CHA₂DS₂-Vasc-Score for determining embolic risk
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",isbn:"978-1-83968-571-2",printIsbn:"978-1-83968-570-5",pdfIsbn:"978-1-83968-599-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"dd81bc60e806fddc63d1ae22da1c779a",bookSignature:"Dr. Sebahattin Demirkan and Dr. Irem Demirkan",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10818.jpg",keywords:"Decision Making, Blockchain, Accounting, Earnings Management, Strategic Alliances, Innovation, Performance, Corporate Governance, Accounting Quality, Digital Assets, Internationalization, MNCs",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"January 28th 2021",dateEndSecondStepPublish:"February 25th 2021",dateEndThirdStepPublish:"April 26th 2021",dateEndFourthStepPublish:"July 15th 2021",dateEndFifthStepPublish:"September 13th 2021",remainingDaysToSecondStep:"6 hours",secondStepPassed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Academician in the area of accounting who believes in the impact of interdisciplinary research. Dr. Sebahattin Demirkan's research interests are in the areas of financial accounting, capital markets, auditing, corporate governance, strategic alliances, taxation, CSR, and data analytics.",coeditorOneBiosketch:"Researcher of strategic management, corporate entrepreneurship, and international business; specific interests include innovation, the ambidexterity framework, inter-organizational relationships, and networks. Experienced in teaching graduate and undergraduate courses in strategy, entrepreneurship, and international business and management areas.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"336397",title:"Dr.",name:"Sebahattin",middleName:null,surname:"Demirkan",slug:"sebahattin-demirkan",fullName:"Sebahattin Demirkan",profilePictureURL:"https://mts.intechopen.com/storage/users/336397/images/system/336397.jpg",biography:"Dr. Sebahattin Demirkan is a Professor of Accounting. He earned his Ph.D. in Accounting/Management Science at Jindal School of Management of the University of Texas at Dallas where he got his MS in Accounting, MSA Supply Chain, and MBA degrees. He got his BA in Economics and Management at the Faculty of Economics and Administrative Sciences at Bogazici University, Istanbul. He worked at Koc Holding, a private venture capital firm, and the University of California, Berkeley during and after his education at Bogazici University. His research interests are in the areas of financial accounting, capital markets, auditing, corporate governance, strategic alliances, taxation, CSR, and data analytics. Dr. Sebahattin Demirkan has published articles in Contemporary Accounting Research, JAPP, JAAF, TEM, Journal of Management, and other top academic journals. He teaches several different classes in both undergraduate and graduate levels in Accounting and Analytics programs. He is a treasurer and vice president of the TASSA, board member of the BURCIN and member of the American Accounting Association.",institutionString:"Manhattan College",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Manhattan College",institutionURL:null,country:{name:"United States of America"}}}],coeditorOne:{id:"342242",title:"Dr.",name:"Irem",middleName:null,surname:"Demirkan",slug:"irem-demirkan",fullName:"Irem Demirkan",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000033HrA8QAK/Profile_Picture_1606729803873",biography:"Dr. Irem Demirkan earned her Ph.D. in International Management Studies and M.S. in Administrative Studies at Jindal School of Management at the University of Texas at Dallas, USA. She got her BA in Economics at the Faculty of Economics and Administrative Sciences at Bogazici University, Istanbul, Turkey. She worked in the finance and textile industries before joining to academia. Dr. Demirkan has published research in the areas of strategic management and corporate entrepreneurship in journals such as the Journal of Management, Journal of Business Research, Management Science, European Journal of Innovation and Management, IEEE Transactions on Engineering Management, among others. Dr. Demirkan currently teaches strategic management, entrepreneurship, and international business at Loyola University Maryland in Baltimore, MD.",institutionString:"Loyola University Maryland",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Loyola University Maryland",institutionURL:null,country:{name:"United