Recurrences 2008. 1. 11 : 1 Chapter 3. Growth of function Chapter 4. Recurrences.
3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have...
-
Upload
valentine-nicholson -
Category
Documents
-
view
215 -
download
0
Transcript of 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have...
![Page 1: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/1.jpg)
![Page 2: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/2.jpg)
www.washingtonhra.com
![Page 3: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/3.jpg)
3 million Americans 160,000 new cases each
year 16 million by 2050 90% of patients have
recurrences Incremental cost = $26
billionJACC 2004; 43(1): 47-52.Circ 2006; 114: 119-125.
Circ Cardiovasc Qual Outcomes 2011; 4(3): 313-20.
![Page 4: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/4.jpg)
RATE CONTROL
RHYTHMCONTROL
STROKE PREVENTION
![Page 5: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/5.jpg)
An 84 year old woman with HTN presents for routine follow-up of long-standing atrial fibrillation. She is active and asymptomatic. She is on Toprol 100 mg daily and warfarin. Her resting HR is irregular and 97, blood pressure 110/68. Her exam is otherwise normal. What should you do next?
A. Continue current therapy. B. Increase her Toprol to 150 mg daily.
C. Start dronedarone 400 mg bid.D. Add digoxin 0.125 mg daily.E. Refer for DCCV.
![Page 6: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/6.jpg)
An 84 year old woman with HTN presents for routine follow-up of long-standing atrial fibrillation. She is active and asymptomatic. She is on Toprol 100 mg daily and warfarin. Her resting HR is irregular and 97, blood pressure 110/68. Her exam is otherwise normal. What should you do next?
A. Continue current therapy. B. Increase her Toprol to 150 mg daily.
C. Start dronedarone 400 mg bid.D. Add digoxin 0.125 mg daily.E. Refer for DCCV.
![Page 7: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/7.jpg)
Rest heart rate ≤ 80 bpm. 24-hr Holter average ≤ 100 bpm. 6-min walk HR ≤ 110 bpm.
NEJM. 347(23): 2002.
![Page 8: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/8.jpg)
614 patients with permanent atrial fibrillation
Strict vs. lenient rate control: < 80 bpm vs. < 110 bpm
Noninferiority trial 1˚ EP: death from cardiovascular causes,
hospitalization from CHF, CVA, systemic embolization, bleeding and life threatening arrhythmic events
Follow-up: 2-3 years
![Page 9: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/9.jpg)
![Page 10: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/10.jpg)
Dyspnea, fatigue or palpitations 45.6% vs. 46.0%
Avg HR: 94±9 vs. 76±12
![Page 11: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/11.jpg)
Paroxysmal <7 daysPersistent >7 daysPermanent >12 months
![Page 12: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/12.jpg)
A 52 year old man with atrial fibrillation and mild LV systolic dysfunction presents with recurrent atrial fibrillation and heart failure despite multiple attempts at DCCV followed by trials of dofetilide and amiodarone. Vitals: HR 68, BP 120/80 . What should you do next?
A. Titrate heart failure medications, nothing further can be done for the atrial fibrillation. B. Refer for AV node ablation and pacemaker placement.
C. Start dronedarone 400 mg bid.D. Cardiovert and refer for catheter ablation
(pulmonary vein isolation).
![Page 13: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/13.jpg)
A 52 year old man with atrial fibrillation and mild LV systolic dysfunction presents with recurrent atrial fibrillation and heart failure despite multiple attempts at DCCV followed by trials of dofetilide and amiodarone. Vitals: HR 68, BP 120/80 . What should you do next?
A. Titrate heart failure medications, nothing further can be done for the atrial fibrillation. B. Refer for AV node ablation and pacemaker placement.
C. Start dronedarone 400 mg bid.D. Cardiovert and refer for catheter ablation
(pulmonary vein isolation).
![Page 14: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/14.jpg)
A 52 year old man with atrial fibrillation and mild LV systolic dysfunction presents with recurrent atrial fibrillation and heart failure despite multiple attempts at DCCV followed by trials of dofetilide and amiodarone. Vitals: HR 68, BP 120/80 . What should you do next?
