e16 An important misconception about warfarin is that if anticoagulated patients bleed, the risk can be quickly reversed, but most trial experience has found that warfarin reversal requires 24 hours to halve the INR value. Reversal of anticoagulation with the NOACs is unproven at present; possible approaches are presented in this review, but since the NOACs have both rapid onsets of action and short biologic half-lives, they do not present the same reversal challenges as warfarin. Finally, physicians must be aware of thromboembolic risk assessment. The principal risk assessment scores are CHADS2, updated with the more recent CHA2DS2-VASc to provide more accurate assessment of low-risk patients; this review concludes with a novel flow-chart showing physicians how the CHADS2/ CHA2DS2-VASc scoring systems can be used. Ó 2014 Published by Elsevier Inc. The American Journal of Medicine (2014) 127, e15-e16
AUTHOR DISCLOSURES James A. Reiffel, MD, has disclosed the following relevant financial relationships: Served as an advisor or consultant for: sanofi-aventis; Gilead Sciences, Inc.; CV Therapeutics; GlaxoSmithKline; Merck & Co., Inc.; Cardiome Pharma Corp.; Boehringer Ingelheim Pharmaceuticals, Inc.; Medtronic, Inc. Served as a speaker or a member of a speakers bureau for: sanofi-aventis; Boehringer Ingelheim Pharmaceuticals, Inc. Received grants for clinical research from: Boehringer Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline. Dr. Reiffel does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.
AFib Treatment: General Population Steven A. Rothman, MD Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania.
ABSTRACT When primary care physicians are presented with a patient with atrial fibrillation (AFib), there are two concerns. (online video available at: http://education.amjmed.com/video.php? event_id¼445&stage_id¼5&vcs¼1). One is the choice of strategy to treat the AFib, ie, whether to use rate control or a rhythm control strategy (to keep patients in sinus rhythm). The second concern is preventing the principal risk associated with AFib: stroke and systemic embolism. The focus of this review is stroke prevention, concentrating on risk assessment and traditional versus the new oral anticoagulation agents. For the past several decades, oral anticoagulation therapy has meant warfarin, which has the benefit of >50 years of clinical experience: it is inexpensive, it has generic availability, and it
The American Journal of Medicine, Vol 127, No 4, April 2014 has a wide range of clinical use indications beyond merely stroke prophylaxis in patients with AFib. On the other hand, only about half of the patients who should be receiving warfarin are prescribed it (and even fewer older patients are prescribed it), and only 30% of patients maintain time in therapeutic range (TTR) for serum warfarin levels at or above INR 2e3. According to a recent survey, almost a quarter of physicians employ rhythm control to treat AFib, and many of these believe that rhythm control decreases stroke and mortality risk sufficiently that anticoagulation therapy is not necessary. In addition, many physicians believe that when AFib is paroxysmal as opposed to permanent, then risk of stroke is low enough that long-term anticoagulation is not necessary. As discussed in this review, however, neither of these beliefs is true. Regarding bleeding risk, the same survey found that physicians perceive the risks of anticoagulation to be far greater than the benefits. Again, the evidence reveals that the patients at highest risk of bleeding are also at highest risk of stroke, and the benefits of preventing stroke with anticoagulation therapy almost always outweigh the risk of bleeding. This is discussed in the context of the new NOACs (discussed in the next review), including addressing what physicians should do if patients move from warfarin to one of the NOACs or vice versa. A final challenge for physicians treating patients with AFib has been the often mistaken belief that patients are at a low-risk status, and this review concludes with an overview of the use of the CHADS2 versus the CHA2DS2-VASc risk scoring systems, including why CHA2DS2-VASc provides a better assessment of which patients are or are not at low risk. Ó 2014 Published by Elsevier Inc. The American Journal of Medicine (2014) 127, e16
AUTHOR DISCLOSURES Dr. Rothman is a consultant or has participated in a Speaker’s Bureau for Astra-Zeneca, sanofi-aventis, Boehringer Ingelheim, Boston Scientific, and St. Jude Medical.
Novel Oral Anticoagulants James A. Reiffel, MD Department of Medicine, Columbia University, New York, New York.