States of America"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"7",title:"Business, Management and Economics",slug:"business-management-and-economics"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"301331",firstName:"Mia",lastName:"Vulovic",middleName:null,title:"Mrs.",imageUrl:"https://mts.intechopen.com/storage/users/301331/images/8498_n.jpg",email:"mia.v@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3621",title:"Silver Nanoparticles",subtitle:null,isOpenForSubmission:!1,hash:null,slug:"silver-nanoparticles",bookSignature:"David Pozo Perez",coverURL:"https://cdn.intechopen.com/books/images_new/3621.jpg",editedByType:"Edited by",editors:[{id:"6667",title:"Dr.",name:"David",surname:"Pozo",slug:"david-pozo",fullName:"David Pozo"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"43332",title:"Anticoagulant Therapy in Patients with Atrial Fibrillation and Coronary Artery Disease",doi:"10.5772/54147",slug:"anticoagulant-therapy-in-patients-with-atrial-fibrillation-and-coronary-artery-disease",body:'Atherosclerotic cardiovascular disease and atrial fibrillation (AF) are causes of increased mortality and morbidity all over the world. Coexistence of both leads to even higher rates of mortality and morbidity. In AF, the main reason responsible for increased mortality and morbidity is thromboembolisation and consequently the development of a stroke [1]. Among patients with atrial fibrillation, the incidence of atherosclerotic cardiovascular disease has been reported to be 20-30% [2]. Thus, development of an acute coronary syndrome (ACS) requiring percutaneous coronary intervention is very probable in patients with atrial fibrillation. Despite a 17% reduction in the incidence of stroke with aspirin compared to placebo, vitamin K antagonist (VKA) warfarin is superior to both aspirin and aspirin plus clopidogrel combinations due to its preventing AF patients from thromboemboli [3]. While triple antithrombotic therapy (VKA+aspirin+clopidogrel) lowers the risk of stroke in stent implanted patients with AF, it increases the risk of bleeding at long- term. Thus careful judgement of the risk of emboli and bleeding, the stent type (drug eluted or bare metal) to be implanted and the duration of appropriate treatment regimen is important.
In patients with atrial fibrillation the main goal of antithrombotic therapy is to prevent stroke. In patients with non-valvular AF, the atherosclerotic cardiovascular disease (especially a history of myocardial infarction) has been found to be associated with an increased incidence of stroke. Other important risks factors are diabetes, hypertension, previous stroke/ transient ischemic attack and age. In patients with non valvular AF CHADS2DS2-Vasc-Score [6] derived from a European Heart Survey were found to be beneficial for estimation of the risk of stroke. This scoring system is suggested for risk stratification in both the European Society of Cardiology (ESC) [7] and the American College of Cardiology/American Heart Association (ACC/AHA) [8] guidelines. (Table1). According to this scoring system, the patients are stratified into three risk groups as low (0), medium (1 – 2) and high (>2). While the risk of emboli is 1.3 % at score 1, the risk increases to 15.2 % at score 9. While previous embolism/TIA/stroke and age ≥75 are the major risk factors, the other clinical situations are classified as the non-major risk factors. Not only previous myocardial infarction but also complex atheroma plaques and peripheral vascular disease have also been included in the definition of vascular disease.
\n\t\t\t\tLetter\n\t\t\t | \n\t\t\t\n\t\t\t\tClinical Condition and age\n\t\t\t | \n\t\t\t\n\t\t\t\tPoints\n\t\t\t | \n\t\t
C | \n\t\t\tCongestive heart failure† | \n\t\t\t1 | \n\t\t
H | \n\t\t\tHypertension | \n\t\t\t1 | \n\t\t
A | \n\t\t\tAge≥75 years | \n\t\t\t2 | \n\t\t
D | \n\t\t\tDiabetes mellitus | \n\t\t\t1 | \n\t\t
S | \n\t\t\tStroke/TIA/Thromboembolism | \n\t\t\t2 | \n\t\t
V | \n\t\t\tVascular disease* | \n\t\t\t1 | \n\t\t
A | \n\t\t\tAge 65 – 74 | \n\t\t\t1 | \n\t\t
S | \n\t\t\tFemale sex | \n\t\t\t1 | \n\t\t
\n\t\t\t | \n\t\t\t | max. 9 points | \n\t\t
CHA₂DS₂-Vasc-Score for determining embolic risk
†Heart failure or moderate to severe left ventricular systolic dysfunction (e.g. LV EF < 40%)
*Prior myocardial infarction, peripheral artery disease, aortic plaque. TIA =transient ischaemic attack.
