Okay, so now we're going to hark back to the cases that we had in the beginning, think about them now in the context of the lectures, and have our panel come in with opinions. And while the questions mostly had a one best answer, I'll tell you at the front, they were also meant to spark thinking. As we practice medicine, it's an art, there isn't always necessarily one best answer. So case one, this was the 65-year-old woman presented for clinic, past medical history, persistent AFib on rivaroxaban with hypertension, diabetes, and sleep apnea. She had been having increased dyspnea on evening walks. She had an exercise nuclear stress testing showing a reversible apical ischemia, as you can see here. Her medical therapy was up titrated, she underwent cath as she still had symptoms. She got a drug eluting stent to the mid-LAD, she was placed on clopidogrel. On exam, she was comfortable uvolemic, radial arterial site well healed, hemoglobin is 12, creatinine 0.8, GFR 60. Due to the following was the best anticoagulation plan in the setting of her clopidogrel use, she has persistent atrial fibrillation, and the correct answer we were looking for was rivaroxaban 15 milligrams daily with dinner. So again, she's on clopidogrel, so we're having dual therapy, and that harks back to the pioneer AF study using rivaroxaban at the 15 milligram dose. So again, thinking about what is the correct dose, as Dr. Tracy alluded to, and Dr. Kumbani's talk on how to correctly manage antithrombotic therapy after stenting. So I'm going to move on to the next one. So now this patient develops heart failure, HFPEF, over the next several years. Hospitalized for heart failure three times in the past year. She leaves the hospital with end-stage renal disease and now requiring dialysis. So now she's on dialysis. Her sister had had a stroke while on warfarin with a subtherapeutic INR, so she prefers to avoid BKA. She's on metoprolol, amlodipine, rizuvastatin, RIVA, now at 20 milligrams, and several years later on insulin, she weighs 55 kilos. Now which is the following appropriate anticoagulation strategy? So here the correct answer would be 2.5 milligrams twice daily. Why? For the lower dose of apixaban, there's three parameters to consider. Age over 80, creatinine over 1.5, or weight less than 60 kilos, and we presented two of those things here, and so the correct answer would be apixaban 2.5. Now what if the, what if she weighed 65 kilos or 70 kilos? Dr. Tracy, what would have, how would you have answered this? Five. Five. Right. Yeah. So even, and yet, even though these drugs weren't necessarily studied in the dialysis, you want to go into that too? Yeah, I think that's, that, you're absolutely right, but that, that the, the guidelines do for renal failure, absent the 55 kilograms, the correct dose per the guidelines would be five milligrams twice daily. And the data support it too in dialysis, so I think it gets underutilized, everyone thinks it's dialysis, therefore you have to put it on low dose, one of the classic times. And they have better outcomes with a full five milligrams, right. I think that's one of the more common times that it gets underutilized. Yeah, absolutely. Can I make a point as well? I'm sorry? Yeah, please, I'm sorry. Yeah. The other thing I was going to point out, which, you know, if you do the pioneer AF dosing and you drop them to 15, you, when you stop the clopidogrel, you also have to remember to go back up on the river oxybander 20, because that is actually the stroke AF prophylaxis dose. Okay. So now, case two that Dr. Hewitt presented, a 70-year-old man presents to the clinic for follow-up with a history of lung cancer, COPD, permanent AFib on apixaban, five milligrams twice daily, CKD stage three, creatinine 1.3 with a GFR of 56, previously reported several months of dyspnea and chest pain, undergoes cath, and there was a mid-LED lesion that even me as an AP doc can see. He is found to have severe mid-LED disease and gets a drug-eluting stent. He is discharged on a baby aspirin, 81, clopidogrel 75, in addition to his apixaban, five milligrams twice daily. He's seen in clinic now one month later. And the answer we were looking for, and I think there was, if I remember, a spread in answers on this one, discontinue aspirin now, continue clopidogrel for five more months, and continue apixaban indefinitely. Again, this is harking back to Dr. Kumbani's talk and the consensus clinical decision pathway. You do not want to continue triple therapy for more than one month, preferably less, but you do need to at least keep dual therapy going for six months. This is a person who had presented with ischemic heart disease, but not an acute MI, but apixaban should be indefinitely, and so the other answers would not be correct. Any comments on that one, or? The only other thing I'll say is, you know, option three is not completely incorrect because, you know, at six months, as I said, so we didn't go into this, but there are data for de-escalation beyond one year where you can actually drop down for patients who have CAD, low-risk CAD, you can actually drop down to just NOAC monotherapy after one year based on a fire, but again, as I mentioned specifically, there is really no evidence or data that guides us between six and 12 months, and so most people would say you should still continue some kind of antiplatelet agent between six and 12 months. You could say, in that duration, I'm going to do aspirin plus apixaban, that's fine, or you could, like I said, C is not completely incorrect because you could also opt if the patient's tolerating that, continue