Antiplatelet therapy and afib CHADS2 vs CHA(2)DS2-VASC scores

[VentdependenT]

Ok whats the deal here.

European guidelines use chads-vasc. They dont recommend asa for CVA reduction for score of 1, they say its basically useless. This goes against everything I was taught concerning chads2 score of 1 and use of ASA.

In fact they recommend using oral anticoagulant therapy for a score of 1 or more. And furthermore they PREFER the new agents over coumadin ($$$$).

Basically everyone with a CHADS2 score of 1, i have been using ASA on. If I have a CHADS2 score of 0-1 chances are I'll have a CHADS2-vasc score greater or equal to one which AUTOMATICALLY places the patient on ORAL ANTICOAGULATION.

What are you guys doing? What is the right thing to do? If I go with european guidelines I am wayyyyyyyyyyyyyyyyyy off with stroke prevention on NON-VALVULAR afibbers.

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[Trifling Jester]

This is what I do... not sure about others.

CHADS2 of two or greater is coumadin.
CHADS2 of 1, check CHADS2VASC and medicate accordingly
CHADS2 of 0 is aspirin

 

[joejabjab]

This is what I do... not sure about others.

CHADS2 of two or greater is coumadin.
CHADS2 of 1, check CHADS2VASC and medicate accordingly
CHADS2 of 0 is aspirin

I do the same

 

[redy]

I do the same

Whats the dose of Aspirin? 81 or 162 or 325? Cuz I have been told differently by different cardiologists.

 

[Bostonredsox]

CHADS 0 - ASA 81. Have not seen any data showing 162 or 325 is superior
CHADS-VASC-1 ASA 81, but I have seen pts on antithrombotics. little unsure here.
CHADS-VASC -2, IF they are non-valvular fib...dabigitran or rivarox. Apixiban is not on formularly yet. We had a good CME on this the other night from so of the leaders in the field. The trials for Apixiban are superior to coumadin in all endpoint and have less bleeding events. in fact, there is a trend to all cause mortality reduction with apixiban. Rivar/dabigitran are superior in some endpoints, non inferior in others.

Coumadin is such a bad drug. most tirlas, even pharmD run ones, show that pts are in theraputic window at best 55-60% of the time. and the cost of coumadin on the HEALTHCARE system (our tax dollars) is higher. Coumadin is cheaper FOR THE PATIENT, but with al the monitoring and stuff the healthcare cost is higher. it is a drug of the past with a million interactions and poor efficacy in terms of staying theraputic. If in ANY way my patients can afford dabig/apixi/rivaox...i use them.

 

[VentdependenT]

From what I read ASA is no better than placebo for stroke prevention from nonvalvular afib. Hence the jump to anticoag for chadsvasc of 1. BTW, oral anticoag is also an option for Chads2 of 1 as well. However many of these pts (besides chadsvasc 0 with framingham <10%) do have all cause lower mortality/morbidity from cardiac events when given asa.

 

[glorfindel]

If in ANY way my patients can afford dabig/apixi/rivaox...i use them.

Great! Next time I see a GI bleeder on dabigatran I'm admitting them to YOU!

 

[VentdependenT]

Dialyse.

There us no question that the new OACs are superior. Higher risk of nonfatal bleeds. There is a lower risk of ICH with the factor X inhibitors and the ARE reversible with PCCs or assloads of FFP. If all else fails Novo7.

 

[Bostonredsox]

Great! Next time I see a GI bleeder on dabigatran I'm admitting them to YOU!

I have news for you, which probably isnt news....99/100 of the supratherputic Coumadinized old ladies coming in with ICH's...they die. Yes coumadin is reversible...but the fact that they are already dead by the time it happens, there is no reversing that. Dabig and rivarox and all of the other newer oral agents have statistically significant decreases in the rate of intracranial bleeding compared with warfarin. theyre rates of NONFATAL GI bleed is a touch higher. But I will absolutely take the increase rates of nonfatal rectal bleeding in order to have 1) significantly less strokes, 2) significanty less chance of IC bleed when they slip and fall on the ice, which old people do daily. 3) less cost on the healthcare system. Every time a PCP puts a coumadin'r on levaquin for that viral URI they come in 4 days later with rectal bleeding and an INR of 7. Coumadin is an ancient drug, literally a rat poision. These drugs are the evolution of anticoagulation. And my hunch is the side effect profiles will continue to improve as the biochemists tinker with the formulations.

