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Atrial Fibrillation Warfarin and its newer alternatives

Atrial Fibrillation Warfarin and its newer alternatives. Dr Mark Abelson Cardiologist Somerset West. Association of AF and Stroke. MM00453 (01) Intl 06/09. Occluded Left ICA-T Pre and Post Embolectomy. 54y M, “Wake up” >4h,NIHSS=32. MRS=1 @ 90 d. Carotid Embolectomy. AF and Stroke.

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Atrial Fibrillation Warfarin and its newer alternatives

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  1. Atrial Fibrillation Warfarin and its newer alternatives Dr Mark Abelson Cardiologist Somerset West

  2. Association of AF and Stroke MM00453 (01) Intl 06/09

  3. Occluded Left ICA-T Pre and Post Embolectomy 54y M, “Wake up” >4h,NIHSS=32 MRS=1 @ 90 d

  4. Carotid Embolectomy

  5. AF and Stroke AtrialFibrillation and Stroke • 3 million in US and 4.5 million in the EU have AF • 2/3 of AF population are at high-risk of stroke • AF is responsible for 15-20% of ischemic strokes • AF Incidence increases with age • -- 0.4% in general population • -- 0.2% of 25-34 yrs of age • -- 2-5% of >60 yrs of age • -- 10% of > 80 yrs of age

  6. Relationship of AF and Stroke

  7. Risk Stratification and Annual Stroke Risk for Patients with AF Annual Stroke Risk for Patients with AF By CHADS(2) Score F GAGE et al., 2004; 110:2287-2292

  8. Clot Prevention Currently Available Management Options • Medical Management: Anticoagulant • Effective: 67% stoke risk reduction(1) • Narrow therapeutic window for proper dose • Contraindicated in 14-47% of patients at risk of stroke (2) • Major complication: bleeding • Surgical Excision (Appendectomy) • Residual shunt: 10% (3) • Inconsistent outcomes due to incomplete exclusion; • Can create pouch with stagnant blood flow (4,5) • High invasiveness • Transcatheter Device Closure • Minimally invasive nature • Designed for percutaneous closure of the LAA in prevention of clot embolization that may form in the LAA • Intended as an alternative to warfarin therapy for patients with non-valvular atrial fibrillation

  9. Warfarin Therapeutic Window - INR of 2 to 3 A small window: difficult to achieve a well controlled therapeutic range

  10. INR Control – Not Good Low INR <1.6 Efficacy  4-fold TherapeuticINR 2-3 High INR >3.2 % Bungard: Pharmacotherapy 20:1060, 2001 3000838-14

  11. New Warfarin Alternatives • NO INR monitoring - Dabigatran ( Pradaxa) – direct thrombin inhibitor - Rivaroxaban (Xarelto) – F10a inhibitor • Aspirin plus clopidogrel • Aspirin (reduces stroke risk by 20%)

  12. Risk of Stroke or Embolism Connolly SJ et al. N Engl J Med 2009;361:1139-1151.

  13. Can’t Take Warfarin?? • Frail, falls • GI bleeds • Cerebral bleeds • Stroke despite therapeutic warfarin • Non-compliant / labile INR • (Do not want warfarin)

  14. 90% of clots in appendage

  15. Left Atrial Appendage Occluders Transcatheter Occlusion of the LAA Currently available in limited markets AMPLATZER® Cardiac Plug WATCHMAN®

  16. Protect AF – 21month F/U

  17. Vergelegen Experience • 7 patients – all elderly men with Chads>2 • Significant GI bleeds on warfarin • Warfarin stopped – 2 had small strokes • One INR very labile due to recurrent UTI (antibiotics. Suprapubic catheter) • All discharged next day – ASA and plavix for 1 month then ASA alone.

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