Đột quỵ do rung nhĩ - Góc nhìn từ bác sĩ thần kinh - Nguyễn Huy Thắ

Outline

Các trường hợp BN rung nhĩ của BS Thần

kinh.

Gánh nặng đột quỵ liên quan đến rung nhĩ.

Phòng ngừa đột quỵ thứ phát trên BN rung

nhĩ.

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5.6 
12.3 
16 
13..6 
16 
40.3 
22.5 
5.1 4.7 
22.8 
33.8 
0
5
10
15
20
25
30
35
40
45
Xuất viện 3 tháng
0 1 2 3 4 5 6
mRS 3-5: 43.2% 
Nguyễn Huy Thắng, Đỗ Thi Minh Chi– Abstract submit European Stroke Conference 2015 
Mar 2013 
Outline 
Các trường hợp BN rung nhĩ của BS Đột quỵ. 
Gánh nặng đột quỵ liên quan đến rung nhĩ. 
Phòng ngừa đột quỵ thứ phát trên BN 
rung nhĩ. 
Aspirin compared with placebo for stroke 
prevention in AF 
31 
Mar 2013 
*Aspirin compared with no treatment 
Hart RG et al. Ann Intern Med 2007;146:857–67 
Studies comparing Aspirin with placebo for 
stroke prevention in AF 
Study Year Secondary 
prevention (%) 
Patient no. 
(Aspirin/placebo) 
Aspirin 
dosage 
RRR for 
stroke (%) 
P value 
AFASAK 1989 6 336/336 75 mg/d 17 NS 
SPAF 1991 7 552/568 325 mg/d 44 <0.05 
UK-TIA 1991 
100 
100 
13/15 
21/15 
300 mg/d 
1200 mg/d 
17 
14 
NS 
NS 
EAFT 1993 100 404/378 300 mg/d 11 NS 
ESPS II 1996 100 104/107 50 mg/d 29 NS 
LASAF* 1999 
0 
0 
104/91 
90/91 
125 mg/d 
125 mg QOD 
–17 
67 
NS 
NS 
JAST* 2006 3 426/445 150 mg/d –10 NS 
All trials – 30 2050/2046 – 19 
95% CI: 
–1 to 35% 
Warfarin compared with placebo for 
stroke prevention in AF 
33 
Mar 2013 
Random effects model; Error bars = 95% CI; *P>0.2 for homogeneity; †RRR for all strokes (ischaemic and haemorrhagic) 
Hart RG et al. Ann Intern Med 2007;146:857–67 
Warfarin better Placebo better 
RRR (%)† 
100 –100 50 0 –50 
AFASAK 
SPAF 
BAATAF 
CAFA 
SPINAF 
EAFT 
All trials RRR 64%* 
(95% CI: 4974%) 
Warfarin reduces the risk of stroke 
in patients with AF 
Warfarin compared with Aspirin for the 
prevention of stroke in AF 
35 
Mar 2013 
RRR 38% 
(95% CI: 18–52%) 
RRR (%)* 
100 –100 50 0 –50 
AFASAK I 
AFASAK II 
EAFT 
PATAF 
Warfarin better Aspirin better 
Chinese ATAFS 
SPAF II 
Age 75 yrs 
Age >75 yrs 
All trials 
Random effects model; Error bars = 95% CI; *P>0.2 for homogeneity; †RRR for all strokes (ischaemic and haemorrhagic) 
Hart RG et al. Ann Intern Med 2007;146:857–67 
Warfarin compared with Aspirin 
for stroke prevention in AF 
36 
Mar 2013 
Major bleeds 
Warfarin Aspirin 
Intracranial bleeds 
Age 75 yrs Age >75 yrs 
AFASAK I 
A
n
n
u
a
l 
ra
te
 (
%
) 
5.0 
4.0 
3.0 
2.0 
1.0 
0.0 
AFASAK II PATAF SPAF II 
Major bleeds = transfusion or hospitalization required, or critical anatomic location (e.g. intracranial, perispinal); 
Within trial differences not statistically significant; *Data not available for intracranial bleeds for ESPS II 
Albers GW et al. Chest 2001;119:194S–206S 
Bleeding risk with warfarin compared with Aspirin 
37 
Mar 2013 
Dual antiplatelet therapy 
Clopidogrel (75 mg/d) + 
Aspirin (75–100 mg/d) 
Oral anticoagulation 
VKA (target INR = 2.0–3.0) 
RR 1.72 
(95% CI: 1.242.37) 
P=0.001 
n= 3335 3168 2419 941 
n= 3371 3232 2466 930 
Stroke 
C
u
m
u
la
ti
v
e
 h
a
z
a
rd
 r
a
te
s
Years 
0.05 
0 
0.00 
0.5 1.0 1.5 
0.04 
0.03 
0.02 
0.01 
ACTIVE Investigators. Lancet 2006;151:1903–12 
ACTIVE W: dual antiplatelet therapy is inferior to 