In choosing the antithrombotic therapy regime, both the risk of bleeding and the evaluation of thromboembolic risk are important. The use of VKA causes a more meaningful decrease in embolic risk compared to aspirin alone or DAPT (dual antiplatelet therapy) in patients with a medium and high risk. However the use of VKA increases the risk of major bleeding especially when used with DAPT. Therefore, determining the risk of bleeding is important before starting the therapy. Although various risk scores evaluating the risk of bleeding have been obtained, they were all developed to estimate the risk of major bleeding and they can be classified into three groups as low, medium and advanced. ESC guidelines recommend using HAS-BLED scoring [Table 2] (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly (>65), drugs/alcohol concomitantly) in the estimation of bleeding risk [9]. HAS-BLED≥3 was found to be related to high risk of bleeding. However, parameters such as a history of stroke, old age, and hypertension also affect the risk of emboli estimated by using the CHA₂DS₂-Vasc-Score,. Thus, patients with a high bleeding risk must be carefully managed.
\n\t\t\t\tLetter\n\t\t\t | \n\t\t\t\n\t\t\t\tClinical characteristic*\n\t\t\t | \n\t\t\t\n\t\t\t\tPoint\n\t\t\t | \n\t\t
H | \n\t\t\tHypertension | \n\t\t\t1 | \n\t\t
A | \n\t\t\tAbnormal renal or liver function (1 point each) | \n\t\t\t1 or 2 | \n\t\t
S | \n\t\t\tStroke | \n\t\t\t1 | \n\t\t
B | \n\t\t\tBleeding history | \n\t\t\t1 | \n\t\t
L | \n\t\t\tLabile INR | \n\t\t\t1 | \n\t\t
E | \n\t\t\tElderly ("/>65 years) | \n\t1 | \n
D | \n\tDrugs or alcohol comsumption (1 point each) | \n\t1 or 2 | \n
\n\t | \n\t | Max 9 poits | \n
HAS-BLED bleeding score
*Hypertension’ is defined as systolic blood pressure >160 mmHg. ‘Abnormal kidney function’ is defined as the presence of chronic dialysis or renal transplantation or serum creatinine ≥200 mmol/L. ‘Abnormal liver function’ is defined as chronic hepatic disease (e.g. cirrhosis) or biochemical evidence of significant hepatic derangement (e.g. bilirubin >2 x upper limit of normal, in association with aspartate aminotransferase/alanine aminotransferase/alkaline phosphatase >3 x upper limit normal, etc.). ‘Bleeding’ refers to previous bleeding history and/or predisposition to bleeding, e.g. bleeding diathesis, anaemia, etc. ‘Labile INRs’ refers to unstable/high INRs or poor time in therapeutic range (e.g.,60%). Drugs/alcohol use refers to concomitant use of drugs, such as antiplatelet agents, non-steroidal anti-inflammatory drugs, or alcohol abuse, etc. INR = international normalized ratio. Adapted from Pisters et al (9).
In coronary artery disease, DAPT has been found superior to aspirin plus oral anticoagulant (OAC) therapy in preventing recurrent ischemic events [10]. Although, in a long term period, OAC therapy has been found superior to DAPT in AF patients, this therapy, especially in situations when it must be combined with DAPT, has a major bleeding incidence of up to 4.7 %. This bleeding usually happens within the first month and has been fatal in almost half of the patients [11]. Therefore, the management of patients with nonvalvular AF who require PCI (percutaneous coronary intervention) is very important for many clinicians.
Nowadays, therapy guidelines include a therapy of low aspirin dose or no therapy for low risk patients, OAC or aspirin for medium risk patients, and a therapy of OAC in patients with a high risk. In medium risk patients, DAPT has been found inequivalent to VKA in studies conducted on DAPT therapy (aspirin+ clopidogrel). VKA is related to lower bleeding and stroke. Therefore, in medium and high thromboli risk patients, if the risk of hemorrhage is high, because of the high incidence of intracranial and extra cranial bleeding incidence, the option of DAPT should not be preferred.
In the abovementioned patients the low dose dabigatran option must be considered and if they are treated with VKA, a lower INR (1.8-2.5) target should be chosen. However according to the studies made, patients with an INR <2 have double the risk of stroke compared to patients whose INR is > 2.
