Αντιμετώπιση ασθενούς με βαλβιδική κολπική μαρμαρυγη Χριστίνα Χρυσοχόου Επιμελήτρια Α, Α Πανεπιστημιακή Καρδιολογική Κλινική ΙΓΝΑ
The Majority of AF Cases Occur in the Context of Pre-existing CV Disease Lone atrial fibrillation (Also known as idiopathic AF) Secondary atrial fibrillation No evidence of cardiac or pulmonary disease that could explain the development of AF Usually a consequence of atrial structural remodelling in the context of pre-existing disease Acute CV cause - Myocardial infarction - Cardiac surgery - Myocarditis Chronic CV cause - Hypertension - Coronary artery disease - Congestive heart failure - Valvular disease Non-cardiovascular cause - Hyperthyroidism - Pulmonary disease - Obesity ACC/AHA/ESC 2006 guidelines J Am Coll Cardiol 2006;48:854-906
Περιστατικό Ασθενης γυναίκα ηλικίας 68 ετων με ιστορικό αρτηριακής υπέρτασης και υπερλιπιδαιμίας εισήχθη λόγω αισθήματος εντονων παλμών Αναφέρει μείωση λειτουργικού σταδίου τον τελευταίο μήνα και επεισόδια παροξυσμικής κολπικής μαρμαρυγής Λαμβάνει ήδη αγωγή με olmesartan 40mg, rivaroxaban 20 mg, bisoprolol 5mg, atorvastatin 20mg.
Εργαστηριακός έλεγχος Αιμοσφαιρίνη/ Αιματοκρίτης 12.8mg/dl/ 38.5% INR 1.0 Ολικη χολερυθρίνη 0.73 mg/dl Ολικα λευκώματα/ λευκωματίνη 6.4/ 4 mg/dl TSH 2 μiu/ml Γλυκόζη ορού 112 Ουρία/κρεατινίνη 25/ 0.8 mg/dl SGOT/SGPT 17/28 mg/dl γgt/ldh 47/ 229 mg/dl Na/ K/ Ca/ Mg 140/ 3,5/ 9.4/ 2.3 mg/dl CPK/ALP 89/26 mg/dl Τchol/ HDL/ Trig/ LDL 190/50/120/86 mg/dl
Πορεία νόσου Λογω του αναφερόμενου ιστορικού δυσφορίας στην άσκηση και παρουσίας παραγόντων κινδύνου για αθηροσκλήρωση με ηπια επηρεασμένη τη συστολική απόδοση της αριστερής κοιλίας υποβλήθηκε σε στεφανιογραφικό έλεγχο, όπου ανέδειξε στεφανιαια αγγεία χωρίς στενώσεις. Το ΗΚΓ παρουσίασε άλλόδρομη αγωγή σε μορφή διδυμίας και αποφασίστηκε η αντικατάσταση της βισοπρολόλης με διλτιαζέμη 60 mg x 3. Τελικά εξήλθε με βισοπρολόλη 10mg και διλτιαζέμη 60mg x 2 και με αγωγή για αρτηριακή υπέρταση και υπερλιπιδαιμία Θα λάβει αντιπηκτική αγωγή και ποια? Δεδομένης της μέτριας ανεπάρκειας μιτροειδούς και τριγλώχινας βαλβίδας
CHA2DS2-VASC score=3 HAS BLED score=2
NOACs in valve disease? ESC valves guidelines 2017
NOACs in valve disease? Non-vitamin K antagonist oral anticoagulants (NOACs) are approved only for non-valvular atrial fibrillation, but there is no uniform definition of this term. Recent subgroup analyses of randomized trials on atrial fibrillation support the use of rivaroxaban, apixaban, dabigatran and edoxaban in patients with aortic stenosis, aortic regurgitation or mitral regurgitation presenting with atrial fibrillation. ROCKET AF trial.eur Heart J 2014;35:3377 3385 (ARISTOTLE) Trial. Circulation 2015; 132 :624 632 the RE-LY Trial (Randomized Evaluation of Long-Term Anticoagulant Therapy). Circulation 2016; 134 :589 598.
Anticoagulation Mechanisms
Hazard ratio with 95% confidence interval of efficacy outcomes (NOACs vs warfarin) in patients with and without VHD. For stroke
Hazard ratio with 95% confidence interval of efficacy outcomes (NOACs vs warfarin) in patients with and without VHD. For death
Safety concerns for major bleeding
Safety concerns for intracranial hemorrhage
Efficacy and safety outcomes in patients with and without valvular heart disease (VHD) in the total RE-LY trial (Randomized Evaluation of Long-Term Anticoagulant Therapy) population (propensity-adjusted analysis). In RELY study there were 3950 patients with any VHD: 3101 had mitral regurgitation, 1179 with tricuspid regurgitation, 817 had aortic regurgitation, 471 with aortic stenosis, and 193 with mild mitral stenosis.
NOACs in valve disease? The use of NOACs is discouraged in patients who have atrial fibrillation associated with moderate to severe mitral stenosis, given the lack of data and the particularly high thromboembolic risk. Despite the absence of data, NOACs may be used in patients who have atrial fibrillation associated with an aortic bioprosthesis >3 months after implantation but are strictly contraindicated in patients with any mechanical prostheses N Engl J Med 2015; 372 :1399 1409.
Surgical ablation and anticoagulation Surgical ablation of atrial fibrillation combined with mitral valve surgery is effective in reducing the incidence of atrial fibrillation, but at the expense of more frequent pacemaker implantation, and has no impact on short-term survival. Surgical ablation should be considered in patients with symptomatic atrial fibrillation and may be considered in patients with asymptomatic atrial fibrillation if feasible with minimal risk. The decision should factor in other important variables, such as age, the duration of atrial fibrillation and LA size. Surgical excision or external clipping of the LA appendage may be considered combined with valvular surgery, although there is no evidence that it decreases thromboembolic risk Even in case of surgical ablation life long anticoagulation is mandatory
Conclusion NOACs may be used in patients with atrial fibrillation and aortic stenosis, aortic regurgitation, mitral regurgitation or aortic bioprostheses >3 months after implantation but are contraindicated in mitral stenosis and mechanical valves The safety and efficacy of NOACs in patients with surgical or transcatheter bioprostheses in the first 3 months after implantation should be studied.