STRATIFICAZIONE DEL RISCHIO TROMBOEMBOLICO INDIVIDUALE 2013/dati/bocconcelli.pdf · un’embolia...

STRATIFICAZIONE DEL RISCHIO TROMBOEMBOLICO INDIVIDUALE

Paolo Bocconcelli

Azienda Ospedali Riuniti Marche Nord

Unitagrave Operativa di Cardiologia

bullLa fibrillazione atriale associata a valvulopatia

mitralica comporta un rischio embolico molto

elevato (incidenza di stroke 17 volte piugrave

frequente rispetto ai controlli (Framingham)

bullLa fibrillazione atriale non valvolare egraversquo

associata a rischio embolico sistemico eo

cerebrale del 45 per anno che sale a circa

lrsquo8 per anno nei pazienti di etagrave gt di 75 anni

FIBRILLAZIONE ATRIALE VALVOLARE E NON VALVOLARE

ldquoIt is conventional to divide AF into cases which

are described as ldquovalvularrdquo or ldquonon-valvularrdquo

No satisfactory or uniform definition of these

terms exists

In this guideline the term valvular AF is used to

imply that AF is related to rheumatic valvular

disease (predominantly mitral stenosis) or

prosthetic heart valves

European Heart Journal (2012)

Validation of risk stratification schemes for predicting

stroke and thromboembolism in patients with atrial

fibrillation nationwide cohort study

Schemes for stratifying the risk of stroke have been largely derived from non-anticoagulated arms of clinical trial cohorts in which many potential thromboembolic risk factors were not recorded In these historical trials less than 10 of patients screened were randomised and over the past 15-20 years the evolution of risk schemes has not improved their predictive value for patients at high risk

An ideal validation cohort for a thromboembolic risk scheme would be a large real world cohort of patients with atrial fibrillation without any use of anticoagulation treatment

Jonas Bjerring Olesen et al BMJ 2011342d124

Clin Cardiol 2012 Jan35 Suppl 121-7 doi 101002clc20969

Can we predict stroke in atrial fibrillation Lip GY

Centre for Cardiovascular Sciences University of Birmingham City Hospital BirminghamUnited Kingdom

stroke risk in AF is not homogeneous but despite stroke risk in AF being a continuum prior stroke risk stratification schema have been used to artificially categorise patients into low moderate and high risk stroke strata so that the patients at highest risk can be identified for warfarin therapy

What Are the Risk Factors for Thromboembolism

Whereas it is recognized that AF increases the risk of

stroke and thromboembolism by 5-fold we do

increasingly appreciate that that this risk is not

homogeneous and is altered by the presence of

various stroke risk factors

Also the risk profile changes over time

However multivariate predictors of adverse outcomes

including thromboembolism were arrhythmia

progression (ie from paroxysmal to permanent AF)

development of cardiac diseases and older age (all P

lt005)

Potpara TS Stankovic GR Beleslin BD et al A 12-year followup

study of patients with newly-diagnosed lone atrial fibrillation

implications of arrhythmia progression on prognosis the Belgrade

Atrial Fibrillation Study Chest (in press)

Two comprehensive systematic reviews from the Stroke in

AF Working Group and the UK National Institute for Health

and Clinical Evidence (NICE) guidelines have summarized

the published evidence for various risk factors on stroke

largely based on nonwarfarin arms of clinical trials and a

few epidemiological cohorts

These risk factors have been used to formulate stroke risk

stratification schemes such as the CHADS2 (Congestive

heart failure Hypertension Age ge75 Diabetes mellitus

and prior Stroke or transient ischemic attack [doubled])

Stroke Risk in Atrial Fibrillation Working Group Independent predictors of stroke in

patients with atrial fibrillation a systematic review Neurology 200769546ndash554

Hughes M Lip GY Stroke and thromboembolism in atrial fibrillation a systematic

review of stroke risk factors risk stratification schema and cost effectiveness data

