«Δύσκολες αποφάσεις στην αντιμετώπιση της κολπικής μαρμαρυγής. Παραδείγματα από κλινικά περιστατικά» Ασθενείς με ελάσσονες αιμορραγίες και

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Ἀπφία Ανδρεάδης
8 χρόνια πριν
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1 «Δύσκολες αποφάσεις στην αντιμετώπιση της κολπικής μαρμαρυγής. Παραδείγματα από κλινικά περιστατικά» Ασθενείς με ελάσσονες αιμορραγίες και υψηλό θρομβοεμβολικό κίνδυνο Γεώργιος Σ. Γκουμάς MD, PhD, FESC Αν. Διευθυντής Β Καρδιολ. Κλινικής, Ευρωκλινική Αθηνών Ομάδα Εργασίας Πρόληψης και Αποκατάστασης της ΕΚΕ

2 ΔΗΛΩΣΗ ΣΥΓΚΡΟΥΣΗΣ ΣΥΜΦΕΡΟΝΤΩΝ Τα προηγούμενα δύο χρόνια έχω λάβει τιμητικές αμοιβές ως σύμβουλος ή ομιλητής από τις ακόλουθες φαρμακευτικές εταιρείες: SANOFI, MENARINI, GALENICA, ASTRAZENECA, VIANEX, PFIZER, BAYER

3 Case 1 Patient with permanent AF is admitted to the hospital with a stroke female 76 years old Arterial Hypertension controlled (ramipril 5 1X1, amlodipine 5 1X1) Diabetes Mellitus (metformin 850 1X1)

4 Case 1 Patient with permanent AF is admitted to the hospital with a stroke Left middle cerebral artery (MCA) infarction. Axial nonenhanced computer tomography demonstrates hypoattenuating foci throughout the left sided white matter (arrows) and sulcal effacement in the left MCA territory, consistent with infarction.

5 Case 1 Patient with permanent AF is admitted to the hospital with a stroke Was diagnosed with AF six months ago Advised to start taking tabl dabigatran 150 mg 1X2 Took the medication for one month and then stopped it because of -stomach pain and indigestion -easy bruising, purple pinpoint spots under her skin which was very annoying and made her worry -sick and tired of taking so many pills

6 Case 1 Patient with permanent AF is admitted to the hospital with a stroke Creatinine Clearance 52 ml/min CHA 2 DS 2 -Vasc score 5 HAS-BLED score 1

7 Bleeding definitions (TIMI) Minimal: any clinically overt sign of hemorrhage (including imaging) that is associated with a fall in hemoglobin < 3 g/dl (or, when hemoglobin is not available, a fall in hematocrit of < 9%). Minor: any clinically overt sign of hemorrhage (including imaging) that is associated with a fall in hemoglobin of 3 to 5 g/dl (or, when hemoglobin is not available, a fall in hematocrit of 9 to 15%).

8 Fear of Bleeding: An Obstacle to Stroke Prevention The reluctance of doctors to prescribe the non-adherence of patients to anticoagulant therapy

10 anticoagulants Stroke Both in-hospital as well as bleeding after hospitalization is associated with an increased risk for mortality and morbidity from recurrent stroke or systemic embolism. this risk is actually driven by non-adherence!!

11 Νuisance bleeding easy bruising bleeding from small cuts minor hemorrhages from broken capillary vessels (petechia, and ecchymosis) In as many as 85% of patients receiving antiplatelet or anticoagulant treatment Among patients who reported nuisance bleeding, 70% experienced bleeding on a daily basis Roy P et al. Am J Cardiol 2008; 102:

12 Νuisance bleeding More than one in 10 of patients stops taking their medication as result of this superficial, or nuisance, bleeding Roy P et al. Am J Cardiol 2008; 102:

14 Case 2 Patient with paroxysmal AF under treatment with rivaroxaban is admitted with epistaxis Male 80 years old Diabetes Mellitus (metformin 850 1X2) History of stroke (5 years ago) Until 3 months ago he was treated with acenocoumarol but switched to rivaroxaban 15 mg 1X1 due to poor INR control

15 Case 2 Patient with paroxysmal AF under treatment with rivaroxaban is admitted with epistaxis Creatinine Clearance 47 ml/min CHA 2 DS 2 -Vasc score 5 HAS-BLED score 2

16 Case 2 Patient with paroxysmal AF under treatment with rivaroxaban is admitted with epistaxis The patient is admitted to the hospital because of persistent epistaxis despite the efforts to stop the bleeding at home.

