TY - JOUR
T1 - Questions pratiques dans le traitement de la fibrillation atriale
AU - Ederhy, S.
AU - Lang, S.
AU - Haddour, N.
AU - Boyer-Châtenet, L.
AU - Soulat-Dufour, L.
AU - Adavane, S.
AU - Fleury, G.
AU - der Vynckt, C. Van
AU - Charbonnier, M.
AU - Asri, C. El
AU - Boccara, F.
AU - Cohen, A.
PY - 2013/6
Y1 - 2013/6
N2 - Non-valvular atrial fibrillation is the most common clinically significant cardiac arrhythmia; it increases both the risk for and the severity of strokes and is associated with substantial morbidity and mortality, decreased quality of life and related health care costs. Guidelines recommend anticoagulation therapy for most patients with atrial fibrillation.Several clinical factors in addition to older age have been linked to anticoagulant-associated bleeding risk. Newer fixed-dose oral anticoagulants have emerged as viable alternatives to warfarin and the choice of anticoagulant should depend on the presence of comorbid conditions such as reduced renal function, side-effect profile, cost and patient preference. Although bleeding risk is elevated in older patients, the net clinical benefit favours anticoagulation for most older adults. Chronic kidney disease affects up to 10% of the adult population, particularly the elderly, and carries a high risk for cardiovascular disease, including atrial fibrillation. Apixaban has demonstrated a reduction in the primary endpoint of stroke or systemic embolism and in major haemorrhage, regardless of renal function.If percutaneous coronary intervention, which increases both the risk, and morbidity and mortality, of atrial fibrillation, is required in patients with coronary artery disease taking oral anticoagulants, antiplatelet therapy with aspirin and clopidogrel is indicated, but such triple therapy increases the risk of serious bleeding. No prospective data are available, but results from clinical trials involving patients with acute coronary syndromes suggest that the addition of a new oral anticoagulant to antiplatelet therapy results in a modest reduction in cardiovascular events but also in a substantial increase in bleeding risk. This risk is most pronounced when new oral anticoagulants are combined with dual antiplatelet therapy.Although available data are scarce, dabigatran is a reasonable alternative to warfarin in patients requiring cardioversion and can be considered in ablation procedures, although additional data on safety are required. Rivaroxaban and apixaban are being investigated in this indication. These agents represent a promising alternative to conventional warfarin therapy and may be associated with lower risk of intracranial haemorrhage, especially in patients exposed to a higher risk of bleeding.Finally, perioperative management for optimal safety regarding the risk of bleeding and thrombosis related to new anticoagulants has been proposed, but has not been validated and approved, as there are no confirmed antagonists, they cannot be monitored by simple standardized labora tory assays, and their pharmacokinetics vary greatly between patients.
AB - Non-valvular atrial fibrillation is the most common clinically significant cardiac arrhythmia; it increases both the risk for and the severity of strokes and is associated with substantial morbidity and mortality, decreased quality of life and related health care costs. Guidelines recommend anticoagulation therapy for most patients with atrial fibrillation.Several clinical factors in addition to older age have been linked to anticoagulant-associated bleeding risk. Newer fixed-dose oral anticoagulants have emerged as viable alternatives to warfarin and the choice of anticoagulant should depend on the presence of comorbid conditions such as reduced renal function, side-effect profile, cost and patient preference. Although bleeding risk is elevated in older patients, the net clinical benefit favours anticoagulation for most older adults. Chronic kidney disease affects up to 10% of the adult population, particularly the elderly, and carries a high risk for cardiovascular disease, including atrial fibrillation. Apixaban has demonstrated a reduction in the primary endpoint of stroke or systemic embolism and in major haemorrhage, regardless of renal function.If percutaneous coronary intervention, which increases both the risk, and morbidity and mortality, of atrial fibrillation, is required in patients with coronary artery disease taking oral anticoagulants, antiplatelet therapy with aspirin and clopidogrel is indicated, but such triple therapy increases the risk of serious bleeding. No prospective data are available, but results from clinical trials involving patients with acute coronary syndromes suggest that the addition of a new oral anticoagulant to antiplatelet therapy results in a modest reduction in cardiovascular events but also in a substantial increase in bleeding risk. This risk is most pronounced when new oral anticoagulants are combined with dual antiplatelet therapy.Although available data are scarce, dabigatran is a reasonable alternative to warfarin in patients requiring cardioversion and can be considered in ablation procedures, although additional data on safety are required. Rivaroxaban and apixaban are being investigated in this indication. These agents represent a promising alternative to conventional warfarin therapy and may be associated with lower risk of intracranial haemorrhage, especially in patients exposed to a higher risk of bleeding.Finally, perioperative management for optimal safety regarding the risk of bleeding and thrombosis related to new anticoagulants has been proposed, but has not been validated and approved, as there are no confirmed antagonists, they cannot be monitored by simple standardized labora tory assays, and their pharmacokinetics vary greatly between patients.
KW - Apixaban
KW - Aspirin
KW - Clopidogrel
KW - Dabigatran
KW - Edoxaban
KW - Rivaroxaban
KW - Stroke
KW - VKA
UR - http://www.scopus.com/inward/record.url?scp=84884691112&partnerID=8YFLogxK
U2 - 10.1016/S1878-6480(13)70889-9
DO - 10.1016/S1878-6480(13)70889-9
M3 - Articolo in rivista
AN - SCOPUS:84884691112
SN - 1878-6480
VL - 5
SP - 148
EP - 160
JO - Archives of Cardiovascular Diseases Supplements
JF - Archives of Cardiovascular Diseases Supplements
IS - 2
ER -