Thromb Haemost 200899295ndash304

In the Loire Valley AF Project among nonanticoagulated

AF patients with no CHADS2 risk factors (N = 1035) the

impact of age was clearly seen because the

strokethromboembolic event rate per 100 person-

years was 023 (95 CI 008ndash072) 205 (107ndash393)

and 399 (263ndash606) in those aged lt65 65 to 74 and

ge75 years respectively

Olesen JB Fauchier L Lane DA et al Risk factors for stroke and

thromboembolism in relation to age amongst patients with atrial

fibrillation the Loire Valley Atrial Fibrillation Project Chest (in

press)

Female gender has also been associated with a higher risk

of stroke in some studies but many of these studies have

included much older female subjects and clearly

young female subjects (eg agelt65 years) with

lone AF would be considered at low risk

Lane DA Lip GY atrial fibrillation patients Thromb Haemost

2010104653] Female gender is a risk factor for stroke and

thromboembolism in

To complement the CHADS2 score the new European Society of

Cardiology guidelines have deemphasized the low moderate and high

risk stratification given the poor predictive value of such artificial strata

and more emphasis was put on a risk factorndashbased

approach

The first derivation and validation of the CHA2DS2-VASc score was

performed in an European cohort from the EuroHeart survey on AF to provide

European data for the European guideline

In a nationwide Danish cohort study of 73538 hospitalized on anticoagulated

patients with AF in Denmark reported that in low risklsquolsquo subjects

(CHA2DS2-VASc score = 0) the 1-year rate of thromboembolism per 100

person-years was 078 (058ndash104) in contrast to an event rate with the

CHADS2 score of 167 (95 CI 147ndash189) The c-statistics (a statistical

measure of the predictive value of a risk score) with the CHA2DS2-VASc

score clearly outperform the CHADS2 at 1 5 and 10 years of follow-up

Boriani G Botto G Padeletti L et al Improving stroke risk stratification using the CHADS2 and

CHA2DS2-VASc risk scores in paroxysmal atrial fibrillation patients by continuous arrhythmia

burden monitoring Stroke 2011421768ndash1770

CHADS 0

CHADS Vasc 0

CHADS Vasc 1

CHADS Vasc 2

CHADS Vasc 3

La valutazione del rischio cardioembolico durata della FA e fattori di

rischio embolico

Per quanto riguarda la durata della FA da studi che utilizzano la registrazione a lungo termine

fornita dai PM impiantati sappiamo che pazienti con periodi di FA superiori alle 24 ore

hanno un rischio embolico triplicato rispetto a pazienti senza FA o con

periodi piugrave brevi e che periodi di FA superiori a 5 minuti raddoppiano il

rischio di morte o ictus in pazienti con malattia del nodo del seno Cappucci ha

studiato 725 pazienti impiantati con PM-DDDR con un follow up di 22 mesi il 2 di questi ha avuto

unrsquoembolia arteriosa Associazioni indipendenti di rischio per lrsquoembolia sono state la cardiopatia ischemica

embolie pregresse diabete ipertensione il rischio di FA egrave di 31 volte se lrsquoaritmia dura piugrave di 24 ore

Un recente studio di Botto utilizzante come metodo di registrazione la memoria del PM (568 pazienti con

malattia del nodo del seno impiantati con un PM-DDDR 25 di eventi tromboembolici a un follow up di

anno) combina la durata degli episodi (sintomatici o asintomatici) di FA con il punteggio di rischio CHADS2

questo studio ha identificato una popolazione a basso rischio tromboembolico (pazienti senza FA e con

punteggio CHADS2 fino a 2 con FA di durata da 5 minuti a 24 ore e CHADS2 0 o 1 o pazienti con FA della

durata di oltre 24 ore e con CHADS 0 rischio embolico 08 annuo) contrapposta a una popolazione ad

alto rischio embolico (pazienti senza FA e con punteggio CHADS2 da 3 in su con FA di durata da 5 minuti a

24 ore e con CHADS2 da 2 in su con FA della durata di oltre 24 ore e con CHADS2 da 1 in su rischio

embolico 5 annuo)