oral anticoagulation for stroke prevention in AF 
38 
Mar 2013 
Stroke 2014 
“Khuyến cáo các BN đột quỵ liên quan 
đến rung nhĩ nên được sử dụng thuốc 
kháng Vitamin K, duy trì ngưỡng điều trị 
từ 2-3” 
Mar 2013 
LCL-C <70 mg/dL (NCEP-III, high risk) 
TG <150 mg/dL (normal ATP-III level) 
HDL-C >50 mg/dL (NCEP-III) 
Huyết áp <120/80 mm Hg (JNC-7) 
Mục Tiêu Kiểm Soát các Yếu Tố Nguy Cơ 
Trong Đột Quỵ do Xơ Vữa ĐM 
Mar 2013 
Phòng Ngừa Đột Quỵ do Nguyên Nhân Xơ Vữa ĐM 
Aspirin 
Aspirin 
plus 
Statin 
ACE 
Diabetes 
Mar 2013 
Highest efficacy for stroke related AF prevention 
Mar 2013 
43 
Mar 2013 
44 
GARFIELD 
Mar 2013 
None 
Antiplatelet 
AntiVit K AntiVit K 
Mar 2013 
Kháng Đông mới: 21.3% 
Kháng Vitamin K: INR 2-3: 25.8% 
17.3% 
62.1% 
68.1% 
19.1% 
26.9% 
22% 
63.6% 
11% 9.9% 
0
10
20
30
40
50
60
70
80
Trước nhập viện Xuất viện 3 tháng
Kháng đông
KKTTC
Không
Nguyễn Huy Thắng, Đỗ Minh Chi– Abstract submit European Stroke Conference 2015 
Mar 2013 
\ 
Mar 2013 
Hylek EM. N Eng J Med. 1996;335:540-6 
Hylek EM. Ann Int Med. 1994;120:897-902 
O
d
d
s
 R
a
ti
o
0 
5.0 6.0 8.0 
INR 
1.0 2.0 3.0 4.0 7.0 
5.0 
15.0 
10.0 
Đột quỵ Xuất Huyết não 
1.0 
Warfarin: A Thin Red Line 
Unpredictable INR 
 (food/drug interactions, 
low specificity) 
Mar 2013 
Mar 2013 
Stroke. 
2012;43:1812-
1817 
Mar 2013 
Stroke. 2013;44:350-355 
Mar 2013 
BN nữ 77T, tiền căn rung nhĩ, đang sử dụng 
kháng đông, INR 4,8 
Mar 2013 
INR 1,4 sau 2 giờ, CT não sau 6 giờ 
Mar 2013 
Mar 2013 
55 
Mar 2013 
56 
Mar 2013 
57 
Mar 2013 
Including 44,563 patients were randomized to 
warfarin or new oral anticoagulants 
(apixaban, dabigatran, and rivaroxaban) 
Am J Cardiol 2012;110:453– 460 
Mar 2013 
All-cause stroke and systemic embolism 
Ischemic and unspecified stroke 
Hemorrhagic stroke 
22% 
13% 
55% 
Am J Cardiol 2012;110:453– 460 
Mar 2013 
60 
Benefits of Noacts in Asian ? 
Mar 2013 
Adjusted Hazard Ratio for Intracranial 
Hemorrhage on warfarin treatment 
Shen AY, et al: J Am Coll Cardiol 50: 309-315, 2007 Multiethnic cohort of 18,867 patients hospitalized with 
first-time AF (January 1995 – December 2000) 
White 
Black 
Hispanic 
Asian 
0 1 2 3 4 5 6 7 Hazard Ratio 
Hazard Ratio (95% CI) p Value 
White 1 - 
Black 2.05 (1.25–3.36) 0.005 
Hispanic 2.06 (1.31–3.24) 0.002 
Asian 4.06 (2.48–6.66) <0.0001 
Mar 2013 
RE-LY® - Recruitment by Region, 
 N=18,113 
 Patients (n) 
Total 2,782 
East Asia 1,648 
 China 541 
 Hong Kong 90 
 Japan 326 
 South Korea 336 
 Taiwan 355 
South Asia 1,134 
 India 578 
 Malaysia 185 
 Philippines 157 
 Singapore 59 
 Thailand 155 
RE-LY® Asian Countries 
Latin America 5% 
N America 
36% 
Other 6% Asia 
15% 
Europe 38% 
Mori et al. Stroke. 2013;44:1891 
Mar 2013 
Asia (n=2,782) Non-Asia (n=15,331) 
Age (yr)* 68.0±9.8 72.1±8.3 
 <65 (%) 26.8 14.6 
 65-74 (%) 45.8 43.2 
 75 (%) 27.4 42.2 
Weight (Kg)* 66.3±12.8 85.6±19.2 
Blood pressure (mmHg) 
 Systolic* 129±17.5 131±17.4 
 Diastolic* 78±10.7 77±10.5 
Male sex (%) 63.8 63.5 
Type of atrial fibrillation 
 Paroxysmal(%) 27.7 33.7 
 Persistent (%) 41.4 30.3 
 Permanent (%) 30.9 36.0 
Creatinine clearance (mL/min)* 65.3±22.1 74.2±28.1 
 <50 (%) 26.6 18.3 
 50-79 (%) 51.3 46.5 
 80 (%) 21.8 34.2 
*: mean±SD 
Patients Characteristics -1 