17 Case 2 Patient with paroxysmal AF under treatment with rivaroxaban is admitted with epistaxis Nasal packing and cauterization of culprit vessel

18 Case 2 Patient with paroxysmal AF under treatment with rivaroxaban is admitted with epistaxis The patient is advised not to stop receiving anticoagulant treatment because of his high risk for stroke

19 Case 2 Patient with paroxysmal AF under treatment with rivaroxaban is admitted with epistaxis Next day, while getting ready for discharge, the patient goes to the toilet and becomes terrified as he realizes that he urinates blood!!! Calls the cardiologist asking him whether they are trying to kill him with this medication!

20 Case 2 Patient with paroxysmal AF under treatment with rivaroxaban is admitted with epistaxis Urologic consultation, ultrasound examination and cystoscopy reveal nothing except prostate hyperplasia

21 Case 2 Patient with paroxysmal AF under treatment with rivaroxaban is admitted with epistaxis Seeing so many doctors taking care of him, the patient asks for a dermatological consultation Why? Well, I forgot to mention

22 Case 2 Patient with paroxysmal AF under treatment with rivaroxaban is admitted with epistaxis but the patient also forgot to mention that for the last 10 days he was treated with Sporanox (Itraconazole) 200 mgx1 for Tinea cruris!!

24 Πρωτεϊνες μεταφοράς στις κυτταρικές μεμβράνες: P-gp Στο γαστρεντερικό περιορίζει την απορρόφηση των φαρμάκων μεταφέροντάς τα εκτός των κυττάρων Στο ήπαρ και τα νεφρικά σωληνάρια μεσολαβεί για την αποβολή των φαρμάκων Έτσι, οι αναστολείς της P-gp μπορούν να αυξήσουν τα επίπεδα των φαρμάκων ενώ οι επαγωγείς της P-gp μπορούν να μειώσουν τα επίπεδα του φαρμάκου και άρα και την αποτελεσματικότητά του

25 Σύστημα του κυτοχρώματος P450 Το ηπατικό σύστημα παίζει βασικό ρόλο στην ενεργοποίηση και κάθαρση πολλών φαρμάκων Ο μεταβολισμός των φαρμάκων γίνεται μέσω ηπατικών ενζύμων, των κυτοχρωμάτων (CYPs), τα οποία σε ένα καταλυτικό κύκλο μεταβολίζουν μεγάλη ποικιλία υποστρωμάτων

26 Σύστημα του κυτοχρώματος P450 Several drugs may affect CYPs either by inhibiting or by inducing their function. Inhibitors of CYPs decrease drug metabolism in the liver, and regarding NOAC their clearance, resulting in the increase of their anticoagulant effect and the risk of bleeding. Inducers of CYPs increase NOAC clearance, resulting in the decrease of their anticoagulant effect and the increase of risk of thrombosis.

27 Some advise Extreme caution when these disease processes are coexistent in the cardiology patient: HIV (protease inhibitors) fungal infection (azole antimycotics) arrhythmia patients (dronedarone, verapamil, amiodarone) staph infections (rifampin) epilepsy ( carbamazepine, phenytoin, phenobarbital) graft patients (cyclosporine)

28 Before Some advise

29 Some advise Be careful with the elderly Increased age is tightly correlated with increased risk of DDIs

33 Thank you for your attention!

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Νεώτερα αντιπηκτικά και αλληλεπιδράσεις µε άλλα φάρµακά. Γεώργιος Σ. Γκουµάς MD, PhD, FESC Αν. Διευθυντής Καρδιολογικής Κλινικής, Ευρωκλινική Αθηνών

Νεώτερα αντιπηκτικά και αλληλεπιδράσεις µε άλλα φάρµακά. Γεώργιος Σ. Γκουµάς MD, PhD, FESC Αν. Διευθυντής Καρδιολογικής Κλινικής, Ευρωκλινική Αθηνών ΔΗΛΩΣΗ ΣΥΓΚΡΟΥΣΗΣ ΣΥΜΦΕΡΟΝΤΩΝ Τα προηγούµενα δύο χρόνια