Fallbericht 74-jähriger Mann Zuweisung: „Thrombinzeit > 90 Sekunden, Beg. und Therapieempfehlung erbeten“ VHFL, St. p. SM-Implantation, St. p. Ablation CHA2DS2 Vasc = 1 (Alter > 65) Pradaxa 2 x 110 mg 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. 1 1

Sind Blutgerinnungsuntersuchungen erforderlich? VHFL – neue Antikoagulantien Sind Blutgerinnungsuntersuchungen erforderlich? Kein Gerinnungsmonitoring 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. 2 2

Fallbericht 57 jährige Frau Zuweisung: „paroxysmales VHFL, labile HTN, CHADS Score 2, dzt. 15 mg Xarelto, Pradaxa von WGKK nicht bewilligt“ lt. Patientin RR manchmal etwas höher, keine Medikamente, CHA2DS2 VASc = 1 (weibl. Geschlecht) 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. 3

Fallbericht 72 J, männl. Z. n. mech. AKE Einstellung mit VKA (Marcoumar) suboptimal Umstellung auf Xarelto (20 mg tgl.) Zuweisung: „häufig Nasenbluten“ 4

Fallbericht 67 J, männl. Z. n. Mitralklappenrekonstruktion, mech. AKE, red. Linksventrikelfunktion, pAVK IIb Z. n. mehreren art. Embolien (unter INR 2-3) und Thrombektomien 7/2012: Marcoumar  Pradaxa 2 x 150mg (+ 2 x 75mg Plavix) 8/2012: Embolie Bein, kritische Ischämie 5

NOACs CAVE Indikation 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. 6 6

78-jähriger Mann

78-jähriger Mann

78-jähriger Mann

78-jähriger Mann Alle Antikoagulantien pausiert 10 mg Konakion p.o. 2 d später INR 3.4, OAK weiter Pause 3 d später INR 4.2  4 mg Konakion po  ad CMP Ambulanz  Vd. Lebersyntheseinsuffizienz 3 d später INR 2.9 3 d später INR 3.4

78-jähriger Mann

Wie wird umgestellt? INR < 2: NOAKs sofort VHFL – neue Antikoagulantien Wie wird umgestellt? INR < 2: NOAKs sofort INR > 2: VKA absetzen  kurzfristige INR-Ko  NOAKs , wenn INR < 2 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. 12

Welche Dosis soll verwendet werden? VHFL - Dabigatran Welche Dosis soll verwendet werden? < 80 Jahre: 2 x 150 mg/Tag 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. 13

Welche Dosis soll verwendet werden? VHFL - Dabigatran Welche Dosis soll verwendet werden? 2 x 110 mg/Tag ist empfohlen Patienten > 80 Jahre Verapamil (Isoptin®) als Begleitmedikation   2 x 110 mg/Tag ist zu erwägen Patienten zwischen 75 und 80 Jahren mit erhöhtem Blutungs- und niedrigem Thromboembolierisiko Patienten mit hohem Blutungsrisiko und beeinträchtigter Nierenfunktion (CrCl 30-50 ml/min) Patienten mit Gastritis, Ösophagitis oder gastro-ösophagealem Reflux 14 14

Welche Dosis soll verwendet werden? VHFL - Rivaroxaban Welche Dosis soll verwendet werden? Kreatinin Clearance > 50 ml/min: 20 mg 1 x tgl. Kreatinin Clearance < 50 ml/min: 15 mg 1 x tgl. 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. 15

Welche Dosis soll verwendet werden? VHFL - Apixaban Welche Dosis soll verwendet werden? Kreatinin Clearance > 30 ml/min: 5 mg 2 x tgl. Kreatinin Clearance 15-29 ml/min; Serum-Kreatinin ≥ 1,5 mg/dl (133 μmol/l); ≥ 80 Jahre oder Körpergewicht ≤ 60 kg : 2.5 mg 2 x tgl. 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. 16

CAVE Indikation Dosierung NOACs 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. 17 17 17

86-jährige Frau Hypertonie, DM II CHA2DS2 VASc: 4 P Marcoumar, INR 2.0-3.0, TTR ~ 60% BB, LB, NB im Normbereich möchte auf eine neues Antikoagulans umgestellt werden Pradaxa? Xarelto? auf Marcoumar belassen?

