Initial assessment of patient with AF in primary care DR BRUCE TAYLOR GPwSI Cardiology SCN Merseyside and Cheshire Clinical Lead Primary care

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1 Initial assessment of patient with AF in primary care DR BRUCE TAYLOR GPwSI Cardiology SCN Merseyside and Cheshire Clinical Lead Primary care 11 th and 25 th September 2014

2 3 KEY OBJECTIVES OF TALK 1. TO BECOME CONFIDENT IN DIAGNOSIS AND INITIAL MANAGEMENT OF PATIENT WITH AF 2. TO BECOME CONFIDENT IN THE EVALUATION AND MANAGEMENT OF THROMOBEMBOLIC RISK IN PATIENTS WITH AF 3. TO BECOME CONFIDENT IN DECIDING WHICH PATIENTS WITH AF TO REFER

3 Summary of presentation Background to AF in community setting Causes and diagnosis of AF in practice Immediate assessment of patient Rate or rhythm Assessment of thromboembolic risk When to refer Take home messages Top Taylor Tips

4 Summary of presentation Background to AF in community setting Causes and diagnosis of AF in practice Immediate assessment of patient Rate or rhythm Assessment of thromboembolic risk When to refer Take home messages Top Taylor Tips

5 National and local perspectives AF is the most common heart arrhythmia, with a prevalence of approximately 1.9% in primary care in the UK Estimated numbers affected by AF: England: 600,000 Europe: 4.5 million Nearly one in four people at age 55 years will go on to develop AF (24% of men and 22% of women)

6 AF PREVALENCE Atrial Fibrillation and Stroke Report 2012/2013 Cheshire and Merseyside Strategic Clinical Networks & Bayer Healthcare

7 Prevalence of AF predicted to more than double by People with AF in the US (millions) Projected incidence of AF assuming a continued increase in age-adjusted incidence as evident in Projected incidence of AF assuming no further increase in age-adjusted incidence Year 2050

8 Stroke is a frequent complication of AF Patients with AF have a five-fold higher stroke risk than those without AF AF doubles the risk of stroke when adjusted for other risk factors Without preventive treatment, each year approximately 1 in 20 patients (5%) with AF will have a stroke When transient ischaemic attacks and clinically silent strokes are considered, the rate of brain ischaemia associated with non-valvular AF exceeds 7% per year It is estimated that 15% of all strokes are caused by AF and that 12,500 strokes per year in England are directly attributable to AF

9 AF and AF stroke incur substantial healthcare costs AF accounts for more than 1% of healthcare expenditure in the UK Total costs for treating the 12,500 strokes in England that are attributable to AF is 148 million in the first year The cost per stroke due to AF is estimated to be 11,900 in the first year after a stroke occurs

10 AF COSTS OF STROKE Atrial Fibrillation and Stroke Report 2012/2013 Cheshire and Merseyside Strategic Clinical Networks & Bayer Healthcare

11 Summary of presentation Background to AF in community setting Causes and diagnosis of AF in practice Immediate assessment of patient Rate or rhythm Assessment of thromboembolic risk When to refer Take home messages Top Taylor Tips

13 TYPES OF AF PAROXYSMAL AF Self terminating usually within 48 hours PERSISTENT AF Present when an AF episode either lasts longer than 7 days or requires termination by cardioversion either with antiarrhythmic drugs or dc cardioversion PERMANENT AF Exists when the arrhythmia is accepted by the patient and a rhythm controlled strategy is not pursued

14 CAUSES OF AF Abnormalities of Atrial wall Stretch through raised atrial pressure Fibrosis Abnormalities of substrate Inflammatory conditions Electrical remodeling Genetic factors

17 Consequences of AF Increase stroke risk Increase risk of cardiac failure Risk of syncope Compromised exercise capacity Exacerbation of CAD

18 Diagnosis of AF Symptoms None Breathlessness Fatigue Diminished exercise capacity Palpitations Light headiness or syncope Chest pains Stroke

19 Diagnosis of AF Signs Irregular irregular pulse Accelerated or reduced Heart rate Hypotension Signs of fluid overload Stroke N.B. always do the ECG

20 Summary of presentation Background to AF in community setting Causes and diagnosis of AF in practice Immediate assessment of patient Rate or rhythm Assessment of thromboembolic risk When to refer Take home messages Top Taylor Tips

21 Initial assessment of patients Confirm diagnosis with ECG then Only 3 key decisions to make 1. Urgent admission or not? 2. Rate or rhythm control? 3. Anticoagulate or not?