A. Titrate heart failure medications, nothing further can be done for the atrial fibrillation. B. Refer for AV node ablation and pacemaker placement.
C. Start dronedarone 400 mg bid.D. Cardiovert and refer for catheter ablation
(pulmonary vein isolation).
![Page 15: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/15.jpg)
![Page 17: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/17.jpg)
![Page 18: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/18.jpg)
1˚ EP (recurrence or premature study drug discontinuation): 74% vs 55%
Atrial fibrillation recurrence 63.5% vs. 42% Premature discontinuation 10.4% vs. 13.3%
J Cardiovasc Electrophysiol 2010; 21: 597-605.
![Page 19: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/19.jpg)
DAFNE: to determine the most appropriate loading dose for prevention of AF after DCCV
Fre
ed
om
fro
m A
tria
l Fib
rillati
on
![Page 20: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/20.jpg)
Resting HRExertional
HR
![Page 21: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/21.jpg)
4628 patients: dronedarone 400 mg bid vs placebo
1˚ EP: 1st hospitalization due to CV events or death
Mean f/u 21 months
Rx discontinuation: 30.2% vs 30.8%
> 70 years oldhypertension
diabetes mellitusprior TIA/CVA/embolization
LA diameter ≥50 mmLVEF ≤ 40%
![Page 22: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/22.jpg)
![Page 23: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/23.jpg)
![Page 24: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/24.jpg)
![Page 25: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/25.jpg)
![Page 26: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/26.jpg)
Multi-national, RDBPC trial comparing placebo to dronedarone in patients with permanent atrial fibrillation
Inclusion criteria: > 65 years old with history of embolization, myocardial infarction, ASCAD, prior CHF or >75 years old/HTN/DM.
Exclusion criteria: class IV or unstable class III CHF Composite endpoint: MACE (stroke, systemic
arterial embolization, MI, cardiovascular death), cardiovascular hospitalization and all-cause mortality
![Page 27: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/27.jpg)
Target enrollment: 10,800 patients
Stopped at 3149 patients significant increase in cardiovascular events in patients taking dronedarone
(Permanent Atrial fibriLLAtion outcome Study using dronedarone)
![Page 28: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/28.jpg)
Hypothesis: Dronedarone will reduce the rate of hospitalization due to heart failure and possibly also reduce mortality by reducing arrhythmia.
Inclusion Criteria: Class III-IV CHF or PND with LVEF ≤ 35%
Exclusion Criteria: Acute pulmonary edema <12 hours prior Recent myocardial infarction Planned or recent cardiac surgery or
angioplasty
![Page 29: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/29.jpg)
Planned enrollment: 1000 patients Terminated after a median follow-up of 2
months
HR 2.13; 95% CI: 1.07 to 4.25, p =0.03
![Page 30: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/30.jpg)
![Page 31: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/31.jpg)
A 52 year old man with atrial fibrillation and mild LV systolic dysfunction presents with recurrent atrial fibrillation and heart failure despite multiple attempts at DCCV followed by trials of dofetilide and amiodarone. Vitals: HR 68, BP 120/80 . What should you do next?
A. Titrate heart failure medications, nothing further can be done for the atrial fibrillation. B. Refer for AV node ablation and pacemaker placement.
C. Start dronedarone 400 mg bid.D. Cardiovert and refer for catheter ablation
(pulmonary vein isolation).
![Page 32: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/32.jpg)
A 52 year old man with atrial fibrillation and mild LV systolic dysfunction presents with recurrent atrial fibrillation and heart failure despite multiple attempts at DCCV followed by trials of dofetilide and amiodarone. Vitals: HR 68, BP 120/80 . What should you do next?
A. Titrate heart failure medications , nothing further can be done for the atrial fibrillation. B. Refer for AV node ablation and pacemaker placement.
C. Start dronedarone 400 mg bid.D. Cardiovert and refer for catheter ablation
(pulmonary vein isolation).
