Aidosaban Asian population has more evidence, better patient compliance, and stronger dose selectivity.
2018 epidemic survey shows that the prevalence of atrial fibrillation in China increases with age, with the total prevalence of 2.35% among people ≥75; many studies have also shown that most patients with non-valvular atrial fibrillation in China are elderly, and the average age of patients is >65 years old.
In addition, since cardiogenic emboli produced by atrial fibrillation is a major cause of ischemic stroke, active anticoagulant treatment for patients with atrial fibrillation has become the key to preventing ischemic stroke and its recurrence.
However, anticoagulant treatment is always accompanied by the risk of bleeding, and how to choose anticoagulant treatment suitable for the elderly has become a common topic among cardiovascular and neurologists.
At the youth speech on May 22, we invited Professor Yu Manli from the Department of Cardiology of , Changhai Hospital, , and , to share with us the preferred plan for anticoagulant treatment for elderly patients with atrial fibrillation. The discussion also participated in this discussion. Chen Shaoping, chief physician of the Department of Cardiology of Changhai Hospital, Affiliated to , and Pan Xiaoming, chief physician of the Department of Cardiology of , and , and , , and , , , , , affiliated to , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , .
01 How should you deal with such a case?
First, let’s take a look at a real case:
patient, female, 76 years old; she had been ongoing atrial fibrillation for more than 5 years, had previously taken warfarin 3 mg qd orally, and was admitted to the hospital for INR 5.6.
patient weighs 58 kg. CHADS-VASc: 5 points; HAS-BLED: 3 points. The patient's current CHADS-VASc score suggests that the patient needs anticoagulant treatment, but HAS-BLED suggests a high risk of bleeding. How will you deal with such a patient?
After visiting the patient, the doctor immediately asked him to stop using warfarin and at the same time, he quietly recommended vitamin K 10 mg antagonize . After a review of INR 1.96, the new oral anticoagulant (NOACs) was switched to edoxaban. In addition, considering that the patient's weight is less than 60 kg, the dose is 30 mg qd.
Warfarin is a very classic coumarin oral vitamin K antagonist (VKA) that can antagonize the synthesis of coagulation factors II, VII, IX and X in the liver. Many studies including AFASAK and SPAF believe that VKA can effectively reduce the risk of ischemic stroke in patients with atrial fibrillation.
However, the VKA treatment window is narrow and will benefit the patient only when the INR is 2-3. When the INR is <2>3, the risk of stroke or bleeding will inevitably increase. In long-term observation, only 42% of patients were warfarin-anti-coagulant, of which only half of them met the INR standards.
Figure 1: Warfarin treatment in elderly patients with atrial fibrillation will increase the risk of bleeding
Therefore, taking into account both efficacy and safety and improving medication compliance have become the focus of anticoagulation treatment in elderly patients with atrial fibrillation.
02
The numerous NOACs Which one is more suitable for elderly patients with atrial fibrillation? Subgroup analysis tells you that the
RE-LY, ROCKET AF, ARISTOTLE and ENGAGE AF TIMI 48 studies all used different NOACs as interventions to compare the differences between NOACs and VKA safety and effectiveness. Although the NOACs used in the four clinical studies were different, all four studies showed that NOACs were not inferior to warfarin and were more safe.
Based on this, the "2019 AHA/ACC/HRS Atrial Flint Management Guidelines" believe that
is better than warfarin for patients with atrial fibrillation (except for moderate-to-severe mitral stenosis or mechanical heart valves) who meet the NOACs indications (except for moderate-to-severe mitral stenosis or mechanical heart valves).