Renal function (Cockroft-Gault) Neue Antikoagulanzien bei Vorhofflimmern Renal function (Cockroft-Gault) 19

Renal function (Cockroft-Gault) Neue Antikoagulanzien bei Vorhofflimmern Renal function (Cockroft-Gault) 86 48 kg 1.2 CCr = 25.5 ml/min 20

Fallbericht 83-jähriger Mann Vorhofflimmern Art. Hypertonie Herzinsuffizienz, EF 30% Antikoagulation?

Fallbericht 83-jähriger Mann CHADS2: 3 P CHA2DS2VASc: 4 P Marcoumar, INR 2.0-3.0 1 a später Sturz in Straßenbahn Subduralhämatom INR >7.0

Fallbericht 83-jähriger Mann Krea 1.3, 80 kg CCr ~ 50 ml/min Pradaxa 2 x 110 mg tgl. 6 Mo später stat. Aufnahme wg. GI-Blutung Kreatinin 2.6 mg/dl

Fallbericht 82-jährige Frau VHFL, CHA2DS2VASc: 4 P Zuweisung: “Inzision Infiltrat UK, Nbltg” … Xarelto 20mg tgl. Kreatinin 3.4 mg/dl

CAVE Indikation Dosierung Nierenfunktion NOACs 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. 25 25 25

Fallbericht 67-jährige Frau VHFL  CHA2DS2VASc: 2 (Hypertonie) Pradaxa 2 x 150 mg tgl. Medikamente: Blopress, Multaq

Sind Wechselwirkungen mit anderen Medikamenten zu erwarten? VHFL - Dabigatran Sind Wechselwirkungen mit anderen Medikamenten zu erwarten? Das Wetter wird schlechter, die Stimmung trüber. Muss ja nicht sein. Gegen Herbstdepressionen ist ein Kraut gewachsen. Johanniskraut. 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. 27

Fallbericht 56-jähriger Mann VHFL  CHA2DS2VASc: 1 (Hypertonie) Xarelto 20 mg tgl. Medikamente: u.a. RR-Senker, Norvir

Sind Wechselwirkungen mit anderen Medikamenten zu erwarten? VHFL - Rivaroxaban Sind Wechselwirkungen mit anderen Medikamenten zu erwarten? Systemische Azol-Antimykotoka (Ketoconazol, Itraconazol, Voriconazol, Posaconazol) HIV-Proteaseinhibitoren ASS, Thrombozytenaggregationshemmer, NSARs 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. 29

CAVE Indikation Dosierung Nierenfunktion Medikamenteninteraktion NOACs 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. 30 30 30

Zeitpunkt für das Absetzen von Dabigatran VHFL – Dabigatran Wann kann operiert werden (elektiv)? Nierenfunktion (CrCl in ml/min) Geschätzte Halbwertszeit (Stunden) Zeitpunkt für das Absetzen von Dabigatran Hohes Blutungsrisiko oder größerer Eingriff Standardrisiko ≥ 80 ca. 13 2 Tage vorher 24 Stunden vorher ≥ 50 bis < 80 ca. 15 2‑3 Tage vorher 1‑2 Tage vorher ≥ 30 bis < 50 ca. 18 4 Tage vorher 2‑3 Tage vorher (> 48 Stunden) 31

Zeitpunkt für das Absetzen von Dabigatran VHFL – Dabigatran Wann kann operiert werden (elektiv)? Nierenfunktion (CrCl in ml/min) Geschätzte Halbwertszeit (Stunden) Zeitpunkt für das Absetzen von Dabigatran Hohes Blutungsrisiko oder größerer Eingriff Standardrisiko ≥ 80 ca. 13 2 Tage vorher 24 Stunden vorher ≥ 50 bis < 80 ca. 15 2‑3 Tage vorher 1‑2 Tage vorher ≥ 30 bis < 50 ca. 18 4 Tage vorher 2‑3 Tage vorher (> 48 Stunden) 32

Präoperatives Vorgehen bei Rivaroxaban (persönl. Einschätzung) Absetzen 24 h vor Eingriff Erhöhtes Blutungsrisiko Op. an kritischen Organen Entscheidung abhängig vom Thromboserisiko des Patienten und der Op. Absetzen > 48 h vor Eingriff

Überbrückung mit Heparin? Neuen oralen Antikoagulanzien Überbrückung mit Heparin? Nein!

Was ist bei einer Blutung zu tun? VHFL – neue Antikoagulantien Was ist bei einer Blutung zu tun? 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. 35

Afib and coronary stenting