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GRAND ROUNDS

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

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  1. GRAND ROUNDS Alyssa Morris , R4 May 12, 2011

  2. CASE • 63F says she has felt unwell and like her heart is racing since yesterday morning.

  3. OBJECTIVES • Guidelines • Risk of stroke scores • CHA2DS2-VASc • Risk of bleeding score • HAS-BLED • Anticoagulation • Dabigatran • New drugs • Vernakalant • Dronedarone

  4. CHADS2

  5. ISSUES • ASA Or Warfarin • BAFTA trial • Known risks not in score

  6. CHA2DS2-VASc

  7. ANTICOAGULATION • Warfarin • Narrow therapeutic window • Many drug interactions • Many food interactions • Inter-individual variable response • Slow onset of action • Constant monitoring

  8. CONTRAINDICATIONS • Renal failure • CrCl 30-50 mL/min  reduced dose • CrCl <30mL/min  can’t use • Severe hepatic impairment • Bleeding tendency • Quinidine

  9. Cost • 4-8$/day • 120-240$/month • Blue Cross doesn’t cover • Non-formulary in hospital

  10. BLEEDING EMERGENCY • Can measure PTT/TT • No antidote • TRY FFP and packed cells • ? Activated Factor VII • Can be dialyzed

  11. PETRO STUDY

  12. 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

  13. ADVERSE EVENTS • Dyspepsia • Stopping drug early • MI • GIB • Not hepatotoxic

  14. 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

  15. ISSUES • No antidote • Dyspepsia • No way to objectively know compliance • Unknown dosing at extremes of weight

  16. What do the stroke and cardiology services think?

  17. CCS GUIDELINES • “Most patients should receive dabigatran in preference to warfarin” • Dyspepsia • GIB • High risk for CAD

  18. BACK TO CASE • Q: Who would give her UFH before cardioversion? • Q: Who would give her LMWH before cardioversion?

  19. CCS GUIDELINES • No prior anticoagulation, except: • High risk patient • AF onset unknown • AF onset >48

  20. VERNAKALANT • Atrial selective • Multiple ion channel blocker • Rapidly and extensively distributed • Oral and IV forms

  21. 3mg/kg over 10m, wait 15m, then 2mg/kg over 10m • 59.4% converted in 90m • Median conversion was 12m

  22. 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

  23. RHYTHM CONTROL

  24. DRONEDARONE • De-iodinated amiodarone • Long term antiarrhythmic • Normal VF • ATHENA trial

  25. SUMMARY • CHADS2vs CHA2DS2-VASc • Dabigatran • HAS-BLED • Vernakalant

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