Gli studi mostrano come il rischio cardioembolico sia direttamente correlato

sia alla durata degli episodi aritmici sia alle patologie concomitanti

Capucci A Santini M Padeletti L et al Monitored atrial fibrillation

duration predicts arterial embolic events in patients suffering

from bradycardia and atrial fibrillation implanted with antitachycardia

pacemakers J Am Coll Cardiol 2005 461913-20

Botto GL Padeletti L Santini M et al Presence and Duration of

Atrial Fibrillation Detected by Continuous Monitoring Crucial

Implications for the Risk of Thromboembolic Events J Cardio -

vasc Electrophysiol 2009 20(3) 241-248

ICTUS CRIPTOGENETICO E FIBRILLAZIONE ATRIALE

CORRELAZIONE EVENTO EMBOLICO ndash BURDEN DI FA

Implications of the CHA2DS2-

VASc and HAS-BLED Scores for

Thromboprophylaxis in Atrial

Fibrillation Gregory Y H Lip MD

The American Journal of Medicine (2010)

xx xxx

DA UNA CLASSIFICAZIONE DEL RISCHIO PER

GRUPPI (DISOMOGENEI)

AD UNA CLASSIFICAZIONE DEL RISCHIO PER

IL SINGOLO INDIVIDUO

Controversies in cardiovascular medicine

Stroke and bleeding risk assessment in atrial

fibrillation when how and why Gregory YH Lip

European Heart Journal (2013) 34 1041ndash1049

Can stroke risk assessment be further refined

1 Assessment of AF burden

2 Echocardiography - transoesphageal echocardiography

3 Blood biomarkers

4 Renal (dys)function

5 Detailed cerebral imaging

However this would be at the cost of reduced simplicity and

practicality limiting its (immediate) quicklsquo use in everyday

clinical practice

A further large validation study was performed in a United Kingdom cohort

of 79884 AF patients aged ge18 years in the UK General Practice

Research Database who were followed for an average of 4 years

Again low-risk subjects (CHA2DS2-VASc score = 0) were truly low risk

(with annual stroke events lt05) with the CHA2DS2-VASc score

In an analysis of the Stroke Prevention Using Oral Thrombin Inhibitor in

Atrial Fibrillation (SPORTIF) trial population an anticoagulated AF

cohort (N = 7329 subjects) the CHA2DS2-VASc scheme correctly

identified the greatest proportion of AF patients at high risk and the

negative predictive value (ie the percent categorized as not high

risklsquolsquo actually being free from thromboembolism) for CHA2DS2-VASc

was 995

Notwithstanding the above comments all the published stroke risk

scores (including CHADS2 and CHA2DS2-VASc) are not very useful

in the elderly with only limited ability to predict the risk of stroke

Conclusions

All the schemes studied had a similar limited ability to predict the risk of

stroke With the exception of the original CHADS2 their performance is

better than chance though further development is required to improve

the accuracy of the tools in older people and it might be better to

pragmatically recommend that clinicians classify all

patients over 75 as high risk and offer oral anticoagulation

for these patients until better tools are available

Performance of stroke risk scores in older people with

atrial fibrillation not taking warfarin comparative cohort

study from BAFTA (Birmingham Atrial Fibrillation in the Aged) trial F D R Hobbs professor and head of department 1 A K Roalfe senior lecturer in medical statistics 2 G Y H Lip

consultant cardiologist3 K Fletcher research fellow2 D A Fitzmaurice professor of primary care 2 J Mant