Mori et al. Stroke. 2013;44:1891 
Mar 2013 
Asia 
(n=880) 
Non-Asia 
(n=4,909) 
 INR 3 3 
 Mean 35.4 54.5 10.1 19.8 66.2 14.0 
 Median 30.8 56.5 8.1 15.4 68.9 11.6 
INR 2-3 
 Asia Mean: 54.5, Median: 56.5 
 Non-Asia Mean: 66.2, Median: 68.9 
INR Control 
Asia Pacific Stroke Conference 2012 
Mar 2013 
0 
3.0 
HR 0.55 
(95% CI: 0.32–0.95) 
0 
3.0 
1.0 1.0 
%
 /
 y
ea
r 
Asia Non-Asia 
HR 0.82 
(95% CI: 0.62–1.10) 
2.0 2.0 
Dabigatran 
150mg bid 
(20/933) 
Dabigatran 
110mg bid 
(36/923) 
Warfarin 
(35/926) 
Dabigatran 
150mg bid 
(83/5,143) 
Dabigatran 
110mg bid 
(116/5,092) 
Warfarin 
(99/5,096) 
2.05 
1.12 
2.02 
1.14 
0.81 
0.98 
Ischemic Stroke 
HR 1.01 
(95% CI: 0.63–1.61) 
HR 1.17 
(95% CI: 0.89–1.53) 
Mori et al. Stroke. 2013;44:1891 
Mar 2013 
0 
1.0 
HR 0.22 
(95% CI: 0.06–0.77) 
0 
1.0 
%
 /
 y
ea
r 
Asia Non-Asia 
0.17 
0.75 
HR 0.28 
(95% CI: 0.13–0.58) 
0.09 
0.32 
0.5 0.5 
0.11 0.12 
Dabigatran 
150mg bid 
(3/933) 
Dabigatran 
110mg bid 
(2/923) 
Warfarin 
(13/926) 
Dabigatran 
150mg bid 
(9/5,143) 
Dabigatran 
110mg bid 
(12/5,092) 
Warfarin 
(32/5,096) 
Hemorrhagic Stroke 
HR 0.15 
(95% CI: 0.03–0.66) 
HR 0.37 
(95% CI: 0.19–0.72) 
Mori et al. Stroke. 2013;44:1891 
Mar 2013 
ESC 2012 focused update: 
choice of antithrombotic therapy in AF 
*Includes rheumatic valvular disease and prosthetic valves; ESC = European Society of Cardiology; 
NOAC = novel oral anticoagulant; VKA = vitamin K antagonist 
Camm AJ et al. Eur Heart J 2012;33:2719–47 
67 
Yes 
Atrial fibrillation 
Valvular AF* 
<65 years and lone AF (including females) 
Assess risk of stroke 
CHA2DS2-VASc score 
Assess bleeding risk 
(HAS-BLED score) 
Consider patient values and 
preferences 
No antithrombotic 
therapy 
Oral anticoagulant therapy 
NOAC VKA 
0 1 
No (i.e. nonvalvular) 
Yes 
No 
≥2 
= CHA2DS2-VASc 0 
= best option 
= CHA2DS2-VASc 1 
= CHA2DS2-VASc ≥2 
= alternative option 
Disclaimer: Dabigatran etexilate, rivaroxaban, and apixaban are approved for clinical use in stroke prevention in atrial fibrillation in certain countries. 
Please check local prescribing information for further details 
Mar 2013 
Japanese scientific statement on dabigatran 
68 
*<70 years: target INR 2.0–3.0; ≥70 years: target INR 1.6–2.6 
CAD = coronary artery disease; INR = international normalized ratio 
Available at:  accessed August 2011 
1 points 
Nonvalvular AF 
CHADS2 score Other risk factors 
• 65–74 yrs 
• Female 
• CAD or 
cardiomyopathy 
• Thyrotoxicosis 
≥2 points 
Recommended 
NOACs 
Warfarin* 
Options to be considered 
NOACs 
Warfarin* 
Recommended 
NOACs 
Option to be considered 
Warfarin* 
Mar 2013 
Kết Luận 
Rung nhĩ là yếu tố nguy cơ quan trọng của 
ĐQ & hậu quả rất năng nề. 
Phòng ngừa đột quỵ bằng các thuốc kháng 
đông rất hiệu quả, tuy nhiên việc chỉ định 
đang ở dưới mức cần thiết, trong đó có vai 
trò của các thầy thuốc. 
Mar 2013 
International Journal of Stroke . Vol 7, February 2012, 139–141 
Warfarin 
Dabigatran 
Rivaroxaban 
Apixaban 
Mar 2013 
71 
ASPIRIN 
Born in 1978 
Died in 2014 
Aspirin in AF: Please Keep Rest in Peace 
Mar 2013 
Rẻ 
Nhanh chóng 
Thời Trang 
But, You have to choose 2 of them !!! 
Mar 2013 
Thank you for your attention 

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