
CCS GUIDELINES
  • “Most patients should receive dabigatran in preference to warfarin”
    • Dyspepsia
    • GIB
    • High risk for CAD
back to case
BACK TO CASE
  • Q: Who would give her UFH before cardioversion?
  • Q: Who would give her LMWH before cardioversion?
ccs guidelines1
CCS GUIDELINES
  • No prior anticoagulation, except:
    • High risk patient
    • AF onset unknown
    • AF onset >48
vernakalant
VERNAKALANT
  • Atrial selective
  • Multiple ion channel blocker
  • Rapidly and extensively distributed
  • Oral and IV forms
slide33

3mg/kg over 10m, wait 15m, then 2mg/kg over 10m

  • 59.4% converted in 90m
  • Median conversion was 12m
slide34

51.7% vs 5.2% converted in 90m

  • Median conversion time 11min
  • 53.4% vs 32.8% symptom relief at 90m
  • No TDP, VF, sustained VT
dronedarone
DRONEDARONE
  • De-iodinated amiodarone
  • Long term antiarrhythmic
    • Normal VF
  • ATHENA trial
summary
SUMMARY
  • CHADS2vs CHA2DS2-VASc
  • Dabigatran
  • HAS-BLED
  • Vernakalant