professor of cardiovascular research 4

BMJ 2011342d3653 doi 101136bmjd3653

In sintesi il CHA2DS2-VASc score egrave chiaramente

superiore al CHADS2 nelllsquoidentificare il soggetto

fibrillante con vero basso rischiolsquolsquo embolico

ed egrave almeno altrettanto valido ndash probabilmente

superiore ndash rispetto al CHADS2 score nel definire

il soggetto ad alto rischiolsquolsquo

Do We Need to Take the Risk of Bleeding into

Account and How Is This Quantified

Risk factors for bleeding on OAC have been identified from

general anticoagulated cohorts but few bleeding risk

assessment tools have been derived and validated in AF

populations

Many risk factors for anticoagulation-related bleeding are

also risk factors for stroke in AF patients

Older bleeding risk tools were also complicated and difficult to

use in everyday clinical practice

Thus many prior guidelines have avoided formal

recommendation of bleeding risk assessment using a specific

bleeding risk score in AF patients

Conclusions

In patients with AF receiving

anticoagulant therapy the HAS-

BLED score shows significantly

better prediction ability than the

weighted (and slightly more

complex) ATRIA score Our findings

reinforce the incremental usefulness

of the HAS-BLED score over other

bleeding risk scores in patients with

AF

In the nationwide Danish cohort the c-statistics for the

HAS-BLED and HEMORR2HAGES (Hepatic or renal failure

Ethanol abuse Malignancy Older [age gt75 years] Reduced

platelet count or function 2 points for Rebleeding risk

Hypertension [uncontrolled] Anemia Genetic factors

Excessive fall risk [including neurodegenerative and

psychiatric disorders] and history of Stroke) schemes were

0795 (0759ndash0829) and 0771 (0733ndash0806) respectively

with comparable results found in AF patients not

receiving OAC

the HAS-BLED score performed similar to

HEMORR2HAGES in predicting bleeding risk

but the HAS-BLED score is much simpler and

easier to use in everyday clinical practice

Performance of the HEMORR2HAGES ATRIA and HAS-

BLED Bleeding RiskndashPrediction Scores in Patients With

Atrial Fibrillation Undergoing Anticoagulation The AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With

Atrial Fibrillation) Study Stavros Apostolakis MD PHD Deirdre A Lane PHD Yutao Guo MD Harry Buller MD PHDdagger Gregory Y H Lip MD

Birmingham United Kingdom and Amsterdam the Netherlands

(J Am Coll Cardiol 201260861ndash7)

Conclusions

All 3 tested bleeding riskndashprediction scores demonstrated only modest

performance in predicting any clinically relevant bleeding although the

HAS-BLED score performed better than the

HEMORR2HAGES and ATRIA scores as reflected by ROC

analysis reclassification analysis and decision-curve analysis Only

HAS-BLED demonstrated a significant predictive performance for

intracranial hemorrhage Given its simplicity the HAS-BLED score

may be an attractive method for the estimation of oral

anticoagulantndashrelated bleeding risk for use in clinical practice

supporting recommendations in international guidelines

CHA2DS2-VASc criteria Score

Congestive heart failure left ventricular dysfunction

1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1

Stroketransient ischaemic attackTE 2

Vascular disease (prior myocardial infarction peripheral artery disease or aortic plaque)

1

Age 65ndash74 yrs 1

Sex category (ie female gender) 1

HAS-BLED risk criteria Score

Hypertension 1

Abnormal renal or liver function (1 point each)

1 or 2

Stroke 1

Bleeding 1

Labile INRs 1

Elderly (eg age gt65 yrs)

1

Drugs or alcohol (1 point each)

1 or 2

Imprevedibilitagrave a priori della rispostabeneficio clinico netto dato che alcuni fattori di rischio per trombo embolismo ed emorragia

sono gli stessi

How should we use this bleeding risk

score

In the ESC guidelines a HAS-BLED score of ge3 represents a

sufficiently high risk such that caution andor regular

review of a patient is needed

It also makes the clinician think of correctable common

bleeding risk factors eg improving blood pressure control and

labile INRs would reduce points on the HAS-BLED score

The availability of such a score allows informed decisions

when deciding whether to use a low-dose or high-dose

regime of new OACs such as dabigatran

In the net clinical benefit analysismdashbalancing ischaemic

stroke against intracranial bleedingmdashby Olesen et al

those patients with a high HAS-BLED score had an even

greater net clinical benefit with warfarin given that the

higher-risk individuals would have a much greater

absolute reduction in stroke risk with warfarin which

would outweigh the small absolute increase in major

bleeding events

Similar observations were reported in a much larger dataset

by Friberg et al where the adjusted net clinical benefit

favoured anticoagulation for almost all AF patients with

the exception of patients at very low risk of ischaemic

stroke with a CHA2DS2-VASc score of 0 and moderatendash

high bleeding risk Olesen JB Lip GY Lindhardsen J Lane DA Ahlehoff O Hansen ML

Raunsoslash J Tolstrup JS Hansen PR Gislason GH Torp-Pedersen C

Risks of thromboembolism and bleeding with thromboprophylaxis in

patients with atrial fibrillation a net clinical benefit analysis using a lsquoreal

worldrsquo nationwide cohort study Thromb Haemost 2011106739ndash749

Friberg L Rosenqvist M Lip G Net clinical benefit of

warfarin in patients with atrial fibrillation A report from the

Swedish Atrial Fibrillation cohort study Circulation

20121252298ndash2307

Risk of Falls and Major Bleeds in Patients on Oral

Anticoagulation Therapy

Jacques Donzeacute MD MSca Carole Clair MSc MDb Balthasar Hug MD MBA MPHc Nicolas Rodondi

