Fibrillazione atriale

ASL PROVINCIA DI BERGAMO

La gestione del paziente in Terapia Anticoagulante Orale (TAO)

Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):

• For patients with AF of > or =48 h or of unknown duration for whom pharmacologic or electrical cardioversion is planned, anticoagulation for 3 weeks before elective cardioversion and for at least 4 weeks after sinus rhythm has been maintained (Grade 1C).

• For patients with AF of > or = 48 h or of unknown duration undergoing pharmacological or electrical cardioversion, either immediate anticoagulation with unfractionated IV heparin, or low-molecular-weight heparin (LMWH), or at least 5 days of warfarin by the time of cardioversion (achieving an INR of 2.0-3.0) as well as a screening multiplane transesophageal echocardiography (TEE). – If no thrombus is seen, cardioversion is successful, and sinus rhythm is maintained,

anticoagulation for at least 4 weeks. – If a thrombus is seen on TEE, then cardioversion should be postponed and anticoagulation

should be continued indefinitely. – We recommend obtaining a repeat TEE before attempting later cardioversion (Grade 1B

addressing the equivalence of TEE-guided vs non-TEE-guided cardioversion).

• For patients with AF of known duration <48 h, we suggest cardioversion without prolonged anticoagulation (Grade 2C). However, in patients without contraindications to anticoagulation, we suggest beginning IV heparin or LMWH at presentation (Grade 2C).

Antithrombotic Therapy For Paroxysmal AF National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and

secondary care. London (UK): Royal College of Physicians; 2006

• B - Decisions on the need for antithrombotic therapy in patients with paroxysmal AF should not be based on the frequency or duration of paroxysms (symptomatic or asymptomatic) but on appropriate risk stratification, as for permanent AF.

Follow-Up Post Cardioversion National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and

secondary care. London (UK): Royal College of Physicians; 2006

• D - Following successful cardioversion of AF routine follow-up to assess the maintenance of sinus rhythm should take place at 1 month and 6 months.

• D - At the 1-month follow-up the frequency of subsequent reviews should be tailored to the individual patient taking into account comorbidities and concomitant drug therapies.

• D (GPP) - At each review the clinician should take the opportunity to re-assess the need for, and the risks and benefits of, continued anticoagulation.

• D - At 6 months, if patients remain in sinus rhythm and have no other need for hospital follow-up, they should be discharged from secondary care with an appropriate management plan agreed with their GP.

• D (GPP) - Patients should be advised to seek medical attention if symptoms recur.

• D (GPP) - Any patient found at follow-up to have relapsed into AF should be fully re-evaluated for a rate-control or rhythm-control strategy

Antithrombotic Therapy For Permanent AF National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and

secondary care. London (UK): Royal College of Physicians; 2006

• D (GPP) - In patients with permanent AF a risk–benefit assessment should be performed and discussed with the patient to inform the decision whether or not to give antithrombotic therapy.

• In patients with permanent AF where antithrombotic therapy is given to prevent strokes and/or thromboembolism :

• A - adjusted-dose warfarin should be given as the most effective treatment

• A - adjusted-dose warfarin should reach a target INR of 2.5 (range 2.0 to 3.0)

• B - where warfarin is not appropriate, aspirin should be given at 75 to 300 mg/day

• B - where warfarin is appropriate, aspirin should not be co-administered with warfarin purely as thromboprophylaxis, as it provides no additional benefit.

Antithrombotic Therapy For Asymptomatic AF

National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and

secondary care. London (UK): Royal College of Physicians; 2006

• D (GPP) - Patients with asymptomatic AF should receive thromboprophylaxis as for symptomatic AF

Risks of Long-Term Anticoagulation National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and

secondary care. London (UK): Royal College of Physicians; 2006

• D (GPP) - Both the antithrombotic benefits and the potential bleeding risks of long-term anticoagulation should be explained to and discussed with the patient.

• The assessment of bleeding risk should be part of the clinical assessment of patients before starting anticoagulation therapy. Particular attention should be paid to patients who:

• D - are over 75 years of age • C - are taking antiplatelet drugs (such as aspirin or clopidogrel) or non-

steroidal anti-inflammatory drugs • C - are on multiple other drug treatments (polypharmacy) • C - have uncontrolled hypertension • C - have a history of bleeding (for example, peptic ulcer or cerebral

haemorrhage) • D (GPP) - have a history of poorly controlled anticoagulation therapy

Anticoagulation Self-Monitoring National Collaborating Centre for Chronic Conditions. Atrial fibrillation. National clinical guideline for management in primary and secondary

care. London (UK): Royal College of Physicians; 2006

• C - In patients with AF who require long-term anticoagulation, self-monitoring should be considered if preferred by the patient and the following criteria are met:

• the patient is both physically and cognitively able to perform the self-monitoring test, or in those cases where the patient is not physically or cognitively able to perform self-monitoring, a designated carer is able to do so

• an adequate supportive educational programme is in place to train patients and/or carers

• the patient's ability to self-manage is regularly reviewed • the equipment for self-monitoring is regularly checked via a

quality control programme

Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):

• For patients with AF and mitral stenosis, we recommend long-term anticoagulation with an oral VKA (Grade 1B).

• For patients with AF and prosthetic heart valves we recommend long-term anticoagulation with an oral VKA at an intensity appropriate for the specific type of prosthesis (Grade 1B).

Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):

• AF, including paroxysmal AF, with prior ischemic stroke, transient ischemic attack (TIA), or systemic embolism, long-term anticoagulation (Grade 1A).

• AF, including paroxysmal AF, with two or more of the risk factors *for future ischemic stroke long-term anticoagulation (Grade 1A).

• AF, including paroxysmal AF, with only one of the risk factors long-term antithrombotic therapy (Grade 1A), either as anticoagulation with an oral VKA, such as warfarin (Grade 1A), or as aspirin, at a dose of 75-325 mg/d (Grade 1B). In these patients at intermediate risk of ischemic stroke we suggest a VKA rather than aspirin (Grade 2A).

• AF, including paroxysmal AF, age < or =75 years and with none of the other risk factors, long-term aspirin therapy at a dose of 75-325 mg/d (Grade 1B)

• For patients with atrial flutter, we recommend that antithrombotic therapy decisions follow the same risk-based recommendations as for AF (Grade 1C)

• *risk factors : age >75 years, history of hypertension, diabetes mellitus, moderately or severely impaired left ventricular systolic function and/or heart failure

CHADS score

• 2 points:prior ischemic stroke, transient ischemic attack (TIA), or systemic embolism

• 1 point: - age >75 years, - history of hypertension, - diabetes mellitus, - moderately or severely impaired left ventricular systolic function and/or heart failure

Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation

Lancet 2007; 370: 493–503

• There were 24 primary events (21 strokes, two other intracranial haemorrhages, and one systemic embolus) in people assigned to warfarin and 48 primary events (44 strokes, one other intracranial haemorrhage, and threesystemic emboli) in people assigned to aspirin (yearly risk 1·8% vs 3·8%, relative risk 0·48, 95% CI 0·28–0·80,p=0·003; absolute yearly risk reduction 2%, 95% CI 0·7–3·2).

• Yearly risk of extracranial haemorrhage was 1·4%(warfarin) versus 1·6% (aspirin) (relative risk 0·87, 0·43–1·73; absolute risk reduction 0·2%, –0·7 to 1·2).

• These data support the use of anticoagulation therapy for people aged over 75 who have atrial fibrillation, unless there are contraindications or the patient decides that the benefits are not worth the inconvenience