HEARTBEATA Publication of South Jersey Heart Group

March 2019

What's Changed?

Important changes include the preference of DOACs(dabigatran [a direct thrombin inhibitor] and rivaroxaban, apixiban and edoxaban [factor Xa inhibitors]) to warfarin; the dropping of female sex as a risk factor in CHA2DS2-VASc scores; clarifications to triple therapy in patients undergoingpercutaneous coronary intervention (PCI); and recommendations for left atrial appendage (LAA) occlusion devices and catheter ablation in patientswith heart failure with reduced ejection fraction (HFrEF).

CHA2DS2-VASc Score Congestive heart failure: 1 point

Hypertension: 1 point

Age: 65-74 =1 point; >75=2 points

Diabetes: 1 point

Stroke or TIA: 2 points

VAScular disease: 1 point (PAD, previous MI or aortic plaque)

Female sex: 1 point (ONLY if other risk factors are present)

A Disease of Privilege

As we age, the incidence of atrial fibrillation (AF) continues to increase—from one in 20,000 in our 20s toone in eight in our mid-60s. With our aging society andthe association of AF with morbidity and mortality, wemust continue to optimize our treatment plan. Numerouslandmark studies relevant to AF management have been published since the comprehensive 2014 AmericanHeart Association/American College of Cardiology/HeartRhythm Society guidelines were released.1

New Update to the Atrial Fibrillation Guideline:A Focus on Anticoagulation Strategies

The guideline task force has updated key aspects, especially with regards to new data on direct-actingoral anticoagulants (DOACs)—also known as non-vitamin K oral anticoagulants (NOACs).2 Several randomized, controlled trials published since the2014 guidelines serve as the basis for this importantupdate, which primarily changes recommendationsregarding DOACs. These changes will potentially affect our informed shared-decision discussions with many of our patients—to improve outcomes.

Key Points

� The decision to use an anticoagulant for stroke

prevention should be determined by the

CHA2DS2-VASc risk score—and not be influenced

by whether the AF is paroxysmal or persistent—

or resolved post-ablation.

� Female sex, if the only risk factor, does not confer

a CHA2DS2-VASc score of 1. Female sex adds to the

score only when another risk factor is present. Oral

anticoagulants (OACs) are recommended for

patients with AF and elevated CHA2DS2-VASc

scores — ≥2 in men and ≥3 in women.

� For patients with low CHA2DS2-VASc scores,

aspirin is no longer recommended. OACs might

be reasonable for men with CHA2DS2-VASc score

of 1 and women with CHA2DS2-VASc score of 2.

This is an individualized shared decision-making process

with the patient—as always—but I push harder to

anti-coagulate in obese patients, those with obstructive

sleep apnea and those with chronic kidney disease (CKD)

as these factors increase stroke risk but are not included

in the risk score. Many patients choose anticoagulation

because they do not want to have a debilitating stroke

and will tolerate the increased risk of bleeding.

� DOACs are the preferred OAC over warfarin,

although this has been the standard practice for most

cardiologists for several years, except in certain cases

such as valvular heart disease (VHD). Hepatic

and renal function should be evaluated before

initiation and checked yearly.

� VHD is now defined more narrowly as moderate-

to-severe mitral stenosis (MS) or a mechanical

heart valve. For patients with AF who have

mechanical heart valves or moderate-to-severe MS,

warfarin, not DOACs, is recommended. Optimal

therapy for bio-prosthetic heart valves is uncertain,

although limited data suggest apixiban and edoxaban

are non-inferior to warfarin in that population (we use

apixiban). In patients with hypertrophic obstructive

cardiomyopathy and AF, we lean toward warfarin

because there isn’t enough data to use DOACs.

� In end-stage renal disease, apixaban is a reasonable

alternative to warfarin. Apixaban has a lower risk of

bleeding and is easier to use. The appropriate dose is 5 mg

Bid unless the patient meets one or more of the following

exclusion criteria (age 80 or greater and weight less than

132 pounds). They obviously have a creatinine greater

than 1.5 mg/dL. There is a lot of under-dosing of apixiban.

The lower 2.5 mg dose Bid is not as effective.3 The lower

dose should only be used if two of the following criteria are

met: 80 years of age or greater, weight less than 132

pounds and creatinine greater than 1.5 mg/dL.

