GENERATION X – CHALLENGES IN ANTICOAGULATION!

Authors

  • Anita Arsovska University Clinic forNeurology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Republic of North Macedonia https://orcid.org/0000-0003-1927-9614
  • Hristo Pejkov University Clinic for Cardiology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Republic of North Macedonia
  • Lidija Poposka University Clinic for Cardiology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Republic of North Macedonia
  • Ana Doneva General City Hospital “8September”, Department of Neurology, Skopje, Republic of North Macedonia
  • Aleksandra Angelova University Clinic forNeurology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Republic of North Macedonia
  • Arbana Rexhepi Clinical Center, Department of Neurology, Tetovo, Republic of North Macedonia
  • Galina Hristovska General City Hospital “8September”, Department of Neurology, Skopje, Republic of North Macedonia
  • Elizabeta Hroneska Clinical Hospital, Department of Neurology, Prilep, Republic of North Macedonia
  • Ana Chelikikj University Clinic for Cardiology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Republic of North Macedonia
  • Tamara Bojkovska Kanevche University Clinic for Cardiology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Republic of North Macedonia
  • Nikola Manev University Clinic for Cardiology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Republic of North Macedonia
  • Elif Vranjko University Clinic for Cardiology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Republic of North Macedonia
  • Glorija Gashpar PHI Specialized Hospital for Geriatric and Palliative Medicine "13 November", Bitola, Republic of North Macedonia
  • Dimitar Cvetkovski University Clinic for Cardiology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Republic of North Macedonia

Keywords:

primary prevention, secondary prevention, anticoagulation therapy, direct oral anticoagulants, rivaroxaban, atrial fibrillation, ischemic stroke, haemorrhagic stroke

Abstract

Atrial fibrillation (AF) increases an individual’s risk of stroke by 4 to 6 times on average. The risk increases with age. In people over 80 years old, AF is the direct cause of 1 in 4 strokes. In these cases, anticoagulation therapy is recommended for primary prevention and secondary stroke prevention. Direct oral anticoagulants (DOACs) such asRivaroxaban are preferred over Vitamin K antagonists (VKA), according to the latest guidelines. To present interesting and challenging cases from the clinical practice and discuss use of Rivaroxaban in primary and secondary prevention in patients with AF and stroke.

In November 2022 we organized a two-day workshop, under the auspices of the pharma company Bayer d.o.o. Ljubljana-Representative Office Skopje, Macedonia. Neurology and Cardiology residents presented 10 clinical cases, under the mentorship of respective specialists, experts in their fields. Clinical features, laboratory analysis, neuroimaging findings and contemporary management of each case were discussed in detail. Designated mentors presented the latest guidelines and recommendations regarding use of Rivaroxaban in primary and secondary prevention in patients with AF and stroke.

Below we present 10 clinical cases and describe in detail their physical and neurological condition, laboratory and imaging findings and therapeutic approach.

References

References

Ferrari R, Bertini M, Blomstrom-Lundqvist C, Dobrev D, Kirchhof P, Pappone C, et al. An update on atrial fibrillation in 2014: from pathophysiology to treatment. Int J Cardiol 2016; 203: 22-29. doi: 10.1016/j.ijcard.2015.10.089.

Stollberger C, Chnupa P, Abzieher C, Länger T, Finsterer J, Klem I, et al. Mortality and rate of stroke or embolism in atrial fibrillation during long-term follow-up in the Embolism in Left Atrial Thrombi (ELAT) Study. Clin Cardiol 2004; 27(1): 40-46. doi: 10.1002/clc.4960270111.

Klijn CJ, Paciaroni M, Berge E, Korompoki E, Kõrv J, Lal A, et al. Antithrombotic treatment for secondary prevention of stroke and other thromboembolic events in patients with stroke or transient ischemic attack and non-valvular atrial fibrillation: A European Stroke Organisation guideline. Eur Stroke J 2019; 4(3): 198-223. doi: 10.1177/2396987319841187.

Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2021; 42(5): 373-498. doi: 10.1093/eurheartj/ehaa612.

Kleindorfer DO, Towfighi A, Chaturvedi S, Cokroft KM, Gutierrez J, Lombardi-Hill D, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52(7): e364-e467. https://doi.org/10.1161/STR.0000000000000375.

Zweibel S, Passman R, Sarkar S, Koehler J, Ziegler P. Are all CHA2DS2-VASc risk factors created equal? An assessment of stroke risk among 34,470 patients with CHA2DS2-VASc scores of 1 or 2, European Heart Journal, 2020; 41(Issue Suppl 2): ehaa946.0519. https://doi.org/10.1093/ehjci/ehaa946.0519.

Jones M, McEwan P, Morgan CL, Peters JR, Goodfellow J, Currie CJ. Evaluation of the pattern of treatment, level of anticoagulation control, and outcome of treatment with warfarin in patients with non-valvar atrial fibrillation: a record linkage study in a large British population. Heart 2005; 91(4): 472-477. https://heart.bmj.com/content/91/4/472.

Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. ESC Scientific Document Group, 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; 39(2): 119-177. doi: 10.1093/eurheartj/ehx393.

Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004; 110(9): 1042-1046. doi: 10.1161/01.CIR.0000140263.20897.42.

Patel M, Mahaffey K, Garg J, Pan G, Singer D, Hacke W, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365(10): 883-891. doi: 10.1056/NEJMoa1009638.

Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, et al. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23(10): 1612-1676. doi: 10.1093/europace/euab065.

Mant J, Hobbs FD, Fletcher K, Roalfe A, Fitzmaurice D, Lip GY, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007; 370(9586): 493-503. doi: 10.1016/S0140-6736(07)61233-1.

Halperin JL, Hankey GJ, Wojdyla DM, Piccini JP, Lokhnygina Y, Patel MR, et al. ROCKET AF Steering Committee and Investigators. Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). Circulation 2014; 130(2): 138-146. doi: 10.1161/CIRCULATIONAHA.113.005008.

Downloads

Published

2022-12-20

Issue

Vol. 2 No. 2 (2022): Acad Med J

Section

Case Reports