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Prevencion de complicaciones en fibrilacion atrial

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Complicaciones comunes de la fibrilacion atrial y su prevencion
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PREVENCION DE COMPLICACIONES EN FIBRILACION ATRIAL NO VALVULAR Dr. Daniel Meneses Cardiólogo Intervencionista © Daniel Meneses, 2014
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  • 1. PREVENCION DE COMPLICACIONESEN FIBRILACION ATRIAL NOVALVULARDr. Daniel MenesesCardilogo Intervencionista Daniel Meneses, 2014

2. http://www.pinterest.com/ 3. 5 millones de pacientes actualmentePara el 2050 sern 12-16 millonesFA es la arritmia mas comn.En el 2010 se diagnosticaron 1.2 millones de casosFA contribuye a mas de 80 000 muertes anualesEl riesgo de por vida de desarrollarla en mayores de 40aos es de 1:4En el mundo hay 600 millones de casos26 Billones de dlares anuales son sus costosSe ha caracterizado como una nueva epidemiaGonzalez, A. (July 07, 2011). Atrial fibrillation is emerging as the new epidemic.Cardiac Rhythm News. Retrieved August 23, 2011, 4. Dynamic interactions between atrial and ventricular function during atrial fibrillation (AF).Iwasaki Y et al. Circulation. 2011;124:2264-2274Copyright American Heart Association, Inc. All rights reserved. 5. 1. RESERVORIO DE PRESION PARA MANTENER LA PRESION DEL ATRIO IZQUIERDO2. ORGANO SENSOR DE PRESION. 30% DE LA PRODUCCION DE PEPTIDO ATRIAL NATRIURETICO3. RESERVORIO DINAMICO DE SANGRE EN EL CICLO ATRIAL4. CONTRACCION ACTIVA MEJORA EL LLENADO ATRIAL Y LA SISTOLE VENTRICULAR 6. MECANISMOS DE LA FIBRILACION ATRIALIwasaki Y et al. Circulation. 2011;124:2264-2274Copyright American Heart Association, Inc. All rights reserved. 7. Abnormalities of refractoriness (A) and conduction velocity (B) are the major determinants ofatrial fibrillation (AF) reentry substrates.Iwasaki Y et al. Circulation. 2011;124:2264-2274Copyright American Heart Association, Inc. All rights reserved. 8. Conceptual models of reentry and implications for atrial fibrillation (AF).Iwasaki Y et al. Circulation. 2011;124:2264-2274Copyright American Heart Association, Inc. All rights reserved. 9. Types of atrial fibrillation (AF)promoting remodeling.Iwasaki Y et al. Circulation. 2011;124:2264-2274Copyright American Heart Association, Inc. All rights reserved. 10. 1. RECURRENCIA PRECOZ DESPUES DE LA CARDIOVERSION2. RESISTENCIA PROGRESIVA A LOS MEDICAMENTOS3. PROGRESION DE FIBRILACION ATRIAL PAROXISTICA A FORMAS PERSISTENTES1. FIBROSIS LLEVA A RIGIDEZ ATRIAL Y A PERPETUACION DE LA FIBRILACION ATRIAL2. DILATACION ATRIAL3. REDUCCION DE LA FUNCION SISTOLICA DEL VENTRICULO IZQUIERDO 11. Mechanisms underlying atrial fibrillation (AF)related thromboembolism. vWF indicates vonWillebrand factor; NOS, nitric oxide synthase; TF, tissue factor; TFPI, tissue factor pathwayinhibitor; TM, thrombomodulin; TNF, tumor necrosis factor-; VEGF, vascular endothelialgrowth factor; TGF-1, transforming growth factor-1; F1+2, prothrombin fragment 1+2; TAT,thrombin/antithrombin complex; tPA-Ag, tissue-type plasminogen activatorantigen; tPA-PAI,tissue-type plasminogen activator/plasminogen activator inhibitor; and -TG, -thromboglobulin.Iwasaki Y et al. Circulation. 2011;124:2264-2274Copyright American Heart Association, Inc. All rights reserved. 12. January, CT et al.2014 AHA/ACC/HRS Atrial Fibrillation Guideline 13. ANTICUAGULANTES ORALES Inhibidores directos de Trombina: Ximelagatran (retirado: SPORTIF III + V Dabigatran: RE-LY Inhibidores directos del factor Xa Apixaban: AVERROES y ARISTOTLE Edoxaban: ENGAGE AF-TIMI 48 (en curso) Rivaroxaban: ROCKET AF 14. RE-LYDabigatran vs warfarina Evaluar la seguridad y eficacia de Dabigatrancomparado con Warfarina en pacientes confibrilacion atrial no valvula para prevencion deictus o embolismo sistemico 15. RE-LYDabigatran vs warfarin Study designRandomized, phase III, open label, non-inferiority studyNon-valvularAF plusat least 1additionalrisk factor*N=18,113 Primary efficacy: composite of all-cause stroke orsystemic embolism Major safety: major bleeding Excludes: patients with severe renal impairment(CrCl 30 ml/min)Connolly SJ et al. N Engl J Med 2009;361:11391151Dabigatran 110 mg bidDabigatran 150 mg bidOpen-label warfarin(target INR range 23)RFollow-upEnd oftreatment*Previous stroke or TIA , NYHA Class II HF, LVEF 85 countries8,101 patients vs.standard therapy(enoxaparin)CompletedChronicIndications4,832 patients vs.standard therapy(enoxaparin &warfarin)Completed14,264 patients vs.standard therapy(warfarin)Completed15,526 patients inaddition tostandard therapyVTE prevention after orthopedic surgeryVTE prevention in medically ill patientsVTE treatment and secondary preventionStroke prevention in atrial fibrillationSecondary prevention ACS Completed 19. ROCKET AFRivaroxaban vs warfarin Conclusiones Based on the prespecified primary efficacy outcome: A once-daily fixed-dose regimen of rivaroxaban was non-inferior to warfarin forprevention of stroke or non-CNS systemic embolism Rivaroxaban was superior to warfarin while patients were taking study drug A sensitivity analysis in the ITT population that followed all patients in the trial untilcompletion showed a benefit for rivaroxaban, but did not reach superiority Safety: Similar overall incidence of bleeding and adverse events Increase in gastrointestinal bleeds but fewer intracranial haemorrhages and less fatalbleeding with rivaroxaban Implication: Rivaroxaban, administered once daily, has demonstrated non-inferiority to warfarin inthe prevention of stroke or systemic embolism, with similar overall bleeding and fewerintracranial haemorrhages and fatal bleedsPatel MR et al. N Engl J Med 2011;365:883891


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