In elective percutaneous coronary interventions (PCI), if there is no obligatory indication (long lesion, small vessel, diabetes, etc.) the intervention must be limited to a bare metal stent (BMS). Because after the implantation of a drug eluting stent (DES), there is a requirement for a triple antiplatelet for a longer time (3 months for sirolimus, 6 months for paclitaxel) and this may lead to a higher mortality rate associated with increased bleeding risk. While the post BMS triple anti platelet therapy is limited to a 4 week period, it has to be used longer following DES. In patients with low-medium bleeding risk but low embolic risk, during the first four weeks after BMS, triple anti platelet therapy is suggested. After 4 weeks, lifelong OAC (INR=2-3) should be preferred. As an approach, there is a difference between ESC guidelines and USA clinical practice [12]. In patients with low-medium hemorrhagic risk both the ESC and the USA approaches suggest triple anti platelet therapy for BMS and DES, but in the USA approach, only DAPT is suggested in patients with a high bleeding risk. However, in ESC guidelines, despite the high bleeding risk, during the 2-4 week interval after BMS elective implantation, triple anti platelet therapy is advised.
US Approach-Adapted from Paikin et al [12]
As a therapy regime, OAC (INR=2 – 2.5), aspirin daily ≤100 mg and clopidogrel 75 mg daily is included. In patients with a high risk of bleeding, it has been stressed in both guidelines that DES should be avoided and if possible BMS should be implanted. Among patients having a low and medium bleeding risk, for those who have been implanted BMS, 1 month of triple anti platelet therapy is advised. Among those patients who are DES implanted, for the limus group, 3 months of triple antiplatelet therapy is advised while for the paclitaxel group, 6 months of DAPT is advised. Furthermore, in DES implanted patients, a dual therapy of OAC plus aspirin up to 1 year or OAC plus clopidogrel is advised and after 1 year only OAC mono therapy is advised. Therefore, DES implantation should be avoided because it requires long term dual and triple therapy (Table3).
\n\t\t\tHemorrhagic risk\n\t\t | \n\t\t\n\t\t\tClinic\n\t\t | \n\t\t\n\t\t\tStent type\n\t\t | \n\t\t\n\t\t\tAnticoagulation regime\n\t\t | \n\t
Low-Medium HAS-BLED (0 – 2) | \n\t\tElective | \n\t\tBMS | \n\t\t1 month: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≤ 100 mg/day + clopidogrel 75 mg/day Lifelong: warfarin (INR 2.0–3.0) alone | \n\t
Elective | \n\t\tDES | \n\t\t3 (-olimus group) to 6 (paclitaxel) months: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≤ 100 mg/day + clopidogrel 75 mg/day Up to 12 months: combination of warfarin (INR 2.0–2.5) + clopidogrel 75 mg/day (or aspirin 100 mg/day)* Lifelong: warfarin (INR 2.0–3.0) alone | \n\t|
ACS | \n\t\tDES/BMS | \n\t\t6 months: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≤ 100 mg/ day + clopidogrel 75 mg/day Up to 12 months: combination of warfarin (INR 2.0–2.5) + clopidogrel 75 mg/day (or aspirin 100 mg/day)* Lifelong: warfarin (INR 2.0–3.0) alone | \n\t|
High HAS-BLED (≥3) | \n\t\tElective | \n\t\tBMS | \n\t\t2–4 weeks: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≤ 100 mg/day + clopidogrel 75 mg/day Lifelong: warfarin (INR 2.0–3.0) alone | \n\t
ACS | \n\t\tBMS | \n\t\t4 weeks: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≤ 100 mg/ day + clopidogrel 75 mg/day Up to 12 months: combination of warfarin (INR 2.0–2.5) + clopidogrel 75 mg/day (or aspirin 100 mg/day); mg/day)* Lifelong: warfarin (INR 2.0–3.0) alone | \n\t
ESC suggestions for anticoagulation in patients with coronary stent who have medium and high emboli risk
ACS=Acute coronary syndrome, BMS=Bare metal stent, DES=Drug eluted stent, INR=International normalized ratio
*Combination of warfarin (INR 2.0–2.5) + aspirin ≤ 100 mg/day may be considered as an alternative.
Drug-eluting stents should be avoided.Adapted from Lip et al
In patients with non-valvular AF who have acute coronary syndrome (ACS), the puncture site for PCI is important. In anti- coagulated patients, how the therapy will be conducted in the hospital and choosing the right type of stent bears an importance. As for those patients who are not anti coagulated, the antithrombotic therapy during discharge is important. In anticoagulated patients, femoral intervention is an independent predictor for major hemorrhage and other vascular complications and therefore in those patients radial intervention is preferred because it causes less bleeding and better results [13,14].
