1. Evolving anticoagulation in primary care
DRIVING THE FRONTIER
Evolving anticoagulation in primary care

2. Clinical Conundrums in thrombosis

3. Reviewed and approved by an expert panel of healthcare professionals
Dr Andrei Catanchin
Cardiologist and Electrophysiologist, Epworth Hospital, Richmond, VIC
Professor Andrew Sindone
Director, Heart Failure Unit and Department of Cardiac
Rehabilitation, Concord Hospital, NSW
Dr Brad Wilsmore
Staff specialist in cardiology at John Hunter Hospital, NSW
Dr Chris Moodie
General Practitioner, North Ringwood Medical Centre, VIC
Dr Damian Flanagan
General Practitioner, South Coast Medical, Blairgowrie, VIC
Dr Jennifer Curnow
Staff specialist in haematology, Concord Hospital, NSW
Dr Peter Hay
General Practitioner, Castle Hill Medical Centre, NSW
Dr Scott Dunkley
Senior staff specialist haematologist, Royal Prince Alfred Hospital, Sydney, NSW
Dr Tony Best
General Practitioner, Surgery 82, Busselton, WA
Dr Vincent Thijs
Austin Health, University of Melbourne, VIC

4. Disclaimer
Bristol-Myers Squibb and Pfizer abide by the Medicines Australia Code of Conduct and our own internal policies, and as such, will not engage in the promotion of unregistered products or unapproved indications. This workshop has been reviewed and approved by an independent steering committee of healthcare professionals. Statements made may be the opinion of the expert committee and do not necessarily reflect those of the sponsor Bristol-Myers Squibb or Pfizer. Please refer to the appropriate approved Product Information before prescribing any agents mentioned in this workshop.
Bristol-Myers Squibb Australia Pty Ltd, ABN , Level 2, 4 Nexus Court, Mulgrave, VIC, Australia.
Pfizer Australia Pty Ltd, ABN Wharf Road, West Ryde, NSW, AUSTRALIA. 432AU PP-ELI-AUS-0554

5. Clinical Conundrums in thrombosis
Case 1: Managing a patient newly identified with AF
Case 2: 81-year-old develops prolonged bleeding from scalp laceration
Case 3: Patient on aspirin presents with stroke
Case 4: Elderly patient with co-morbidities refuses treatment
Case 5: 74-year-old on apixaban requires minor surgical procedure
Case 6: Whether or when to switch a warfarin-stable patient to a NOAC
Case 7: Patient with comorbidities, presenting with acute DVT

6. Managing a patient newly identified with AF
Case 1
Slide 1
Managing a patient newly identified with AF
Aged 68 years, 3 children, 5 grandchildren
Non-smoker
BP 153/100, currently taking ramipril 10 mg/day
Total cholesterol 5.5 mmol/L
LDL cholesterol 2.5 mmol/L
HDL cholesterol 1.1 mmol/L
BMI 29 kg/m2, waist circumference 82 cm
GORD, osteoarthritis in hands, but generally in good health
AF: Atrial fibrillation; GORD: Gastro-oesphageal reflux disease

7. Case 1
Slide 2
Managing a patient newly identified with AF AF identified using AliveCor

8. Start low dose aspirin to lower stroke risk
Case 1
Slide 3
Managing a patient newly identified with AF Audience Discussion Would you:
Determine if her AF is paroxysmal or permanent as this affects her symptom management
Ask about symptoms
If she is truly asymptomatic and the AF has no impact on her quality of life no rate control medication is required if the rate is well controlled on Holter.
If there is poor rate control, heart rate slowing medication needs to be started irrespective of whether there are symptoms or not.
Start low dose aspirin to lower stroke risk
Determine her stroke risk to guide treatment
Speaker notes
There is no difference in stroke risk or management with paroxysmal versus permanent AF. Note also that risk of stroke risk should be calculated using the CHA2DS2-VASc scoring system. Whether the patient has symptoms or not does not affect stroke risk.
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9. 81-year-old falls, develops prolonged bleed from scalp laceration
Case 2
Slide 1
81-year-old falls, develops prolonged bleed from scalp laceration
History
NVAF, diabetes, excess alcohol, major compliance issues
Initially commenced on warfarin 5 years ago, INR fluctuating between 1.2  and 4.0
Serious fall resulting in prolonged bleeding from a scalp laceration
Warfarin ceased as perceived falls risk; health improved and alcohol consumption decreased
Commenced on NOAC (rivaroxaban) 2 years ago via Webster Pak and daily nurse supervision
Episode of severe peri-rectal bleeding dropping Hb to 90; colonoscopy not done due to comorbidities
Now off all anticoagulants
NVAF: Non-valvular atrial fibrillation

