stratificazione del rischio embolico ed - sigg.it · maximum score = 9; hypertension – sap...
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Niccolò Marchionni
Cattedra di Geriatria, Università di Firenze
SOD di Cardiologia e Medicina Geriatrica
Azienda Ospedaliero-Universitaria Careggi, Firenze
Società Italiana di Cardiologia Geriatrica (SICGe)
Stratificazione del
Rischio Embolico ed
Emorragico nell’Anziano
Simposio
I nuovi Anticoagulanti Orali:
nella Fibrillazione Atriale
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Epidemiologia e fattori di rischio di FA
Key point
• L’età avanzata è uno dei principali fattori di rischio di FA
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Age (years) 45-49 -3 – 1 PR (ms) <160 0
50-54 -2 – 2 160 – 199 1
55-59 0 – 3 >200 2
60-64 1 – 4 Age / Cardiac
murmur
45-54 5
65-69 3 – 5 55-64 4
70-74 4 – 6 65-74 2
75-79 6 – 7 75-84 1
80-84 7 – 7 >85 0
>85 8 – 8 Age / HF 45-54 10
BMI (Kg/m2) <30 0 55-64 6
>30 1 65-74 2
>75-84 0
SBP (mmHg) <160 0 Tx Hypertension No 0
>160 1 Yes 1 Women / Men; Age / Cardiac murmur: Age at which significant cardiac murmur developed; Age / HF: Age of heart failure
Schnabel RB et al, Lancet 2009
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Tipi di ictus e ruolo della FA
Key points
• La FA è il principale fattore di rischio per ictus cardioembolico
• Quale è la proporzione di ictus ischemici attribuibile a cardioembolismo?
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Cerebrovascular Disease: Stroke Subtype
Albers GW et al. Chest. 1998;114:683S-698S. Rosamond WD et al. Stroke. 1999;30:736-743.
Ischemic stroke (83%) Hemorrhagic stroke (17%)
Atherothrombotic disease (20-25%)
Embolism (20%)
Lacunar small vessel disease (25%)
Cryptogenic (30%)
Intracerebral hemorrhage (59%)
SAH (41%)
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Ictus cardioembolico in FA: fattori di rischio
Key point
• L’età avanzata è uno dei principali fattori di rischio di ictus cardioembolico secondario a FA
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Bejot Y, 2009
0 0 4
28
108
0 1 2
216227
12
73
0
40
80
120
160
200
240
Age (years)
<40 40-50 50-60 60-70 70-80 >80
CE
/AF
Str
oke r
ate
(N/1
00
.00
0/y
ear)
Men
Women
CE/AF stroke = 572/3064 (18.7%)
CE/AF 80.6 vs. other strokes 73.6 years
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C - recent Congestive heart failure 1
H - Hypertension 1
A - Age >75 years 1
D - Diabetes mellitus 1
S2 - History of Stroke or TIA 2
Risk Factors Score
Gage, JAMA, 2001 Rockson, JACC, 2004
CHADS2 Risk Stratification Scheme
Validation of clinical classification schemes for predicting stroke Results from the National Registry of Atrial Fibrillation
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Linee Guida ESC per la gestione della FA
2010
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Gage, JAMA, 2001
Rockson, JACC, 2004
Limiti del CHADS2
•Statistica C: 0.60 discriminazione modesta
•Pazienti classificati “a basso rischio” hanno una non trascurabile, effettiva incidenza di ictus
… quindi …
Lip GYH, et al. Lancet 2012
la predittività complessiva è poco soddisfacente
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Stroke Risk Factor Score
Congestive Heart Failure / LV Dysfunction 1
Hypertension 1
Age >75 years 2
Diabetes mellitus 1
Stroke / TIA / TE 2
Vascular Disease (MI, PAD, aortic plaque) 1
Age 65-74 years 1
Sex category (female) 1
Stroke Risk Assessment in AF: the CHA2DS2-VASc Score
Maximum score = 9; Score >1 – OAC; Score = 1 – ASA (75-325 mg) or OAC (preferred); Score = 0 - ASA (75-325 mg) or None (preferred)
Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach - The Euro Heart Survey on Atrial Fibrillation
Lip, Chest, 2010
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Linee guida ESC per la gestione della FA
2010
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Choice of anticoagulant
Antiplatelet therapy with ASA plus clopidogrel or – less effectively – ASA only, should be considered in patients who
refuse any OAC or cannot tolerate anticoagulation for reasons unrelated to bleeding. If there are contraindications to OAC
or antiplatelet therapy, left atrial appendage occlusion, closure or excision may be considered
Colour CHA2DS2-VASc: green = 0, blue = 1, red ≥2; line: solid = best option; dashed = alternative option
*Includes rheumatic valvular disease and prosthetic valves; ASA = acetylsalicylic acid; NOAC = novel oral anticoagulant; VKA = vitamin K antagonist
Camm AJ et al. Eur Heart J doi:10.1093/eurheartj/ehs253
No antithrombotic therapy
NOACs VKA
1
No (i.e. non-valvular AF)
Yes
No
≥2
Oral anticoagulant therapy
Assess bleeding risk (HAS-BLED score)
Consider patient values and
preferences
Atrial fibrillation
Valvular AF*
Yes
0
<65 years and lone AF (including females)
Assess risk of stroke CHA2DS2-VASc score
2012
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Prevenzione dell’ictus cardioembolico nell’anziano con FA
Key points
• Secondo CHA2DS2-VASC gli anziani sono a rischio di ictus cardioembolico almeno moderato, con indicazione assoluta alla TAO (in assenza di controindicazioni)
• Quale è la effettiva utilizzazione della TAO nel mondo reale?