In patients with ACS, especially those in whom primary PCI have been applied, BMS should be preferred because it requires a shorter duration triple antithrombotic therapy. OAC should be given to non-STEMI patients when they are hospitalized and DAPT and heparin should be given to those patients who have no therapy. If the thromboembolic risk is too high, OAC therapy might as well be started in those patients during in-hospital period. There are two approaches for patients who receive OAC during hospitalization. The first and mostly used approach in clinical practice is the bridge therapy which involves stopping OAC therapy and starting heparin. The second approach is to continue OAC therapy so that INR will be in the 2-2.5 interval. The main drawback of the bridge therapy is when the therapy is stopped and then restarted, Protein –C and –S are not suppressed, and they increase embolic complications paradoxically in patients with a very high emboli risk [15]. Therefore, in patients with ACS having a very high embolic risk, it is advised that DAPT should be added to the therapy without stopping OAC and without adding heparin (if the INR <2, then heparin may be added) [16,17]. In STEMI patients for whom P-PCI is applied, if the INR is within the interval of 2 – 3, then a similar approach is applicable. However, glycoprotein (GP) IIb/IIIa inhibitors may have to be used due to the high thrombus burden. In those patients with a high thrombus burden, if the INR>2, then GP IIb/IIIa inhibitor must not be started, and, if possible thrombectomy should be considered instead. Alternatively, in patients with INR<2, bivaluridin might be considered for use instead of GP IIb/IIIa inhibitor + heparin. Due to high hemorrhagic risks, in patients using OAC and having optimal INR, additional heparin should not be used. In patients whose bleeding risk is high, triple therapy should not be used for more than 1 month. Due to the need for short triple therapy, BMS should always be preferred. Following ACS, triple therapy should be given for 1 month, dual therapy including OAC should be given up to 12 months, and after 12 months only OAC should be given lifelong. The short and long term antithrombotic therapy regimen of the ACS patients is summarized in table 3.
Advice On Decreasing Hemorrhagic Risk:
The balance between hemorrhagic risk and embolic risk should be maintained very well.
No therapy may be given to patients who are under 65 years of age having a low embolic risk.
In combined therapies, the dose of aspirin should be kept low (75 – 100 mg).
In patients having a high bleeding risk hypertension should be treated aggressively.
Hepatic and renal functions should be followed closely in patients who take OAC.
In case of stent requirement, BMS should be preferred as much as possible.
During ACS, additional heparin, GP IIb/IIIa inhibitor or bivaluridin should not be given to those patients who have an effective INR and who take OAC.
Radial intervention should be applied to patients who take OAC and who are intervened with STEMI.
Triple antiplatelet therapy should not be used for more than 1 month in patients whose bleeding risk is high.
DAPT should not be given for a long time, instead only OAC should be given in long term therapy.
Proton pump inhibitors may be added to the therapy.
In long term therapy, dabigatran 110 mg twice a day or rivaroxaban once a day should be considered for use (compared to VKA lower bleeding incidence, equal stroke rates) in patients whose bleeding risk is high (especially in the presence of INR labile).
In AF patients, oral anticoagulation is traditionally done with VKA. However, due to personal differences in responses, the need for a balance in dose, labile INR and bleeding risk; studies have been made on new drugs which do not require follow-up. With these new drugs such as direct thrombin inhibitor dabigatran, factor Xa inhibitors apixaban and rivaroxaban, the incidence of major bleeding is significantly lower compared to VKA. When Dabigatran 110 mg twice a day is compared with VKA, nonvalvular AF stroke prevention in the RELY study (Randomized Evaluation of Long-term Anticoagulant Therapy) there is no difference between stroke and systemic embolism, but the rate of major hemorrhage is meaningfully less in 110 mg Dabigatran than it is in VKA [18]. In the dose of 150 mg, the rates of major bleeding and stroke were determined to be similar. In patients with non valvular AF whose INR values were labile, if they cannot be followed closely and if they do not have an advanced hepatic and renal problem, dabigatran is an alternative to warfarin. In non- valvular AF patients, in the ARISTOTLE study done with Apixaban, apixaban is related to lower hemorrhage complication and lower mortality compared to warfarin [19]. In the ROCKET-AF [20] study, while there was no difference between the major hemorrhage rates of patients using rivaroxaban and warfarin, the fatal and intracranial hemorrhage rates were lower in patients using rivaroxaban than in those patients using warfarin. The systemic emboli and stroke prevention rates between the two were equal.
