AF pt with ACS General Recommendation #ESC 💙
🌸Pretreatment with a P2Y12 inhibitor is recommended in STEMI patients or when coronary anatomy is known
🌸it should be withheld in non-STEMI ACS until the time of coronary angiography in case of an early invasive strategy within 24 hours.
🌸 Observational studies indicate that PCI on uninterrupted VKAs is generally safe compared with OAC interruption and heparin-bridging therapy,
particularly with radial artery access
🌸 In contrast, studies on NOACs are conflicting, predominantly discouraging a PCI on fully
uninterrupted NOAC therapy.
🌸If urgent PCI is needed, administration of a parenteral anticoagulant (UFH, LMWH, or bivalirudin) is suggested, with temporary withdrawal of NOAC at least for the initial post procedural period (e.g. 24 h) depending on the patient's thrombotic and bleeding risk profile.
🌸 Where thrombolysis is being considered in a patient with STEMI, the initial step should be to assess the anticoagulation status (e.g. INR in a patient taking VKA; with a NOAC, assessing, for example, activated partial thromboplastin time on dabigatran or anti-factor Xa activity on factor Xa in hibitors).
🌸 Thrombolytic therapy may be associated with an increased risk of bleeding in systemically anticoagulated patients, especially if parenteral heparin and antiplatelet drugs are coadministered.
🌸A balance between the potential benefit (e.g. large anterior myocardial infarction) and harm (e.g. ICH) is needed, as well as the reassessment of urgent transfer to a PCI centre.
🌸If the supposedly anticoagulated patient does not have evidence of a therapeutic anticoagulation effect (e.g. INR <2.0 on warfarin; or no NOAC anticoagulant effect detected), systemic thrombolysis may be considered if no access to primary PCI is possible.
🌸Pretreatment with a P2Y12 inhibitor is recommended in STEMI patients or when coronary anatomy is known
🌸it should be withheld in non-STEMI ACS until the time of coronary angiography in case of an early invasive strategy within 24 hours.
🌸 Observational studies indicate that PCI on uninterrupted VKAs is generally safe compared with OAC interruption and heparin-bridging therapy,
particularly with radial artery access
🌸 In contrast, studies on NOACs are conflicting, predominantly discouraging a PCI on fully
uninterrupted NOAC therapy.
🌸If urgent PCI is needed, administration of a parenteral anticoagulant (UFH, LMWH, or bivalirudin) is suggested, with temporary withdrawal of NOAC at least for the initial post procedural period (e.g. 24 h) depending on the patient's thrombotic and bleeding risk profile.
🌸 Where thrombolysis is being considered in a patient with STEMI, the initial step should be to assess the anticoagulation status (e.g. INR in a patient taking VKA; with a NOAC, assessing, for example, activated partial thromboplastin time on dabigatran or anti-factor Xa activity on factor Xa in hibitors).
🌸 Thrombolytic therapy may be associated with an increased risk of bleeding in systemically anticoagulated patients, especially if parenteral heparin and antiplatelet drugs are coadministered.
🌸A balance between the potential benefit (e.g. large anterior myocardial infarction) and harm (e.g. ICH) is needed, as well as the reassessment of urgent transfer to a PCI centre.
🌸If the supposedly anticoagulated patient does not have evidence of a therapeutic anticoagulation effect (e.g. INR <2.0 on warfarin; or no NOAC anticoagulant effect detected), systemic thrombolysis may be considered if no access to primary PCI is possible.
Management of active bleeding in patients receiving anticoagulation
Management of AF in pregnancy
1-Rate vs. Rhythm control?
Answer: Rhythm control is preferred over rate control to avoid side effects of the drugs(Rhythm control is usually achieved by DC cardioversion).
2-Drugs used for rate control :
-Selective B1 blockers(metoprolol or bisoprolol) (class I)
-Calcium channel blockers(Verapamil)(class IIa)
-Digoxin (class IIa)
3-Drugs used for Rhythm control:
-Sotalol
-Propafenone or flecainide (for structually normal heart or pre-excitation)
NB:Amiodarone is contraindicated with pregnancy
4-Drugs used for anticoagulation:
Either therapeutic weight based LMWH or warfarin based on stage of pregnancy
NB:NOACs are contraindicated in pregnancy and lactation
I-First trimester:
LMWH or warfarin if dose less than 5mg
II-Second trimester until 36 weeks:
Warfarin
III-After 36 weeks to 36 hours before delivery:
LMWH
IV-36 hours before and After deliverly:
UFH infusion
(stop 6 hours before delivery)
(instead of the UFH strategy, you can stop LMWH 24 hours before delivery if low risk for thromboembolism)
5-The decision for giving anticoagulation is based on CHADS-VASc score
Reference: ESC guidelines for management of CVD with pregnancy 2018
#CQtips
By Dr Ahmed Mohsen
1-Rate vs. Rhythm control?
Answer: Rhythm control is preferred over rate control to avoid side effects of the drugs(Rhythm control is usually achieved by DC cardioversion).
2-Drugs used for rate control :
-Selective B1 blockers(metoprolol or bisoprolol) (class I)
-Calcium channel blockers(Verapamil)(class IIa)
-Digoxin (class IIa)
3-Drugs used for Rhythm control:
-Sotalol
-Propafenone or flecainide (for structually normal heart or pre-excitation)
NB:Amiodarone is contraindicated with pregnancy
4-Drugs used for anticoagulation:
Either therapeutic weight based LMWH or warfarin based on stage of pregnancy
NB:NOACs are contraindicated in pregnancy and lactation
I-First trimester:
LMWH or warfarin if dose less than 5mg
II-Second trimester until 36 weeks:
Warfarin
III-After 36 weeks to 36 hours before delivery:
LMWH
IV-36 hours before and After deliverly:
UFH infusion
(stop 6 hours before delivery)
(instead of the UFH strategy, you can stop LMWH 24 hours before delivery if low risk for thromboembolism)
5-The decision for giving anticoagulation is based on CHADS-VASc score
Reference: ESC guidelines for management of CVD with pregnancy 2018
#CQtips
By Dr Ahmed Mohsen