Page 2417 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 147 Atrial Fibrillation 2157

to identify bleeding risk factors that can be modified to reduce 8. Wynn GJ, Todd DM, Webber M, et al: The European Heart Rhythm
bleeding risk. Association symptom classification for atrial fibrillation: validation and
improvement through a simple modification. Europace 16:965–972,
2014.
Reversal of Anticoagulation 9. Wolf PA, Abbott RD, Kannel WB: Atrial fibrillation as an indepen-
dent risk factor for stroke: the framingham study. Stroke 22:983–988,
The management of bleeding is still a clinical challenge in the setting 1991.
of anticoagulation. In patients taking VKAs, physicians have many 10. Jørgensen HS, Nakayama H, Reith J, et al: Acute stroke with atrial
years of experience with reversing the agent by using a number of fibrillation: the copenhagen stroke study. Stroke 27:1765–1769,
therapies, such as intravenous vitamin K, fresh frozen plasma (FFP), 1996.
and prothrombin complex concentrate (PCC). When rapid reversal 11. Ott A, Breteler MM, de Bruyne MC, et al: Atrial fibrillation and
is needed, PCC is preferred over FFP; recombinant factor VIIa is not dementia in a population-based study. The Rotterdam Study. Stroke
recommended. In contrast, reversal agents for specific NOACs have 28:316–321, 1997.
only recently become available, and action is usually limited to sup- 12. Wang TJ, Larson MG, Levy D, et al: Temporal relations of atrial fibril-
portive care (e.g., ceasing therapy, volume resuscitation, and hemo- lation and congestive heart failure and their joint influence on mortality:
dynamic support). Nonetheless, PCC is often administered in the framingham heart study. Circulation 107:2920–2925, 2003.
patients with life-threatening bleeds. Given their short elimination 13. Mamas MA, Caldwell JC, Chacko S, et al: A meta-analysis of the
half-lives, time is the most important factor in bleeding associated prognostic significance of atrial fibrillation in chronic heart failure. Eur
with NOACs. This emphasizes the importance of asking patients J Heart Fail 11:676–683, 2009.
about the exact time of last intake and ascertaining factors influencing 14. Benjamin EJ, Wolf PA, D’Agostino RB, et al: Impact of atrial fibril-
plasma concentrations and hemostasis (e.g., age, comorbidities, and lation on the risk of death: the Framingham Heart Study. Circulation
concomitant use of antiplatelet drugs). 33 98:946–952, 1998.
15. Transesophageal echocardiographic correlates of thromboembolism in
high-risk patients with nonvalvular atrial fibrillation. the stroke preven-
FUTURE DIRECTIONS tion in atrial fibrillation investigators committee on echocardiography.
Ann Intern Med 128:639–647, 1998.
Current gaps in the evidence base for management of AF include 16. Hijazi Z, Oldgren J, Siegbahn A, et al: Biomarkers in atrial fibrillation:
comparison of different rate control therapies, defining the place of a clinical review. Eur Heart J 34:1475–1480, 2013.
rhythm control with hybrid approaches to restoration of sinus 17. Al-Khatib SM, Allen LaPointe NM, Chatterjee R, et al: Rate- and
rhythm, and determining how best to manage patients with AF and rhythm-control therapies in patients with atrial fibrillation: a systematic
concomitant heart failure. We have seen an evolution in the anti- review. Ann Intern Med 160:760–773, 2014.
thrombotic management of AF in recent years due to widespread 18. Kotecha D, Kirchhof P: Rate and rhythm control have comparable
availability of NOACs. It is hoped that greater uptake of all forms of effects on mortality and stroke in atrial fibrillation but better data are
anticoagulation will result in reductions in the burden of stroke and needed. Evid Based Med 19:222–223, 2014.
thromboembolism due to AF. Though reduction in stroke will remain 19. Kotecha D, Holmes J, Krum H, et al: Efficacy of β blockers in patients
a major priority for these patients in the future, the risk of death with heart failure plus atrial fibrillation: an individual-patient data meta-
remains unacceptably high, with etiology typically due to sudden analysis. Lancet 384:2235–2243, 2014.
cardiac death and progressive heart failure. Further attention on these 20. Van Gelder IC, Groenveld HF, Crijns HJ, et al: Lenient versus strict rate
areas is vital, considering the rapidly increasing incidence and preva- control in patients with atrial fibrillation. N Engl J Med 362:1363–1373,
lence of AF, and the burden this condition places on patients and 2010.
health care systems. 21. Zimetbaum P: Antiarrhythmic drug therapy for atrial fibrillation.
Circulation 125:381–389, 2012.
22. Wazni O, Wilkoff B, Saliba W: Catheter ablation for atrial fibrillation.
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