The results of this study are hopeful for long term anticoagulation regimes. There is no sufficient clinical evidence regarding the fact that these drugs are appropriate for a combination therapy (DAPT plus OAC). However, regarding these three studies (RELY, ROCKET-AF, and ARISTOTLE), when the dual therapy using VKA is compared with dual therapy using new anticoagulant drugs (apixaban, rivaroxaban, dabigatran), there is no additional difference in terms of hemorrhage rate. Thus, when the combination of DAPT with new drugs is compared to the combination of VKA and DAPT, there is no additional increase in hemorrhage. Nevertheless, in the monotherapy with OAC, the risk of hemorrhage is at its lowest. However, regarding the safety of the combined use of the new anticoagulant drugs with dual antiplatelet therapy, there is no sufficient evidence regarding long-term use and there is a need for further studies.
Imbalances between generation and consumption cause frequency variations in a power system [1]. To maintain frequency in its nominal value, power systems rely on synchronous machines connected to the grid, which store kinetic energy automatically extracted in response to a sudden power imbalance [2]. However, due to the new environmental policies and the limited fossil fuel reserves, conventional generators are being replaced by renewable energy sources (RES)-based generators [3]. Among the different RES available, the most promising for electrical power generation are PV and wind power installations, which are inverter-interfaced RES (II-RES) [4]. However, the massive penetration of II-RES into the grid can involve several issues that should be taken into account [5]. First, as they depend on weather conditions, these sources are intermittent and uncertain, placing stress on power system operation [6]. Moreover, as they are connected to the grid through inverters which electrically decouple them from the grid [7], the effective inertia of the power system can be reduced [8]. This inertia reduction affects the system reliability, compromising the frequency stability [9]. The rotational inertia is related to both nadir (minimum frequency) and rate of change of frequency (ROCOF) [10]. In fact, larger nadirs and faster ROCOFs are obtained in low rotational inertia power systems, subsequently making them more sensitive to frequency deviations [11, 12]. As a result, over the last decade, several frequency control techniques have been proposed to facilitate the massive penetration of wind and PV resources into the grid [13]. In addition, recent contributions investigated the use of smart inverters with voltage and frequency support to enhance grid stability [14]. Such solutions are commonly referred to as hidden, synthetic or virtual inertia [15].
This chapter focuses on the current and future inertia concept for power systems. A methodology to estimate the current rotational inertia of power systems based on their electricity generation mix is proposed. In addition, the possibilities of wind and PV power plants to contribute to inertia and participate in frequency control are also presented. The rest of the chapter is organized as follows. The inertia analysis and swing equation of generators and current and future power systems are presented in Section 2. In Section 3, the inertia constant estimation methodology is explained, comparing the results to a previous report published by the European Network of Transmission System Operators for Electricity (ENTSO-E). Section 4 reviews different frequency control techniques for PV and wind power plants. Finally, Section 5 gives the conclusion.
Rotating masses of a synchronous generator store kinetic energy
Moment of inertia
Work in [10] reviews the inertia constants
In power systems, the motion of each turbine-generator group is expressed as Eq. (3), where
However, as
where
and in steady state:
In consequence, considering small variations around the steady state, Eq. (3) can be rewritten as in Eq. (7) [19]:
Furthermore, some electrical loads connected to the grid are also frequency-dependent, working as a load resource under frequency deviations (i.e., synchronous machines). In this way, the electrical power of those loads can be expressed as:
where
To apply the swing Eq. (9) to a power system, all synchronous generators are grouped in an equivalent rotating mass. This is carried out by determining the equivalent inertia constant
where
In the same way, loads are reduced to an equivalent one with damping factor
In recent decades, several policies have promoted the penetration of RES-based generation units, which have replaced synchronous generators directly connected to the grid [22]. However, as some of them are II-RES (i.e., wind and PV), power systems with a high penetration of those RES require new frequency control strategies that emulate the behavior of conventional power plants under power imbalance conditions [23]. Such techniques are commonly referred to as hidden, synthetic, emulated or virtual inertia [15]. By including this emulation of inertia into power systems, equivalent inertia
where
Power system with synchronous, hidden and virtual inertia.