MD MASd Geacuterard Waeber MDe Jacques Cornuz MD MPHb Drahomir Aujesky MD MScd

A high falls risk is

not statistically

significantly

associated with a

risk of major bleeds

(hazard ratio 109

95 confidence

interval 054-221)

suggesting

that being at risk of

falls is not a valid

reason to avoid oral

anticoagulants in

medical patients

The American Journal of Medicine (2012) 125 773-778

RISCHIO ANNUALE DI ICTUS O EMBOLISMO SISTEMICO IN BASE AL PUNTEGGIO RAGGIUNTO CON LO SCORE CHA2DS2VASC

00

50

100

150

200

Rischio embolico percentuale per anno in base allo score CHA2DS2Vasc

Score 0 1 2 3 4 5 6 7 8 9

Renal Dysfunction as a Predictor of Stroke and Systemic Embolism in Patients With Nonvalvular Atrial Fibrillation Validation of the R2CHADS2 Index in the ROCKET AF (Rivaroxaban Once-daily oral direct factor Xa inhibition Compared with vitamin K

antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation) and ATRIA (AnTicoagulation and Risk factors In Atrial fibrillation) Study Cohorts Piccini JP Stevens SR Chang Y Singer DE Lokhnygina Y Go AS Patel MR Mahaffey KW Halperin JL Breithardt G Hankey GJ Hacke W Becker RC Nessel CC Fox KA Califf RM ROCKET AF Steering Committee and Investigators

CONCLUSIONS

In patients with nonvalvular AF at moderate to high risk of stroke impaired renal function is a potent predictor of stroke and systemic embolism Stroke risk stratification in patients with AF should include renal function

Circulation 2013 Jan 15127(2)224-32

CRUSADE Bleeding Score Nomogram

Note Heart rate is truncated lt70 bpm

CrCl Cockcroft-Gault is truncated gt90 mLmin Prior Vascular disease is defined as prior PAD or stroke

Predictor Range Score

Baseline Hematocrit () lt 31 31-339 34-369 37-399

ge 40

9 7 3 2 0

Creatinine Clearance (mLmin) le 15 gt15-30 gt30-60 gt60-90 gt90-120

gt120

39 35 28 17 7 0

Heart rate (bpm) le 70 71-80 81-90

91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8

Signs of CHF at presentation No Yes

0 7

Prior Vascular Disease No Yes

0 6

Diabetes Mellitus No Yes

0 6

Systolic blood pressure (mm Hg) le 90 91-100 101-120 121-180 181-200

ge 201

10 8 5 1 3 5

Lancet 2012 379 648ndash61

The CHADS(2) and CHA (2)DS (2)-VASc scores predict

new occurrence of atrial fibrillation and ischemic stroke Ming-Liang Zuo Shasha Liu Koon-Ho Chan Kui-Kai Lau Boon-Hor Chong Kwok-Fai Lam Yap-Hang Chan Yuk-Fai

Lau Gregory Y H Lip Chu-Pak Lau Hung-Fat Tse Chung-Wah Siu

J Interv Card Electrophysiol (2013) PMID 23389054

CONCLUSION The CHADS(2) and CHA(2)DS(2)-VASc scores can be used in

patients who presented with arrhythmic symptoms to identify those who are at

risk with developing new-onset clinical AF and ischemic stroke for close

clinical surveillance and early intervention

CHADS2 CHA2DS2-VASc and long-term stroke

outcome in patients without atrial fibrillation George Ntaios Gregory Y H Lip Konstantinos Makaritsis Vasileios Papavasileiou Anastasia Vemmou Eleni

