2. Managing AF in Patients with Complex Comorbidities and Over the Long Term

3. Disclaimer
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4. Mechanisms of AF and Relation to Disease States1
Diabetes
Heart failure
Obesity
Coronary artery disease
Valvular heart disease
Hypertension
Hyperthyroidism
Renal impairment
Anaemia
Sepsis
Surgical procedures
Ageing
Genetic predisposition
Stretch-induced atrial fibrosis
Hypocontractility
Fatty infiltration
Inflammation
Vascular remodelling
Ischaemia
Ion channel dysfunction
Ca2+ instability
Electrolyte abnormalities
Hyperstimulation of myocardial tissue
Sympathetic overstimulation
Reference
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

5. Mr P Aged 79 years, 65 kg Hypertension and dyslipidaemia
Diet-controlled diabetes
Persistent AF
Stroke 2 years ago without any residual weakness.
Alzheimer’s disease – MMSE 23
Medications include a NOAC and perindopril

6. Mr P’s Renal Function Deteriorates Following Yearly Check-up
Recommendations
Class
Level
Assessment of kidney function by serum creatinine or creatinine clearance is recommended in all AF patients to detect kidney disease and for correct dosing of
therapy. I A
All AF patients treated with oral anticoagulation should be
considered for at least yearly renal function evaluation to detect chronic kidney disease.
IIa B
Reference
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

7. Dose Reductions of NOACs in Renal Disease
Apixaban1
no dose adjustment is necessary in patients with mild or moderate renal impairment.
Contraindicated for patients with CrCl <25 mL/min
Dose adjustment recommended if serum creatinine ≥133 μmol/L, age ≥80 years, body weight ≤60 kg
Rivaroxaban2
Adjust dose from 20 mg to 15 mg o.d. in patients with CrCl mL/min
Contraindicated for patients with CrCl < 30 mL/min
Dabigatran3
In NVAF patients with moderate renal impairment (30-50 mL/min CrCL), a dose reduction from 150 mg b.d. to 110 mg b.d. may be considered
Contraindicated for patients with CrCl <30 mL/min
References:
ELIQUIS Approved Product Information.
XARELTO Approved Product Information.
PRADAXA Approved Product Information.
References: 1. ELIQUIS Approved Product Information. 2. XARELTO Approved Product Information. 3. PRADAXA Approved Product Information.

8. Renal Dysfunction – Key Considerations
Assess1
Before initiating NOAC
If a decline in renal function is suspected
Review1
Yearly
6-monthly if
CrCl 30–60 mL/min
Taking dabigatran etexilate
>75 years of age
Fragile
Reference
1. Heidbuchel H, Verhamme P, Alings M et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17:
Reference: 1. Heidbuchel H et al. Europace 2015; 17:

9. Mr P Requires Surgery
Mr P presents to the surgery for removal of a skin lesion on his left arm (small lesion requiring approx. 4 sutures).
Considerations:
Patient factors:1
renal function, age, history of bleeding complications, concomitant medications
Estimation of thromboembolic risk 1
Major factors include presence of atrial fibrillation, prosthetic heart valves, and recent venous or arterial thromboembolism (eg, within the preceding three months)
CHA2DS2-VASc score
Estimation of procedural bleeding risk1
High risk (coronary artery bypass surgery, kidney biopsy, and any procedure lasting >45 minutes)
2-day risk of major bleeding 2 to 4%
Low risk (cholecystectomy, carpal tunnel repair, and abdominal hysterectomy)
2-day risk of major bleeding 0 to 2%
Does Mr P need to stop his NOAC prior to the procedure? If so, how soon before?
Examples of high bleeding risk procedures include coronary artery bypass surgery, kidney biopsy, and any procedure lasting >45 minutes; low bleeding risk procedures include cholecystectomy, carpal tunnel repair, and abdominal hysterectomy. Importantly, these categories do not substitute for clinical judgement or consultation between the surgeon and other treating clinicians. (Lip)
NOACs during surgery: Patient factors including renal function, age, history of bleeding complications, concomitant medications
and surgical factors should be considered prior to discontinuing the drug. Compared with warfarin, which
may need bridging anticoagulation in patients with higher thromboembolic risks, patients on
NOACs are less likely to require bridging therapy. This is explained by the short halflife
which allows for properly timed short-term cessation and early reinitiation after surgery.2
References
1. Lip GY, Douketis JD. Perioperative management of patients receiving anticoagulants. < [Accessed 30/12/2016].
2. Rahman A, Latona J. New oral anticoagulants and perioperative management of anticoagulant/antiplatelet agents. Aust Fam Physician 2014; 43:
Reference: 1. Lip GY et al. In: Uptodate.com (Leung LLK, ed), Vol. 2016: Wolters Kluwer, Rahman A et al. Aust Fam Physician 2014; 43:

