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Stroke, an Animation & Telehealth ER evaluation

Stroke, an Animation & Telehealth ER evaluation | Heart and Vascular Health | Scoop.it
A description of what happens when a stroke occurs.
Seth Bilazarian, MD's insight:

Very good animation of the carotid artery and development of atherosclerosis and then thrombosis.  The feature following the animation is a real telehealth visit for a patient with a stroke in the setting of atrial fibrillation making a decision about whether to use thrombolytic treatment (tPA) for clot busting of the stroke causing clot.

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Xarelto (rivaroxaban) approved for stroke prevention in atrial fibrillation 2 years ago

Xarelto (rivaroxaban) approved for stroke prevention in atrial fibrillation 2 years ago | Heart and Vascular Health | Scoop.it

#OnThisDay (11/4/2011) two years ago the first Factor Xa inhibitor and second novel oral anticoagulant (NOAC) was approved to prevent stroke in atrial fibrillation.  We now have three NOACs available.

Seth Bilazarian, MD's insight:

There are now three NOACs available as an alternative to warfarin (coumadin) and one on the horizon in 2014.   The uptake in the US has been slow.  Xarelto is the only one of the NOACs that has been approved for other indications such as DVT's (clots in the leg), PE (clots in the lung), or the prevention of these problems after knee and hip surgery. Physician and patient familairity and comfort with these new options is slowly growing.

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Famous people with Atrial Fibrillation

Famous people with Atrial Fibrillation | Heart and Vascular Health | Scoop.it
Seth Bilazarian, MD's insight:

Atrial fibrillation is the most common arrhythmia (irregular heart rhythm). It increases with each decade of life. About 15% of people in their 80's have it. The rhythm causes the upper chamber to wiggle (Fibrillate) instead of contracting in synchrony with the lower chamber.

There are three main issues of Atrial Fibrillation:
1. a reduced cardiac output due to loss of atrial systole and transport
2. rapid heart rate and rhythm irregularity
3. risk of thromboembolism and Cerebrovascular accident in the range of 1.9% to 18.2% per year without anti-coagulation, based on a risk prediction score called CHADS2.

On the famous people list the only striking unanswered question is, why are the American politicians all Republicans?

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Cynthia Tait's comment, May 18, 2013 1:28 AM
so you are suggesting it is related to conservatism or that perhaps the person who curated these pics, well these are the ones they picked. Interested as I have just come out of CCU after having an ablation for a congenital 'electrical' problem.
Steve S Ryan, PhD's comment, October 6, 2013 9:33 PM
Is this collage on the internet? We have a complete Pinterest board dedicated to Celebs with A-Fib. Go to http://www.pinterest.com/ssryan90265/celebrities-with-a-fib/
Steve S Ryan, PhD's curator insight, October 6, 2013 10:34 PM

See our A-Fib, Inc. Pinterest board for "Celebs with A-Fib". go to: http://www.pinterest.com/pattijryan/celebs-with-a-fib/

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Eliquis: New Medication for Atrial Fibrillation

An in-depth conversation between Pentucket Medical cardiologists Seth Bilazarian and Sunny Srivastava, focusing on a newly released medicine to reduce the risks of atrial fibrillation. The latest among recently approved blood thinners, Eliquis joins Pradaxa and Xarelto as an alternative to Coumadin, a drug that has been in use since the 1950s. Like Pradaxa and Xarelto, Eliquis has been shown to reduce risk of stroke and bleeding, as well as mortality. All the new drugs eliminate the need for regular blood testing that Coumadin necessitates.

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Warfarin in the Prevention of Stroke Associated with Nonrheumatic Atrial Fibrillation — NEJM

Warfarin in the Prevention of Stroke Associated with Nonrheumatic Atrial Fibrillation — NEJM | Heart and Vascular Health | Scoop.it

20 years ago today the SPINAF trial was published.  This was one of the last studies to compare warfarin to placebo in atrial fibrillation (Afib)  for the prevention of stroke.  For the lsat 20 years warfarin has been the standard of care.  Anticoagulants (blood thinners) prevent stroke in Afib.  After this there were only a few more studues that were done comparing warfarin to placebo or aspirin (SPAF-II in 1994)  because it was felt to not be ethical since the benefits of warfarin are so clear for stroke prevnetion.  

AIn teh US, we've had only warfarin (coumadin) until 2 years ago (10/2010) when the first of the novel oral anticoagulants (NOACs) were introduced.  Pradaxa (dabigatran) and Xarelto (rivaroxaban) are now available in the US.  We expext Eliquis (apixiban) in 2013 with others to follow.