10. In all cases (i.e. all patients at risk of falls)
Slide 2
81-year-old falls, develops prolonged bleed from scalp laceration Audience discussion According to the 2016 ESC guidelines for the management of AF, anticoagulation should only be withheld in patients at risk of falls:
In all cases (i.e. all patients at risk of falls)
In patients with severe uncontrolled falls (e.g. epilepsy or advanced multi system atrophy with backwards falls)
In patients who have previously had prolonged bleeding due to a fall
In patients who do not want to receive an anticoagulant
The second option is the correct answer
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:
ESC: European Society of Cardiology
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

11. Case 2
Slide 3
81-year-old falls, develops prolonged bleed from scalp laceration Audience discussion Falls are associated with increased mortality in AF. But there is no evidence that patients at high risk of falls are at increased risk of major bleeds.1,2 How do you currently manage AF patients requiring anticoagulation that are at falls risk?
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: Banerjee A et al. Am J Med 2014; 127:

12. The average number of falls in elderly patients is 1.8 per year
Case 2
Slide 4
81-year-old falls, develops prolonged bleed from scalp laceration Patients’ risk of falls not an important factor in guiding stroke prevention therapy1
The average number of falls in elderly patients is 1.8 per year
A patient with average stroke risk of 5% would have to fall 295 times in a year to outweigh the stroke reduction benefit with therapy
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Reference: 1. Man-Son-Hing M et al. Arch Intern Med 1999; 159:

13. Patient on aspirin presents with stroke
Case 3
Slide 1
68 year old female, CHA2DS2-VASc = 2
Admitted to Emergency Department with congestive cardiac failure (CCF)
History of NVAF, apixaban 5 mg b.d. started
Cardiologist switched to aspirin
Subsequent admission with stroke

14. In male patients with a CHA2DS2-VASc score of 1
Case 3
Slide 2
Patient on aspirin presents with stroke Audience discussion When is antiplatelet monotherapy recommended for stroke prevention in AF patients, according to 2016 the ESC guidelines for the management of AF?
In male patients with a CHA2DS2-VASc score of 1
In male or female patients without additional stroke risk factors
Antiplatelet monotherapy is not recommended for stroke prevention in AF patients, regardless of stroke risk
In female patients with a CHA2DS2-VASc score of 2
Speaker notes
Antiplatelet monotherapy is not recommended for stroke prevention in AF patients, regardless of stroke risk
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:
ESC: European Society of Cardiology
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

15. Case 3
Case 3
Slide 3
Patient on aspirin presents with stroke Audience discussion Do we switch AF patients on aspirin to an OAC?
Speaker notes
Yes, Aspirin for stroke prevention is not recommended. Aspirin is ‘not useful/effective and may be harmful’1
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:
Return to main menu
OAC: Oral anticoagulant

16. Elderly patient with co-morbidities refuses treatment
Case 4
Slide 1
Elderly patient with co-morbidities refuses treatment
84 year old hypertensive, very active male in NVAF
In discussion with treating physician for >10 years regarding the potential benefit of anticoagulant, but patient not keen on commencing warfarin or having at least monthly blood tests/finger pricks
NOACs became available, he agrees to try apixaban
Reviewed 1 month later, all ok
Reviewed another 2 months later, had ceased apixaban after 2 episodes of epistaxis
Patient unable to be convinced that he should recommence his NOAC
NOAC: Non-vitamin K antagonist oral anticoagulant

17. Discussion Return to main menu
Case 4
Case 4
Slide 2
Elderly patient with co-morbidities refuses treatment Audience discussion How do we manage an AF patient that refuses any anticoagulation?
Discussion
Speaker notes
Discuss with patient
Educate/give literature – explain risk vs benefit referring to CHA2DS2-VASc
Document that patient made an informed choice and risk was explained
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18. 74-year-old on apixaban requires minor surgical procedure
Case 5
Slide 1
74-year-old on apixaban requires minor surgical procedure
74-year-old male, paroxysmal non-valvular AF, on apixaban
Elective admission for minor surgery, apixaban stopped before procedure

19. How long before procedure should NOAC therapy be stopped?
Case 5
Slide 2
74-year-old on apixaban requires minor surgical procedure
Audience discussion
How long before procedure should NOAC therapy be stopped?
2 days before procedure
36 h before procedure
24 h before procedure
12 h before procedure

20. Case 5
Case 5
Slide 3
74-year-old on apixaban requires minor surgical procedure Audience discussion Is bridging needed? OAC interruptions should be minimised to prevent stroke.1 Are we bridging NOAC patients for cardiovascular interventions that could be performed safely on continued therapy?
Speaker notes
Bridging with NOACs is not needed in most patients undergoing surgery.2 The BRIDGE trial has shown that in VKA-treated patients, bridging with LMWH has no impact on thromboembolic risk but has a deleterious impact on major-bleeding.3
Review the Product information for the OAC the patient is taking for further information on dosing for surgical procedures.
References
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:
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:
Douketis JD, Spyropoulos AC, Kaatz S et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med 2015; 373:
Return to main menu
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