clopidogrel for 11 months. Something that may be mythical that I've seen people do is sort of a merger of B and C. They'll stop the aspirin, continue the clopidogrel, but then at 12 months, they'll reverse, and they'll go back to aspirin and apixaban. Is there any logic to that? I think it's based on, because, you know, after one year, you know, even if your initial presentation was, let's say, for ACS, on the spectrum of CAD, unless you've had more ischemic events, you are now considered a stable patient, and so I think the paradigm has always been for stable disease, you know, that you would switch them over to aspirin. So I don't think, but your point is correct, I don't think there are, you know, very concrete data that would guide you to what you would do beyond 12 months between aspirin versus clopidogrel. But as I said, I think there are low-risk patients where you could actually consider stopping. Again, this is, you know, limited data, but there are certainly some, you know, a fire was the biggest one where you could, you know, drop all antiplatelet therapy if they were low-risk and just do the, you know, no act. I'll confess, when we made the cases, because it very quickly gets too complicated to describe all the different options, we weren't thinking beyond 12 months, necessarily, on the antiplatelet side. Case 3, a 75-year-old woman presents to the emergency department with vague chest discomfort. Her past medical history is notable for hypertension, sick sinus syndrome, she has a dual chamber pacer, obesity, CKD stage 3, ECG shows nonspecific STT wave abnormalities, high sensitivity to proponents 20 and then 50, so ruling in. She is hospitalized and undergoes a cath the next day. This has a 90% lesion in the mid-RCA and she is stented. Three months later, she's doing well. She's at cardiac rehab. Her meds are metoprolol, lisinopril, atorvastatin, furosemide, aspirin 81, clopidogrel 75, and on device interrogation of her pacemaker, she has had several new episodes of AFib. Five of the seven episodes last more than 24 hours and the diagnosis of AFib is new. You're seeing her in follow-up three months after her non-STEMI, so what is the best next step in her medication management? And what we were going after was now to start a PIXA bench. She has now been diagnosed with AFib. These are significantly long episodes. Stop the aspirin and continue clopidogrel for nine more months in this patient who had been in the setting of an acute MI. All right. Sorry. The interesting aspect of that is the sort of subclinical AFib and how to manage that. Yes. One of the 24 hours came in of a sub-analysis of a cert that showed that 24 hours is where the risk goes way up and, you know, that was a unspecified sub-analysis and the ARTESIA study is completed enrollment and we'll have data out hopefully soon that's going to answer these questions of, which has not been addressed in any of this, is these patients who have implantable devices and you start to see AFib, what do you do with those because we really don't have a great handle of, it's clearly not the similar risk as clinical atrial fibrillation in patients. Right. Yeah. This is probably, we know the burden and the burden is probably much lower than it typically is. Right. And it stymies all of us at what point is the AF burden high enough to warrant integrations. But that's why we tried to pick 24 hours, it would be a little less controversial on that side. Yeah. I mean, just, you know, for the audience, there's data to suggest that five or six hours is the threshold. There's data to suggest as little as six minutes. But you know, the strongest data is for sort of longer duration AF, there does seem to be a burden threshold and there's some relationship that we're still defining about where that threshold is for a given patient. Excellent. Now, I think before we move on, I want to remember there was a couple of questions that came through the ARS. So I'm going to just segue a smidge, remind myself about it a little bit more. So one was about real world use of DOACs and in the setting post bypass surgery. So the question was how, when do you, if someone has just had bypass surgery, when should you initiate a DOAC? How do you work with your surgeons for anticoagulation? Does anyone want to take that one? Well, I guess for me, I think I would emphasize the importance of partnership. So the real question is when the surgeon thinks from a bleeding perspective, they're quite comfortable with a DOAC. I think the other even more intriguing question for me is when they develop new onset AFib perioperatively after surgery, how long are you committed to continue to anticoagulate them? Right. And also, I know in our institution, how long is too long? You need to stick to a strict 48 hour. I find myself conflicted because sometimes you don't get called until hour 60. So that's, you're absolutely right. It is absolutely a collaborative effort between the surgeon and the cardiology team. And it's a little bit of a moving target and some of those intangible things like the frailty, the other, you know, how much were they bleeding at the time of surgery? What are the other factors that have to be weighed in there? Did they, oh, I sure hope they did tie off the left atrial appendage. I mean, those other factors really come into play. It is, you know, you really have to work with the surgeon and if the left atrial appendage is occluded, well, maybe, you know, or sewn off, well, then maybe you are a little bit more comfortable not anticoagulating them as, you know, early or as aggressively as you might otherwise