Wednesday, November 12, 2008
AF (atrial fibrilation)
De chads2staat voor congestive heartfailure, hypertension, age meer dan 75, diabetes en 2 punten voor een reeds eerder geval van TIA enz.
Een score van 0 dan 1,9 % kans op hersen infarct en een score vanb 6 dan 18,2 % kans
zie ook nieuwe middelen onder in dit stuk
(New Orleans, LA, USA), November 10, 2008: Many advances in the medical management of atrial fibrillation (AF) have debuted in the past few years. In this session, presenters discussed strategies for improving outcomes related to warfarin use and described investigational approaches to the management of AF.
Approximately 15% of strokes occur in patients with atrial fibrillation (AF). The risk of stroke in AF patients increases with age, from a 1.5% annual risk in patients aged 50-59 years to 23.5% in those aged 80-89 years. Indeed, elderly patients with AF are at the highest risk for stroke and the highest risk for hemorrhage. After adjusting for comorbid cardiovascular conditions, AF is associated with a 50% to 90% increase in mortality risk. Furthermore, stroke is a leading cause of serious long-term disability.
Five landmark clinical trials - AFASAK, SPAF, BAATAF, CAFA, and SPINAF - have demonstrated the unequivocal benefits of warfarin in preventing stroke among patients with AF. Additional trials have shown that the optimal international normalized ratio (INR) for patients with AF is 2.0 to 3.0. Below 2.0, patients have an increased risk for ischemic stroke, and above 3.0, the risk for intracranial bleeding begins to rise.
Dr. Hylek emphasized the importance of the CHADS2 score in identifying patients for whom the burdens and risks of warfarin therapy are justified. The CHADS2 scoring system assigns 1 point to each of four risk factors for stroke: Congestive heart failure, Hypertension, Age ≥75 years, and Diabetes. In addition, 2 points are assigned for prior Stroke, TIA, or systemic embolus. The annual risk for stroke is directly related to CHADS2 score, ranging from 1.9% for a CHADS2 score of 0 to 18.2% for a CHADS2 score of 6.
“There’s no excuse for not being able to calculate a CHADS2 score when discussing the importance of warfarin use with your patients,” Dr. Hylek said. The 2006 American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) guidelines for the management of patients with AF recommend therapy based on CHADS2 risk category. [1] For patients with no risk factors, aspirin 81 to 325 mg daily is recommended. For patients with a CHADS2 score of 1, the guidelines suggest aspirin 81 to 325 mg daily or warfarin (INR 2.0-3.0). For patients with a CHADS2 score >1, the guidelines recommend warfarin therapy (INR 2.0-3.0) for long-term risk management.
Despite considerable evidence supporting the use of anticoagulation therapy in the management of AF, warfarin is under-utilized across treatment settings. In a survey of community and academic hospitals in the US, nearly half of high-risk AF patients (47%) were not being treated with warfarin therapy. [2] In a European survey, only 54% of high-risk AF patients were receiving warfarin therapy. [3]
Long-term adherence to warfarin therapy is also low among patients with AF. Up to 25% of patients aged 80 years or older discontinued therapy within 90 days for reasons excluding death or return to normal sinus rhythm. [4] Factors associated with decreased use of oral anticoagulation include perceived bleeding risk, lack of proximity to an INR monitoring site, patient preference, and the innate difficulties of warfarin use.
Many strategies are available for improving adherence to anticoagulant therapy. For example, gastrointestinal (GI) complications are an important cause of early treatment withdrawal, particularly among elderly patients who are more sensitive to the mucosal effects of antiplatelet therapy. In 2008, the ACC and AHA published an expert consensus document on reducing the GI risks of antiplatelet therapy and NSAID use. [5]
New research will allow physicians to improve risk stratification for patients requiring anticoagulant therapy. Emerging tools that may be incorporated in risk-stratification models include genetic information and a range of biomarkers, including d-dimer and markers of anti-oxidant and anti-inflammatory activity.
“For the first time in years, there is some promise for medical therapy in AF,” said Dr. Page. In this presentation, he described recent trials that have demonstrated the benefits of pharmacologic cardioversion as a method for restoring sinus rhythm in patients with AF.
Vernakalant hydrochloride, a novel mixed ion channel antagonist, is under investigation for acute conversion in patients with AF. In the ACT I trial, 336 patients were randomly assigned to treatment with vernakalant or placebo and stratified by AF duration: 3 hours to 7 days (short duration) or 8 to 45 days (long duration). Among vernakalant-treated patients, 52% in the short-duration group converted to sinus rhythm compared with 4% of patients in the placebo group
The AF-CHF trial compared pharmacological rate control with drug- and defibrillation-based sinus rhythm maintenance in 1376 patients with systolic heart failure and AF. [7] Researchers found that a routine strategy of rhythm control did not reduce the rate of cardiovascular death compared with a rate-control strategy. After a mean of 37 months, 27% of patients in the rhythm-control group died from cardiovascular causes, compared with 25% in the rate-control group (HR 1.06; p=0.59). Findings from AF-CHF suggest that clinicians can safely use the rate-control approach, which is far less invasive and usually less costly than rhythm control, in high-risk AF patients.
The ATHENA trial, the largest AF trial to date, compared dronedarone and placebo in 4628 patients (mean age: 72 years) with paroxysmal/persistent AF. [8] After a mean follow-up of 21 months, dronedarone reduced the risk of first cardiovascular hospitalization or death by 24% compared with placebo (p<0.001).>p=0.176), it did reduce the risk of cardiovascular death by 29% (HR: 0.71; p=0.034) and cardiovascular hospitalization by 25% (HR: 0.75; p<0.001).
Additional data from the ATHENA trial will be published in upcoming months, Prof. Page said. Together, findings from ACT I, AF-CHF, and ATHENA may provide physicians with a range of new options for the medical management of AF.