21. Whether or when to switch a warfarin-stable patient to a NOAC
Case 6
Slide 1
Whether or when to switch a warfarin-stable patient to a NOAC
History
70-year-old male (farmer), paroxysmal non-valvular AF, on warfarin
CHA2DS2-VASc = 3; monthly INRs are stable
Complained of not being able to have his green leafy vegetables from his own garden when in season – issue of dietary restriction

22. Case 6
Case 6
Slide 2
Whether or when to switch a warfarin-stable patient to a NOAC Audience discussion According to the 2016 ESC guidelines for the management of AF, commencing therapy with a NOAC is recommended in preference to a vitamin K antagonist for patients eligible for anticoagulation1 When should we consider switching a warfarin-stable patient to a NOAC?
Speaker notes
Note it is not always just about the evidence. Sometime patients may prefer not having needles, and checking all their food and medications for interactions.
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:
Return to main menu
ESC: European Society of Cardiology
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

23. Patient with comorbidities, presenting with acute DVT
Case 7
Slide 1
Patient with comorbidities, presenting with acute DVT
56-year old female, 85 kg, BMI 29 kg/m2
Hypertension, type 2 diabetes, normal BMI, renal function
Recently took a long-haul flight
Right leg slightly erythematous, slight limp when walking, right calf larger than left by 3 cm diameter

24. Manage conservatively with bandaging and rest
Case 7
Slide 2
Patient with comorbidities, presenting with acute DVT Audience discussion The patient's vital signs are stable and she is afebrile. What will you do next?
You realise a DVT is quite likely. You order a compression ultrasound of right leg at a local private radiology clinic
You realise a DVT is quite likely. You initiate a low dose of Clexane or a NOAC. You don’t order an ultrasound
Manage conservatively with bandaging and rest
Send for physiotherapy treatment
DVT: Deep vein thrombosis

25. Case 7
Slide 3
Patient with comorbidities, presenting with acute DVT Ultrasound results
Ultrasound results reveal a deep venous thrombus in the patient’s posterior tibial vein extending into her popliteal vein.
The thrombus is 10 cm in length and extends for 8 cm above the popliteal crease.
The features of DVT on ultrasound include lack of compressibility of the vessel lumen, a distended vessel, and lack of flow in the vessel

26. Refer to a specialist immediately Refer to ED immediately
Case 7
Slide 4
Patient with comorbidities, presenting with acute DVT Audience discussion What do you do next?
Refer to a specialist immediately
Refer to ED immediately
Commence a NOAC
Commence other anticoagulation
Send home to rest

27. Send for specialist review
Case 7
Slide 5
Patient with comorbidities, presenting with acute DVT Audience discussion NOAC is prescribed and patient returns 4 weeks later. The redness has gone down but there is still swelling of the calf. What are your treatment options?
Send for specialist review
Maintain patient on a NOAC for further 4 weeks and return for review
Reduce dose for further 4 weeks and return for review
Switch to warfarin treatment

28. Case 7
Slide 6
Patient with comorbidities, presenting with acute DVT Audience discussion NOAC is maintained and patient returns 12 weeks following initial diagnosis of DVT. CUS is normal and she is not complaining of any symptoms. What would be your next steps be?
Maintain NOAC therapy
Discontinue NOAC therapy. Ask patient to continue wearing stocking for any travel-induced immobilisation
Discontinue therapy but do not prescribe continued compression stocking or DVT prophylaxis medication for longer travel (Note: currently available NOACs are not indicated for DVT prophylaxis during long-haul travel)
Initiate aspirin treatment as prophylaxis
Return to main menu
CUS: Compression ultrasound; DVT: Deep vein thrombosis

29. Workshop end

30. Reviewed and approved by an expert panel of healthcare professionals
Dr Andrei Catanchin
Cardiologist and Electrophysiologist, Epworth Hospital, Richmond, VIC
Professor Andrew Sindone
Director, Heart Failure Unit and Department of Cardiac
Rehabilitation, Concord Hospital, NSW
Dr Brad Wilsmore
Staff specialist in cardiology at John Hunter Hospital, NSW
Dr Chris Moodie
General Practitioner, North Ringwood Medical Centre, VIC
Dr Damian Flanagan
General Practitioner, South Coast Medical, Blairgowrie, VIC
Dr Jennifer Curnow
Staff specialist in haematology, Concord Hospital, NSW
Dr Peter Hay
General Practitioner, Castle Hill Medical Centre, NSW
Dr Scott Dunkley
Senior staff specialist haematologist, Royal Prince Alfred Hospital, Sydney, NSW
Dr Tony Best
General Practitioner, Surgery 82, Busselton, WA
Dr Vincent Thijs
Austin Health, University of Melbourne, VIC

31. Evolving anticoagulation in primary care
DRIVING THE FRONTIER
Evolving anticoagulation in primary care