Antikoagulantien beim älteren Patienten mit Vorhofflimmern Paul Kyrle Wiener Intensivmedizinische Tage, Februar 2013

Swedish Cohort AF Study Vorhofflimmern - Risikofaktoren für Insult/systemische Embolie Swedish Cohort AF Study ESC Guidelines, Eur Heart J 2012

stroke rate at 1 yr follow-up (%) Vorhofflimmern - Risikofaktoren für Insult/systemische Embolie CHA2DS2-VASc - Score CHA2DS2-VASc criteria Score Congestive heart failure/ left ventricular dysfunction 1 Hypertension Age 75 yrs 2 Diabetes mellitus Stroke/transient ischaemic attack/TE Vascular disease (prior myocardial infarction, peripheral artery disease or aortic plaque) Age 65–74 yrs Sex category (i.e. female gender) Total score Patients stroke rate at 1 yr follow-up (%) 6369 0.8 1 8203 2.0 2 12771 3.7 3 17371 5.9 4 13887 9.27 5 8942 15.3 6 4244 19.7 7 1420 21.5 8 285 22.4 9 46 23.6 ESC Guidelines, Eur Heart J 2012

ESC Guidelines, Eur Heart J 2012

x 100 patient-yrs fatal major minor Palareti, Lancet 1999

Bleeding Thrombosis Palareti, Arch Intern Med 2000

Risk of anticoagulation-associated bleeding in the elderly Higher risk of major bleeding (2.1% pt/y vs. 1.1% pt/y) 2.5-fold higher risk of ICH in pts > 85 yrs Annual incidence of ICH between 0.2% and 1% Higher bleeding risk outside clinical studies 1.4-fold increase in ICH per decade of age There are 2 important consequences of recurrent venous thromboembolism. One complication is the development of the post-thrombotic syndrome, or worsening of an preexisting PTS if venous thrombosis occurs in the same leg. The PTS is often associated with serious consequences for patient, such as life-style alterations, loss of work or frequent hospitalizations. It also results in a considerable increase in health costs. Much more important, 5 to 10 percent of the patients with recurrent thrombosis die from pulmonary embolism. Therfore, prevention of recurrent VTE is of utmost clinical importance. Hylek 1994, Fang 2004, Fihn 1996, Steffenson 1997 7

Wie viele Patienten werden behandelt? Indizierter Einsatz von Warfarin (%) Gesamteinsatz = 55% Alter (Jahre) 100 <55 80 60 40 20 55–64 65–74 75–84 85 44% 58% 61% 57% 35% Go A et al. Ann Intern Med 1999;131:927–34 8

Wie lange sind die Patienten im therapeutischen INR-Bereich? 35% 34% 30% 65% 66% 70% (1) Eichinger (2012), (2) RE-LY (NEJM 2009), (3) Watzke (Thromb Res 2002)

HAS-BLED Risiko-Score

ESC Guidelines 2012

ESC Guidelines, Eur Heart J 2012

RE-LY – bleeding according to age (intracranial) Eikelboom, Ciculation 2011

RE-LY – bleeding according to age (extracranial) Eikelboom, Ciculation 2011

RE-LY - stroke and bleeding in pts > 75 yrs Eikelboom, Ciculation 2011

ROCKET-AF - stroke and bleeding in pts > 75 yrs Halperin, AHA 2012

VHFL – Antikoagulanzien beim älteren Patienten