Inertia constant values H for different wind turbine technologies.
On the other hand, PV has no rotating masses [30]. Thus, PV power plants cannot store kinetic energy and their inertia constant is
Due to the repercussions of II-RES with regard to the rotating inertia of power systems [36], they should start providing active power support under disturbances [37]. The specific literature includes several technologies that allow II-RES to participate in frequency control by providing additional power under disturbances [38, 39, 40].
Energy global statistics are provided by the International Energy Agency (IEA). Considering Eq. (10) and the electricity supply within a year presented in [41], it is possible to calculate the equivalent inertia
Figure 3 depicts the generation mix change between 1996 and 2016. Over these two decades, the total electricity consumption increased by more than 80%. However, in the same time period, RES electricity generation only increased by 4%. Based on the approach previously described to estimate
Generation mix in the world: change between 1996 and 2016. (a) Generation mix in 1996. (b) Generation mix in 2016.
Estimated equivalent inertia constants in the world by continent: change between 1996 and 2016.
In line with the inertia reduction suffered, RES supply in Europe increased by nearly 20% (refer to Figure 5). Actually, ENTSO-E has already focused on the high RES integration-low synchronous inertia problem. In one of their published reports, ENTSO-E estimated the evolution of system inertia for different TYNDP scenarios for 2030 in Europe and certain countries (i.e., the United Kingdom, France and Germany), considering that II-RES do not contribute to inertia [42]. In those estimations,
Generation mix in Europe: change between 1996 and 2016. (a) Generation mix in 1996. (b) Generation mix in 2016.
The transition of
Equivalent inertia constants estimated in EU-28: change between 1996 and 2016.
To maintain frequency within an acceptable range, generation and load in the power system must be continuously balanced [43]. In fact, frequency variations from the nominal value can cause several problems including under-/overfrequency relay operations and disconnection of some loads from the grid, among others [44]. Thus, frequency stability is an essential issue for power systems [45].
With the increase in II-RES, the equivalent inertia constant of power systems is reduced, subsequently obtaining (i) larger frequency deviations after an imbalance and (ii) higher ROCOF [7, 46]. As a consequence, II-RES should start providing active power support under disturbances [37].
In order to provide additional active power during imbalanced situations, PV power plants can integrate different solutions, mainly based on two principal approaches: energy storage systems (ESS) or de-loading control strategies. Moreover, the technical challenge is more severe with PV power plants than with wind generation, since PV systems cannot provide any inertial response unless special countermeasures are adopted [47].
With regard to ESS, different solutions have been proposed in the literature to be applied to PV systems. Although the relevant benefits of ESS to power system’s operation is widely recognized, some significant challenges can be identified: (i) the selection of a suitable technology to match the power system application requirements, (ii) an accurate evaluation of the energy storage facilities estimating both technical and economic benefits and (iii) a cost decreasing to a realistically acceptable level for deployment [48]. Among the different ESS, the battery energy storage is considered by some authors as the oldest and most mature ESS [49]. In work [50], it is concluded that the Li-Ion batteries are those that best suit frequency regulation services. Batteries are limited in power, though present a high storage ratio [51, 52, 53]; on the other hand, supercapacitors have high levels of power with low energy storage ratio. As a consequence, the battery-supercapacitor combination is proposed as an interesting ESS solution [54]. Indeed, these technologies can help to solve the problem of the ‘intermittent’ nature of solar PV supply [55]. Additional solutions for PV installations based on supercapacitors can be found in [56, 57]. Flywheels are another solution widely proposed as ESS, being applied from very small micro-satellites to large power systems [58]. Work in [59] points out a great benefit of flywheels backing up solar PV power plants, mainly focused on the cloud passing, which can cope with the high cycles of the flywheel technologies. Indeed, flywheels excel in short duration and high cycle applications [60]. Moreover, flywheels have a high efficiency, usually in the range between 90% and 95%, with an expected lifetime of around 15 years [61]. Different solutions propose hybrid ESS coupled to PV power plants [53], such as a battery hybridization with mechanical flywheel [62].