Koroboki Paraskevi Savvari Efstathios Manios Haralampos MilionisKonstantinos Vemmos

Neurology (2013) PMID 23408865

CONCLUSIONS Prestroke CHADS(2) and CHA(2)DS(2)-VASc scores predict

long-term stroke outcomes in non-AF patients with acute ischemic stroke These

scores may provide a simple way of stroke prognostic risk stratification

among non-AF stroke patients

CHADS(2) and CHA(2)DS(2)-VASc Scores for Prediction

of Immediate and Late Stroke after Coronary Artery

Bypass Graft Surgery Fausto Biancari Muhammad Ali Asim Mahar and Olli-Pekka Kangasniemi

J Stroke Cerebrovasc Dis (2012) PMID 23253529

CONCLUSIONS A significant number of patients may suffer stroke late after

CABG and patients with a high risk of stroke can be identified by

CHADS(2) and CHA(2)DS(2)-VASc scores independently from the presence

of pre- or postoperative atrial fibrillation

CHADS(2) Score Statin Therapy and Risks of Atrial

Fibrillation Chen-Ying Hung Ching-Heng Lin El-Wui Loh Chih-Tai Ting Tsu-Juey Wu

Am J Med 126(2)133-140e1 (2013) PMID 23331441

CONCLUSION Statin therapy in elderly patients with hypertension reduces

the risk of new-onset atrial fibrillation Statins are more beneficial in

patients with CHADS(2) score ge2 than in those with score of 1

Prognosis and Guideline-Adherent Antithrombotic Treatment in

Patients With Atrial Fibrillation and Atrial Flutter Implications of Undertreatment and Overtreatment in Real-life Clinical Practice

the Loire Valley Atrial Fibrillation Project

CHEST 2011 140(4)911ndash917

How should we approach stroke risk

assessment in AF

By being more inclusive rather than

exclusive of common stroke risk factors in AF we

can clearly do much better in reducing stroke and

mortality in AF which are the 2 main endpoints that

are significantly reduced by oral anticoagulation

compared to placebocontrol

TAKE HOME MESSAGEShellip

1 La stratificazione del rischio tromboembolico dei pazienti con

fibrillazione atriale non valvolare egrave essenziale per selezionare il

migliore trattamento antitrombotico

2 Lo schema di stratificzione del rischio piulsquo utilizzato egrave il

CHA2DS2-Vasc che egrave stato sviluppato dal precedente CHADS2

considerando altri elementi aggiuntivi in grado di modificare il

rischio

3 Il CHA2DS2-Vasc definisce con maggiore precisione il soggetto a

rischio veramente basso e a rischio intermedio e definisce

altrettanto bene il rischio elevato Il soggetto a punteggio ―0

non richiede alcun trattamento

4 Il sistema a punteggio consente di passare da categorie di

rischio stratificato in basso medio e alto alla individualizzazione

del rischio per singolo paziente con un equivalente di

probabilitagrave di eventi per anno

6 Llsquoaccuratezza nella definizione del rischio embolico nelllsquoanziano

non egrave tuttora adeguata (elevato in questa popolazione egrave anche il

rischio emorragico) tuttavia in genere la correzione del rischio

embolico appare vantaggiosa rispetto al rischio emorragico

indotto dalla terapia anticoagulante orale

7 ll sesso femminile rappresenta un fattore di rischio embolico

quando isolato solo al di sopra di 65 anni di etagrave

8 Un elevato rischio di cadute non egrave statisticamente associato

ad un rischio di sanguinamenti maggiori e non rappresenta

una valida ragione per evitare il trattamento anticoagulante

orale

9 Un fattore di rischio embolico aggiuntivo egrave rappresentato dalla

insufficienza renale che tuttavia egrave un elemento che incrementa

anche il rischio emorragico proporzionalmente al suo grado

(vedere come esempio il Crusade bleeding score risk)

