Antikoagulantien beim älteren Patienten mit Vorhofflimmern

Paul Kyrle

Wiener Intensivmedizinische Tage, Februar 2013

Swedish Cohort AF Study

Vorhofflimmern - Risikofaktoren für Insult/systemische Embolie

ESC Guidelines, Eur Heart J 2012

CHA2DS2-VASc - Score

Vorhofflimmern - Risikofaktoren für Insult/systemische Embolie

ESC Guidelines, Eur Heart J 2012

Total score

Patients stroke rate at 1 yr follow-

up (%)0 6369 0.81 8203 2.02 12771 3.73 17371 5.94 13887 9.275 8942 15.36 4244 19.77 1420 21.58 285 22.49 46 23.6

CHA2DS2-VASc criteria Score

Congestive heart failure/left ventricular dysfunction 1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1

Stroke/transient ischaemic attack/TE 2

Vascular disease (prior myocardial infarction, peripheral artery disease or aortic plaque)

1

Age 65–74 yrs 1

Sex category (i.e. female gender) 1

ESC Guidelines, Eur Heart J 2012

Palareti, Lancet 1999

x 100 patient-yrsfatal major minor

Palareti, Arch Intern Med 2000

Bleeding

Thrombosis

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

Risk of anticoagulation-associated bleeding in the elderly

Hylek 1994, Fang 2004, Fihn 1996, Steffenson 1997

Wie viele Patienten werden behandelt?In

dizi

erte

r Ein

satz

von

War

farin

(%)

Gesamteinsatz= 55%

Alter (Jahre)

100

<55

80

60

40

20

055–64 65–74 75–84 85

44%

58% 61%57%

35%

Go A et al. Ann Intern Med 1999;131:927–34

Wie lange sind die Patienten im therapeutischen INR-Bereich?

0102030405060708090

100

Clinic (1) Trial (2) Self-management (3)

(1) Eichinger (2012), (2) RE-LY (NEJM 2009), (3) Watzke (Thromb Res 2002)

65% 66% 70%

35% 34% 30%

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

ROCKET-AF - stroke and bleeding in pts > 75 yrs

Halperin, AHA 2012

VHFL – Antikoagulanzien beim älteren PatientenCHA2DS2 Vasc?

KI gg. AK?, HAS-BLED?, GFR?

AVK keine AVK

VKA (INR 2-3) GFR < 30 (50) ml/min

GFR > 30 (50) ml/min

VKA (INR 2-3)

NOAK (ggf. Dosisreduktion!)

GFR 2x/J bzw. bei Bedarf

NOAK + ASS

VKA (INR 2-3)