want to. But you know, it's, I certainly, and I'm sure all or many of us have seen people post-operatively have strokes related to atrial fibrillation. So I think you have to really wrestle with those decisions on a case-by-case base. My thinking is that they have risk factors for stroke and that I should try to be as aggressive as I can in terms of having them appropriately anticoagulated without increasing the risk of bleeding too much. So if the surgeon in their, you know, in their operative experience feels that the patient is at too high of a risk, well, then I'll have to bow to that, you know, to that opinion. But I may not be that anxious to cardiovert them then. So, you know, you just have to really weigh that. But if all things are equal, then I would err on the side of anticoagulation, certainly. I mean, the guidance we generally give is the shortest possible duration of holding it, the better. And, you know, one of the things is that often the surgeons, at least at our institution, seem to be biased towards warfarin still. And so we've tried to disaffect them of that habit. And I think it's also, if we're talking about postoperative AF, it's for operative atrial fibrillation in the context of surgery, it's worth just emphasizing the Laos 3 study, which we touched on real briefly, but was looking at patients with atrial fibrillation who underwent cardiac surgery, primarily CABG. And what they showed is that if you clip the left atrial appendage and continue anticoagulation, the patients did better than if they were just on anticoagulation. So I think that answered that question, and I think has tried to move us with our surgeons towards clipping the appendage in patients with no atrial fibrillation or undergoing cardiac surgery. But it doesn't necessarily tell us we should be stopping anticoagulation in those people. And it gets at this issue of residual risk, addressing both the thrombus associated with the left atrial appendage and then other sources of stroke. All right. Well, I'm going to move on to the next case. A 71-year-old woman presents for further management of persistent atrial fibrillation diagnosed by her primary doctor a month earlier. She experiences a pounding in her chest whenever she walks her dog. Metopaltar trait, 25 twice daily initiated, no difference in symptoms, also started on anticoagulation. Also has type 2 diabetes, hypertension. Her ejection fraction is 58%. Her heart rate is 93 beats per minute. To prevent cardiovascular-related death, stroke, heart failure, hospitalization, or acute coronary syndrome, what is the best next step? And what we were going after here was answer C, direct current cardioversion, initiate flecainide, getting after the EAST-AF net trial, that early rhythm control. And again, that was not a trial that was about exclusively ablation. It was just about rhythm control reduces these outcomes. Yeah. And to be clear, flecainide's not the anti-rhythmic of choice here. It's just the notion of initiating some kind of rhythm control strategy and giving that a shot in this patient. And again, also in that study, the rates of use of catheter ablation were quite low. It was only about 20%. Yeah. Yeah. And then the follow-up to that was the patient elected to continue metoprolol, but had more palpitations, exertional dyspnea. Husband had to take over walking the dog. So to improve her symptoms of quality of life and quality of life, what is the best next step? And here, we were looking for an answer of catheter ablation, with now studies showing improvement in quality of life with ablation versus anti-rhythmic drugs. So I'm going to move on now to the next case. We've got about six minutes left. So we're going to finish. A 76-year-old man with a history of hypertension, on amlodipine, coronary disease, prior intervention to the LAD over 20 years ago, not on antiplatelet therapy, longstanding persistent AFib, asymptomatic on apixaban, and presents the emergency department with a headache, memory difficulties, aphasia, a blood pressure of 185 or 105, and here, intracranial hemorrhage. We see him in clinic six months later. There were no residual neurologic deficits. Aspirin's resumed because of the prior coronary history. Chaz vasc was deemed four, has blood of four, assuming hypertension, I guess, was still uncontrolled. And what was the best next step? So here, we were going after the preference for going after left atrial appendage occlusion. But then I'll ask the panel, you know, we also picked the point of six months later. So would anyone have thought of resuming apixaban? Is there any argument to any of that? I think left atrial appendage occlusion would be the most appropriate, but. Do you have a question? Oh, go ahead. I'm so sorry. I don't think so. But our magic people over here are going to work on that. While they're getting that working, I mean, I think, you know, intracranial hemorrhage, there are actually, we have an ongoing study at Yale looking at the issue of whether you can re-anticoagulate people after intracranial bleeding. But a lot of people would start to move as we have this increasingly, you know, attractive alternative in left atrial appendage closure towards that. And I should say, we're actually about to present data, real-world data on the FLEX device versus the older Watchman device, and peri-procedural adverse event rates continue to drop pretty dramatically. So the safety profile of these devices continues to get better over time. The only other thing to address is that the rates of bleeding after left atrial appendage closure remain not insubstantial, because