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Letter Clinical Characteristic Points
H Hypertension 1
A Abnormal Renal / Liver Function 1
S Stroke 2
B Bleeding 1
L Labile INRs 2
E Elderly 1
D Drugs / Alcohol 1
Bleeding Risk Assessment in AF: HAS-BLED Bleeding Risk Score
Maximum score = 9; Hypertension – Sap >160 mmHg; Drugs – antiplatelets agents or NSAIDS Score > 3 – High risk patient: Caution and regular review following the initiation of antithrombotic therapy (OAC & ASA)
A novel user-friendly score (HAS-BLED) to assess one-year risk of major bleeding in atrial fibrillation patients: the Euro Heart Survey
Pisters, Chest, 2010
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A T A
F Antithrombotic Treatment by Age
Total (7148 pts)
58.8%34.1%
7.1%
≤75 years (3085 pts)
66.2%
25.5%
8.4%
p<.0001
OAC
None Other ATT
Di Pasquale G , et al. Int J Cardiol2012
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• only 51% (n=206)
discharged on warfarin
• of others 199, 83% had 2+
stroke risk factors
• risk of falling and of
intracranial hemorrhage 2
most commonly cited
reasons for not prescribing warfarin to
patients older than 80
years
Hylek E M et al. Stroke 2006;37:1075-1080
405 patients with AF , OAC therapy naïve on admission
Antithrombotic Prophylaxis in AF Patients by
Age & Risk Category
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Prevenzione dell’ictus cardioembolico nell’anziano con FA
Key points
• Il rischio della TAO aumenta con l’età, ma [forse] anche il suo beneficio
• Quale è il beneficio NETTO?
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J Thromb Haemost. 2011;9:1460-7
Età e rischio di sanguinamento
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No Si No Si No Si
1
4.9 4.3
5.7
3.5
8.1
0
2
4
6
8
Ris
ch
io r
ela
tivo
an
nu
ale
Fattori di rischio
10 <65 65 - 75 >75
1 1.7
1.1 1.7 1.7
1.2
Gruppi di età (anni)
Fattori di rischio:
diabete,
ipertensione,
storia di ictus/TIA
Placebo
Warfarin
Rischio annuale di ictus in pazienti con
fibrillazione atriale, per gruppi di età The Atrial Fibrillation Investigators
AFI, Arch Int Med, 1994
Rockson, JACC, 2004
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Olesen JB, et al. Thromb Haemost 2011
• Net clinical benefit = (incidenza ictus ischemico in assenza di terapia – incidenza ictus ischemico in presenza di terapia) – 1.5 x (incidenza emorragia intracranica in presenza di terapia – incidenza emorragia intracranica in assenza di terapia) (n=132,372)
Beneficio clinico netto della tromboprofilassi nella FA: rischio tromboembolico vs. rischio emorragico
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The ATRIA Cohort of AF pts N = 13,559; Age: 73 years
Net Clinical Benefit :
(annual rate of ischemic strokes / systemic emboli prevented by warfarin) minus (intracranial hemorrhages
due to warfarin) * impact weight. The impact weight was 1.5, reflecting the greater clinical impact of
intracranial hemorrhage versus thromboembolism
Real-world, observational study
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Conclusions
1. Physicians may be apprehensive about prescribing OAC to elderly patients, given concerns about a higher risk of hemorrhage.
2. However, age alone should not prevent prescription of OAC in elderly patients, given the potential greater net clinical benefit among such patients.
3. Appropriate stroke and bleeding risk stratification and choice of antithrombotic therapy are essential.
4. Once OAC is initiated, good INR control (at least 65% TTR) and the provision of a health care infrastructure to support such INR therapeutic targets are crucial to prevent warfarin-associated complications.
2010
2012: NOACs preferable!!