![Page 33: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/33.jpg)
…...
www.atrialfibrillationablation.org
![Page 34: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/34.jpg)
![Page 35: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/35.jpg)
www.aafp.org
![Page 36: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/36.jpg)
Multicenter, prospective, randomized, open-label clinical trial
Hypothesis: Percutaneous LACA for the purpose of eliminating atrial fibrillation is superior to current state-of-the-art therapy with either rate control or rhythm control drugs.
Inclusion criteria: paroxysmal or persistent atrial fibrillation with stroke/TIA or one or more risk factors
1˚ Endpoint: total mortality Follow-up: minimum of 2 years
![Page 37: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/37.jpg)
A 76 year old male with HTN and diabetes presents with the new diagnosis of atrial fibrillation, discovered on a preoperative EKG for cataract surgery. He is active and asymptomatic. Medications include Toprol and Metformin. His resting heart rate is well controlled. What do you advise to decrease his risk for stroke?
A. No additional treatment is necessary.
B. Start ASA 325 mg daily.
C. Start ASA 81 mg daily and Plavix 75 mg daily.
D. Begin warfarin.
E. Jantoven, dabigatran or rivaroxaban should be started.
![Page 38: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/38.jpg)
www.med.umich.edu
otm.oxfordmedicine.com
![Page 39: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/39.jpg)
A 76 year old male with HTN and diabetes presents with the new diagnosis of atrial fibrillation, discovered on a preoperative EKG for cataract surgery. He is active and asymptomatic. Medications include Toprol and Metformin. His resting heart rate is well controlled. What do you advise to decrease his risk for stroke?
A. No additional treatment is necessary.
B. Start ASA 325 mg daily.
C. Start ASA 81 mg daily and Plavix 75 mg daily.
D. Begin warfarin.
E. Jantoven, dabigatran or rivaroxaban should be started.
![Page 40: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/40.jpg)
Low risk = ASA
High Risk = AC
![Page 41: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/41.jpg)
*Vascular disease = prior MI, aortic plaque or peripheral vascular disease
*
Anticoagulation for scores ≥ 2
![Page 42: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/42.jpg)
![Page 43: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/43.jpg)
1° Endpoint: stroke, systemic embolization, myocardial infarction or vascular death
![Page 44: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/44.jpg)
![Page 45: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/45.jpg)
Hypothesis: The addition of clopidogrel to ASA will reduce the risk of vascular events.
1° Endpoint: stroke, systemic embolization, myocardial infarction or vascular death
![Page 46: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/46.jpg)
7,554 patients, median follow-up 3.6 years
1° Endpoint: stroke, systemic embolization, myocardial infarction or vascular death
![Page 47: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/47.jpg)
![Page 48: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/48.jpg)
![Page 49: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/49.jpg)
FDA NEWS RELEASE : 19 OCT 2010FDA approves Pradaxa to prevent stroke in
patients with ATRIAL FIBRILLATION
![Page 50: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/50.jpg)
![Page 51: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/51.jpg)
A 76 year old male with HTN and diabetes presents with the new diagnosis of atrial fibrillation, discovered on a preoperative EKG for cataract surgery. He is active and asymptomatic. Medications include Toprol and Metformin. His resting heart rate is well controlled. What do you advise to decrease his risk for stroke?
A. No additional treatment is necessary.
B. Start ASA 325 mg daily.
C. Start ASA 81 mg daily and Plavix 75 mg daily.
D. Begin warfarin.
E. Jantoven, dabigatran or rivaroxaban should be started.
![Page 52: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/52.jpg)
A 76 year old male with HTN and diabetes presents with the new diagnosis of atrial fibrillation, discovered on a preoperative EKG for cataract surgery. He is active and asymptomatic. Medications include Toprol and Metformin. His resting heart rate is well controlled. What do you advise to decrease his risk for stroke?
