Professor DA Fitzmaurice Primary Care Clinical Sciences University of Birmingham

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1 New Guidelines for SPAF Professor DA Fitzmaurice Primary Care Clinical Sciences University of Birmingham

2 Stroke prevention and atrial fibrillation Epidemiology of atrial fibrillation How common is it? What is it s impact? EPCCS/NICE guidelines Stroke prevention in atrial fibrillation Rate versus rhythm control INR control Target INR Impact of quality of INR control

4 Prevalence & detection rates of new cases of AF in people aged > control opportunistic systematic Baseline 12 mth prevalence 12 mth incidence SAFE study, BMJ 2007

5 Age specific prevalence of AF 12% 10% 8% 6% 4% 2% 0% Age group

6 Descriptive epidemiology of AF Becoming more common Framingham: 3 fold increase % paroxysmal More common in men than women Many have underlying cardiac disease

7 Prevalence of cardiovascular disease in AF Furberg et al % 35% 57% Clinical CVD Sub-clinical CVD No CVD

8 Impact of AF Increased risk of death Increased risk of stroke Associated with higher mortality from CHD and heart failure?impaired cognition/ dementia

9 AF and mortality the Framingham study Circulation residents aged enrolled in new cases of AF identified over 40 years of follow up

10 AF and mortality the Framingham study Circulation Median survival AF no AF M F M F M F M F Age gp & sex at entry

11 Odds ratios for death Multi-variate analysis: Men: 1.5 (95% CI: ) Women: 1.9 (95% CI ) CHD commonest cause of death

12 Consensus guidance on stroke prevention in atrial fibrillation (SPAF) in primary care. European Primary Care Cardiovascular Society (EPCCS) SPAF working group Editors Hobbs, FD Richard, Taylor, Clare J

13 Contributing Authors (in alphabetical order) Brotons, Carlos, Charra, Clément. Del Zotti, Francesco, de la Figuera, Fitzmaurice, David, Geersing, Geert-Jan, Hoes, Arno W, Hollander, Monika, Karotsis, Antonis K, Lionis, Christos, Lucassen Wim, Lühmann, Dagmar, Middeldorp, Saskia, Rutten, Frans H, Schianchi, Paolo, Verheugt, Freek WA, Wagner, Hans-Otto

14 NICE Guidline June 2014 Update of 2006 guideline Chair: Dr Campbell Cowan GP reps: Fitzmaurice/Fay

15 Diagnosis Pulse palpation ECG 24 hr tape Event monitor EPCCS recommend screening in primary care

16 Personalised Package of Care (NICE) Stroke awareness and measures to prevent stroke Rate control Assessment of symptoms for rhythm control Who to contact for advice if needed Psychological support if needed Up to date and comprehensive education and information on: Cause, effects, and possible complications of atrial fibrillation Management of rate and rhythm control Anticoagulation Practical advice on anticoagulation Support networks (such as cardiovascular charities)

17 Referral (NICE) Symptoms Prompt within 4 weeks (specifically for failed cardioversion)

18 AF and stroke Five fold increase in risk of stroke What does this mean for an individual patient? Need to know risk of stroke Factors that increase risk of stroke

19 Change in stroke incidence Rothwell et al, Lancet 2004; 363:

20 Stroke risk stratification in atrial fibrillation CHADS2 Congestive HF 1 Hypertension 1 Age 75 1 Diabetes 1 Stroke/TIA - 2 Low = 0 Moderate = 1 High = 2 or more ACC/AHA/ESC 06 High: stroke/tia or 2 mod factors Mod: Age 75; HF Hypertension; Diabetes; LVEF 35%; fractional shortening < 25% Low: No factors ACCP 08 High: stroke/tia or 2 mod factors Mod: Age 75; HF Hypertension; Diabetes; impaired LV systolic function Low: No factors Hart & Pearce, Stroke 2009

21 EPCCS/NICE Stroke and bleeding risk should be assessed in all people with atrial fibrillation. CHA2DS2VASc HAS-BLED

22 CHADS 2 CHA 2 DS 2 VASc CHADS2 risk Score CHA2DS2-VASc risk Score CHF 1 CHF or LVEF < 40% 1 Hypertension 1 Hypertension 1 Age >75 1 Age > 75 2 Diabetes 1 Diabetes 1 Stroke or TIA 2 Stroke / TIA 2 Thromboembolism Vascular Disease 1 Age Female 1

Patients (%) Patients (%) Distribution of CHADS 2 and CHA 2 DS 2 VASc scores CHADS 2 score Mean ± SD 2.0 ± 1.1 62.