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Pradaxa turns 19 (in dog years)

Pradaxa turns 19 (in dog years) | Heart and Vascular Health | Scoop.it

As Pradaxa (dabigatran) celebrates its second anniversary since FDA approval, the clock is ticking to 2018, when its first patent is set to expire.  What are the impediments to new blood thinners despite a strong set of data from the development of this first in class new blood thinner. My thoughts in theheart.org Vlog.

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It's official: New Oral Antithrombotic Agents in Nonvalvular AF now in guidelines

It's official: New Oral Antithrombotic Agents in Nonvalvular AF now in guidelines | Heart and Vascular Health | Scoop.it

The new oral anticoagulants (NOAC): dabigatran (Pradaxa) and rivaroxaban (Xarelto), both FDA approved, and apixaban (Eliquis), which has not been approved, can all be considered for stroke prevention in nonvalvular atrial fibrillation, a science advisory from AHA/ ASA stated.

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New iPhone app can detect atrial fibrillation

New iPhone app can detect atrial fibrillation | Heart and Vascular Health | Scoop.it

Take Home: UMass Medical School and WPI have developed an app that can detect atrial fibrillation.  This moves connected and mobile health closer to reality.  The really important development with this approach might allow us to treat patients who have AF intermittently (paroxysmal) differently than we currently do.  Because we are worried about stroke, patients now get blood thinners all the time because we are concerned that they will have recurrences without knowing about it.  With this technology, in the future, we might see validation of a strategy that allows use of blood thinners when patients are in AF only, sometimes called a pill in the pocket.

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Bridging Anticoagulation

Bridging Anticoagulation | Heart and Vascular Health | Scoop.it

Cardiology Patient Page
Bridging Anticoagulation
Is it Needed When Warfarin Is Interrupted Around the Time of a Surgery or Procedure?

from the  The BRIDGE Study Investigators

 

There are many patients who are receiving long-term treatment with the blood thinner warfarin, whether because of atrial fibrillation (the commonest reason for taking warfarin) or a mechanical heart valve. Such patients frequently require warfarin to be stopped because of an upcoming surgery/procedure. There is uncertainty whether such patients should receive bridging anticoagulation before and after the surgery/ procedure.

 

For patients interested in learning more about this trial happening in Haverhill at PMA see...

 

http://www.pmaonline.com/clinical-trials.htm

 

 

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Facts About AFib & The Risk Of Stroke

Facts About AFib & The Risk Of Stroke | Heart and Vascular Health | Scoop.it

Atrial fibrillation (AFib), a type of irregular heartbeat, not caused by a heart valve problem affects approximately 5.8 million people in the U.S. – including me. AFib not caused by a heart valve problem puts people at a 5 times greater risk for stroke. It's why I'm challenging you now to learn the fibs and the facts about AFib-related stroke risk, and share them with everyone you care about.

Seth Bilazarian, MD's insight:

Good basic quiz providing info about  atrial fibrillation.  Fibs or Facts is an educational campaign from Bristol-Myers Squibb and Pfizer to help people learn the fibs and facts about AFib not caused by a heart valve problem and its associated increased risk of stroke.

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Donovan Baldwin's curator insight, December 4, 2013 9:19 AM

Having had my own AFib event, I found this interesting and informative.

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Novel Oral Anticoagulant transitions

Novel Oral Anticoagulant transitions | Heart and Vascular Health | Scoop.it

In my clinical practice, this is one of the most frequent things that I am asked to address -- whether it is dual antiplatelet therapy, stopping antiplatelet therapy in general, or stopping anticoagulants and adopting NOACs. It has been a challenge, but we have pretty good data to help guide decisions about NOACs, and this has been extensively covered.

But the issue about NOAC transitions is that we don't have a lot of data. It is uncharted territory. Making sense of NOAC transitions is something that I am trying to address for myself and sharing here in this blog to you as the "co-pupil" or "co-traveler" in this difficult area.

Seth Bilazarian, MD's insight:

My attempt to manage the topic of transitions with novel oral anti-coagulants (Pradaxa, Xarelto, Eliquis) - stiopping, starting, holding these agents for procedures. Interested in other physicians insights on this topic.

