ESC Guidelines for the Anticoagulation in AF with co-morbidities

ESC Guidelines for the Anticoagulation in AF with co-morbidities�

1. GUIDELINE PRESENTATION

2. Presenter Dr. Rifat Hasan Antor D-Card Student BMU 2024 ESC Guidelines for the Anticoagulation in AF with co-morbidities Moderator Dr. Abdus Salam Assistant Professor BMU Chairperson Dr. Fakhrul Islam Khaled Associate Professor BMU

3. ∎ Role of Anticoagulation in Atrial Fibrilation ∎Choice of Anticoagulation in AF with Co-morbidities Today’s Agenda

4. AF is a supraventricular arrythmia with uncoordinated atrial activation and ineffective atrial contraction. Electrocardiographic characteristics of AF : Irregularly irregular R-R interval (absence of AV block) Absence of regular P wave Irregular activation of the ventricles Definition of Atrial Fibrillation

5. Role of oral anticoagulation in AF Atrial fibrillation is a major risk factor for thromboembolism. If untreated, the risk of ischemic stroke in AF is increased 5-fold.     So we should provide OAC to all eligible patients Antiplatelet Drugs alone (aspirin, or aspirin in combination with clopidogrel) are not recommended for stroke prevention in AF.

6. ThePhoto by PhotoAuthor is licensed under CCYYSA. DRUGS USED IN COAGULATION PATHWAYS

7. Mechanism of action-Anticoagulants

8. Case 1

9. The incidence of AF in acute coronary syndromes (ACS) ranges from 2% to 23%. The risk of new-onset AF is increased by 60%–77% in patients suffering an MI, and AF may be associated with an increased risk of STEMI or non-STEMI ACS. Overall, 10%–15% of AF patients undergo percutaneous intervention (PCI) for CAD.           AF in Acute Coronary Syndromes

10. Case 2

11. Case 3

12. OAC significantly reduces the risk of ischaemic stroke in patients with AF, but there remains a residual risk. One-third of patients with AF presenting with an ischaemic stroke are already on anticoagulation. This may include non-AF- related stroke mechanisms,non -adherence to therapy, an inappropriately low dose of anticoagulant, or thromboembolism despite sufficient anticoagulation. Ischemic stroke risk despite anticoagulation

13. Role of 1,3,6,12

14. Case 4

15. Pregnancy is associated with a hypercoagulable state and increased thromboembolic risk. The preferred agents for anticoagulation are unfractionated or low molecular weight heparins (LMWHs), which do not cross the placenta. VKA should be avoided in the first trimester (risk of miscarriage, teratogenicity) and from week 36 onwards (risk of foetal intracranial bleeding). DOAC are not recommended during pregnancy due to safety concern. Vaginal delivery should be advised but is contraindicated during VKA treatment because of the risk of foetal intracranial bleeding.                       AF in Pregnancy

16. Anticoagulation in pregnancy with AF

17. Case 5

18. Case 6

19. Case 7

20.         AF in C ongenital Heart Disease Patients with AF and other congenital heart diseases should follow the general risk stratification for OAC use in AF (i.e. depending on the thromboembolic risk or CHA2DS2-VA score). DOAC are contraindicated in patients with mechanical heart valves but   safe in patients with congenital heart disease or with a valvular bio-prosthesis.

21. AF WITH SOME OTHER  CO-MORBIDITIES

22. AF with CKD

23. AF with hyperthyroidism Excess thyroid hormone increases sensitivity to catecholamines. Nonselective beta blockers may reduce the systemic symptoms of hyperthyroidism a bit more than beta-1–selective agents do, and propranolol reduces the peripheral conversion of T4 to T3. Amiodarone causes hyperthyroidism Anti-coagulation needs to continue up to 4 weeks after restoration of sinus rhythm.

24. AF with CLD

25. Anticoagulation in post-operative AF

26. Anticoagulation in post-operative AF

27. BLEEDING MANAGEMENT

28. Category ESC 2016/2020 Guidelines ESC 2024 Guidelines Stroke Risk Stratification CHA₂DS₂-VASc used; anticoagulation if score ≥2 (men) or ≥3 (women) Anticoagulation recommended for men ≥1, women ≥2 (lower threshold) Bleeding Risk HAS-BLED used to assess bleeding risk; score ≥3 = high risk Same use, but stronger emphasis: don’t withhold anticoagulation based on HAS-BLED alone Choice of Anticoagulant DOACs preferred over VKAs in non-valvular AF Reinforced preference for DOACs in nearly all non-valvular AF; Apixaban favored in elderly/CKD CKD Management DOACs used down to eGFR 30 mL/min; warfarin below that Apixaban allowed if eGFR ≥15; Warfarin may be considered <15 or on dialysis AF + CAD/Post-PCI Triple therapy (OAC + DAPT) up to 6 months; then OAC monotherapy Triple therapy limited to 1 week, then dual therapy ≤12 months (DOAC + clopidogrel) Mechanical Valves / Mitral Stenosis Warfarin required Same — DOACs contraindicated Elderly Patients Dose reduction based on age, weight, renal function Clear preference for Apixaban 2.5 mg BID if ≥80 yrs + criteria met Liver Disease DOACs avoided in moderate-severe liver dysfunction Clear recommendation: avoid DOACs in Child-Pugh C; use caution in B AF + Recent Stroke/TIA Start anticoagulation after 3–14 days (based on size/severity) Same guidance reaffirmed; early initiation after minor stroke encouraged Cancer-Associated AF Limited guidance Now DOACs acceptable unless drug–drug interactions or bleeding risk LAA Occlusion Mentioned for high bleeding risk cases Recommended in patients with absolute contraindications to anticoagulation Monitoring Annual stroke/bleeding reassessment; DOAC dose check More specific: renal/liver function every 6–12 months for DOACs; TTR for warfarin Patient-Centered Care Emphasized shared decision-making Reinforced with stronger focus on personalized care and risk–benefit review

29. Take Home Messages AF –CARE pathway is the optimal treatment option for AF management. DOAC is the choice of anticoagulant over VKA (except mechanical heart valves & moderate to severe MS) Oral anticoagulation (OAC) should not be delayed.Early iniciation may reduce the stroke risk.

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