Thực trạng sử dụng thuốc chống huyết khối trong dự phòng đột quỵ trên người bệnh rung nhĩ

‘REAL-LIFE’ USE OF ANTITHROMBOTICS IN ATRIAL FIBRILLATION PATIENTS FOR STROKE PREVENTION AT CHO RAY HOSPITAL NGUYEN THE QUYEN Prof NGUYEN VAN TRI BACKGROUND Good efficacy of Vitamin K Antagonist (VKA): • Nonvavular AF: reduce stroke risk over 2.5 times • Valvular AF: embolic events decrease – 15 times However, previous studies of using VKA remains low in Vietnam: • Nonvavular AF: – 13% use • Valvular AF: 34% This study will re-evaluate the situation Camm AJ, et al Eur Heart J 2010;31:2369-429 Bonow RO, et al J Am Coll Cardiol 2008;52:e1-142 Pham Chi Linh, Nguyen Van Si HCMC University of Medical and Pharmacy 2011 Le Hoai Nam Y Hoc Tp.Ho Chi Minh 2014;18:209-14 ESC 2012 ACC 2014 Optional A score ≥ is considered “high bleeding risk” ESC recommends “caution” using OACs STUDY OBJECTIVES Identify the using rate of antithrombotics in nonvalvular AF patients based on the stroke risk stratification CHA2DS2-VASc Identify the using rate of antithrombotics in nonvalvular AF patients based on the bleeding risk stratification HAS-BLED Identify the using rate of VKA in valvular AF patients based on the bleeding risk stratification HAS-BLED STUDY METHODS Study design Prospective, cross-sectional study Study population All patients who were diagnosed AF during admission into Cho Ray hospital from October 2013 to May 2014 Sample size We use the proportion formular: 𝑍1−𝛼/2 n = p(1 − p) d • Nonvalvular AF group: p = 0,8 based on Pham Chi Linh study → n = 246 (N in our study = 258) • Valvular AF group: p = 0,915 based on our pilot study from October 2013 to November 2013 → n = 120 (N in our study= 132) STUDY PROCESS RESULTS PATIENT CHARACTERISTIC Population Nonvalvular AF Valvular AF 258 132 69,8 ± 15,9 54,5 ± 14,1 SAMPLE SIZE Age Male 132 (51,2) 41 (31,1) Female 126 (48,8) 91 (68,9) Heart failure(%) 86 (33,3) 63 (47,7) History of stroke/TIA (%) 51 (19,8) 33 (25,0) Diabetes (%) 46 (17,8) (2,3) History of major bleeding (%) 14 (5,4) (6,1) 158 17 (61,2) (3,8) Sex catergory (%) Hypertension (%) BP ≥ 140/90mmHg SBP > 160mmHg History of myocardial infarction (%) 39 (10,8) (15,1) Objective Identify the using rate of antithrombotics in nonvalvular AF patients based on the stroke risk stratification CHA2DS2-VASc Stroke risk stratification CHA2DS2-VASc in nonvalvular AF patients % nonvalvular AF patients n = 258 25 20.9 22.1 20 15 13.6 12.8 12 10 8.5 6.2 3.1 0.8 0 CHA2DS2-VASc score STUDY CHA2DS2-VASc = CHA2DS2-VASc ≥ GARFIELD 2,9% 84,4% J-RHYTHM 6,6% 77,9% Ours 6,2% 81,8% The use of antithrombotics based on CHA2DS2-VASc score in nonvalvular AF patients % nonvalvular AF patients n = 258 100% 14 90% 80% 43.7 70% 41.9 25 50 45.5 24.1 63.6 50 No antithrombotic Antiplatelet VKA 14.3 30% 20% 9.1 38.6 9.7 12.5 40% 29.6 57.1 60% 50% 18.2 48.4 43.8 46.3 47.4 36.4 28.6 10% 50 27.3 25 0% CHA2DS2-VASc score % patients with CHA2DS2-VASc = use OAC % patients with CHA2DS2-VASc ≥ use OAC EORP-AF Pilot 56,4% 78,0% J-RHYTHM 71,1% 89,2% Ours 43,8% 42,5% STUDY n = 211 (Nonvalvular AF patients with CHA2DS2-VASc ≥ 2) VKA 22.7% 42.5% Antiplatelet No antithrombotic 34.8% The univariate relationship between CHA2DS2-VASc and antithrombotic use in nonvalvular AF patients Reference value Compared value Use VKA OR 95% CI p 1,48 0,78 – 2,82 0,234 3,35 1,44 – 7,82 0,005 CHA2DS2-VASc < CHA2DS2-VASc ≥ Use Antiplatelet Not follow the current guideline Objective Identify