PV power plants usually work at the maximum power point (MPP) according to ambient temperature
De-loading techniques for PV power plants. (a) Vdel.1 > VMPP. (b) Vdel.2 < VMPP.
Wind power plants can also participate in frequency control by using different solutions. Apart from the use of ESS or working with the de-loading control strategy, wind turbines can provide inertial response as conventional generators due to the rotational inertia of the blades and generator [10].
With regard to ESS, wind power plants can also include batteries [71], supercapacitors [72] and flywheels [73]. ESS are considered an alternative to compensate the lack of short-term frequency response ability of wind power plants [74]. The utility-scale battery ESS helps to reduce the ROCOF, providing frequency support and improving the system frequency response [75]. A battery ESS based on a state-machine-based coordinated control strategy is developed in [76] to support frequency response of wind power plants, including both primary and secondary frequency control. A real-time cooperation scheme by considering complementary characteristics between wind power and batteries is discussed in [77] to provide both energy and frequency regulation, considering the battery life cycle. The combination of battery and supercapacitor is considered in [78] as an effective alternative to improve the battery lifetime and enhance the system economy. In this way, an enhanced frequency response strategy is investigated in [79] to improve and regulate the wind frequency response with the integration of ultra-capacitors. With the aim of smoothing the net power injected to the grid by wind turbines (or by a wind power plant), some authors propose to use flywheels [80, 81]. Flywheels are also proposed to dynamically regulate the system equivalent inertia and damping, enhancing the frequency regulation capability of wind turbines [38, 82] and also the entire grid [83]. A coordinated regulation response of the turbine power reserves and the flywheels while participating in primary frequency control is described in [84]. Finally, other works include not only frequency response but also voltage control by using flywheels [85, 86].
In line with PV installations, wind turbines also work in the MPP according to the wind speed
De-loading techniques for wind power plants. (a) Pitch control. (b) Over-speed control.
In order to provide an inertial response, at least one supplementary loop control is introduced into the power controller to increase the generated power by the wind power plant. This additional loop is only activated under power imbalances (i.e., frequency deviations), supplying the kinetic energy stored in the blades and generator to the grid as an additional active power for a few seconds [94]. The droop control provides an additional active power
Droop control for VSWTs. (a) Droop characteristic. (b) Block diagram of droop control.
The hidden inertia emulation technique is based on emulating the inertial response of traditional synchronous generators. Two possibilities are found in the specific literature, as presented in Figure 10: (i) one loop, where the additional power is proportional to the ROCOF [100, 101, 102], and (ii) two loops, where the additional power is proportional to the ROCOF and the frequency deviation. The second strategy causes the frequency to return to its nominal value [103, 104, 105]. In both cases, the rotor and generator speeds are reduced to release the stored kinetic energy.
Hidden inertia emulation controllers. (a) One loop. (b) Two loops.
The fast power reserve approach is similar to the hidden inertia emulation technique: an additional power is initially supplied, which makes the rotor speed to decrease. However, in this technique, the additional active power
Fast power reserve emulation technique [106]. (a) P – Ω curve. (b) Power variation.
In this chapter, we have conducted an extensive literature review of inertia of power systems. A methodology to estimate the inertia constants of different power systems is proposed and verified with the inertia constant results of ENTSO-E. The contribution of wind and PV power plants as ‘hidden inertia’ and ‘virtual inertia,’ respectively, to participate in frequency control has also been discussed, providing significant information for their participation in frequency control.
This work was supported by the Spanish Education, Culture and Sports Ministry (FPU16/04282), Spanish Economy and Competitiveness Ministry and European Union FEDER, which supported this work under Project ENE2016-78214-C2-1-R.
The authors declare no conflict of interest.
DFIG | double-fed induction generator |
ESS | energy storage systems |
ENTSO-E | European Network of Transmission System Operators for Electricity |
FSWT | fixed-speed wind turbine |
HAWT | horizontal axis wind turbine |
II-RES | inverter-interfaced renewable energy sources |
PMSG | permanent magnet synchronous generator |
PV | photovoltaic |
RES | renewable energy sources |
ROCOF | rate of change of frequency |
SCIG | squirrel cage induction generator |
VSWT | variable speed wind turbine |
WPP | wind power plant |
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