22 Urgent admission Overall clinical condition Chest pains Severe breathlessness Hypotension Other known co-morbidities Overall rate? Other factors

23 Case 1: ecg

24 Initial assessment of stable patients Confirm with ECG with AF Assess cause and lifestyle factors Baseline Bloods FBC/TFTs/LFTs/U&Es Consider ECHO Consider 24hr ECG Decide on either rate or rhythm control Evaluate thromboembolic risk Provide patient information Arrange follow up

25 AF management Rhythm control Younger patients Patients if AF less than one year Reversible cause Structurally normal ECHO AF poorly tolerated Achieved by Medication DC cardioversion Ablation

26 AF Management Rhythm control Medication Most helpful in PAF Reversible cause Beta blockers usually Soltalol or Bisoprolol Flecanide Amiodarone Digoxin not helpful

27 AF Management Rhythm control Cardioversion Local Pathway with leaflet Must be anti coagulated at target INR 4 weeks Usually with Amiodarone up to 4 weeks post Does not effect their long term risk of stroke Therapeutic to see if symptomatic benefit Like rebooting computer!

28 AF Management Rhythm control Ablation Pathway via LHCH usually after discussion with either APH or WICC via EPS cardiologist Most suitable for patients with paroxysmal AF Failed cardioversion Poorly tolerated AF Targets area around origin of Pulmonary veins Procedure can take up to 4 hours Risk of permanent pacemaker Still doesn t affect overall thromboembolic risk Offers chance of cure

29 AF Management Rate control Suitable for most Drugs not always needed 24 hr. ECG helpful in evaluation Beta- blockers mainstay Digoxin less widely used nowadays If pauses then pacemaker may be needed Pace and ablate useful in patients who tolerate AF poorly

30 Summary of presentation Background to AF in community setting Causes and diagnosis of AF in practice Immediate assessment of patient Rate or rhythm Assessment of thromboembolic risk When to refer Take home messages Top Taylor Tips

31 ASSESSMENT OF THROMBOEMBOLIC RISK Vital element of AF management Use well accredited scoring systems CHADS2 or CHA2DS2VASC Use Audit tools such as Grasp to help identify high risk missed patients Consider risks benefits - HASBLED QBLEED Involvement of patient

36 Warfarin reduces the risk of stroke in patients with AF Warfarin better Placebo better AFASAK SPAF BAATAF CAFA SPINAF EAFT All trials RRR = 64% ARR = 2.7% 95% CI: 49 to 74% Relative risk reduction (%)* Error bars = 95% CI; *Relative risk reduction for all strokes (ischaemic and haemorrhagic) 36 Hart RG et al. Ann Intern Med 2007;146:857 67

37 Limited efficacy of aspirin in reducing the risk of stroke in patients with AF AFASAK SPAF EAFT ESPS II LASAF 125 mg/d 125 mg QOD UK-TIA 300 mg/d 1200 mg/d JAST All trials Aspirin better RRR = 19% ARR = 0.8% 95% CI: 1 to 35% Placebo better Relative risk reduction (%)* Error bars = 95% CI; *Relative risk reduction for all strokes (ischaemic and haemorrhagic) Hart RG et al. Ann Intern Med 2007;146:

38 The BAFTA study: risk of haemorrhage per year Aspirin Warfarin RR p Major extracranial 1.4% 1.6% All major (intracranial & haemorrhagic stroke) 1.9% 2.0% Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) Study compared the efficacy and safety of warfarin compared with aspirin in 973 patients, aged 75 years or more. Mant J et al. Lancet 2007;370:

39 NICE 2014 guidelines re antithrombotic therapy in AF Use the CHA2DS2-VASc to evaluate stroke risk Do not offer stroke prevention therapy to people aged under 65 years with atrial fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA2DS2-VASc score of 0 for men or 1 for women). [new 2014] Consider anticoagulation for men with a CHA2DS2-VASc score of 1. Take the bleeding risk into account. [new 2014] Offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account. [new 2014] Discuss the options for anticoagulation with the person and base the choice on their clinical features and preferences. [new 2014]

41 QBLEED Developed by same team that developed QRISK Uses up to 21 variables More typical population base than used in HASBLED Goes up to 85 years old Gives an absolute risk for both GI and CNS bleeds Not yet adopted by NICE Published in BMJ in July