A. No additional treatment is necessary.
B. Start ASA 325 mg daily.
C. Start ASA 81 mg daily and Plavix 75 mg daily.
D. Begin warfarin.
E. Jantoven, dabigatran or rivaroxaban should be started.
![Page 53: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/53.jpg)
18,113 patients randomized to twice daily dabigatran (110,150 mg) or warfarin.
Inclusion: over 75 years old and ≥1: Prior CVA or TIA EF <40%, h/o NYHA class II 65-74 years old with DM, HTN or ASCAD
1⁰ Endpoint: stroke or systemic embolization
Median follow-up = 2 years
![Page 54: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/54.jpg)
![Page 55: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/55.jpg)
![Page 56: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/56.jpg)
![Page 57: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/57.jpg)
![Page 59: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/59.jpg)
History of heart valve disorder Need for anticoagulant treatment of
disorders other than atrial fibrillation Stroke in the previous 6 months Severe renal impairment (CrCl <30 cc/min) Reversible causes of atrial fibrillation
(cardiac surgery, untreated hyperthyroidism) Plan to perform pulmonary vein isolation
![Page 60: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/60.jpg)
Increased bleeding risk:-major surgery <1 month or planned > 3 months-history of intracranial, intraocular, spinal or
retroperitoneal or atraumatic intra-articular bleeds-gastrointestinal hemorrhage <1 year; PUD < 1
month-hemorrhagic disorder-uncontrolled hypertension-malignancy or radiation therapy < 6 months;
survival < 3 years
![Page 61: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/61.jpg)
Anemia (Hgb <10) or thrombocytopenia (<100)
Active endocarditis Active liver disease Pregnancy or not taking contraception
![Page 62: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/62.jpg)
For patients with CrCl >30 mL/min: 150 mg orally, twice daily.
For patients with CrCl 15-30 mL/min: 75 mg orally, twice daily.
Missed doses should be skipped if it cannot be taken at least 6 hours before the next scheduled dose.
![Page 63: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/63.jpg)
From warfarin: When converting patients from warfarin
therapy to PRADAXA, discontinue warfarin and start PRADAXA when the international normalized ratio (INR) is below 2.0
From Parenteral Therapy: start 0 to 2 hours before the time that the
next dose of the parenteral drug was to have been administered
![Page 64: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/64.jpg)
Before initiating treatment with a parenteral anticoagulant:
Wait 12 hours for CrCl ≥30 mL/min
Wait 24 hours for CrCl <30 mL/min.
![Page 65: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/65.jpg)
For CrCl >50 mL/min, start warfarin 3 days before discontinuing PRADAXA.
For CrCl 31-50 mL/min, start warfarin 2 days before discontinuing PRADAXA.
For CrCl 15-30 mL/min, start warfarin 1 day before discontinuing PRADAXA.
![Page 66: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/66.jpg)
Discontinue PRADAXA 1 to 2 days (CrCl ≥50 mL/min) or 3 to 5 days (CrCl <50 mL/min) before invasive or surgical procedures.
Consider longer times for patients undergoing major surgery, spinal puncture, or placement of a spinal or epidural catheter.
![Page 67: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/67.jpg)
Most common adverse reactions (>15%) are gastritis-like symptoms and bleeding.
P-gp inducers and inhibitors: avoid coadministration of rifampin.
