Atrial fibrillation and Thromboembolic complications

Suneetha Sampath

PGY-1

Splenic infarct

Proximal SMA

Ileocecal branch

Distal brachial artery

Common femoral arteries

Right popliteal artery

• Stroke risk: 2.3% (30% lethal)• Ac.Limb ischemia: 0.4% (60% lethal)

• Ac.mesentric ischemia: 0.14% (70% lethal) Jan Menke et al, Am J Cardiol 2010;105:502–510

Acute mesenteric ischemia

Jia-Ming Wang et al, N Engl J Med 2011; 364:1349

70% mortalityPneumatosis intestinalisMesentric venous gas

Outcome of renal artery occlusion

N Hazanov et al, Medicine 2004;83:292–299

Risk of Stroke

2014 AHA/ACC/HRS Guidelines for Mx of Afib

Stroke Vs Intracranial Hge

Risk of Bleeding

>3: “high risk”closer observation, frequent INRs

Why still anti-coagulate???

Annual risk of extra cranial Hge: 1.4%

But

RR: 64%

ARR : 2.7% per year

NNT: 37 (primary)12 (prior TIA/Stroke)

for 1 year to prevent 1 stroke.

Warfarin vs NOA :-Primary outcome

All cause stroke and systemic embolism

Ischemic or unspecified stroke

Hemorrhagic stroke RE-LY: DabigatranROCKET: RivaroxabanARISTOTLE: Apixiban

NOA reduce stroke and embolic events comparable to warfarin

Miller CS et al, Am J Cardiol 2012;110:453– 460

Intra cranial bleed

Major bleed

GI bleed

RE-LY: DabigatranROCKET: RivaroxabanARISTOTLE: Apixiban

-- Major bleeding and gastrointestinal bleeding: inconclusive-- Intra cranial bleeding: substantial reduction

Miller CS et al, Am J Cardiol 2012;110:453– 460

Warfarin vs NOA :-Risk of Bleeding

Mechanism of action of NOA

Warfarin is still the choice of drug in

1. Mechanical valve

2. Already on warfarin and comfortable

3. CKD with CrCl <30mL/min

4. Anti-epileptic drugs and Protease inhibitors

5. Unaffordable cost

Take home points

• Not just strokes

• CHA2DS2-VASc is superior

• Warfarin has 66% RR

• NOAc are superior to Warfarin

• Warfarin is still the choice in mechanical mitral valve

Choose

Or

Thank you