―e piu interessante sapere quale tipo di paziente e colpito da una determinata

malattia che non quale malattia affligge il paziente

WILLIAM OSLER 1849-1919

Grazie per lrsquoattenzione

bullLa fibrillazione atriale associata a valvulopatia

mitralica comporta un rischio embolico molto

elevato (incidenza di stroke 17 volte piugrave

frequente rispetto ai controlli (Framingham)

bullLa fibrillazione atriale non valvolare egraversquo

associata a rischio embolico sistemico eo

cerebrale del 45 per anno che sale a circa

lrsquo8 per anno nei pazienti di etagrave gt di 75 anni





terms exists



























lt005)






























press)








thromboembolism in





approach














CHADS 0

CHADS Vasc 0

CHADS Vasc 1

CHADS Vasc 2

CHADS Vasc 3


rischio embolico

















embolico 5 annuo)


















xx xxx












3 Blood biomarkers





clinical practice












was 995




Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale













terms exists



























lt005)






























press)








thromboembolism in





approach














CHADS 0

CHADS Vasc 0

CHADS Vasc 1

CHADS Vasc 2

CHADS Vasc 3


rischio embolico

















embolico 5 annuo)


















xx xxx












3 Blood biomarkers





clinical practice












was 995




Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale






























lt005)






























press)








thromboembolism in





approach














CHADS 0

CHADS Vasc 0

CHADS Vasc 1

CHADS Vasc 2

CHADS Vasc 3


rischio embolico

















embolico 5 annuo)


















xx xxx












3 Blood biomarkers





clinical practice












was 995




Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale


































press)








thromboembolism in





approach














CHADS 0

CHADS Vasc 0

CHADS Vasc 1

CHADS Vasc 2

CHADS Vasc 3


rischio embolico

















embolico 5 annuo)


















xx xxx












3 Blood biomarkers





clinical practice












was 995




Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale













approach














CHADS 0

CHADS Vasc 0

CHADS Vasc 1

CHADS Vasc 2

CHADS Vasc 3


rischio embolico

















embolico 5 annuo)


















xx xxx












3 Blood biomarkers





clinical practice












was 995




Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale









CHADS 0

CHADS Vasc 0

CHADS Vasc 1

CHADS Vasc 2

CHADS Vasc 3


rischio embolico

















embolico 5 annuo)


















xx xxx












3 Blood biomarkers





clinical practice












was 995




Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale










rischio embolico

















embolico 5 annuo)


















xx xxx












3 Blood biomarkers





clinical practice












was 995




Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale
















xx xxx












3 Blood biomarkers





clinical practice












was 995




Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale




















3 Blood biomarkers





clinical practice












was 995




Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale




















was 995




Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale









Conclusions













BMJ 2011342d3653 doi 101136bmjd3653












populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale




















populations








Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale









Conclusions










AF










receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale


















receiving OAC











Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale















Conclusions













1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale











1

Hypertension 1

Age 75 yrs 2

Diabetes mellitus 1



1

Age 65ndash74 yrs 1



Hypertension 1


1 or 2

Stroke 1

Bleeding 1

Labile INRs 1


1


1 or 2


sono gli stessi


score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale










score

















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale
















bleeding events














20121252298ndash2307






not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale














not statistically

significantly

associated with a


(hazard ratio 109

95 confidence

interval 054-221)

suggesting




anticoagulants in

medical patients



00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale










00

50

100

150

200


Score 0 1 2 3 4 5 6 7 8 9



CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale











CONCLUSIONS








ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale














ge 40

9 7 3 2 0


gt120

39 35 28 17 7 0


91-100 101-110 111-120

ge 121

0 1 3 6 8

10 11

Sex Male Female

0 8


0 7


0 6


0 6


ge 201

10 8 5 1 3 5




























Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale




































Am J Med 126(2)133-140e1 (2013) PMID 23331441







CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale












CHEST 2011 140(4)911ndash917


assessment in AF














rischio



















orale










assessment in AF














rischio



















orale
















rischio



















orale



















orale









STRATIFICAZIONE DEL RISCHIO TROMBOEMBOLICO INDIVIDUALE 2013/dati/bocconcelli.pdf · un’embolia...

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Transcript of STRATIFICAZIONE DEL RISCHIO TROMBOEMBOLICO INDIVIDUALE 2013/dati/bocconcelli.pdf · un’embolia...