� Idarucizumab is recommended for the reversal of

dabigatran in the event of a life-threatening

bleed or urgent surgical procedure. Andexanet alfa

(re combinant factor Xa) is recommended for the

reversal of rivaroxaban and apixaban in the same

situations. One of the biggest advantages of DOACs

is their average short half-life of about 10 hours, working

in our favor. With good renal function, we should not get

into trouble that often and will not need to use these very

expensive reversal agents.

� Percutaneous LAA may be considered in patients

with AF who have heightened risks for stroke and

contraindications to long-term anticoagulation. It is

not an equal option to OAC therapy, as it is not as effective

for stroke reduction and carries an up-front surgical risk.

� In specific patients with symptomatic AF and

HFrEF, catheter ablation may be reasonable as it

could lower mortality and HF hospitalizations. The

focused update only assigns a “soft” indication for catheter

ablation in patients with AF and HF, suggesting that the

task force believed some or all these studies provided only

moderate-quality evidence, as there were limitations to

each study. Nevertheless, referral of patients with reduced

LVEF, HF symptoms and paroxysmal or persistent AF for

catheter ablation should be considered early—certainly

prior to committing patients to long-term amiodarone

or if a potentially recoverable cardiomyopathy if AF

is eliminated.

� The update clarifies the use of anticoagulants in

AF patients undergoing percutaneous coronary

intervention (PCI) with stenting.

• For triple therapy, choosing clopidogrel over

prasugrel for the P2Y12 inhibitor is reasonable for

the anti-platelet component of therapy along with

aspirin 81mg.

• The guideline strengthens its preference for dual

therapy with warfarin and clopidogrel (i.e., “it is

reasonable to choose” it) over triple therapy—to reduce the

risk of bleeding.

Dual therapy can involve rivaroxaban (15 mg daily) or

dabigatran (150 mg twice daily). Our usual protocol is to

use triple therapy for the first month and add a proton-pump

inhibitor, then switch to clopidogrel and a DOAC. Obviously,

NSAIDs are always contraindicated in all patients on OACs

and/or antiplatelet treatment. Results of the AUGUSTUS trial

presented at the American College of Cardiology meeting on

March 17 concluded that “less is more.” In patients with

atrial fibrillation and a recent acute coronary syndrome or PCI

treated with a P2Y12 inhibitor, an antithrombotic regimen

that included apixaban, without aspirin, resulted in less

bleeding and fewer hospitalizations without significant

differences in the incidence of ischemic events than regimens

that included a vitamin K antagonist, aspirin, or both.4

� Weight loss combined with risk factor modification

is recommended for overweight and obese patients

with AF. Obesity is associated with atrial remodeling and

is recognized as both a risk factor for AF and a barrier to

maintenance of sinus rhythm. Modification of key risk

factors (including, but not limited to, sleep apnea,

hypertension, alcohol and smoking) and exercise are all

recommended.

� In patients with cryptogenic stroke in whom

external ambulatory monitoring is inconclusive,

implantation of a cardiac monitor (loop recorder)

is reasonable for detection of subclinical AF—not

surprising, considering both the ease of implant and the

growing evidence to suggest sensitivity increases

dramatically beyond several weeks of monitoring.

� Perioperative bridging is only indicated for patients

with mechanical valves and those with very high-

risk CHA2DS2-VASc scores (greater than 6) or

history of stroke. Holding DOACS for 24 hours is

sufficient for minor surgery and 48 hours for more

complicated surgeries unless renal function is

significantly compromised. We usually hold

warfarin five days.

Special Guest Editor: Rohan Penmetcha, DO, Cardiology Fellow PGY V

Mario L. Maiese, DO, FACC, FACOI Clinical Associate Professor of Medicine, Rowan SOM

Email: maiese1@comcast.net

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References

1 January CT, Wann LS et al. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol December 2 2014; 64: e1-16.

2 January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol January 21 2019; pii: S0735-1097(19)30209-8. doi: 10.1016/j.jacc.2019.01.011.

3 Siontis KC et al. Outcomes associated with apixiban use in end stage kidney disease patients with atrial fibrillation in the US. Originally published 24 Jul 2018 Circulation 2019; 0:CIRCULATIONAHA.118.035418.

4 Lopes RD, et al for the AUGUSTUS Investigators. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med Online March 17 2019; DOI: 10.1056/NEJMoa1817083.