these patients are, about 70 percent of them in the United States have had a history of prior clinically relevant bleeding, and we're giving them anticoagulation or dual antitherapy for off and out to about six months. And so I think we need to be doing a lot of studies to look at this space, and we've got a paper coming out on that as well, showing that actually similar to what we've seen with the PCI literature, if we get rid of the aspirin and just do the anticoagulation, or if we just do DAPT, we can lower rates of bleeding without an ischemic incident. And it's lower rates. You're not taking anything to zero. Correct. But if this person had bled on Warfarin, then it'd be much more reasonable to think about a DOAC and not having to go straight to a left atrial appendage occluder device. Yeah. And we can probably bag the aspirin. Got it. Okay. So, oh, yeah. Oh, we got the mic on. Go ahead. Oh, hello. Okay. Hi. My name's Percy. I'm a first-year fellow. Can we go back to case four? Case four. Yes. Yes. Just the answers. Yeah. Okay. So I was thinking, what are you guys' thoughts on answer A, mainly because, you know, we sometimes think pursuing the non-invasive options first. And so in someone who's, like, appropriately anticoagulated, giving a shot with cardioversion before pursuing catheter ablation. So the question is about improving quality of life. So... Yeah. So it really gets to this issue of the three trials that were all published in the last year that all showed that the burden of atrial fibrillation was about 50% lower, or the risk of recurrence of atrial fibrillation was about 50% lower. The FEQT scores were 10 points higher. The healthcare utilization was lower with catheter ablation. So I think there's a real paradigm shift, you know, albeit relatively recently, but now with three good trials, all of which were moderately sized with very consistent results showing that as first-line therapy, we should be thinking about catheter ablation. Let's be clear. This is an invasive procedure. It's not for everyone. You know, you have to take it in the clinical context of the patient, but I think increasingly we should be thinking about catheter ablation as a first-line therapy. Particularly for quality of life. How old was she? How old is this hypothetical patient? She was 70. 70, yeah. And then there was also, wasn't there a sub-study on the CABANA trial for quality of life that came out too? Yeah, exactly. It was dramatic. Yeah. I mean, all the catheter ablation trials have shown decreases in symptoms and improvements in quality of life. That's been a very consistent finding. Thank you. All right. So, in this patient underwent Watchman Flex on this last, and what I want to get to, because So here, this question, we didn't bold an answer, and I wanted to get the panel's insight on this. So, that patient that we discussed then had undergone a Watchman Flex implant. Which one of the following is the most appropriate antithrombotic therapy post-implantation in this case? No oral antiplatelet or anticoagulant. Aspirin and clopidogrel for six months, then aspirin. Aspirin and morphine for 45 days, then aspirin and clopidogrel until six months, then aspirin definitely. Aspirin and pixaband for 45 days, then aspirin and clopidogrel until six months, and then aspirin. So, I want to ask the panel, because this is not about, if you want to be strict about FDA labeling and which type of device, but this is real world experiences. In the amulet trial, 80% of the Watchmen got it, but the other 20% obviously didn't. So what would be your view on how you'd approach a patient like this? So this, we've got a paper on antithrombotics after Watchman implant, that's just, it's about to be published in Jack, and we presented at AHA last year. So in the real world, what's happening is that only about 35% of patients are discharged on morphine and aspirin. And there are very high rates of DOAC use, and often DOAC with aspirin, but sometimes DOAC without, and sometimes warfarin without aspirin. And what we actually showed was that anticoagulation without an antiplatelet agent was associated with lower rates of bleeding and no increase in risk of stroke. So we probably don't need the aspirin at all. And how about not needing the DOAC? Yeah, so then there was a group with dual antiplatelet therapy, and again, this is the Watchman device, so the bias was towards using anticoagulation. But we showed that DAPT was equivalent to warfarin and aspirin, it was still a slightly higher risk of bleeding than the anticoagulation alone arm. But those patients were the one outlier in terms, they were higher risk for bleeding. So clearly people had used DAPT in patients that were higher risk for bleeding. And then with the amyloid IDE study data, I think there's increasing comfort with the use of dual antiplatelet therapy, and that's with the Watchman device and with amyloid, and that's very common in Canada and Europe. In Europe in particular, yeah. Great. So, and you know, I think we've got to try and figure out what we can get away with to reduce the risk of bleeding and not have an increase in thrombotic risk. Design of the device is also going to improve to mitigate that risk. Yeah. So stay tuned, there's going to be a change in practice and probably a clinical decision pathway is going to happen out there. So that brings us to 7.30. We'll still be up here for questions, but I want to give another round of thank you to all of you and to our panel for a really lovely session tonight.

atrial fibrillation

anticoagulation plan

clopidogrel

stroke

warfarin

stenting