![Page 68: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/68.jpg)
Offering PRADAXA to all eligible new atrial fibrillation consultations
Prescribing PRADAXA to appropriate existing atrial fibrillation patients who request it
Screening existing atrial fibrillation patients and providing educational materials
![Page 69: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/69.jpg)
limelightprsonar.files.wordpress.com
![Page 70: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/70.jpg)
![Page 71: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/71.jpg)
Wafarin
Dabigatran
Rivaroxaban
Apixaban
X
X
X
X X
![Page 72: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/72.jpg)
Dabigatran Rivaroxaban Apixaban
Pharmacology 12-17 hrs (bid) 7-11 hrs (daily) 12 hrs (bid)
CHADS2
Prior TIA/CVA
Primary Outcome
Bleeding
Death
Notes
![Page 73: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/73.jpg)
Dabigatran Rivaroxaban Apixaban
Pharmacology 12-17 hrs (bid) 7-11 hrs (daily) 12 hrs (bid)
CHADS2 2.1 3.5 2.1
Prior TIA/CVA 20% 55% 19%
Primary Outcome
Bleeding
Death
Notes
![Page 74: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/74.jpg)
Dabigatran Rivaroxaban Apixaban
Pharmacology 12-17 hrs (bid) 7-11 hrs (daily) 12 hrs (bid)
CHADS2 2.1 3.5 2.1
Prior TIA/CVA 20% 55% 19%
Primary Outcome Superior (1.53%) Noninferior/Superior? (1.7-
2.1%)
Superior (1.27%)
Bleeding
Death
Notes
![Page 75: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/75.jpg)
Dabigatran Rivaroxaban Apixaban
Pharmacology 12-17 hrs (bid) 7-11 hrs (daily) 12 hrs (bid)
CHADS2 2.1 3.5 2.1
Prior TIA/CVA 20% 55% 19%
Primary Outcome Superior (1.53%) Noninferior/Superior? (1.7-
2.1%)
Superior (1.27%)
Bleeding Noninferior (3.11%)
Noninferior (3.6%)
Superior (2.1%)
Death
Notes
![Page 76: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/76.jpg)
Dabigatran Rivaroxaban Apixaban
Pharmacology 12-17 hrs (bid) 7-11 hrs (daily) 12 hrs (bid)
CHADS2 2.1 3.5 2.1
Prior TIA/CVA 20% 55% 19%
Primary Outcome Superior (1.53%) Noninferior/Superior? (1.7-
2.1%)
Superior (1.27%)
Bleeding Noninferior (3.11%)
Noninferior (3.6%)
Superior (2.1%)
Death Noninferior (p=0.051)
Noninferior Superior
Notes
![Page 77: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/77.jpg)
Dabigatran Rivaroxaban Apixaban
Pharmacology 12-17 hrs (bid) 7-11 hrs (daily) 12 hrs (bid)
CHADS2 2.1 3.5 2.1
Prior TIA/CVA 20% 55% 19%
Primary Outcome Superior (1.53%) Noninferior/Superior? (1.7-
2.1%)
Superior (1.27%)
Bleeding Noninferior (3.11%)
Noninferior (3.6%)
Superior (2.1%)
Death Noninferior (p=0.051)
Noninferior Superior
Notes GIB? MI? ACS, DVT Not FDA Approved
![Page 78: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/78.jpg)
Dabigatran Rivaroxaban Apixaban
Pharmacology 12-17 hrs (bid) 7-11 hrs (daily) 12 hrs (bid)
CHADS2 2.1 3.5 2.1
Prior TIA/CVA 20% 55% 19%
Primary Outcome Superior (1.53%) Noninferior/Superior? (1.7-
2.1%)
Superior (1.27%)
Bleeding Noninferior (3.11%)
Noninferior (3.6%)
Superior (2.1%)
Death Noninferior (p=0.051)
Noninferior Superior
Notes GIB? MI? ACS, DVT Not FDA Approved
![Page 79: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/79.jpg)
I’m not dead yet!
Bring out your dead-
45% of patients with atrial fibrillation appropriately anticoagulated.
Broad indications for use. Safety with renal dysfunction. $$$$$$$
![Page 80: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/80.jpg)
Strict rate control is not necessary in well compensated atrial fibrillation (III).
Dronedarone is an option to decrease cardiovascular hospitalizations in patients with paroxysmal atrial fibrillation (IIa). Not with class IV CHF or recent decompensation (III).
Evidence is mounting for catheter ablation (I). Dual anti-platelet therapy is an option in
patients unsuitable to safely sustain AC or due to patient preference (IIb).
Oral alternatives to warfarin are available (I).
![Page 81: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/81.jpg)
![Page 82: 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost.](https://reader036.fdocuments.us/reader036/viewer/2022062500/56649ebf5503460f94bc970e/html5/thumbnails/82.jpg)