2 bài BS thắng tối ưu hóa dự phòng đột quỵ trên bệnh nhân rung nhi có tiền căn đột quỵ

SECONDARY STROKE PREVENTION IN NVAF PATIENTS WITH ANTICOAGULATION PGS Nguyễn Huy Thắng Why AF cause stroke ??? Anterior Cerebral Artery collaterals Infarct Core Ischemic Penumbra Posterior Cerebral Artery collaterals How severe of stroke are they ? Stroke in Vietnames patients with atrial fibrillation Prevalence and outcomes Thang H Nguyen, Chi M.T.Do , Phong P Cao • Included 3561 IS patients admitted to the People ‘ 115 hospital in the last months of 2013 • 236 pts was confirmed AF by ECG at the ER (6.63%) Nguyễn Huy Thắng, Đỗ Thi Minh Chi– Abstract European Stroke Conference 2015 Mean Age 67,93 ± 28,44 n 236 Stroke Severity 23% 41% 36% Mild Stroke Moderate Stroke Severe Stroke 4th Qt Nguyễn Huy Thắng, Đỗ Thi Minh Chi– Abstract European Stroke Conference 2015 Only ¼ of AF-Stroke pts can be independence ! 45 40 40.3 33.8 35 mRS 3-5: 43.2% 22.8 30 25 22.5 20 13.6 15 10 16 16 12.3 1.7 5.1 4.2 1.4 5.6 4.7 Xuất viện Discharge tháng 90 days Nguyễn Huy Thắng, Đỗ Thi Minh Chi– Abstract European Stroke Conference 2015 Highest efficacy for stroke prevention in AF Stroke Prevention Before Admission Current Treatment CHADs-VASc ≥ : 97.9% Case (n = 236) (%) Anti-vitamin K 39 16.5 Antiplatelet 41 17.4 Combine anti-vitamin K and antiplatelet 0.8 Combine antiplatelet 1.7 150 63.6 No antithrombotic Nguyễn Huy Thắng, Đỗ Thi Minh Chi– Abstract European Stroke Conference 2015 N Engl J Med 2011;365:2002-12 Mar 2013 Look back of his Gradient echo MRI • We aimed to determine whether presence of cerebral microbleeds can identify patients at high risk of symptomatic intracranial haemorrhage when anticoagulated for atrial fibrillation after recent ischaemic stroke or TIA • Study recruited 1490 pts from 79 hospitals in the UK and one in the Netherlands with AF and recent acute ischaemic stroke or TIA, treated with a vitamin K antagonist or direct oral anticoagulant, and followed up for 24 months Lancet Neurol 2018; 17: 539–47 Cerebral microbleeds were present in 311 (21%) Lancet Neurol 2018; 17: 539–47 Symptomatic intracranial haemorrhage according to the presence or absence of cerebral microbleeds Lancet Neurol 2018; 17: 539–47 Pts with CMB may be times higher risk of sICH when using Anticoagulation ! Lancet Neurol 2018; 17: 539–47 sICH was most seen in VKA used ! Lancet Neurol 2018; 17: 539–47 AF Patients in ROCKET AF had Higher Risk of Stroke than Patients in Other Phase III Trials CHADS2-Score patient distribution CHADS2 score ≤1 3–6 Patel MR et al N Engl J Med 2011;365(10):883–891; Connolly SJ et al N Engl J Med 2009;361(12):1139–1151; Granger CB et al N Engl J Med 2011;365(11):981–992; Edoxaban FDA Briefing Document page 158/398 FDA Briefing Document page 158/398 ROCKET AF có lượng BN có tiền đột quỵ TIA nhiều so với nghiên cứu pha III NOACs Mean CHADS2 score ROCKET AF1–3 (n=14,264) ARISTOTLE4,5 (n=18,201) ENGAGE AF6 (n=21,105) RE-LY7,8 (n=18,113) 3.5 2.1 2.8 2.1 C CHF 62% 35% 57% 32% H Hypertension 91% 87% 94% 79% A Age ≥75 years 44% 31% 40% 40% D Diabetes mellitus 40% 25% 36% 23% S2 Prior stroke or TIA 52% 19% 28% 20% Patients with AF in ROCKET AF had a higher risk of stroke than those in other phase III trials with NOACs Patel MR et al, N Engl J Med 2011;365:883–891; Halperin JL et al, Circulation 2014;130:138–146; Hankey GJ et al, Lancet Neurol 2012;315–322; Granger CB et al, N Engl J Med 2011;365:981–992; Easton JD et al, Lancet Neurol 2012:11:503–511; Giugliano RP et al, N Engl J Med 2013;369:2093–2104; Connolly SJ et al, N Engl J Med 2009;361:1139–1151; Eikelboom JW et al, Circulation 2011;123:2363–2372 ROCKET AF: Stroke and ICH risk is always higher in Prior Stroke Group Kaplan–Meier survival curve showing time to the primary outcome (stroke or systemic embolism) Cumulative event rate – stroke or systemic embolism (%) Prior stroke/TIA, warfarin ICH 0.80 Prior stroke/TIA, Rivaroxaban ICH 0.59 No prior stroke/TIA, warfarin ICH 0.68 No prior stroke/TIA, Rivaroxaban ICH 0.39 0 Intention-to-treat population Hankey G et al Lancet Neurol 2012 12 18 Months from randomisation 24 30 REAFFIRM: Nghiên cứu giới thực khẳng định lại an toàn hiệu Rivaroxaban BN rung nhĩ có tiền đột quỵ/TIA Rate (% per year) HR (95% CI) HR (95% CI) Rivaroxaban Warfarin Combined* 1.67 3.78 0.45 (0.29–0.72) Ischaemic stroke 1.37 2.99 0.48 (0.29–0.79) ICH 0.36 0.90 0.40 (0.15–1.04) Major bleeding events 3.09 3.02 1.07 (0.71–1.61) 0.125 0.25 0.5 Favours rivaroxaban *Ischaemic stroke/ICH Coleman CI et al, Stroke 2017;48:2142–2149 Favours warfarin Conclusion When you have a AF-related stroke patient … For secondary stroke prevention … • Very effective for stroke prevention with Anticoagulation • NOACs are superior or non-inferior compare with Anti Vitamin K • Brain micro-bleed is a new predictor for ICH among AF patients NOACs are more safety to prevent ICH in stroke prevention What types of stroke you likely to see? Risk for Patients AF Patient untreated Risk for Doctors? AIS ICH -70% on VKA INR ICH -50% on NOAC AIS AIS: acute ischemic stroke; ICH: intracranial hemorrhage ICH ... Huy Thắng, Đỗ Thi Minh Chi– Abstract European Stroke Conference 20 15 Only ¼ of AF-Stroke pts can be independence ! 45 40 40.3 33.8 35 mRS 3-5: 43 .2% 22 .8 30 25 22 .5 20 13.6 15 10 16 16 12. 3 1.7... JL et al, Circulation 20 14;130:138–146; Hankey GJ et al, Lancet Neurol 20 12; 315– 322 ; Granger CB et al, N Engl J Med 20 11;365:981–9 92; Easton JD et al, Lancet Neurol 20 12: 11:503–511; Giugliano... 20 12: 11:503–511; Giugliano RP et al, N Engl J Med 20 13;369 :20 93? ?21 04; Connolly SJ et al, N Engl J Med 20 09;361:1139–1151; Eikelboom JW et al, Circulation 20 11; 123 :23 63? ?23 72 ROCKET AF: Stroke and ICH risk is