DISEASE EDUCATION FOR HEALTH CARE PROFESSIONALS

Atrial fibrillation (AF) is associated with 2 types of stroke: haemorrhagic and icshaemic.

  • Haemorrhagic strokes are generally more severe compared with icshaemic; associated with increased mortality 1-3 months post stroke1


Interpatient symptom variability is notoriously common in this patient population and makes comparisons a significant challenge4:

  • Stroke may be the first indication of AF
  • ~20% of patients are asymptomatic
  • There is a wide range of symptomatic severity
  • There s a great variation in correlating symptoms with objective findings
  • The mechanisms of many symptoms of AF are poorly understood

The symptoms of DVT include:

  • Calf tenderness, swelling in one limb5
  • Warmth, superficial venous dilation5


Recognising DVT:

DVT is often asymptomatic; however, there are certain conditions that should be considered before making the differential diagnosis, including Baker’s cyst and haematoma.6,7

DVT is most commonly found in the legs:

  • In the the deep veins of the calf8
  • Proximal lower extremity veins (popliteal, common femoral, superficial femoral, iliac)8
    • More likely to embolise to lungs
  • Upper extremity (UE) veins9


Identifying PE can be a challenge, as the signs and symptoms are not unique to this condition.5,10
Some of the most common symptoms include:

  • Shortness of breath
  • Chest pain
  • Cough
  • Fever
  • Dizziness, light-headedness, or fainting
  • Diaphoresis
  • Arrhythmias
  • Cyanosis

Anticoagulant therapy has become one of the cornerstones of care in reducing the risk of thrombotic events in patients with NVAF, DVT, and PE.

Treatment guidelines recommend anticoagulation treatment as first-line treatment for patients with NVAF, DVT, and PE.10,11

Anticoagulants can act in several ways, including:

  • Vitamin K antagonists (eg, warfarin)
  • Heparin and derivatives (eg, pentasaccharide fondaparinux)
  • Direct thrombin inhibitors
  • Direct factor Xa inhibitors

One anticoagulant mechanism that has been shown to protect patients against clot formation is factor Xa inhibition.

The Factor Xa Signaling Cascade12:


See clinical trials data for one factor Xa inhibitor

Patient Factors to Consider

Certain factors, such as comorbidities, age, concominant medications, and renal impairment, may increase the risk of bleeding whilst receiving anticoagulant therapy; therefore, it is critical to consider these factors before deciding on a treatment paradigm.

In a survey* of 1297 patients with AF:
Approximately 98% of the respondents reported at least 1 comorbidity in addition to AF13


Comorbid conditions can further complicate AF treatment because of the use of concomitant medications.13

Older NVAF patients who are taking oral anticoagulants were found to be at higher risk for both bleeding complications and thromboembolism.14,†

In a survey of 1297 patients with AF:
Concomitant medication used to treat other conditions can complicate a patient's pharmacotherapy and increase the likelihood of drug-drug interactions13


The risks of stroke, systemic thromboembolism, and bleeding were significantly higher in atrial fibrillation patients who also had non–end-stage chronic kidney disease (CKD)15,‡


A treatment decision for anticoagulation therapy must provide efficacy whilst minimising bleeding risk in these specific patient populations.16

  • *

    Retrospective, internet-based observational evaluation of response to the 2009 U.S National Health and Wellness Survey.

  • Data are based on studies from a large (13,559 adults) health maintenance organisation insert: (An integrated healthcare delivery system) in patients with nonvalvular atrial fibrillation (NVAF). Oral anticoagulation in these studies refers to warfarin.

  • Based on a Danish cohort study of patients discharged from a hospital with nonvalvular atrial fibrillation (NVAF) from 1997 through 2008.

References:

  1. Andersen KK, Olsen TS, Dehlendorff C, Kammersgaard LP. Hemorrhagic and ischemic strokes compared: stroke severity, mortality, and risk factors. Stroke. 2009;40(6):2068-2072.
  2. Camm AJ, Kirchhof P, Lip GYH, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010;31(19):2369-2429.
  3. Rho RW, Page RL. Asymptomatic atrial fibrillation. Prog Cardiovasc Dis. 2005;48(2):79-87.
  4. McRae CA. et al. Symptoms in atrial fibrillation: why keep score? Circ Arrhythm Electrophysiol. 2009;2(3):215-217.
  5. Blann AD, Lip GYH. Venous thromboembolism. BMJ. 2006;332(7535):215-219.
  6. Tovey C, Wyatt S. Diagnosis, investigation, and management of deep vein thrombosis. BMJ. 2003;326 (7400):1180-1184.
  7. Gorman WP, Davis KR, Donnelly R. ABC of arterial and venous disease: swollen lower limb–l: General assessment and deep venous thrombosis. BMJ. 2000;320(7247):1453-1456.
  8. Kearon C. Natural history of venous thromboembolism. Circulation. 2003;107(23 suppl 1):I23-I30.
  9. Sadeghi R, Safi M. Systemic thrombolysis in the upper extremity deep vein thrombosis. ARYA Atheroscler. 2011;7(1):40-46.
  10. Dupras D, Bluhm J, Feity C, at al; Institute for Clinical Systems Improvement. Health care guideline: venous thromboembolism diagnosis and treatment, 13th ed. https://www.icsi.org/_asset/5ldx9k/VTE0113.pdf. Updated January 2013. Accessed November 18, 2014.
  11. Weitz, New Anticoagulants for Treatment of Venous Thromboembolism. Circulation. 2004;110:I-19-I26.
  12. Borissof JI, Spronk HM, ten Cate H. The hemostatic system as a modulator of atherosclerosis. N Engl J Med. 2011;364:1746-1760.
  13. LaMori JC, Mody SH, Gross HJ, et al. Burden of comorbidities among patients with atrial fibrillation. Ther Adv Cardiovasc Dis. 2013;7(2):53-62.
  14. Singer DE, Chang Y, Fang MC, et al. The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med. 2009;151(5):297-305.
  15. Olesen JB, Lip GYH, Kamper A-L, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med. 2012;367(7):625-635.
  16. Camm AJ, Lip GY, De Caterina R, et al; ESC Committee for Practice Guidelines- (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. (2012);33(21):2719-2747.