10. Interactive question Does Mr P Need to Stop His NOAC Prior to the Procedure? (small lesion requiring approx. 4 sutures)
Yes, to minimise the risk of bleeding, 7 days before surgery
Yes, to minimise the risk of bleeding, 24 hours before surgery
Only if there is a concern of bleeding, 7 days before surgery
Only if there is a concern of bleeding, 24 hours before surgery
Cessation of NOACs is not necessary before surgery
ELIQUIS should be discontinued at least 24 hours prior to elective surgery or invasive
procedures with a low risk of bleeding or where bleeding would be non-critical in location or
easily controlled.(Eliquis PI)

11. Reference
Periprocedural Management of Anticoagulation Writing C, Doherty JU, Gluckman TJ et al ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol In Press
Reference: 1. Periprocedural Management of Anticoagulation Writing C et al. J Am Coll Cardiol In Press. .

12. Reference
Periprocedural Management of Anticoagulation Writing C, Doherty JU, Gluckman TJ et al ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol In Press
Reference: 1. Periprocedural Management of Anticoagulation Writing C et al. J Am Coll Cardiol In Press. .

13. Cessation Before Surgery: Who Makes the Decision?
Major surgery: GP is able to make recommendation, specialist opinion may be required if there is doubt
Minor surgery (e.g. dentistry):
GP may be asked to make recommendation
Clinical assessment on when to stop and start therapy
Bridging therapy may not be required in NVAF for patients taking a NOAC.1
Discussion
Reference
1. Douketis JD, Spyropoulos AC, Kaatz S et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med 2015; 373:
Reference: 1. Douketis JD et al. N Engl J Med 2015; 373:

14. Mr P Presents Following ACS
Mr P presented to the ED with ACS and underwent a percutaneous coronary intervention and received a stent 6 months ago
He is now on triple therapy of a NOAC + aspirin 75 mg/day + clopidogrel 75 mg/day
He has a calculated CHA2DS2-VASC score of 1 and a low-moderate HAS-BLED score
What medication changes would you make?

15. Mr P presents following ACS. What medication changes would you make
Mr P presents following ACS. What medication changes would you make. Would you?
Move to dual OAC therapy after 6 months and monotherapy after 12 months
Move to dual therapy after 1 month and OAC monotherapy after 12 months
Move to dual therapy after 1 month and OAC monotherapy after 6 months
Either 2 or 3 above depending on bleeding risk
The following guidelines slides provide the answer

16. Antithrombotic Therapy after an Acute Coronary Syndrome in Atrial Fibrillation Patients Requiring Anticoagulation
Reference
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

17. Antithrombotic Therapy After Elective Percutaneous Intervention in Atrial Fibrillation Patients Requiring Anticoagulation
Reference
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

18. Mr P’s Alzheimer’s Disease Deteriorates (MMSE 14) He is Admitted to an Aged Care Facility
Factors that would influence the decision to cease therapy
Aged care facility
Renal failure
High HAS-BLED
High risk of falls
QOL issues apart from dementia
Family or Power of Attorney input as to level of intervention requested

19. Create a Management Plan For All PatientsDO
Evaluate AF for underlying cardiovascular conditions
Propose lifestyle changes to suitable AF patients
Use oral anticoagulation unless they are at low risk for stroke based or have contraindications
Reduce all modifiable bleeding risk factors
Check ventricular rate and use rate control medications to achieve lenient rate control
DO NOT
Use antiplatelet therapy for stroke prevention in AF
Permanently discontinue oral anticoagulation in AF patients at increased risk of stroke unless such a decision is taken by a multidisciplinary team
Use rhythm control therapy in asymptomatic AF nor in patients with permanent AF
This is the final slide. Use this checklist to overview the key points in AF management and reiterate the issues highlighted in this presentation.
Reference
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

20. Presentation End Q & A