In addition, " atrial fibrillation : Current understanding and treatment recommendations 2018" believes that
NOACs reduce ischemic stroke and bleeding events in elderly patients over 75 years old, so it is recommended that the first choice for anticoagulation treatment for elderly patients (over 75 years old) is recommended, and it is not recommended to use antiplatelet preparations such as aspirin instead of warfarin for elderly patients. Nearly 8 of the East Asian subgroup studied in the East Asian population were elderly patients, 74% of whom were over 65 years old, 17.1% of whom were ≥80 years old, and 4.3% of whom were ≥85 years old.
study believes that in terms of effectiveness results, the incidence of ischemic stroke and fatal stroke in the Adoshaban group is not inferior to warfarin, and the probability of hemorrhagic stroke in people over 65 years old is lower; in terms of safety results, the risk of major bleeding among people over 65 years old is lower, especially the risk of intracranial hemorrhage is the highest.
Figure 2: Edoxaban is also safe and effective in treating elderly patients
In addition, among ultra-old patients, the effectiveness of Edoxaban treatment is also not inferior to warfarin. Compared with warfarin patients with INR controlled at 2-3, Edoxaban can significantly reduce the risk of major bleeding in patients with atrial fibrillation aged ≥75 years, ≥80 years, and ≥85 years. In addition, edoxaban only needs to be taken once a day, which can greatly improve the medication compliance of elderly patients.
TIME
Interaction time
Q: Atrial fibrillation is a recognized geriatric disease, and the elderly increase the risk of bleeding from atrial fibrillation thromboembolism and anticoagulant treatment. Please share how you balance the risk of anticoagulation and bleeding in elderly patients.
PreferredNOACsInitial medication, Aidosauban is better than traditional VKA
Chen Shaoping Department of Cardiology, Changhai Hospital Affiliated to Naval Military Medical University Chief Physician
The elderly have many comorbidities. Most patients with atrial fibrillation do not only suffer from atrial fibrillation, but often have other accompanying diseases. Therefore, clinicians need to be extra cautious when taking medication, and to ensure efficacy and avoid drug interactions to ensure safety. Therefore, VKA, which is greatly affected by drug-food interaction, is slightly inferior to NOACs in the elderly.
Currently, the latest atrial fibrillation guidelines in the United States and Europe both believe that NOACs are significantly better than VKA and are not inferior to warfarin, and are recommended as preferred medications. Nowadays, clinicians do not need to switch to NOACs when patients take VKA but INR control is poor, but can directly recommend patients to start medication with NOACs.
There are 4 NOACs approved by the US FDA, and they have commonalities and differences. In terms of dose, we also need to consider the dose based on individual differences of the patient. Taking edoxaban as an example, it is recommended that low weight (≤60 kg) and creatinine clearance of 15-50 ml/min. Those who take P-gp drugs should reduce the dosage to 30 mg.
Finally, edoxaban is easy to use, and only once a day is needed, the patient's compliance is better and the effect is naturally more ideal.
Edoxaban once a day, easy to use medicine, and is more suitable for the elderly
Pan Xiaoming Department of Cardiology, Changzheng Hospital Affiliated to Naval Military Medical University Chief Physician
Age is not only an important factor in the risk of stroke, but also an important factor in the risk of bleeding. Therefore, embolization and bleeding are accompanied by each other. Ten years ago, in the absence of NOACs, it was recommended to reduce anticoagulant intensity and reduce INR below 2.5 for patients with high risk of bleeding, but monitoring and good control of INR was quite difficult in clinical practice. For elderly patients, simplifying medication is very important to ensure the safety and effectiveness of medication.
Nowadays, we have NOACs that do not require monitoring INR available, and some NOACs (such as edoxaban) only need to be taken once a day to obtain anticoagulant efficacy that is not inferior to traditional VKA, and the safety is much higher than VKA. The simplified medication method greatly improves patients' medication compliance, avoids the inconvenience caused by monitoring, and is more suitable for the elderly.
References:
[1] Wang ZW, et al. Am J Cardiol. 2018 Sep1; 122 (5):793-798.
[2] Hart RG et al. Ann Intern Med. 2007 Jun 19;146(12):857-67.
[3] Huang Congxin, et al. Chinese Journal of Cardiac Pacing and Electrophysiology. 2018, 32(4):315-368.