God that picture of Prine is awesome.

 

[atpsynthase]

I think that rivaroxaban and apixaban are more of a mystery at this point, but I think the kinetics of dabigatran have a distinct advantage in that 60% of the drug is dialyzable and if we can maintain adequate diuresis, we can hopefully get the majority of the drug out of the patient in a reasonable amount of time. While we're often taught that we should use drugs with more evidence available... I agree with the post above... there's plenty of evidence that these agents have a place in therapy. In terms of cost to the health care system, though... that's debatable. How much does having to use FFP or NovoSeven or PCC or dialysis, etc. for a Pradaxa, Xarelto or Eliquis bleed compare to the vitamin K for a Coumadin patient on Bactrim or Levaquin? I'm not sure.

On a related note, I've seen in increase in the use of Brilinta over clopidogrel or prasugrel as an antiplatelet agent in Afib patients with ACS

I also agree with 81 mg ASA... no data to suggest 162-325 mg is superior in any way but more bleeding risk

 

[Trifling Jester]

I don't know how much of a real life benefit it is that you can dialyze the drug off in this setting. If the patient is coming in with a big GI bleed they'll likely be hypotensive and the renal guys at my shop call off the HD when their nurses page them about low blood pressures. Maybe you guys see a different pattern of practice where you are.

-The Trifling Jester

 

[atpsynthase]

I don't know how much of a real life benefit it is that you can dialyze the drug off in this setting. If the patient is coming in with a big GI bleed they'll likely be hypotensive and the renal guys at my shop call off the HD when their nurses page them about low blood pressures. Maybe you guys see a different pattern of practice where you are.

-The Trifling Jester

Very good point. I've only personally seen mild-moderate GI bleeds with no s/sx of HOTN

 

[JACO22]

Does no one follow the 2012 ACCP guidelines recommending against antiplatelet therapy for lone afib(CHADS2 score of 0)? The risks outweigh the benefits for most people.

 

[dragonfly99]

I don't know how much of a real life benefit it is that you can dialyze the drug off in this setting. If the patient is coming in with a big GI bleed they'll likely be hypotensive and the renal guys at my shop call off the HD when their nurses page them about low blood pressures. Maybe you guys see a different pattern of practice where you are.

-The Trifling Jester "

I agree with this 1000%. What planet are you guys practicing on/living in that you think you are going to get hemodialysis at 1 a.m. on a bleeding hypotensive patient at your hospital? If you are at Duke/washU/Emory at 1 a.m. perhaps, or some supersize hospital in NYC or Houston with 24/7 coverage for every possible thing. But for most hospitals I don't see it happening.

Also, with those newer drugs Pradaxa and Rivaroxiban you cannot use it if the GFR is too low and I have seen multiple patients who are elderly on INCORRECT/overdose dosages of Pradaxa and rivaroxiban. Also, Pradaxa had a trend toward more harm for those >75, if low body weight, did it not?

Also, I think many of you are underestimating the problem of the cost to the patient. I practice in a relatively well off area and I can tell you that many if not most patients choose warfarin when they find out they'll have to pay $35 per month for one of those newer drugs. And I have filled out prior auth (which is generally required to even get these) on multiple patients only to have them come back to complain to me it's "too expensive" because they have to still pay $30/month for it.

I also have concerns about compliance with Pradaxa since it's a bid drug and we know that compliance goes down with bid or tid drugs compared with Qdaily dosed drugs.

Having said that, I think these new drugs are exciting and they are a good option to have.

I also think patients getting put on Levaquin with no dose adjustment of the warfarin is 99% the physicians fault. There is no excuse for anyone who should be rx'ing warfarin (cardiologist, hospitalist, outpatient primary care, etc.) to not know that all the quinolones can drive up the INR, and they need to cut down the dose 50% or so, or talk with a pharmacist to figure out what to do if quinolones are to be given.