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What to do about bridging with novel oral anticoagulants

What to do about bridging with novel oral anticoagulants | Heart and Vascular Health | Scoop.it
Sharing a rare moment of person-to-person time during the scientific sessions in San Francisco, Dr Seth Bilazarian asks Drs Samuel Goldhaber how he goes about bridging with dabigatran, rivaroxaban, and apixaban.
Seth Bilazarian, MD's insight:

All of the new blood thinners or novel oral anticoagulants (NOAC)  have a warning in their label about the hazard of stopping them. These agents have a short half life so within 1 - 2 days they are out of the system and there is no blood thinner protection from the hazard of atrial fibrillation (AF).  Should patients going for procedures receive "bridging" with intravenous (IV) blood thinners to protect them during the interval off these new agents.  Perspective from Sam Goldhaber of the Clot Blog on theheart.org.

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Risk Factors for Bradycardia Requiring Pacemaker in AFib

Risk Factors for Bradycardia Requiring Pacemaker in  AFib | Heart and Vascular Health | Scoop.it

My comment:  patients with A fib sometimes need a pacemaker because their herat rate slows down to much.  THis study helps identify patient groups that are a thigher risk for needing a pacemeker. heart failure was the most important risk factor for needing a pcaemaker.

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Symptomatic bradycardia may complicate atrial fibrillation (AF) and necessitate a permanent pacemaker. Study Of the 362 patients, 119 cases had permanent pacemakers implanted for bradycardia after AF diagnosis, and 243 controls were alive without pacemakers.

The follow-up was 4.5 years.

Odds ratios were determined

- age at the time of AF diagnosis (1.02, [CI] 1 to 1.04)

- female gender (1.58, CI 0.95 to 2.63)

- previous heart failure (2.72, 95% CI 1.47 to 5.01)

- African American race (0.33, 95% CI 0.12 to 0.94)

The post hoc model identified permanent AF (odds ratio 2.99, 95% CI 1.61 to 5.57) and atrioventricular nodal blocker use (odds ratio 1.43, 95% CI 0.85 to 2.4).

Conclusion, in patients with AF, heart failure and permanent AF each nearly triple the odds of developing bradycardia requiring a permanent pacemaker; although not statistically significant, our results suggest that women are more likely and African Americans less likely to develop bradycardia requiring pacemaker implantation.

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Pradaxa (dabigatran) Safety Review of Serious Bleeding Events by FDA

UPDATED 11/02/2012. Results of FDAs Mini-Sentinel assessment indicate that bleeding rates associated with new use of Pradaxa do not appear to be higher than bleeding rates associated with new use of warfarin.
My comment -= I hope this review by the FDA reassures patients that the use of Pradaxa is safe as an alternative to warfarin,. This adds to the randomized trial RE-L. Patients are being unnecessarily frightened by TV ads by malpractice attorneys and decisions about options fro treatment are being complicated without reason.,
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Atrial Fibrillation Toolkit

Atrial Fibrillation Toolkit | Heart and Vascular Health | Scoop.it

ACC has pulled together a toolkit to help treat patients with atrial fibrillation (AFib) based on the most recent evidence and best practices. Developed by experts and field-tested, the AFib Toolkit is a valuable and free reference or point-of-care resource you can use on your own time.

There is a very useful patient education section at the bottom which paitents will find valuable

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HAS-BLED Bleeding Risk Score in Atrial Fibrillation treated with Warfarin

HAS-BLED Bleeding Risk Score in Atrial Fibrillation treated with Warfarin | Heart and Vascular Health | Scoop.it

Take Home Message:  In cardiovascular medicine there are several circumstances when it is valuable to give anticoagulant medications (blood thinners). These medicines reduce the chance of clot formation and lower the risk of strokes and heart attacks.  Because it is harder to form clots patient will have a higher risk of bleeding.  In atrial fibrillation, we have good criteria for evaluating the risk of clotting and stroke (CHADS2 and CHADS-VASC) but are in search of a good score to help doctors and patients predict bleeding risk when on the blood thinner coumadin  (warfarin).  The HAS-BLED score http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk/ ;  performed best, but not very well in this analysis except for its ability to predict the most serious type of bleeding called intracranial hemmorhage.

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Anticoagulation in AF: Fork in the road or four-way-stop?

Anticoagulation in AF: Fork in the road or four-way-stop? | Heart and Vascular Health | Scoop.it

The FDA's recent decisions on novel anticoagulants in atrial fibrillation have stirred debate and generated some consternation. For the clinical practitioner, how can we efficiently and effectively communicate the issues related to anticoagulation choice to the patient?  Dr Bilazarian proposes -CRABI:

C - Prescription coverage?
R - Normal renal function?
A - Early adopter?
B - GI bleeding?
I - Instability on warfarin?

Download the powerpoint presentation and the comparative Excel sheet.

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