心房颤动抗栓治疗进展.ppt

心房颤动抗栓治疗进展 北京大学人民医院 心脏中心 孙艺红 The Epidemiology of AF in China and other Countries The Epidemic of Atrial Fibrillation Increasing prevalence of risk factors for AF: Older age Systemic hypertension Heart failure Valvular heart disease Diabetes mellitus Obesity Prevalence of Stroke in Patients with NVAF Stratified by Age Efficacy of Warfarin in Atrial Fibrillation The optimal intensity of anticoagulation Anticoagulation of AF in Real-life The Absolute Incidence of Bleeding The Dilemma of Anticoagulation Management Warfarin has a narrow therapeutic window of effectiveness and safety. Many factors influence a patient’s stability in that window. Frequent monitoring is required to maintain patients in the therapeutic window. Monitoring is labor intensive and complex. Physicians avoid warfarin use because of its complexity. Balancing Risk and Benefit Improve risk stratification Improve anticoagulation control Minimize use of concomitant antiplatelet therapy New antithrombotic therapies Balancing Risk and Benefit Improve risk stratification Relative Distribution of Patients by applying differentrisk stratification schemes Balancing Risk and Benefit Improve risk stratification Improve anticoagulation control Variable Dose Response Drug interference Most potent: Amiodarone (inhibits R- and S-enantiomers) Most under-appreciated: Paracetamol (touted interference with enzymes of the vitamin K cycle) Dietary vitamin K VKORC1 Related to Dose of Warfarin GENOTYPE VS STANDARD WARFARIN DOSING Couma-Gen Trial (N=206) Rapid turnaround CYP2C9 and VKORC1 testing vs. “empiric” Primary endpoint: TTR Smaller and fewer dosing changes with genetic testing No difference in TTR Factors Contribute to Stable Dose Warfarin OBJECTIONS TO GENETIC TESTING: Warfarin 1. Considered costly, inconvenient. (Coverage by CMS just shifts costs.) 2. Slows down prescribing warfarin. 3. Not proven to be as good or superior to the current standard of care (“educated guess” approach)—which is getting bette