Een score van 0 dan 1,9 % kans op hersen infarct en een score vanb 6 dan 18,2 % kans
zie ook nieuwe middelen onder in dit stuk
(New Orleans, LA, USA), November 10, 2008: Many advances in the medical management of atrial fibrillation (AF) have debuted in the past few years. In this session, presenters discussed strategies for improving outcomes related to warfarin use and described investigational approaches to the management of AF.
Approximately 15% of strokes occur in patients with atrial fibrillation (AF). The risk of stroke in AF patients increases with age, from a 1.5% annual risk in patients aged 50-59 years to 23.5% in those aged 80-89 years. Indeed, elderly patients with AF are at the highest risk for stroke and the highest risk for hemorrhage. After adjusting for comorbid cardiovascular conditions, AF is associated with a 50% to 90% increase in mortality risk. Furthermore, stroke is a leading cause of serious long-term disability.
Five landmark clinical trials - AFASAK, SPAF, BAATAF, CAFA, and SPINAF - have demonstrated the unequivocal benefits of warfarin in preventing stroke among patients with AF. Additional trials have shown that the optimal international normalized ratio (INR) for patients with AF is 2.0 to 3.0. Below 2.0, patients have an increased risk for ischemic stroke, and above 3.0, the risk for intracranial bleeding begins to rise.
Dr. Hylek emphasized the importance of the CHADS2 score in identifying patients for whom the burdens and risks of warfarin therapy are justified. The CHADS2 scoring system assigns 1 point to each of four risk factors for stroke: Congestive heart failure, Hypertension, Age ≥75 years, and Diabetes. In addition, 2 points are assigned for prior Stroke, TIA, or systemic embolus. The annual risk for stroke is directly related to CHADS2 score, ranging from 1.9% for a CHADS2 score of 0 to 18.2% for a CHADS2 score of 6.
“There’s no excuse for not being able to calculate a CHADS2 score when discussing the importance of warfarin use with your patients,” Dr. Hylek said. The 2006 American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) guidelines for the management of patients with AF recommend therapy based on CHADS2 risk category. [1] For patients with no risk factors, aspirin 81 to 325 mg daily is recommended. For patients with a CHADS2 score of 1, the guidelines suggest aspirin 81 to 325 mg daily or warfarin (INR 2.0-3.0). For patients with a CHADS2 score >1, the guidelines recommend warfarin therapy (INR 2.0-3.0) for long-term risk management.
Despite considerable evidence supporting the use of anticoagulation therapy in the management of AF, warfarin is under-utilized across treatment settings. In a survey of community and academic hospitals in the US, nearly half of high-risk AF patients (47%) were not being treated with warfarin therapy. [2] In a European survey, only 54% of high-risk AF patients were receiving warfarin therapy. [3]
Long-term adherence to warfarin therapy is also low among patients with AF. Up to 25% of patients aged 80 years or older discontinued therapy within 90 days for reasons excluding death or return to normal sinus rhythm. [4] Factors associated with decreased use of oral anticoagulation include perceived bleeding risk, lack of proximity to an INR monitoring site, patient preference, and the innate difficulties of warfarin use.
Many strategies are available for improving adherence to anticoagulant therapy. For example, gastrointestinal (GI) complications are an important cause of early treatment withdrawal, particularly among elderly patients who are more sensitive to the mucosal effects of antiplatelet therapy. In 2008, the ACC and AHA published an expert consensus document on reducing the GI risks of antiplatelet therapy and NSAID use. [5]
New research will allow physicians to improve risk stratification for patients requiring anticoagulant therapy. Emerging tools that may be incorporated in risk-stratification models include genetic information and a range of biomarkers, including d-dimer and markers of anti-oxidant and anti-inflammatory activity.
“For the first time in years, there is some promise for medical therapy in AF,” said Dr. Page. In this presentation, he described recent trials that have demonstrated the benefits of pharmacologic cardioversion as a method for restoring sinus rhythm in patients with AF.
Vernakalant hydrochloride, a novel mixed ion channel antagonist, is under investigation for acute conversion in patients with AF. In the ACT I trial, 336 patients were randomly assigned to treatment with vernakalant or placebo and stratified by AF duration: 3 hours to 7 days (short duration) or 8 to 45 days (long duration). Among vernakalant-treated patients, 52% in the short-duration group converted to sinus rhythm compared with 4% of patients in the placebo group
The AF-CHF trial compared pharmacological rate control with drug- and defibrillation-based sinus rhythm maintenance in 1376 patients with systolic heart failure and AF. [7] Researchers found that a routine strategy of rhythm control did not reduce the rate of cardiovascular death compared with a rate-control strategy. After a mean of 37 months, 27% of patients in the rhythm-control group died from cardiovascular causes, compared with 25% in the rate-control group (HR 1.06; p=0.59). Findings from AF-CHF suggest that clinicians can safely use the rate-control approach, which is far less invasive and usually less costly than rhythm control, in high-risk AF patients.
The ATHENA trial, the largest AF trial to date, compared dronedarone and placebo in 4628 patients (mean age: 72 years) with paroxysmal/persistent AF. [8] After a mean follow-up of 21 months, dronedarone reduced the risk of first cardiovascular hospitalization or death by 24% compared with placebo (p<0.001).>p=0.176), it did reduce the risk of cardiovascular death by 29% (HR: 0.71; p=0.034) and cardiovascular hospitalization by 25% (HR: 0.75; p<0.001).
Additional data from the ATHENA trial will be published in upcoming months, Prof. Page said. Together, findings from ACT I, AF-CHF, and ATHENA may provide physicians with a range of new options for the medical management of AF.
# posted by roodbont @ 1:08 AM 