ABSTRACT Warfarin has a proven record as an oral anticoagulant; almost every study, however, has found that it is not prescribed for 40e60% of patients who are eligible and should receive it, and of those who do receive it, serum warfarin levels only achieved a time in therapeutic range (TTR) equal to INR 2e3 about 55e60% of the time (online video available at: http://education.amjmed.com/video.php?event_ id¼445&stage_id¼5&vcs¼1). This means that only about
AUTHOR DISCLOSURES James A. Reiffel, MD, has disclosed the following relevant financial relationships: Served as an advisor or consultant for: sanofi-aventis; Gilead Sciences, Inc.; CV Therapeutics; GlaxoSmithKline; Merck & Co., Inc.; Cardiome Pharma Corp.; Boehringer Ingelheim Pharmaceuticals, Inc.; Medtronic, Inc. Served as a speaker or a member of a speakers bureau for: sanofi-aventis; Boehringer Ingelheim Pharmaceuticals, Inc. Received grants for clinical research from: Boehringer Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline. Dr. Reiffel does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.
AFib Treatment: General Population Steven A. Rothman, MD Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania.
ABSTRACT When primary care physicians are presented with a patient with atrial fibrillation (AFib), there are two concerns. (online video available at: http://education.amjmed.com/video.php? event_id¼445&stage_id¼5&vcs¼1). One is the choice of strategy to treat the AFib, ie, whether to use rate control or a rhythm control strategy (to keep patients in sinus rhythm). The second concern is preventing the principal risk associated with AFib: stroke and systemic embolism. The focus of this review is stroke prevention, concentrating on risk assessment and traditional versus the new oral anticoagulation agents. For the past several decades, oral anticoagulation therapy has meant warfarin, which has the benefit of >50 years of clinical experience: it is inexpensive, it has generic availability, and it
The American Journal of Medicine, Vol 127, No 4, April 2014 has a wide range of clinical use indications beyond merely stroke prophylaxis in patients with AFib. On the other hand, only about half of the patients who should be receiving warfarin are prescribed it (and even fewer older patients are prescribed it), and only 30% of patients maintain time in therapeutic range (TTR) for serum warfarin levels at or above INR 2e3. According to a recent survey, almost a quarter of physicians employ rhythm control to treat AFib, and many of these believe that rhythm control decreases stroke and mortality risk sufficiently that anticoagulation therapy is not necessary. In addition, many physicians believe that when AFib is paroxysmal as opposed to permanent, then risk of stroke is low enough that long-term anticoagulation is not necessary. As discussed in this review, however, neither of these beliefs is true. Regarding bleeding risk, the same survey found that physicians perceive the risks of anticoagulation to be far greater than the benefits. Again, the evidence reveals that the patients at highest risk of bleeding are also at highest risk of stroke, and the benefits of preventing stroke with anticoagulation therapy almost always outweigh the risk of bleeding. This is discussed in the context of the new NOACs (discussed in the next review), including addressing what physicians should do if patients move from warfarin to one of the NOACs or vice versa. A final challenge for physicians treating patients with AFib has been the often mistaken belief that patients are at a low-risk status, and this review concludes with an overview of the use of the CHADS2 versus the CHA2DS2-VASc risk scoring systems, including why CHA2DS2-VASc provides a better assessment of which patients are or are not at low risk. Ó 2014 Published by Elsevier Inc. The American Journal of Medicine (2014) 127, e16
AUTHOR DISCLOSURES Dr. Rothman is a consultant or has participated in a Speaker’s Bureau for Astra-Zeneca, sanofi-aventis, Boehringer Ingelheim, Boston Scientific, and St. Jude Medical.
Novel Oral Anticoagulants James A. Reiffel, MD Department of Medicine, Columbia University, New York, New York.
ABSTRACT Warfarin has a proven record as an oral anticoagulant; almost every study, however, has found that it is not prescribed for 40e60% of patients who are eligible and should receive it, and of those who do receive it, serum warfarin levels only achieved a time in therapeutic range (TTR) equal to INR 2e3 about 55e60% of the time (online video available at: http://education.amjmed.com/video.php?event_ id¼445&stage_id¼5&vcs¼1). This means that only about
