Dr Irina Savelieva, Lecturer in Cardiology, Division of Cardiac and Vascular Sciences, St George's, University of London, talks to Cardio Debate about atrial fibrillation.
TRANSCRIPT
How to identify patients with AF who are at high risk of stroke?
That’s obviously the question that all physicians who face patients with atrial fibrillation for the first time should ask themselves, that’s a very important component of management of atrial fibrillation.
And of course there is the CHADS VASC score. This is a very good scheme that has been adopted by many regulatory authorities and guidelines, which is pretty simple. It incorporates major risk factors which are easily identifiable during your first interview with your patient. And it includes congestive heart failure, left ventricular dysfunction, age, hypertension, diabetes, previous stroke, advance stage – well if you can see that some aged over 75 years is advanced, so that’s your answer – and female gender.
The problem with the CHADS CASC score is that we don’t have very concrete data in patients with the CHADS VASC score 1, for example. And we don’t know exactly what the weight of separate isolated risk factors are in a patient with the CHADS VASC score of 1, and there were reports that probably these patients are not necessarily at a very high risk of stroke when anticoagulation is warranted. The ESC guidelines however do support anticoagulation in these patients and I think that physicians should follow these guidelines.
On the other hand an important thing is that patients with a CHADS VASC score of 0 are not entirely risk free of stroke. Strokes do happen in otherwise healthy persons with atrial fibrillation, with low atrial fibrillation if you will.
And this is a particular problem for us physicians, because obviously for such patients stroke is an absolutely devastating consequence of untreated atrial fibrillation that we could have prevented in this case.
And we’re trying to develop new markers for example some biomarkers such as brain natriuretic peptide (BNP), troponin, some coagulation parameters in order to assist better risk stratification in this particular patient population.
Some imaging techniques, for example MRI of the atria may indicate that certain morphologies of left atrial appendage, for example, may predispose to high risk of stroke. The extent of left atrial fibrosis also has been shown to be associated with increased risk of stroke. So that risk stratification is ongoing, it’s a moving issue.
But for the time being, for the clinician, when you first face a patient with atrial fibrillation, do CHADS VASC score and this would help you guide your management in terms of oral anticoagulation.
Anticoagulation and bleeding risk: Prevention and treatment
Bleeding as a result of oral anticoagulation is of course a dreadful consequence that was probably imposed on the patient by us, the physicians. So therefore numerous schemes have been developed in order to predict such tragic consequence of treatment with oral anticoagulants.
We advocate the use of HAS-BLED. That’s a very simple one to calculate, and again it does include factors that are easily identifiable, and most importantly they are, to some extent, modifiable at the same time. For example it helps to highlight patients with poorly controlled hypertension that predisposes to high risk of intracranial bleeding, for example, or patients who are receiving concomitant medications that may potentiate the adverse effects of oral anticoagulants for example gastro-intestinal tract, etc.
So by calculating this risk score HAS-BLED, we can identify risk factors that can change and therefore we can reduce the patient’s risk of bleeding.
But at the end of the day it is a very fine balance between the risk and benefit. And therefore here we have to exercise an individual approach to the patient.
And of course again, here, we also have some new developments. For example there is a very interesting observation that finding micro-bleeds on the MRI of the brain may actually predict the subsequent hemorrhagic stroke or even ischemic stroke, and this would help to risk stratify patients in terms of anti-coagulation. Of course it is mainly a research tool, as well as the previously mentioned imaging of the left atrium as we discussed, but it is a research tool today; tomorrow it will be part of risk stratification (protocols) in terms of bleeding.
The role of NOACs in everyday practice: Farewell to warfarin?
NOACs or warfarin – that’s a dilemma. NOACs is an acronym for new oral anticoagulants. However, these drugs are not that entirely new, and NOACs now stand for Non-Vitamin K Anti Oral Coagulants, not New or Novel.
To read the rest of the transcript please visit www.cardio-debate.com
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