42 QOF AF AF1 The contractor establishes and maintains a register of patients with atrial fibrillation [6] AF3 In those patients with atrial fibrillation in whom there is a record of a CHADS2 score of 1, the percentage of patients who are currently treated with anti-coagulation drug therapy or anti-platelet therapy AF4 In those patients with atrial fibrillation whose latest record of a CHADS2 score is greater than 1, the percentage of patients who are currently treated with anti-coagulation therapy

43 QOF [2] Note no points now for doing as assessment of stroke risk Still using CHADS2 score rather than better CHA2DS2VASC Aspirin still permitted when chads score is 1

44 Atrial Fibrillation and Stroke Report 2012/2013 Cheshire and Merseyside Strategic Clinical Networks & Bayer Healthcare

45 WHY NOT WARFARIN ADVANTAGES Cheap Effective Proven track record Familiar to clinicians Can be used in other forms of AF and other cardiac situations Easy to monitor Easy to reverse DISADVANTAGES Fiddly to initiate Significant bleeding risks Narrow therapeutic window Significant drug interactions Patient acceptability Doctor acceptability Need for monitoring

46 So time for newer agents? Dabigitran Rivaroxaban Apixaban

47 Clinical data indirect comparisons No direct head to head clinical trials comparing the new oral agents have been conducted to date All have NICE approval Subtle differences

48 Pharmacology Dabigatran 1-3 Rivaroxaban 4,5 Apixaban 6,7 Mode of action Factor II Factor X Factor X Half life hrs 7-11 hrs 12 hrs Dosing (in atrial fibrillation) B.D. O.D. B.D. Metabolism Esterase catalysed hydrolysis CYP P450 dependant and independent mechanisms CYP P450 Excretion 85% Renal 1/3 Renal 2/3 Hepatic 1/4 Renal 3/4 Non Renal Form Capsule Tablet Tablet Dose 150 mg 110 mg (>80 yrs, verapamil or increased bleeding risk) 20 mg 15 mg (CrCL ml/min) 5 mg 2.5 mg (2 or more: >80yr; weight <60 kg; Cr >1.5 mg/dl) B.D. = twice daily; O.D. = once daily

49 AF ongoing monitoring At least twice a year Evaluate symptoms Review overall cardiovascular risk Review stroke risk assessment Baseline bloods especially renal function Medicines management review Review compliance and concordance Refer as appropriate 10 steps

50 Summary of presentation Background to AF in community setting Causes and diagnosis of AF in practice Immediate assessment of patient Rate or rhythm Assessment of thromboembolic risk When to refer Take home messages Top Taylor Tips

52 TEN STEPS BEFORE REFERRAL 1. Diagnose AF 2. Establish duration and type of AF 3. Assess symptom severity 4. Establish the cause of AF 5. Enquire about relevant co-morbidities 6. Undertake a physical examination of the patient 7. Undertake tests and investigations 8. Reduce symptoms by prescribing rate-controlling medication 9. Start the patient on appropriate anticoagulation 10. Carefully consider the reason for referral

53 When to refer Considering cardioversion Troublesome PAF Poorly tolerated AF Significant other cardiac co-morbidities

54 The GRASP AF tool Identifies patients with Atrial fibrillation Searches for co-morbidities and works out CHADS 2 score Searches for current medication warfarin or aspirin (or both) Searches for recorded reasons for NOT treating with warfarin Has a comprehensive Advice sheet

55 The GRASP AF tool dashboard view

56 Summary of presentation Background to AF in community setting Causes and diagnosis of AF in practice Immediate assessment of patient Rate or rhythm Assessment of thromboembolic risk When to refer Take home messages Top Taylor Tips

57 AF TAKE HOME MESSAGES Always do an ECG at diagnosis At initial diagnosis consider if patient needs urgent admission Decide if rate or rhythm control approach and manage or refer as appropriate Always perform a thromboembolic risk assessment Do not use Aspirin to prevent strokes in AF Consider use of Audit to improve ongoing care AF is a primary care disease

Atrial Fibrillation. A guide for Southwark General Practice. Key Messages. Always work within your knowledge and competency

Atrial Fibrillation. A guide for Southwark General Practice. Key Messages. Always work within your knowledge and competency Atrial Fibrillation A guide for Southwark General Practice Key Messages 1. Routinely offer pulse checks to patients at high risk of AF 2. Use the CHA 2 DS 2 VASc score to identify patients for anticoagulation