23 Patients (%) Patients (%) Distribution of CHADS 2 and CHA 2 DS 2 VASc scores CHADS 2 score Mean ± SD 2.0 ± % CHA 2 DS 2 VASc score Mean ± SD 3.5 ± ,5 23,9 20,7 94.2% 11,3 9,8 4,5 1,

24 HAS-BLED Score for bleeding risk on oral anticoagulation in AF Feature Score if present Hypertension (systolic > 160mmHg) 1 Abnormal renal function 1 Abnormal liver function 1 Age > 65 years 1 Stroke in past 1 Bleeding 1 Labile INRs 1 Taking other drugs as well 1 Alcohol intake at same time 1 HAS-BLED should not be used to decide whether to offer anticoagulation in someone with a CHA2DS2-VASc score of 2 or above, but consider its use to balance the benefits of anticoagulation in patients with a CHA2DS2-VASc score of 1. (EPCCS)

26 Stroke prevention in people with non-valvular atrial fibrillation. Jones C et al. BMJ 2014;348:bmj.g by British Medical Journal Publishing Group

27 Antiplatelets ASA has no role in SPAF (EPCCS) Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation (NICE)

Rate versus rhythm control Rate control first line Offer a standard β blocker (a β blocker other than sotalol) or a rate limiting calcium channel blocker as initial monotherapy to people with atrial

28 Rate versus rhythm control Rate control first line Offer a standard β blocker (a β blocker other than sotalol) or a rate limiting calcium channel blocker as initial monotherapy to people with atrial fibrillation who need drug treatment as part of a rate control strategy. Consider digoxin monotherapy for people with non-paroxysmal atrial fibrillation only if they are sedentary If monotherapy does not control symptoms, and if continuing symptoms are thought to be caused by poor ventricular rate control, consider combination therapy with any two of the following: -A β blocker -Dilitazem -Digoxin Low quality evidence

29 Rate versus rhythm control The AFFIRM trial (NEJM Dec 2002) 4,060 patients in AF age 65 or over or other risk factors for stroke/death Patients randomised to: Rhythm control: cardioversion as necessary; +/- drugs: amiodarone; disopyramide; flecainide; dofetilide etc. Rate control: beta-blockers; verapamil; diltiazem; digoxin. Anticoagulation: could be stopped if sinus rhythm maintained

30 RCT of rhythm versus rate control in atrial fibrillation: mortality after 5 years of follow up in 4,000 patients

31 Results of AFFIRM After 5 yr follow up: Death rate: 24% (rhythm control) versus 21% (rate control). P = Secondary end-points all favoured rate control: Fewer hospitalisations Fewer pulmonary events Fewer GI events Fewer serious arrythmias

32 on treatment analysis of AFFIRM: what factors are associated with improved survival? (Circulation 2004) Improved survival Warfarin use (0.5) Sinus Rhythm (0.53) No association Sex; hypertension; LA enlargement; B blockers Calcium channel blockers Worse survival Older age (1.05 per yr) CAD; CHF; DM; stroke/tia Smoking LV dysfunction Mitral regurgitation Digoxin use Rhythm control drug use

33 What is optimal anticoagulation control? Aim for target INR 2.5, with acceptable range 2-3.

34 Hylek et al, NEJM 2003: effect of intensity of oral anticoagulation on stroke severity & mortality 13,559 patients with AF enrolled in Kaiser Permanente, N Cal Recruited , follow up to end 1999 Strokes identified from hospital databases, with subsequent case note review 596 strokes occurred during follow up

35 Risk of stroke and intra-cranial haemorrhage on warfarin according to INR 10 rate per 100 py < >4.5 INR stroke Intracranial haemorrhage

36 30 day survival after ischaemic stroke in AF by medication status on admission

37 Summary Atrial fibrillation is associated with major morbidity Impact of AF will increase Better survival of people with CHD Ageing population Warfarin is highly effective at reducing risk of stroke Newer agents are with us EPCCS/NICE No role for antiplatelets Rate over rhythm CHA2DS2VASc, HAS-BLED Increased use of anticoagulants

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