the using rate of antithrombotics in nonvalvular AF patients based on the bleeding risk stratification HAS-BLED Bleeding risk stratification HAS-BLED in nonvalvular AF patients % nonvalvular AF patients n = 258 45 38.8 40 33.3 35 30 25 20 18.6 15 10 2.3 0 HAS-BLED score STUDY HAS-BLED = HAS-BLED = - HAS-BLED ≥ AMADEUS 7,8% 68,1% 24,1% J-RHYTHM 14,3% 70,0%% 15,7% Ours 18,6% 72,1% 9,3% The use of antithrombotics based on HAS-BLED score 2.1.2 tình hình sử dụng thuốc chống huyết khối in nonvalvular AF patients % nonvalvular AF patients with CHA2DS2-VASc ≥ n = 211 100% 90% 80% 37.5 16.7 17.8 26.9 20 70% 60% 37.8 30.8 12.5 No antithrombotic 50 Antiplatelet 60 50% VKA 40% 30% 20% 50 44.4 42.3 33.3 20 10% 0% HAS-BLED score STUDY % patients with HASBLED = use OAC % patients with HASBLED = – use OAC % patients with HASBLED ≥ use OAC J-RHYTHM 86,8% 89,7% 86,3% EORP-AF Pilot 78,9% 78,5% - 84,5% 66,7% - 71,1% Ours 50,0% 43,5% 30,4% The univariate relationship between HAS-BLED and antithrombotic use in nonvalvular AF patients Reference value Compared value Use VKA HAS-BLED ≤ Use Antiplatelet Not follow the current guideline OR 95% CI p 0,57 0,23 – 1,43 0,232 2,49 1,07 – 5,83 0,035 HAS-BLED > The multivariate relationship between CHA2DS2-VASc, HAS-BLED and antithrombotic use in nonvalvular AF patients Our study Reference value Compared value Use OAC CHA2DS2-VASc < CHA2DS2-VASc ≥ 42,5% HAS-BLED ≤ HAS-BLED > CHA2DS2-VASc < CHA2DS2-VASc ≥ HAS-BLED ≤ HAS-BLED > OR 95% CI p 1,56 0,82 – 2,99 0,178 0,53 0,21 – 1,34 0,178 3,12 1,33 – 7,32 0,009 2,15 0,081 Use Antiplatelet Not follow the current guideline 0,91 – 5,06 Objective Identify the using rate of VKA in valvular AF patients based on the bleeding risk stratification HAS-BLED Bleeding risk stratification HAS-BLED in valvular AF patients % valvular AF patients n = 132 50 43.9 45 40 35 30.3 30 25 20.5 20 15 10 4.5 0 HAS-BLED score 2.2.2 The use of VKA based on HAS-BLED score tình hình sử dụng AF thuốc chống huyết in valvular patients n = 132 % valvular AF patients n = 132 khối 100% 90% 6.1% 100 93.2 88.9 80% VKA 70% No VKA 60% 85.7 50% 93.9% 40% 30% 20% 10% STUDY % patients use VKA RELY – China 42% Le Hoai Nam 34% Ours 94% Each point of HAS-BLED score rises 0% HAS-BLED score VKA Reference value Compared value VKA No VKA No VKA OR 95% CI p 2,32 1,03 – 5,24 0,042 CONCLUSION In nonvalvular AF population, many patients need to prevent stroke (81,8% CHA2DS2-VASc ≥ 2) And most of them have little bleeding risk (90,7% HAS-BLED ≤ 2), however the using rate of VKA remains low (42,5%) In valvular AF population, the using rate of VKA really achieves actual success (94%) [...]... STUDY HAS-BLED = 0 HAS-BLED = 1 - 2 HAS-BLED ≥ 3 AMADEUS 7,8% 68,1% 24,1% J-RHYTHM 14,3% 70,0%% 15,7% Ours 18,6% 72,1% 9,3% The use of antithrombotics based on HAS-BLED score 2.1.2 tình hình sử dụng thuốc chống huyết khối in nonvalvular AF patients % nonvalvular AF patients with CHA2DS2-VASc ≥ 2 n = 211 100% 90% 80% 37.5 16.7 17.8 26.9 20 70% 60% 37.8 30.8 12.5 No antithrombotic 50 Antiplatelet 60 50%... valvular AF patients n = 132 50 43.9 45 40 35 30.3 30 25 20.5 20 15 10 4.5 5 0 0 1 HAS-BLED score 2 3 2.2.2 The use of VKA based on HAS-BLED score tình hình sử dụng AF thuốc chống huyết in valvular patients n = 132 % valvular AF patients n = 132 khối 100% 90% 6.1% 100 93.2 88.9 80% VKA 70% No VKA 60% 85.7 50% 93.9% 40% 30% 20% 10% STUDY % patients use VKA RELY – China 42% Le Hoai Nam 34% Ours 94% Each